Flanked by scrub-stubbled hills southwest of Johannesburg, the shantytowns that surround this South African gold-mining community are unlikely places for an AIDS success story.
Some 70,000 African men here have left their families to work a dirty, dangerous job. They live in hostels, 18 to a room - far from home. And paid-for sex is rampant.
Until recently, experts say, the prospect for stemming the AIDS epidemic in Carletonville was no better - perhaps worse - than for other places on this continent, where an estimated 23 million have HIV, the virus that said to cause AIDS. An estimated 1 in 4 miners in this town has AIDS - compared with 1 in 10 in South Africa's mining industry as a whole.
Of the 5.6 million people in the world newly diagnosed with HIV last year, 70 percent were in Africa, according to a World Health Organization report released yesterday. And nowhere is the rate of HIV growing faster than in South Africa.
But here in the squatter camps that stretch out in the shadow of Carletonville's gold mines, attitudes and practices are beginning to change. Progress is incremental. But it's a start.
In what is called the Mothusimpilo Outreach Project, some 60 sex workers have been trained in the past 1-1/2 years and are now "peer educators," teaching their colleagues about HIV, and how to prevent it.
"This is the only project I know of that is attempting to manage HIV at the level of an entire community," says Brian Williams, an epidemiologist from the Council for Scientific and Industrial Research in Johannesburg.
Fresh strategy to fight HIV
Four years ago, Professor Williams hosted a conference of international AIDS experts and drew on the best of their experiences to come up with a fresh HIV-fighting strategy for this mining community. As a result, scientists have joined forces here with mine managers, prostitutes, local doctors, health officials, and even high school students and local bar owners.
"A whole community has been mobilized," says Ron Ballard at the South African Institute of Medical Research in Johannesburg. "This country is relatively conservative, and as a result these issues - sex, condom use, empowerment of women - have almost never been discussed in the open. But now we see people at high risk starting to communicate and mobilize themselves."
So far, the greatest success lies in the about-face change in the attitudes of female sex workers toward using condoms - a feat that is all the more remarkable because it required a direct confrontation with African taboos and mining culture.
"There is no doubt that promiscuity is a major contributing factor in the spread of this disease," Ballard says.
There is a debate about how much of this is due to "the culture" and how much comes from "the living conditions" so many Africans experience.
But clearly, danger and loneliness contribute to promiscuity among mine workers. Many of the men working in some 600 South African mines live in cramped, bleak dormitories. Some get home only once or twice a year. And 1 in 40 mine workers is killed on the job.
Mine workers construct macho identities to cope with the risks of their work, according to Catherine Campbell, a social psychologist who has published studies on the Carletonville HIV epidemic.
"Associated with this macho masculinity is the notion of men having insatiable urges to have sex with an unlimited number of women," Ms. Campbell says in a study recently published in Social Science and Medicine, a research journal.
Debunking rural myths
And there's a widely held myth in South Africa's rural areas that AIDS can be cured by having sex with a virgin. According to a report released yesterday by a Joint United Nations Programme on HIV/AIDS, "African girls aged 15-19 are five to six times more likely to be HIV-positive than boys the same age.... Sex with older, infected men appears to be a contributing factor to girls' greater vulnerability to HIV."
Miners view the risk of death by AIDS as a remote possibility in comparison to the danger of dying in a sudden rock blast. And the prostitutes, living a hand-to-mouth existence in shacks, have traditionally had little power to force the issue.
"The man would just take his business elsewhere," explains one Carletonville sex worker, walking the dirt road to her "job."
Williams and the project's managers recognized that people are far more likely to change their behavior if they see that trusted peers are changing theirs. Instead of promoting safe-sex practices through expert outsiders, members of a British and US-funded project began at the grass-roots level. They spent weeks visiting the slums in an effort to win the trust of local prostitutes.
"It wasn't easy," recalls Williams. The prostitutes were distrustful and weren't sure of Williams's motives.
But the sex workers are now listening and promoting chamge.
"Many of our friends have died," explains a wizened woman, who has spent two decades giving unprotected sex to laborers in Carletonville. "Four in this year alone."
This woman, who asked not to be named, is one of the 60 prostitutes who have become "peer educators" in the past 1-1/2 years.
How the program works
Participating in the Mothusimpilo Outreach Project, the sex workers are trained to teach their colleagues about HIV, and they now hold regular meetings in the squatter camps: demonstrating how to use condoms, singing songs about AIDS, and role playing to explore ways of negotiating for safe sex.
The women here go to work as they always did, sitting beneath trees in groups of five or six to wait for the miners to come off their shift.
Each time a woman emerges from an encounter in the bush, she must produce a used condom to show her colleagues. Those who fail to use condoms risk being beaten by their colleagues or even chased out of the community.
"We no longer agree to have unprotected sex," says one woman. She won't use her name she says, because her family does not know what she does for a living. But she is proud of what the women have accomplished. "We have united together."
Finding one's way
One twenty-something prostitute came to Carletonville based on the advice of girlfriends who painted a picture of plentiful money and beautiful clothes. Like several of her generation, she is one of the 52 percent of the 11 million young people in South Africa age 16 to 30 who are unemployed.
"I realize it wasn't true," she says with an embarrassed smile. "It was so hard at first. I think it is wrong."
But the one thing she says she's done right is to use condoms.
"I know about AIDS, and I don't want it to get me. I want to get out of here and get an education one day."
The peer education effort is now being expanded into the mining hostels, with men being trained to teach one another about the importance of condoms. Mine management has long been criticized for its slow response to the AIDS crisis in South Africa, but today many have started to act.
"We have initiatives in place that were almost unheard of five years ago,"says Andre Bester of Gold Fields Ltd., a giant company with eight mines across the country. "Awareness has improved so much, from the board room to the mine shafts."
Companies have started to establish HIV management teams, share information with outside researchers, plaster the workplace with AIDS posters, sponsor education initiatives, and treat sexually transmitted diseases in the mine health clinics. Today, a mine worker can collect a free condom from boxes posted in the underground mine shaft.
Mining companies help
But the mining companies had little choice but to act. One recent study revealed that, with each passing year, the country's mining houses will lose 10 percent of their workforces to AIDS.
And the results are impressive: peer educators have almost single-handedly driven the use of condoms among sex workers up from a mere 20 percent one year ago to 80 percent today.
"These women represent hope for the whole continent," says Williams.
"If we can get sex workers to use condoms, then we will have a major impact on this disease." he adds.
Project workers are expecting to see a dramatic decline in the rate of new HIV cases when they conduct the next round of HIV tests next year.
Ways to help
* Cotlands Babies Sanctuary - an orphanage in Johannesburg seeking families for children with HIV or who are without parents because of AIDS.
PO Box 740
* Africare - a US-based organization with offices in 27 African nations, specializing in grass-roots development and health projects.
440 R Street, NW,
Washington, DC 20001
Tel: (202) 462-3614
(c) Copyright 1999. The Christian Science Publishing Society