Book Reviews

Letting Them Die: Why HIV/AIDS Prevention Programmes Fail By Catherine Campbell, Cape Town, South Africa: Double Storey Books, 2003, ISBN 1-919-930116. Reviewed by Brian van Wyk. The Moral Economy of AIDS in South Africa By Nicoli Nattrass. New York: Cambridge University Press, 2004. ISBN 0-521-54864-0. Reviewed by Shandir Ramlagan. Learning from HIV and AIDS Edited by George Ellison, Melissa Parker, and Catherine Campbell. 2003. New York: Cambridge University Press, ISBN 0-521-80866-9, 0-521-00470-5pbk. Reviewed by Sharon Kleintjes.

Letting Them Die provides a detailed account of a multi-component project aimed at mobilising a local community in a mining town in South Africa to prevent HIV/AIDS.The project included interventions to promote peer education among sex workers and young people, as well as efforts to mobilise various stakeholders to work together to prevent HIV/AIDS. As part of the outcomes evaluation, STI and HIV prevalence were monitored yearly among a random sample of sex workers, mineworkers and township residents over a 3-year period. A process evaluation was also conducted over the entire period of the project.
The book (196 pp.) is divided into four parts.The first part introduces the community in which the intervention took place, as well as several concepts that were central to the programme design.The second part describes attempts to mobilise sex workers living in the informal sector as peer educators, to raise awareness of HIV/AIDS and promote safer sexual behaviour in their profession.The author describes how gender relations and power dynamics within the community counteracted potential benefits of the intervention.The third part describes the implementation of a peer educator training and intervention programme in a high school aimed at promoting safe sex among young people. An interesting comparison is drawn between the respective processes and effects of peer educator interventions in chaotic informal settings versus those implemented in a rigidly controlled school system.The final part describes the difficulties experienced in promoting and maintaining partnerships between stakeholders on various power levels.The author not only seeks to answer the question why various components of the HIV prevention programmes failed, but also gives an in-depth account of how they failed.
Throughout the book the author provides the reader with the necessary background evidence that underpins various research decisions, and also provides possible explanations for events that occurred. At times these explanations felt somewhat premature and at other times downright confusing. However, later chapters or sections would almost always clarify and support decisions and explanations offered earlier.The authorís skills as a journalist are clearly evident in a book that is well-structured, and written in language that is easy to understand for those interested in HIV prevention and other community issues, although not strictly part of the academic community. For the astute intellectual, chapter three provides a detailed exposition of the theoretical framework which informed the intervention components. For the less academic reader the option is given to skip the abovementioned chapter, without losing touch with the rest of the book.
The book provides a compelling argument why interventions based on individual level perspectives often fail to bring about positive sexual behaviour change at community level.The author recommends that short and medium-term HIV prevention interventions should run parallel to initiatives aimed at bringing about social improvement in the long term.
In this respect, attention should be paid to the macro social factors that influence sexual behaviour in groups and communities. Although the quantitative evaluation showed few positive effects resulting from the intervention, qualitative findings from the process evaluation contribute greatly to our understanding of social dynamics and individual sexual health behaviour in this township community.The most important contribution that the book makes is in giving us insight into why evidence-based HIV preventions often fail, and how difficult it is in reality to implement community-based interventions according to strict protocol. Letting Them Die is a must-read for all interested in the social and behavioural aspects of HIV/AIDS and prevention. By Nicoli Nattrass. New York: Cambridge University Press, 2004. ISBN 0-521-54864-0 Has AIDS policy been left in the hands of technocrats? Nicoli Nattrass, in her 224-page book, argues that 'AIDS policy is too important to be left in the hands of technocrats'. As a Professor of Economics and Director of the Centre for Social Science Research at the University of Cape Town, she provides an economic analysis to inform social debate about AIDS policy in South Africa. In particular, Nattrass focuses on and discusses past and current government actions with respect to the provision of antiretroviral therapy (ART), thereby stimulating further questions and debate for both economists and non-economists.

The Moral Economy of AIDS in South Africa
The Moral Economy of AIDS in South Africa 'illustrates how economic analysis can help government and civil society think about addressing AIDS'.The book is divided into seven chapters. Chapter 2 provides a comprehensive overview of the progression of AIDS policy in South Africa from the days of apartheid to the present. Nattrass describes South Africa's history of AIDS policy as a 'sorry tale of missed opportunities, inadequate analysis, bureaucratic failure and political mismanagement'. She compares AIDS management with warfare field-hospital management or triage. Triage makes both rational and reasonable sense because during war medical officers are confronted with stark imbalances between available resources and the need for medical attention.The philosophy of triage states that resources be allocated first to those with a good chance of recovery once treated. Given the resource constraints to the roll-out of mother-tochild transmission prevention (MTCTP) and highly active antiretroviral treatment (HAART) programmes, Nattrass argues that the South African government's policy on AIDS could be described as conforming to the moral economy of triage.
In chapters 3 and 4 Nattrass clearly argues in favour of expanding MTCTP and HAART programmes nationally. Her economic analysis shows that an expanded national MTCTP programme is not only affordable, but would in fact save the South African government money. Her argument of affordability is also drawn from the savings in terms of overall cost to the health and welfare sectors in treating opportunistic infections and caring for orphans, respectively. Nattrass provides evidence for possible cost-benefits to implementing the HAART programme and her argument shows that the conventional wisdom that HAART is not cost effective is untrue. Furthermore, she argues that with the high cost of the regime, the question one asks oneself is how many South Africans would actually prefer an increase in taxation to pay for the programme. It is here that the moral economy is explored.
In chapter 5 Nattrass explores the implication of extended lives of those on HAART with specific mention of behaviour change. She discusses the potential occurrence of increased or continued risky sexual behaviour among those on HAART and also argues that spreading HIV infection could be conceptualised within subculture. She explains that issues of behaviour change should be explored within the social contexts of myths, stigma, voluntary counselling and testing and sexual culture.
Before concluding in chapter 7, Nattrass dedicates a chapter (chapter 6) to the interrelationship between poverty, AIDS and economic growth. In this chapter she shows that economic development is sure to be hampered if AIDS treatment is not made available and accessible. In the final chapter, Nattrass takes a critical viewpoint of government in concluding that 'government's rhetoric of expertise was deflecting attention away from the implicit social choices that were being made on behalf of society'. AIDS policy should be the 'product of broad social deliberation about how society should respond to the moral challenges posed by AIDS'.
Nattrass's book succeeds in its aim to 'facilitate informed social debate about AIDS policy in South Africa'.This book stimulates readers to think, question and seek answers outside of the preselected paradigms. The Moral Economy of AIDS in South Africa by Nicoli Nattrass should be compulsory reading for all those involved with HIV/AIDS. in the debate on multi-disciplinary or inter-disciplinary action, differences evident also in the understanding of the authors of this volume.
Interpretative differences notwithstanding, the selection of authors and contributions to this volume demonstrates this multidisciplinary approach in the eight chapters that follow, in that contributors write about both African and European (London) perspectives on HIV/AIDS; report on work conducted in academic, public health, clinical and community settings; and represent a wide range of disciplines, including anthropology, epidemiology, medicine and psychology. A diverse range of methodological, theoretical, clinical and practice advances in the field are covered in their writings, which span individual through to global influences on the spread and control of HIV/AIDS, with each contribution adding essential threads to the tapestry of complex and interdependent issues needing attention to effectively alter the course of the pandemic. Gaps in our knowledge-base about the disease, and the importance of an integrated approach to the economic, political social, cultural and behavioural influences on effective application of this knowledge are highlighted.
Hutchinson (Ch. 2), Ghani and Boily (Ch. 3) and Gregson (Ch. 4) outline challenges and advances in virology, epidemiology and demographic research respectively, as these pertain to and are influenced by HIV/AIDS. Hutchinson's paper provides a succinct description of the origins, genetic diversity, evolution, transmission and virulence of the virus. Ghani and Boily explain how the unique transmission properties of the HI virus have impacted on modern theory and methodology of epidemiology, as well as on our knowledge of human sexuality, sexual behaviour and the spread of STIs other than HIV. They conclude with a description of the contribution epidemiological modelling can bring to forecasting the demographic impact of HIV, the design and execution of vaccine trials, and the design and implementation of controlled trials for mass treatment of STIs, including HIV. Gregson's paper focuses on the impact of HIV on demographic trends and, consequently, on the demographic research agenda and methodology, particularly in high-prevalence regions, notably sub-Saharan Africa. He notes that if demographic information is to contribute meaningfully to forecasting, planning and financing work in these regions, there is pressure for methods used to be responsive to the rapid changes the impact of HIV is making on demographic trends.
In Wood and Ellison's paper (Ch. 5),Wood, a medical doctor, provides a narrative account of the psychosocial, socio-cultural, religious, gender, mental health and access-to-care barriers experienced by HIVpositive and AIDS patients treated at two multiethnic London-based HIV clinics. He describes the fairly rapid transition in London from a focus on palliative care for terminally ill AIDS patients during the late 1980s and 1990s to, at the turn of the century, a focus on the effective management of HIV as a chronic disease, and resultant improvements in preventive options, with the advent of accessible antiretroviral treatment.This description brings sharply into focus the crisis in poorer countries, the sub-Saharan region in particular, where a similar transition to comprehensive clinical care and support is bedevilled by barriers in all the areas covered by this volume, as well as the lack of nutrition and food security in many of these poverty-stricken countries, problems with the financing of AIDS care and policy implementation, drug-and trade-related issues, legal and customary law issues, and appropriate cultural and community mobilisation, among others.
The next three authors focus on, and demonstrate through their own work, the theoretical renewal needed in psychology and anthropology to improve the contribution of these disciplines to theory, policy and practice in the HIV/AIDS field.
Campbell and Cornish's (Ch. 6) paper starts with the need to develop new theoretical approaches to inform our understanding and practice in the field of behaviour change and health promotion.They assert that psychologists need to go beyond current individual-based psychological approaches, to develop constructs which inform appropriate analysis at community level, and accommodate the influence of environmental factors on behaviour change and health promotion.They discuss the five pillars of health promotion from the perspective of improving health outcomes for commercial sex workers, and illustrate their position by closing their chapter with a focus on a sex worker-led intervention which formed part of a larger community-based prevention intervention in South Africa. Parker (Ch. 7) comments on the limited contribution of anthropologists to the development of public health interventions. Using case studies from her work with gay-identified men who have witnessed or engaged in sexual activity in London backrooms, she demonstrates how anthropological research can inform the development of public health policy and programme development to prevent transmission of HIV. Heald (Ch. 8) also laments the dearth of anthropological contributions to innovations in policy, prevention and care, with her paper focusing on the absence of anthropologists in research and policy formulation in Africa, illustrated by a case study in Botswana.
Alex de Waal (Ch. 9) provides a thought-provoking analysis of some of the current limits of governance in the face of the pandemic. He argues that a clear understanding of and engagement with the governance threats of the HIV/AIDS pandemic is central to the development of an -as yet absent -'roadmap' for response by governments, and the international agencies with whom they work.
Finally, Marks and Ellison conclude the volume with a reflection on the merits and demerits of historical analysis as an aid to our understanding of this infectious disease.They remind the reader of the recent 'historically-based' attribution of the genesis of the pandemic at the door of the African continent by some prominent historians and scientists, the persistence of which can only serve to unnecessarily increase the burden on social science efforts directed at putting effective HIV/AIDS prevention, treatment and support in place in Africa. Along with African-based historical-political contextual reviews, cutting edge social science -such as the work conducted by African and international partners to the SAHARA networkcannot but assist us to dispel such myths, and develop models, policies and practices which will make a difference in fast-tracking the African experience of reversing the impact of HIV/AIDS on the continent.