Book Reviews

HIV/AIDS in South Africa Edited by SS Abdool Karim and Q Abdool Karim. Cape Town: Cambridge University Press, 2005. ISBN-10 0-521- 61629-8 & ISBN-13 978-0-521-61629-4. Reviewed by Shandir Ramlagan. HIV/AIDS and Democratic Governance in South Africa: Illustrating the Impact on Electoral Processes By Per Strand, Khabele Matlosa,Ann Strode & Kondwani Chirambo, Institute for Democracy in South Africa (IDASA), Pretoria, South Africa, 2005. ISBN: 1-919798-80-3 Reviewed by Sarah Pugh. The Health of our Educators: Focus on HIV/AIDS in South African Public Schools Edited by O Shisana, K Peltzer,N Zungu-Dirwayi & JS Louw. Cape Town: HSRC, 2005 Reviewed by Malcolm MacLachlan.

HIV/AIDS in South Africa is a far-reaching, 592-page work which includes contributions by 40 authors who are without exception, accomplished researchers in their various fields. Leading this project are two internationally renowned infectious disease epidemiologists, namely Salim S Abdool Karim and Quarraisha Abdool Karim. This volume, which comprises of 36 chapters divided into 7 sections, covers a broad range of HIV/AIDS issues from basic science and medicine to sociology, psychology, economics and politics, thus living up to its claim of being a 'definitive' text on HIV/AIDS in South Africa. Many different viewpoints are presented, and data sources from which analyses and interpretations are derived are clearly specified, which allows readers to engage critically with the material and construct their own points of view.
Section 1 looks at the evolving HIV epidemic: the unique epidemiology of the disease in South Africa, as well as HIV infection rates. Section 2 describes the HI virus and how the virus interacts with the human host. Social scientists would benefit from these discussions about the biomedical features of the virus, presented in an insightful and interesting manner. Features in this section include clinical issues related to testing and diagnosis of HIV/AIDS, and control in the light of future diversifications (evolving) of the virus as well as the cellular immune response to HIV. Of note is the presentation of a rare number of individuals who appear to have a natural resistance to HIV-1 infection and therefore provide clues to protective immune responses and vaccine development.
Section 3 focuses on HIV risk factors and prevention strategies such as sexual risk behaviour reduction interventions.The author draws on Eaton, Flisher and Aaro's conceptual framework, which describes the forces shaping sexual risk behaviour in terms of personal factors, as well as proximal and distal contexts. This framework is useful for the South African context, because it provides a holistic perspective on sexual behaviour that takes into account structural, environmental and cultural forces as these interact with personal and interpersonal factors.The section includes a discussion on the prevalence of risky sexual behaviour derived from the findings from two nationally representative surveys. In addition to discussions on the successes and challenges of conventional prevention programmes, chapters are also included on the history, current and possible future status of intravenous drug use in South Africa, as well as new prevention strategies under development.The authors warn that 'should the roll-out of antiretroviral therapy in South Africa fail to integrate treatment and prevention, the epidemic is likely to continue to rise'.
Section 4 discusses issues related to 'focal groups' or sectors of the population in which a disproportionate burden of infection is borne by 'discrete high risk groups in which there is a strong gender bias.' Highrisk groups included are sex workers, adolescents, migrant workers and young women.The authors note that even though gender issues related to HIV/AIDS have been interpreted as female issues, dominant behavioural prevention strategies, i.e. condom usage and faithfulness, are those strategies that are least in the control of women. Gender-sensitive interventions such as the 'shosholoza' and the 'inkunzi isematholeni' projects developed by Targeted AIDS Intervention (TAI) are discussed.These interventions take a fresh perspective, and aim to engage males constructively and help them understand how they can be a part of preventing the further spread of the virus.
Section 5 looks at the impact of AIDS on the individual infected with the virus, the burden on the health care system, communities, the macroeconomic and microeconomic impact of AIDS, the impact of HIV/AIDS on democracy, ethics, as well as a AIDSrelated mortality in South Africa.This section begins with a chapter that contains a strong autobiographic, reflective narrative by a person living with HIV/AIDS (PLWHA).This extremely emotional chapter places the reader in the shoes of a PLWHA, thereby giving a human voice to the national/global statistics.
In 2000 HIV/AIDS was the biggest single cause of death in South Africa. It has become an added burden on already strained health care systems and its full extent has not yet been realised, because of the latent period of the illness and death. It is likely to double health care costs by 2010 if current levels of care are maintained.The increased strain on the health care system is currently leading to a decrease in health care standards and an increase in mortality of non-HIVinfected patients, as well as premature mortality in HIV-infected patients. A quote in the section sums this up:'People are dying prematurely because we are so stretched. Medical patients who don't have HIV/AIDS are being severely compromised because we have to discharge them prematurely -everybody is being compromised -the system just can't cope'.
Section 6 revisits the much-debated topic of HIV/AIDS treatment in South Africa.The clinical issues related to ARVs and the challenges to ART rollout are comprehensively covered, presenting the divergent views, and leaving the reader to make up his or her own mind.
In Section 7 projections about the future scenario are made, using models which pose and test key questions about overall disease dynamics.These include projections of the impact of HIV on TB incidence, behavioural change programmes as well as management of other STIs. In this concluding section, we find that although models can currently predict South African trends up until the year 2020, taking into consideration the scenarios plotted into the models, more data and better data are needed to make better and more complex projections. Due to this finding, and given the projections that are made in the section, the author points out the gaps in the data and research, urging researchers to take up the challenge.
The editors conclude the volume by stating the enormity of the challenge that HIV/AIDS poses to South Africa:'If the targets set out in the national AIDS treatment plan are to be met, South Africa will have to create one of the largest AIDS treatment programmes in the world -a feat that will need a concerted approach with assistance from all sectors of South African society as well as international support to achieve success.'They reiterate the importance of strong leadership at national level to lead into a future where HIV/AIDS prevention and treatment are integrated.
As a definitive text on HIV/AIDS in South Africa, the volume comes short of being comprehensive in covering some aspects, and therefore fails in its goal of being the ultimate text on HIV/AIDS in South Africa. The selective use of certain South African data sources diminishes the strength of the arguments that some authors put forward. However, even where the arguments presented are debatable, these chapters do provide good avenues for further discussion beyond the current volume. A critical omission in this volume is the lack of discussion around mental health and HIV/AIDS.The World Health Organization's World Health Report 2001 states that 1 in 4 people in the world will be affected by mental disorders at some point in their lives (WHO, 2001). Currently in the South African general population, approximately 1 in 5 people suffer from a mental disorder severe enough to impact on their lives significantly (Science in Africa, 2002) and the impact thereof is being studied. People who contract HIV can be prone to depression, which in turn could affect the success of treatment regimens (Freeman, Patel, Collins, & Bertolote, 2005). Furthermore, people with certain mental disorders may be at higher risk for HIV infection due to being sexually dis-inhibited.These pertinent issues warrant that a chapter in this volume be set apart to discuss mental health and HIV/AIDS.
Despite the above-mentioned oversights, the volume makes a valuable contribution. A highlight of the book is that besides the material from accomplished researchers and data sources, the text also brings in a more personal side with an autobiographic, reflective narrative by a person living with HIV.This narrative, well-placed in the middle of the text, reminds readers why they are in fact reading the text and also why work in this field is so important.This chapter brings a human voice to statistics.
Overall the book promises to be a valuable source to students and interns as it provides the insight of authors from varying backgrounds and different disciplines who deal with HIV and AIDS. Local and international established social scientists, researchers, health care providers and policy makers involved in the field of HIV/AIDS and related issues will also benefit from reading this book. The authors have also included a series of colour maps that make some of their statistical findings come to life in a way that only GIS mapping can. Early in the book, the authors refreshingly stress that they aim to present their work in a way that is accessible to a broader readership that may not have an extensive background in the issues, nor a solid grasp of statistics and numbers.Throughout the book, the authors also provide transparent reflections on their methodologies and the potential fallibilities of the study, including reflections on some of the existing data sets on which they occasionally draw for their own further research or analysis.

HIV/AIDS and Democratic Governance in South Africa: Illustrating the Impact on Electoral Processes
In the first part of the book, they draw on United Nations Development Programme (UNDP) concepts and definitions to set their theoretical stage, examining what is meant by 'governance' and 'democratic governance'.They follow this with a scrutiny of the UNDP's ideal 'governance response' to HIV/AIDS. Merging the concepts, the authors ask the next logical question: what, then, must a democratic governance response to HIV/AIDS look like? Expanding on the UNDP's principles for democratic governance, the authors provide their own suggestions for the content of an effective democratic governance response to HIV/AIDS. Another interesting avenue to explore might also look at how or if international models of democratic governance (especially as prescribed or implied by International Financial Institution and donor conditionalities) have any bearing on the potential development or effective implementation of HIV/AIDS-sensitive principles of democratic governance.
Strand, Matlosa, Strode and Chirambo provide a compelling theoretical argument as to why such a study is necessary, through a brief literature review of some of the ways in which HIV/AIDS can, in theory, constitute a threat to democratic governance in general. In the theoretical literature, for example, HIV/AIDS can affect democracies through loss of skills, experience and political relationships, and through the potential effective disenfranchisement of ill voters or caregivers. Institutional capacity can be eroded, and the accuracy of the voters' roll can be undermined, as voters die faster than the list can be accurately maintained. Issues of voter fatigue can also come into play, due to an increased frequency of byelections as politicians become ill or die.
In part 2, the authors examine how HIV/AIDS is impacting on the central electoral institutions of southern Africa, highlighting the significance of elections and electoral systems to a working democracy.The advantages and disadvantages of the three main electoral systems used in southern Africa -Proportional Representation (PR), First-Past-the-Post (FPTP) and Mixed Member Proportional Representation (MMP) -are discussed specifically in terms of their respective vulnerabilities to HIV/AIDS.The authors present the findings from their investigations into available data around recent by-election frequency and costs in Zambia, Zimbabwe, Lesotho and South Africa, and suggest that, while their study is not conclusive, the potential correlations between HIV/AIDS and increases in the number of by-elections certainly warrant further research. The authors stress that both the FPTP and the MMP system entail high financial costs for Member of Parliament (MP) replacements, and that these replacements often come at a high political cost as well. The PR system is strongly advocated by the authors as the most HIV/AIDS-resilient electoral system. The authors then turn to focus specifically on South Africa's Independent Electoral Commission (IEC), examining internal institutional vulnerabilities to HIV/AIDS as well as external implications of the epidemic.What, for example, does HIV/AIDS mean for South Africa in terms of the voters' role, voter registration, and voter turnout and/or apathy? Important issues of stigma and discrimination of voters living with HIV/AIDS when they physically go to the polls to vote are probed at greater depth through focus groups and a more qualitative approach in the book's final section.The authors point out that while the special vote is available for voters at national elections in South Africa, it is not an option for municipal elections, which can mean de facto disenfranchisement for increasing numbers of voters too ill to make it to the polls, or to stand in the queues on election day.The impacts of HIV/AIDS on respective South African political parties and policy proposals is also briefly explored, although this subject could be an entire research project in and of itself.
Part 3 of the book seeks to establish empirical data on the potential impacts of HIV/AIDS on voter participation, registration, and turnout, looking at, for example, whether voters might stay away from the polls due to caregiving duties, being ill themselves, or to avoid stigma and discrimination, or whether potential voters are disillusioned by a real or perceived lack of political response and leadership on HIV/AIDS issues. Chapter 9 is perhaps the most inspired chapter of the book, in which the results of the authors' access to unique IEC data sets around voter mortality, and specific national trends arising out of these data are presented and analysed with a convincing urgency. In particular, the gender dimensions of HIV/AIDS are captured and portrayed through statistics around the differential and devastating impacts of HIV/AIDS on young, black, female voters in South Africa.
This book could have benefitted from a tight proof read, and leaves the reader with a myriad of unanswered questions, but this latter point is, of course, the case with most innovative research. As an exploratory project, this study points out many avenues for further research and investigation, and certainly holds important lessons and implications for democratic governance that stretch far beyond the borders of South Africa.

The Health of our Educators: Focus on HIV/AIDS in South African Public Schools
Edited by O Shisana, K Peltzer,N Zungu-Dirwayi & JS Louw. Cape Town: HSRC, 2005 This substantial report is the product of a research consortium comprising the Human Science Research Council (HSRC) and the Medical Research Council (MRC) of South Africa. It was prepared for the Education Labour Relations Council (ELRC) in South Africa to explore the impact of HIV/AIDS on the supply and demand of educators to the education sector.The study had three primary objectives: to determine the prevalence of HIV and tuberculosis (TB), to investigate the determinants of HIV, and to establish the attrition rate among teachers at public (as opposed to private) schools.
This was a study on a massive scale: 1 766 randomly selected schools, incorporating the length and breadth of South Africa, were sampled, through a staggering 24 200 potential respondents. The research team comprised 436 field workers. Despite such large numbers the methodology employed triangulation methods. This included focus groups and key informant interviews that fed into the questionnaire design. The survey combined behavioural risks questionnaire-based survey methods with biological HIV testing (either saliva or blood samples), and with archival research on existing school records. Of those who gave an HIV specimen, 12.7 % were found to be HIV-positive, and this did not differ by gender.The prevalence was highest in the 25 -34-year age group (21.4%, where women had higher rates than men), with those over 55 years having the lowest prevalence (3.1%).Within the highest prevalence age group, major 'racial' differences were apparent, whereby black Africans were greatly over-represented in comparison to the other three groups.They were also much more likely than the other groups to belong to the lowest socio-economic category, this being attributed to their poorer education under the apartheid systems. HIV prevalence was highest in rural areas, followed by informal settlements and lowest in urban areas. KwaZulu-Natal and Mpumalanga had the highest prevalence (both over 19%).
The report goes on to detail determinants and awareness of HIV/AIDS status, condom use and health status, relevant knowledge, and extent of alcohol use.
Most troublesome, the study revealed that 55% of educators intended to leave the education profession, and this was for a variety of reasons including low job satisfaction, stress and violence in schools.
The report concludes with a number of strong recommendations including interventions targeted at behaviour change, HIV knowledge (specific aspects only, as general HIV/AIDS knowledge was good), particular high prevalence districts, improving selfefficacy skills, transmission prevention for those already HIV-positive, discouraging migratory practices that undermine family structures, establishing health workplace programmes, eliminating gender disparities (where they exist -particularly among young 'Africans') and establishing a web-based data-base for future policy and planning decisions. On the human resources side, more directly targeted at combating attrition, the report also recommends improved conditions of service, reducing alcohol intake and reducing workplace violence (to heighten teacher morale).
These recommendations are all worthy, the challenge of course being in the 'how to' detail.While many of these recommendations are relevant to individual behaviour, the social context of the problem -the poverty/HIV gradient -also needs to be addressed at its social and economic roots. Also, a stronger emphasis on using cultural identity (UNESCO, 2005) as a vehicle for combatting HIV may be of particular relevance in South Africa, where both across and within 'racial groups' there may be significantly different resources and challenges to be found.
Overall, The Health of our Educators is a hugely impressive piece of research undertaken on an awesome scale which does deliver socially relevant data for policy makers and planners, not just in education but also in health and related services. If the children of South Africa are to be in (enough) good hands in the next decade, action must be taken now to address and reverse the worrying situation described in this report. Whether the resources are prioritised for this or not, is ultimately a political decision.The researchers who produced this report have however provided a strong evidence base for well-motivated politicians to act. Let's hope they act now!