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Sex, Sugar Daddies and HIV in South Africa

KHAYELITSHA, South Africa — It's the middle of sex education class in Zola Business High School and 90 teenage boys and girls are laughing and talking through a presentation about birth control, condoms and HIV.

The school day is almost over in this township on the outskirts of Cape Town, but that's hardly the only thing keeping the students distracted. At the back of the room, about 10 teenagers – mostly women – wait in line to take an HIV test behind a small white screen. Their fingers are pricked, and then they reassume their seats and wait for the outcome. Ten minutes later, they are called back behind the screen and given the results. The verdict rendered, they rejoin the class.

Thandi, a 17-year-old with a quick smile and thick braids pulled up in a ponytail, stands along a wall, waiting her turn.

"It's hard, because if you take too long, people may know you are positive," says Thandi, who hopes to go to college next year and become an accountant. "I tested twice last year and I was negative, but I'm very nervous."

If statistics are any guide, she has reason to be. AIDS is the leading cause of death among women of reproductive age worldwide, according to the World Health Organization. The issue is particularly pronounced in South Africa, where about 2,500 girls 15 to 24 years old are infected with HIV every week – more than any other country in East and Southern Africa. South African women in the age group arefour more times likely to become infected with HIV than their male peers and account for the highest percentage of new HIV infections.

To eradicate HIV once and for all, experts say, new infections must be prevented in young women like Thandi. But while much headway has been made in the 35 years after the AIDS outbreak, infection rates among South Africa's young women have barely budged in the last 10 years. "We've known for years that the face of AIDS is a woman's face," says Mitchell Warren, executive director of AVAC, a nonprofit organization that advocates for HIV prevention. "What we do not yet know is how to fundamentally disrupt that from happening."

This summer, just in time for bragging rights at the July International AIDS Conference in Durban, two large-scale initiatives will attempt to do just that in South Africa.

By July, the U.S. President's Emergency Plan for AIDS Relief (PEPFAR), the Bill & Melinda Gates Foundation, Johnson & Johnson and other corporate and nonprofit partners plan to fully implement a program in South Africa called DREAMS, or Determined, Resilient, Empowered, AIDS-free, Mentored and Safe women. The $385 million partnership hopes to curb infection rates in adolescent girls in 10 sub-Saharan African countries – the region most affected by HIV – by 40 percent by the end of 2017.

"It's a moonshot," says U.S. Ambassador to South Africa Patrick Gaspard. "But that's what you need when you consider just how acute the epidemic is."

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This month, the South African government hopes to build on the DREAMS program by launching a three-year initiative aimed at curbing HIV infections in young women and the men who are their primary infectors. The program is a 3 billion rand ($200 million) initiative funded by the South African government, the Global Fund to Fight AIDS, Tuberculosis and Malaria and the German Development Agency. Leaders hope the program will advance the country's goal of having an AIDS-free generation under 20 by 2030 – a noteworthy aim for a country whose formerPresident Thabo Mbeki argued that poverty, not a virus, caused AIDS.

The hope is that these kinds of programs, which plan to address the complicated social and structural challenges that drive new infections, will have a bigger impact than biomedical interventions alone. Research suggests that vaginal rings, pre-exposure prophylaxis and vaginal gels can have a positive impact on preventing infections in young women. But they've had mixed results in studies, partly because women haven't always adhered to them.

The causes of HIV in young women

Although South Africa has the most expansive antiretroviral therapy program in the world – a mostly self-funded program accessible to 3.4 million people – it still has the globe's largest epidemic in terms of the number of people living with HIV. About 7 million South Africans had HIV in 2015, according to UNAIDS. Slightly more than half a million of those people were young women, an increase from 2012.

No one is exactly sure why young women in sub-Saharan Africa have such high rates of HIV infection. Some researchers believe a gene or other biological factors are involved. But most agree with the 2016 UNAIDS report that "harmful gender norms and inequalities, obstacles to education and sexual and reproductive health services, poverty, food insecurity and violence" play a role in the high infections.

Young, black women are the the most vulnerable group in South African society, experts say. Sexual violence is common, and women don't have much bargaining power in their relationships. Low self-esteem is a persistent challenge.

Thandi, whose name has been changed, explains it this way: "Our boyfriends, they say they don't want to use condoms," she says as she moves further up in line. "But we tend to trust them, even though we know they might be doing something on the side."

By boyfriends, she could mean someone her age – or middle-aged. During the past few years, more young South African women have had relationships with older men. It's a trend that hasn't gone unnoticed. The South African media has recently made much to do about "sugar daddies" or "blessers," older men who support young women financially in exchange for sexual relationships. The latter term evolved from the social media hashtag #blessed, which some women used to refer to gifts from their boyfriends.

Peer pressure is intense in South Africa's townships, and young women often pair up with older men who can buy them the latest clothes or shoes, says Ntomboxolo Giyose, a community mobilizer with the Treatment Action Campaign, which is coordinating the sex education in Thandi's school. The dynamic helps HIV spread, she says, "Because when a sugar daddy doesn't want to wear a condom – when he wants flesh on flesh – then she can't wear one."

The latest HIV prevention efforts channeled through DREAMS and the South African government aim to help young women navigate these kinds of difficult situations – whether it be having sex in exchange for perks, money, or out of intimidation and fear.

The DREAMS program, which allocates $66 million of PEPFAR funds to South Africa over two years, focuses on the five highest-need districts within the country. The program aims to lessen economic stressors in young women by linking them to cash transfers – essentially social welfare checks – and educational subsidies to help them stay in school.

The school day draws to a close at Zola Business High School. (DEVON HAYNIE)

DREAMS is also providing parenting programs, facilitating access to different kinds of contraceptives, educating communities about preventing and reacting to sexual violence and dispersing PrEP, pre-exposure prophylaxis that can prevent HIV when taken regularly. The initiative, which the South African government is using as a model for its own program, also will identify the male sexual partners of young women to help link them with treatment, such as circumcision, which can reduce HIV infections.

HIV advocates and foreign policy experts say they are happy to see governments, nonprofits and the private sector working together to tackle the issue. But they're eager to see how success will be measured.

"Getting data and getting quality data is always an issue," says Richard Downie, deputy director and fellow with the Africa Program at the Center for Strategic and International Studies. "That will be something to look at."

Ambassador Gaspard says the DREAMS team is working on such a system now. "The goal is to have as much transparency as we can," he says.

Funding also is a concern. PEPFAR is looking at static or declining funding over the next few years, Downie says, and it's the leading partner in DREAMS.

"Changing behavior is a generational task. It's not an overnight thing," he says. "Sustainability around these programs is always an issue. What happens after the two-year funding window expires?"

Back in Thandi's sex education class, educators are hoping they can change behavior in a much shorter window. Ten minutes after her test, Thandi heads back behind the screen to see her results. When she rounds the corner, she smiles and gives two thumbs up.

There's one less obstacle in the way of her dreams – at least for now.