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15 Jun 2004

Source: New York Times, June 13, 2004

The Fidelity Fix

by Helen Epstein

Helen Epstein, who writes frequently about AIDS, is a visiting research scholar at the Center for Health and Wellbeing at Princeton University.

Why is it so hard to loosen the grip of AIDS on southern Africa?  H.I.V.-prevention programs in that part of the world have been under way for years -- there have been campaigns to raise awareness about AIDS and to promote the use of condoms; clinics have been established to conduct H.I.V. testing and to treat sexually transmitted diseases that may accelerate the spread of H.I.V.; more recently, schoolchildren have been taught the benefits of abstinence -- and yet the virus continues to spread. About a third of all sexually active adults in Botswana and South Africa carry H.I.V., a rate nearly 10 times higher than almost anywhere in the world outside Africa. These prevention efforts have been sensible -- abstaining from sex or using condoms consistently do prevent H.I.V. infection -- but their effects have been disappointing.

There is another way to reduce the spread of H.I.V. -- one that is increasingly recognized by public-health experts but that has been relegated, thus far, to an afterthought: fidelity -- either in marriage or in a committed relationship. As experts come to understand more about the African AIDS epidemic, it seems clear that regular sexual contact with more than one person is the key human behavior that enables the rapid spread of H.I.V. Since 2002, international organizations have promoted an approach called ''A.B.C.,'' which stands for abstain, be faithful, use condoms. But the ''be faithful'' part has largely fallen through the cracks, and that may well have undermined efforts to fight the epidemic.

It's not clear why most AIDS campaigns in southern Africa have avoided the subject of infidelity. Perhaps the topic seems weighted with moral judgment; perhaps Western advisers in particular feel it would be insensitive to raise it; perhaps they also feel it would be futile to try to change deeply rooted patterns of behavior. Even secular public-health workers have endorsed programs that encourage teenagers to abstain from sex until they are older -- as long as they are informed about other methods of prevention -- but they have been far more reluctant to tell adults what to do. Whatever the reason, programs to encourage monogamy have seldom been seriously tried in southern Africa. Government planning documents, United Nations agency reports, AIDS awareness campaigns and AIDS education curriculums are strangely silent on the subject. The Bush administration's $15 billion President's Emergency Plan for AIDS Relief discusses faithfulness, but while it sets aside 33 percent of H.I.V.-prevention funds for abstinence-until-marriage programs, it fails to segregate funds to discourage infidelity. In April, Daniel Halperin, senior H.I.V.-prevention adviser at the United States Agency for International Development, and colleagues put it this way in The British Medical Journal: ''Partner reduction has been the neglected middle child of the A.B.C. approach.''

This omission is serious, because wherever H.I.V.-infection rates have fallen -- from the market towns of Uganda, to the military barracks of Thailand, to the gay enclaves of the United States -- reduction in promiscuous sexual behavior very often had a great deal to do with it. These behavioral changes have often been a result of public-health campaigns, like the closings of gay bathhouses and discos. In Africa, the best-known case is Uganda, where the government deliberately encouraged people to stick with one partner and warned them frankly about the risk of H.I.V.

In 1993, I was working as a molecular biologist and spent some 18 months in Uganda, the country with the highest H.I.V.-infection rate in the world at the time. I was conducting research on a vaccine to protect Africans from the virus. The vaccine was not a success, but what I didn't know then was that H.I.V. rates in Uganda were plummeting anyway. In 1995, the Uganda Ministry of Health reported that H.I.V. rates among urban pregnant girls between the ages of 15 and 19 had fallen by about 50 percent during the early 1990's, and rates declined greatly in other groups, too. The epidemiologists Rand Stoneburner and Daniel Low-Beer have shown that at the time H.I.V. rates began falling, very few people used condoms or had H.I.V. tests, and there was only one clinic in the entire country that specialized in the treatment of sexually transmitted diseases. However, the frequency of casual sex fell by 60 percent between 1989 and 1995, and this probably contributed most to the sharp decline in H.I.V.-infection rates.

These promising trends seem to have begun in the late 1980's. At the time, few international health experts were working on AIDS in Uganda, but the Ugandan government developed a simple and effective program on its own. In 1986, the Uganda Ministry of Health started a vigorous H.I.V.-prevention campaign in which the slogans ''Love Carefully,'' ''Love Faithfully'' and ''Zero Grazing'' -- Ugandan slang for ''Don't have sexual partners outside the home'' -- were posted on public buildings, broadcast on radio and bellowed in speeches by government officials, teachers and AIDS-prevention workers across the country. Religious leaders scoured the Bible and the Koran for quotations about infidelity. Newspapers, theaters, singing groups and ordinary people spread the same message.

Their words fell on fertile ground. Stoneburner and Low-Beer argue that the urgent message for partner reduction was conveyed through informal social networks -- within families and neighborhoods and among friends. A realistic fear of AIDS was reinforced by a compassionate response to the suffering the disease created. Ordinary Ugandans have always been much more open about AIDS than people from other African countries, and they were also far more likely to admit that they knew someone who had died of the disease or was infected with H.I.V. Community- and church-based groups sprang up to help families affected by AIDS. Uganda's women's movement, one of the oldest and most dynamic in Africa, galvanized around issues of domestic abuse, rape and H.I.V. The anger of the activists, and the eloquent sorrow of women throughout the country who nursed the sick and helped neighbors cope, was a harsh reproach to promiscuous men. So was their gossip, a highly efficient method of spreading any public-health message.

Some researchers have attributed Uganda's H.I.V.-prevention success to increased sexual abstinence among teenage girls, but statistics suggest that partner reduction, especially on the part of men, was far more important. During the early 1990's, Uganda's teenage-pregnancy rates, which even today are among the highest in the world, barely changed at all. If abstinence among teenage girls had increased significantly, it would be expected that teenage pregnancy rates would have fallen. When I asked epidemiologists about this, they explained that abstinence among unmarried teenage girls did increase significantly in the early 1990's, yet marriage rates for that group also increased at the same time. Thus, the proportion of all teenage girls who were sexually active changed little, but more girls were in committed relationships -- and this could explain why fewer of them became H.I.V.-positive even though roughly the same number became pregnant.

Although condoms and abstinence do prevent H.I.V. infection, these seem not to have been the methods most Ugandans chose to protect themselves from the virus, at least during the early 1990's, when H.I.V. rates were falling most rapidly. Even in urban areas, condoms weren't widely available until around 1993. Since the mid-1990's, condom use in Uganda has soared, and this has almost certainly helped keep H.I.V.-infection rates relatively low; about 5 percent of sexually active adults carry the virus. Condoms have also helped prevent the spread of H.I.V. among prostitutes and gay men the world over. But increased faithfulness seems to have been crucial to the precipitous decline of H.I.V. rates in Uganda.

Partner reduction has been an important factor in H.I.V. prevention elsewhere as well. In Thailand, H.I.V.-infection rates declined steeply during the 1990's. While condom use increased significantly, visits by men to sex workers also fell by 60 percent. Among gays in America, H.I.V. rates fell steeply during the 1980's. Part of this decline was attributable to the increased use of condoms, but partner reduction was very important too. In Zambia and northern Tanzania, where churches promoted faithfulness, H.I.V. rates also declined. Meanwhile, in such countries as Botswana, South Africa and Zimbabwe, condoms have been emphasized as the main method of prevention, and H.I.V. rates have remained high. In all three countries, condoms are used more frequently than in Uganda when H.I.V. rates were falling rapidly in the early 1990's, and teenage sexual debut is later. The problem is not that condoms and abstinence don't prevent H.I.V. -- they do -- but that they are often less popular choices than sticking to one partner. Obviously if your one partner is H.I.V.-positive, you are in trouble, unless you use condoms all the time. But when large numbers of people reduce their partners, it can stop the virus in its tracks.

People are promiscuous and unfaithful everywhere, not just in Africa, so I wondered, What makes relationships there so risky? This winter, I spent five weeks in Botswana and South Africa trying to find some answers. My hypothesis, and that of many social scientists who study the epidemic, was that H.I.V. rates remain high because older men are infecting young women in relationships that are often coercive and abusive and in which women have little power to negotiate the timing of sex or the use of condoms. (The vast majority of H.I.V. transmission in southern Africa is heterosexual.)

I found that my assumption captured only part of the reality. During my travels, I spoke with about 40 men and women, most of them H.I.V.-positive, about their lives, their relationships and about H.I.V. I contacted some people through AIDS organizations, and others I met in taxis and on the street. I was surprised at how open people were with a stranger and how willing they were to share their experiences. As expected, many women described abusive, coercive relationships with men who turned out to be H.I.V.-positive, but many of them willingly stayed with these men. The most striking thing about the stories I heard was how difficult intimate relationships were for both men and women, and how often violence and abuse involved accusations of infidelity -- and thus seemed to emerge from the very same source as H.I.V. itself.

Shortly after I arrived in South Africa, I visited Ngcingane village, which lies on a green plain amid misty hills about 15 miles from Umtata, a large town in the Eastern Cape, South Africa's poorest province. Umtata is notorious for crime, and many people I met had been robbed or carjacked at least once. While I was waiting at a stoplight in the middle of town, I spotted a man in the lunchtime crowd casually loading an automatic pistol. Nelson Mandela's forebears lived in a nearby village and grazed their cattle and grew sorghum and millet on small plots of land. Then, throughout southern Africa, villages like Ngcingane began their long descent into destitution. In the 19th century, European settlers built railways, mines and cities and coerced millions of young men to work in them, forcing them to leave their families behind in their villages for months or years at a time. White settlers appropriated much of the most fertile land, and the black population that remained in rural areas became increasingly dependent on remittances from migrant workers living hundreds of miles away. When South Africa's apartheid government established independent ''homelands'' for the black population, many of the appointed leaders were astonishingly corrupt -- corruption that continues in many areas today. This corruption, along with persistent drought and barriers to agricultural trade imposed by Western nations, have all contributed to the economic crisis that has gripped sub-Saharan Africa since the 1970's and has demolished the small-scale agricultural economy that once sustained rural Africa. Today there are few jobs in rural areas, and most people rely financially on migrant-worker relatives and government pensions.

Rachel Jewkes, an epidemiologist with South Africa's Medical Research Council, has been conducting research on the sexuality of young people in South Africa since 1995. She's an expert on both H.I.V. and violence against women and has found, as she told me, that gender relations in South Africa ''are in a very bad state.'' South Africa has the highest recorded rate of rape in the world, but as Jewkes has shown, women here are at far less risk of H.I.V. from the rapist who climbs in through the window than they are from the men they know best -- their husbands and long-term boyfriends. Jewkes found that women with violent boyfriends or husbands were 50 percent more likely than other women to be H.I.V.-positive, regardless of their own behavior. Women who had been raped by strangers or acquaintances were not more likely to be H.I.V.-positive.

On a Saturday morning in January, Lindiwe Farlane, who was Jewkes's research assistant, introduced me to some of the young women participating in one of Jewkes's research projects. Seven of them were waiting for us under a tree. The first thing that struck me was how beautiful they were. Just looking at them, with their elaborately braided and colored hair, their stylish clothing and the way they yakked and giggled into their cellphones, you would never guess how much hardship and violence they had seen in their young lives.

''He beats me once every two months or so,'' said Mcha, a cheerful 18-year-old high-school student of her boyfriend, a 22-year-old mechanic. ''He beat me the day before yesterday.'' She showed me the wounds on her head. ''Someone called me on my cellphone, and I was on my way to the bathroom and I answered. When I came back, my boyfriend said, 'You have a boyfriend!' I decided to say yes, since he'd beat me anyway. Sometimes he forces me to have sex when I don't want to.''

The young women described their boyfriends' infidelity. ''He does have other girlfriends,'' said Mcha, who has never been tested for H.I.V. but who was treated for a sexually transmitted disease last year. ''He even told me.'' So does the boyfriend of Mcha's friend Thokozile, 21. He works in Cape Town, and Thokozile sees him once every few months. She's unhappy about his other girlfriend. ''I don't know how much care he gives her compared to me. He might be loving her more.'' Thokozile hasn't been tested for H.I.V., either.

Studies show that people in southern Africa don't have nearly as many sexual partners as, say, homosexual men in San Francisco did in the 1980's, when reports of hundreds of sexual partners a year were not uncommon. Such behavior is rare in Africa, but many people -- like the boyfriends of Thokozile and Mcha -- do have a small number of longer-term, simultaneous or ''concurrent'' sexual relationships that may overlap for a few months or even years. This ''concurrency'' links sexually active people up in a giant network, not only to one another but also to the partners of their partners' partners -- and to the partners of those partners, and so on -- via a web of sexual relationships that can extend across huge regions. If one member contracts H.I.V., then everyone else in the web may, too.

Long-term concurrency is far more common in Africa than in Asia and in the West, where heterosexual people tend to practice ''serial monogamy.'' Martina Morris, a sociologist at the University of Washington, has shown that concurrency is more of a public-health danger than serial monogamy because it permits the virus to spread to others quickly, rather than trapping it in a single relationship for months or years. In addition, a recently infected person is much more likely to transmit the virus than a person who has been infected for a while. Thus, when a serially monogamous H.I.V.-positive person eventually finds a new partner, his ability to infect has been reduced. Someone at the hub of a network of concurrent relationships, however, is likely to infect all of his partners very rapidly when he is first infected.

Many people in Western countries and in Asia have one-night stands with prostitutes or acquaintances, but such encounters are often safer than concurrent, long-term relationships. Because it usually takes numerous sexual acts to transmit H.I.V., a relationship with an H.I.V.-positive person involving repeated unprotected intercourse is far more dangerous than a single encounter. Moreover, condom use with prostitutes and in one-night stands is increasingly the norm all over the world, but they are rarely used in longer-term, less businesslike affairs.

I wondered why southern African women so often put up with men who openly cheated on them, sometimes physically and sexually abused them and put them at risk of disease. When I asked, the answer was almost always the same. ''Because I love him,'' both Mcha and Thokozile said in separate interviews. ''But why?'' I asked. ''I like that he's working,'' Thokozile said, ''so he won't ask for money from me. It's boring when your boyfriend asks for 50 cents for a cigarette. This one can help me out with financial problems when I have them, not like the others. Sometimes he loads airtime on my cellphone.''

Mcha said: ''He gives me support, even if I owe fees at school. Sometimes I use the money to buy clothes or do my hair.''

Sexual relationships everywhere are motivated by a combination of physical attraction, emotional rapport and financial calculation. But the last of these seems to have particular weight in southern Africa, where ''transactional'' sexual relationships, in which women expect gifts of cash or consumer goods from boyfriends, are by many accounts extremely common.

''It's totally different from prostitution,'' says Mzikazi Nduna, a research psychologist who works with Rachel Jewkes. ''Prostitution is seen as a business. You go into the street and set a price. With transactional sex, the nature of the relationship is different. It's more committed.''

Even though transactional sex differs from prostitution, it may be almost as dangerous when it comes to H.I.V. Jewkes has shown that women in transactional relationships are more likely to be H.I.V.-positive, even if they have had very few sexual partners in their lives. Women in transactional relationships may be more vulnerable to H.I.V. because they are more likely than other women to tolerate an unfaithful partner and also to seek out additional concurrent sexual relationships themselves.

Transactional sex in its current form has probably become much more common since the economic crisis of the 1970's, says Mark Hunter, who is researching the political economy of AIDS at the University of California, Berkeley. It is not simply that poor young women want or need these gifts, but also that the gifts have enormous symbolic value. Marriages throughout southern Africa are traditionally negotiated through a system of bride-price, in which the groom's family pays the bride's family in cattle. The cattle are powerful symbols, both of mature manhood and of commitment to a woman. However, these days, few young men can afford them. Partly for this reason, marriage rates in southern Africa have plummeted since the 1970's, and men and women increasingly form temporary unions lasting months or years. High rates of female poverty mean some women rely on these liaisons for survival.

The tendency to form transactional sexual relationships has probably also been heightened by the penetration of the global market in consumer goods -- makeup, clothing, cellphones, cars and so on -- into impoverished communities throughout southern Africa. There is greater income inequality in South Africa and Botswana than in most other countries. On the main roads in large cities, BMW's and Mercedes-Benzes swish by, their occupants shuttling between chic shopping malls and lush suburbs. But about 60 percent of black South Africans live beneath the poverty line, and 50 percent are unemployed. Millions of people live in shacks with dirt floors. Even in Botswana, a prosperous country by African standards, almost half the population lives on less than $2 a day, according to the most recent published estimate. When a poor young woman is invited to a shopping mall or a restaurant by a well-dressed man with his own car, it must be like being offered a ride on the Space Shuttle. Unfortunately, these glamorous men are also the most likely to be unfaithful and thus, H.I.V.-positive.

This is a lesson Lulu, a 25-year-old H.I.V.-positive South African woman, learned the hard way. ''I was telling myself, 'He's my husband-to-be,' '' she said of the 26-year-old man who infected her with H.I.V. when she was 18. ''He was the director of a newspaper. He was a family friend and knew my parents from a long time back. He took me out, to lunch, dinner, to the zoo, the ocean. Maybe we went out eight or nine times. He was very good-looking, very well dressed, with a car and lots of money. We went to the mall. Everything was easy. When I asked for something, it was coming. I was feeling so happy, so excited. Then one day he invited me to a party, but he took me to a hotel. I didn't want to go, but I didn't know that he had already booked. He took me to the room.'' At first, Lulu said no, but the man begged her. This was Lulu's first sexual experience. I asked her if she reported it to the police, but this never occurred to her. ''It wasn't rape. I took my clothes off myself. I didn't scream.'' After that, the newspaper director didn't come back for six months. During that time, Lulu was tested for H.I.V. and discovered that she had become infected through her single sexual encounter. ''For me it was terrible,'' she said. She tried to contact her boyfriend by phone, but he was always away or about to leave town. '''I'm in Canada,' he'd say. 'I'm in Cape Town.' I was hurt that he didn't come back. Then I found out he was married at the time. He already had a son.''

Muriel Kubeka, a research assistant with South Africa's Medical Research Council, explained, ''When a girl gets something in a transactional relationship, she sees it as a sign of love, not as an exchange for sex.'' Men don't always see it the same way. Transactional relationships are more likely to be coercive and violent, Jewkes has found, probably because the exchange of money and gifts gives men a sense of ownership over a girlfriend's sexuality. But even nonviolent transactional relationships, like Lulu's, often involve pleading, nagging and coercive pressure -- the man's way of enforcing what he views as an implicit sexual contract.

While young women complained to me of seduction by unfaithful men, young men without much money lamented that women had left them for richer men. ''A man's beauty is considered by his wealth,'' said Siya, a university student in Umtata who lost two girlfriends in a row to wealthier men who, he heard, were abusive. ''The boys I know think love is impossible,'' he said. ''They've been disappointed so many times.''

Confusion about the meaning of love and money in relationships lay at the core of many coldblooded sexual escapades. ''It's easy to get a beautiful girl,'' said Junior, a 27-year-old H.I.V.-positive man I met in Gaborone, Botswana. ''But you have to lie to them and tell them you have things you don't really have.'' Junior recounted for me a decade of philandering. You could see that girls must have loved him. He was athletic and witty and extremely good-looking, although he was now very thin, and his voice was raspy with pneumonia. ''The whole problem is love. It's a failure of love. I never had anyone I could pour my soul to.''

A day after speaking with Junior, I met Natasha, a 28-year-old woman infected with H.I.V., in Gaborone. ''Botswana men aren't very loving and caring,'' she told me. ''They're just users.'' She was never beaten or raped by boyfriends, but she felt the sting of their infidelity. ''When someone doesn't tell you the truth, you've been abused mentally. All the guys had other relationships, some were married. I never met a guy who was just by himself. . . . I want a kind, loving person, an honest person, with a very open mind, who'll tell me what he wants,'' she said.

''What if he doesn't have a lot of money?'' I asked. I was thinking of Junior, also H.I.V.-positive, also wishing to turn over a new leaf.

''What?'' she replied. ''Why would I want that? How are you going to survive if he doesn't have money?''

No public-health campaign can change the economic conditions that motivate transactional relationships. But health campaigns can make people more conscious of the risks they are taking and encourage the kinds of discussions about H.I.V. that took place in Uganda. A growing number of health experts are asking why Zero Grazing campaigns for monogamy have not been emphasized in southern Africa. In his 2003 book, ''Rethinking AIDS Prevention,'' the Harvard anthropologist Edward C. Green attributes the relative neglect of Zero Grazing-style campaigns to the ethnocentrism of the mainly European and American health experts who advise governments about how to draw up policies to fight AIDS. Long before the AIDS crisis, international health agencies were largely dedicated to distributing health-related commodities, including vaccines, antibiotics and contraceptives, in poor countries all over the world. This approach was rapidly embraced to deal with AIDS. But condoms were not commonly used in Africa, and people have been slow to adopt them. If only these experts properly understood African culture and indigenous concepts of sexuality, disease, danger and death, Green argues, the power of the Ugandan Zero Grazing campaign might have been recognized years ago.

Playing down the role of infidelity -- particularly on the part of men -- in the spread of H.I.V. may also have been politically necessary for Western advisers. For years most African governments did little to address the AIDS crisis in their countries; President Thabo Mbeki of South Africa even questioned whether H.I.V. caused AIDS. Outside experts struggled to get policymakers to care about the crisis at all. Perhaps recommending a policy on AIDS that implied criticism of adult sexual behavior -- behavior the elite policymakers might well have engaged in themselves -- would have forced these bureaucrats further into denial. Last month, I sent an e-mail message to the director of the Joint United Nations Program on H.I.V./AIDS, Peter Piot, in which I asked, among other things, why the agency had not done more to promote partner reduction. He sent back a response but did not answer that question. I also asked Michel Carael, a sociologist and former team leader in prevention at the agency, about the silence on this topic. He denied that the U.N. AIDS program, which was established in the mid-1990's, played down fidelity, but when I read through the agency's documents about H.I.V. prevention produced over the past several years, I found almost no mention of either partner reduction or faithfulness.

There are obviously limits to a government's power to change sexual behavior, and Uganda may have been a special case. Whites never settled there in large numbers, never threw large numbers of poor blacks off their land and never subjected people to the particularly degrading conditions of migrant labor endured by people throughout southern Africa. The climate is rainy and the soil fertile, and although this is changing, many Ugandans still make their living on small farms. As a result, Ugandans are more likely to live near their families and know their neighbors, and this probably enabled a more compassionate, open response to AIDS and a more rapid acceptance of the idea that trust and mutual fidelity were possible. The far more brutal history of southern Africa had the opposite effect. It weakened people's sense of trust and undermined relationships between men and women.

Many experts contend that sexual-behavior change in Africa is complicated because women's fear of abusive partners inhibits private discussions of sex, condom use and H.I.V. But in Uganda, gender relations seem to have improved during the Zero Grazing campaign; reports of desertions and divorces declined, and one recent study suggests that domestic battery there, though frequent, is half as common as in South Africa. Similarly, in the wake of the AIDS epidemic in the United States, gay men came to relate to one another differently, placing far more emphasis on friendship and commitment than before. Hopeful changes may be under way in South Africa today. Promiscuity may be declining, according to Stoneburner and Low-Beer, and gender relations in general may be improving. When Jewkes first began her research 10 years ago, between 20 and 30 percent of young women in surveys claimed that their first sexual experience was the result of either rape or, more commonly, forced sex by a boyfriend. Today, she and other researchers find the frequency of forced first sexual intercourse is far lower, reported by some 10 percent of young women in repeated surveys, a rate only slightly higher than that in the United States. ''I think the level of forcing has genuinely fallen,'' Jewkes said. She also has noticed that young South Africans are much more likely to talk about sex and are developing ''a vocabulary for discussing feelings and desires.''

These discussions are unfolding in the midst of a vast debate about sex and love throughout southern Africa. After the fall of apartheid in the early 1990's, it was assumed that South Africans would be preoccupied with issues of race. Instead, notes Deborah Posel, a sociologist at the University of Witwatersrand, gender relations, not race relations, have taken center stage in political and cultural debates. When I was in Botswana and South Africa, the battle of the sexes raged on radio call-in programs and in gossip and advice columns. When the soap opera ''The Bold and the Beautiful'' is televised at 6 p.m., both countries nearly grind to a halt. Reactions to these shows can be profoundly personal. Recently, Don Mlangeni, an actor who plays an unfaithful husband on the South African soap opera ''Isidingo,'' was slapped by a stranger in a shopping mall. He and the actress who plays his mistress have received a flood of hate mail and have found themselves ostracized at parties. In her book ''Talk of Love: How Culture Matters,'' Ann Swidler, a sociologist at the University of California, Berkeley, argues that culture -- meaning discussions, as well as artistic and other expressions of our humanity -- flourishes in the unsettled corners of our lives, where the rules are uncertain or changing. Perhaps the preoccupation with sex in South Africa and Botswana has something to do with the fact that the AIDS epidemic, sexual coercion and violence are forcing people to search urgently for greater understanding of the vicissitudes of love, and for solutions to their own personal dilemmas.

I asked Nkululeko Nxesi, former head of the Johannesburg-based National Association of People Living With H.I.V. and AIDS, whether he thought a campaign to encourage monogamy along the lines of Uganda's Zero Grazing program would be a good idea. He said it would, as long as it was one of a range of prevention programs including condoms, H.I.V.-testing centers and so on. Even encouraging serial faithfulness as practiced in Western countries might make a real difference. But, he said, some people still felt promoting faithfulness might be unrealistic. The problem was history, he explained, and the destabilization of the southern African family by the upheavals of apartheid and the migrant labor system.

Even so, a fidelity campaign does seem worth a try, even if it might seem overly simplistic and preachy. Nxesi put it this way: ''I met a Ugandan AIDS worker a few years ago, and he told me, 'In Uganda we may not have highways and tall buildings, but we take care of our people.''' Nxesi has been thinking about that lately. ''Down the line, we will realize that development is not only about how good your infrastructure is, but it's also about the heart.''