In South Africa, a family and a nation slowly confront HIV

ALEXANDRA, South Africa — He was never a big kid, but Vuyani Ngxalaba was starting to look frighteningly skinny. He turned up at soccer practice in a cold sweat, with sores spread across his hollowing cheeks. His family had little to eat, yet he seemed to vomit constantly.

Ingrid Moloi, a local charity worker who ran Vuyani's soccer team, had seen this kind of illness countless times. It had raced through the narrow, mazelike streets of Alexandra Township over the past decade like an unseen tornado. Three years earlier, it had killed Vuyani's mother, leaving him in the care of four older siblings, none of whom had a steady job.

When his sister learned from a blood test that 14-year-old Vuyani was infected with HIV, the virus that causes AIDS, she and Moloi faced the grim task of telling the shy, soccer-crazed teenager that he had a disease that much of South Africa still considers a death sentence.

How Vuyani slowly came to accept his HIV status offers a glimpse into how South Africa and its ravaged families are finally confronting an illness that's spread to one in five adults, one of the highest rates in the world, and stained a nation that's otherwise embodied sub-Saharan Africa's highest hopes in the 15 years since the end of white apartheid rule.

Around the world, while the spread of HIV slowed over the past decade — thanks largely to multibillion-dollar anti-AIDS campaigns that taught people to have safer sex and made life-saving antiretroviral drugs widely available — South Africa was a glaring exception.

South Africa's AIDS epidemic got worse. It was driven, many experts say, by a government policy marked by denial and disinformation that still echoes in overcrowded black townships such as Alexandra, outside Johannesburg, where few people openly discuss a disease that's nearly wiped out entire households.

Now, South Africa is trying to turn it around. Doctors, researchers and AIDS activists cheered in September when two officials left their posts: Thabo Mbeki, the president who questioned the science surrounding AIDS and for several years refused to subsidize antiretroviral drugs, and Manto Tshabalala-Msimang, who as Mbeki's health minister argued that a proper diet, including garlic and beetroot, could fight the disease.

The government has nearly doubled its anti-AIDS budget over the past five years, to $878 million, and expanded its treatment program into the largest in the world. A new health minister, Barbara Hogan, a respected former political prisoner, is spearheading a plan to cut new HIV infections in half by 2011.

Still, officials acknowledge that only half the people who need the drugs are receiving them, while the number infected with HIV — 5.7 million, the United Nations estimates, in a country of 49 million — is far and away the largest in the world.

"This is a terrible public health problem that required visionary leadership," said Francois Venter, the president of the Southern African HIV Clinicians Society. "Instead, what we got was arrogance and buffoonery that literally cost hundreds of thousands of South African lives.

"So I'm heartened by the change in tone. But the new minister has inherited a problem from hell."

Many think the battle against HIV can only be won in places such as Alexandra, a sprawling labyrinth of simple homes and cement-box shacks north of Johannesburg. Unemployment is high, schools are poorly equipped, children are initiated into sex at an early age, and along the narrow streets of Moloi's neighborhood, few households have been spared from HIV.

"Everyone has lost someone," said Moloi, who was herself diagnosed as HIV-positive in 2001 but today is a plump, healthy 35-year-old after seven years on antiretroviral drugs.

"There was always denial, denial, denial. Saying, 'It won't happen to me.' Slowly we are seeing it change."

In 2004, Vuyani's mother told the family that she was sick. She didn't disclose the illness, but when she died four months later, doctors said she'd had HIV. Rosinah, the middle child of five, took charge of the family, but a gap opened up with Vuyani, the youngest, who disappeared from the two-room family home in the afternoons and spent more and more time on the township's dirt-patch soccer fields.

Three years later, when Rosinah learned that Vuyani was HIV-positive, she thought of their mother, who never intimated that her youngest son could have the disease that killed her.

"She was ashamed, probably," said Rosinah, a slender 25-year-old with close-cropped hair and wide-set, worried eyes.

She went to Moloi, who lives two blocks away in a tidy one-room home. In her stern, den-mother manner, Moloi told of another teenage boy in the neighborhood who learned that he was HIV-positive. One day, his sister came home to find his lifeless body hanging from a length of rope tied to a ceiling beam.

"I said she had to be careful in how she told Vuyani," Moloi said. "You don't know how he will react."

With the boy's health still faltering, Rosinah sat him down one afternoon about three months later in their cramped, dimly lit kitchen.

"You know how in South Africa," she began tentatively, "we have this virus of HIV and AIDS?"

Vuyani nodded.

"Someone in this house has it. Do you know who?"

He shook his head.

"It's you."

Vuyani's face was expressionless. As he explained later, "I thought it was a joke, or a mistake. I could never have HIV." He stood up and left the room, and it was several weeks before Rosinah had the courage to bring the subject up again.

Relief agencies estimate that by next year, South Africa will also have 2.1 million children who've lost a parent to HIV. Family structures have collapsed, leaving many children in the care of inexperienced siblings.

Rosinah began to have sleepless nights. If Vuyani's HIV had advanced to the point where he needed the drugs, would they be able to get them? Would she and her older brothers be able to ensure that Vuyani got enough to eat?

By chance, she landed a $50-a-month job with a community organization that helped educate people about HIV. She brought home a pamphlet for Vuyani, and he studied it for several days.

"I started to understand," he said. "I felt bad. It made me think a lot. But as time passed I could see what they were talking about. Being sick was not my fault."

Last year he enrolled in a counseling group where he met other teenagers with HIV.

The messages from community groups and teachers are sinking in. Vuyani, now 16, can recite what he needs to do to avoid getting sicker or spreading the virus: "Don't drink alcohol; don't sleep with a girl without a condom; don't smoke."

At an age when some of his friends have begun sharing tales of sexual conquests, Vuyani said he's holding off and trying to focus on improving his grades.

His knowledge is far from perfect. When asked if he's on medication, he said, "I'm on ARVs." What he's actually taking is Vitamin A tablets from a local charity group; he's not sick enough to need antiretroviral drugs.

Still, his health has steadily improved and he's put on a bit of weight. Every three months he goes for a free checkup at a nearby clinic, and recently he felt comfortable enough to tell a few friends from the soccer team that he's HIV-positive.

Their response surprised him.

"They don't treat me differently because of it," he said. "Maybe they don't know how serious it is."


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