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A mourner stands over the coffin of an 8-year-old HIV-positive Zambian boy, Aaron Mutti, at his burial in November 25,2005. REUTERS/Salim Henry
Take your pick. What has shaped the slow and complicated South African response to AIDS?
President Thabo Mbeki's questioning if AIDS exists and the virus is sexually transmitted.
The belief of Health Minister Manto Tshabalala-Msimang that antiretrovirals are toxic and a diet of garlic, beetroot and olive oil works better.
Delays in providing antiretroviral treatment and shortages of health staff to roll it out.
Discrimination because AIDS is associated with sex, gay sex, pre-and-extra-marital sex and drug addicts.
All of the above, and more. Read on.
Since 1990, anthropologist Isak Niehaus has been researching traditional beliefs in Bushbuckridge district of Limpopo province, a rural corner tucked near the Mozambican border, north of Nelspruit.
Niehaus says that the government's denial is mirrored by denial in townships and villages - "a stubborn silence, fatalism, denial, extreme reluctance to test or to disclose the condition, ostracising people with AIDS" - albeit for different reasons.
The root of stigma, he says, is the association of AIDS with death and the perception of HIV-positive people as zombies or bewitched.
There is individual biological death and social death, he explains. The emphasis on the first is a Western construct. In Africa, traditionally, death is a process whereby people cross from the realm of living to the realm of death, within a network of relatives and ancestors.
Just like zombies - whose soul is taken by a witch - are perceived as socially dead but physically alive, stuck in a parallel world, HIV-positive people are symbolically located between life and death. "A corpse that is alive" is a common expression. They lose weight, become bony, their flesh dissolves; they lose aura through coughs, diarrhoea and vomiting. They must be shunned and kept out of view - like lepers were.
Just to name the disease is dangerous, especially at funerals. People use colorful euphemisms: the three-letters, the fashionable disease, to own a house in Vereeniging, to buy a single ticket, to be on a diet, to eat herbs that chase people away.
True, AIDS used to be a killer disease. Thanks to ARVs, it no longer is. Buskbuckridge started doling out the drugs in 2003 and today has 3,000 people on treatment. Surely seeing HIV-positive neighbours become healthy, robust and active must erode the association with death?
Very slowly, says Niehaus, who teaches at Brunel University in Britain. The people he has interviewed over 18 years are still incredulous. One man who recovered after starting ARV treatment is convinced that his traditional healer cured him. He does, however, take his pills daily. Because pluralist beliefs co-exist within people.
Other authors have described this mass refusal to test, to get the drugs, to admit AIDS. In his recent and excellent book, The Three Letter Plague, South African journalist Jonny Steinberg explores this fault line in a remote village in the Eastern Cape.
The main character, Sizwe, believes that testing and taking the pills will speed death. So do many of his neighbours. Traditional beliefs around contamination and witchcraft resist the pills and explanations of the good doctors of Médécins sans Frontières.
In his book Witness to AIDS, South African judge Edwin Cameron, himself HIV-positive, speaks eloquently of his own shame around sexual contamination and immorality and how internalization of stigma stops many from seeking life-saving treatment.
Niehaus adds another layer of interpretation. It's less about sex, more about death.
Prevention campaigns stressing how contagious and dangerous AIDS is reinforced this association. Niehaus says: "AIDS awareness campaigns have singled out AIDS for excessive propaganda, hereby creating the impression that AIDS is somehow deadlier than other diseases."
What about AIDS activists and the many NGOs and churches providing care and support? Aren't they making a difference?
In the cities, yes, says Niehaus. In deep rural South Africa, not yet.
South Africa has 540,000 people on ARVs today - the largest programme in the world. Another half a million should also be on ARVs but are not coming for treatment. They may live far from clinics. They may follow Mbeki and his minister's theories. They may fear the sex-related blame and shame. They may have meanings and interpretations of death and disease that the Western biomedical model cannot fit. Or all of the above.
With treatment now firmly placed on the political and health agenda, it is possible to redefine AIDS as a manageable disease, discuss it in the context of other diseases, and critically examine how we communicate AIDS. Because health is not only about pills and clinics - it is also about how we understand the world and ourselves.
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Mercedes Sayagues, a Uruguayan-born journalist, has lived in South Africa since 2001, when she was expelled from Zimbabwe, her home since 1992. Until May this year, she was the editor of the IRIN/PlusNews Portuguese service, and now freelances from her home in Pretoria.
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Mercedes Sayagues, a Uruguayan-born journalist, has lived in South Africa since 2001, when she was expelled from Zimbabwe, her home since 1992. Until May this year, she was the editor of the IRIN/PlusNews Portuguese service, and now freelances from her home in Pretoria.
