Nine Pints

by Rose George

  The scaremongering was necessary because scare was necessary. In 1986 HIV was a rampaging virus that had no cure and that killed inevitably. It could mostly be prevented, then as now, by humans not having unprotected sex or sharing needles, and by properly screening donated blood. But that didn’t make the virus less terrifying, or the people who carried it. Some hospital staff treated AIDS patients while wearing full protective gear and never touching them. One mother told me that her young son, dying of AIDS after a contaminated transfusion, gazed at the hospital staff and said to them, “Are you wearing a condom too?” Most people working with HIV or AIDS patients then call them dark days but also times filled with love. My aunty Barbara, chatting with me in her Ontario apartment in the slumbering hours of the afternoon, told me of her time working as a nurse on Ward 5B of San Francisco General, the earliest and most famous AIDS ward. It was horrible, heartbreaking, but also a hoot. “In three weeks sixty-three people died. But there was such fun and everyone wanted to work there. At that point everyone had Kaposi’s sarcoma. There was one man who opened his shirt and he was covered and he said, look how ugly I am.” Barbara gave him a big hug. On Sundays, Barbara says, a female celebrity came to sing at the piano and always brought tubs of ice cream. Ice cream is easy for a painful throat to swallow. But she was telling me this in the dead time of the afternoon, when sleep is pulling, and she couldn’t remember the woman’s name. Big hair, she says. A singer. Later, I investigate. Elizabeth Taylor.

  Campaigns tried to stop AIDS by appealing to people to use condoms and warning sternly about injecting drugs and sharing needles. Safe sex was a new concept that had to be incised into people’s minds and habits like the lettering on the tombstone. In some of the world, it worked. Public behavior changed. Condoms became conversational along with safe sex. The virus in northern Europe and North America was tamed, contained in small groups and niche populations. There were mistakes: an emphasis on the virus being spread by “bodily fluids,” while true, was interpreted too broadly. That emphasis meant that some people still think HIV can be caught from toilet seats (it can’t), spitting (no), or eye contact (no comment). The state of Texas has laws that have been used to jail people for transmitting HIV by spitting, something that is biologically implausible.9

  In the mid-nineties, there was a revolution: antiretroviral drugs were developed that successfully interfered with HIV’s ability to replicate. When HIV-positive pregnant women in Thailand were given AZT, an early antiretroviral, the rate at which they infected their children was slashed by an astonishing 50 percent.10 In 1996, a Canadian HIV specialist named Julio Montaner presented research at a Vancouver AIDS conference on his experiments with combining several antiretroviral drugs. Montaner, an Argentinian, had got the idea from his father, an infectious disease specialist. If a single drug wasn’t working, try more than one. “We came up with data,” he tells me over the phone from Vancouver, “that demonstrated for the first time, to our surprise, and I’ll be perfectly candid, unexpectedly, that if three drugs given by themselves were insufficient, if they were given together they could actually shut down the replication of the virus and keep it at that level.” Another trial, using three different drugs, reported the same effect. This was remarkable, stunning. It was one of the most transformative breakthroughs ever. Mortality rates dropped. Now, a person living with HIV who takes his or her medication can suppress the virus to the point that it is undetectable. A person with HIV who takes his or her medication is considered uninfectious and can have a normal life span. In many ways, we are now living in the good-news era of HIV and AIDS. In 2000, fewer than one million people with HIV were on antiretroviral therapy: now it’s 18.2 million. In 2000, there were 490,000 new HIV infections in children; in 2015, there were 150,000.11

  I am not supposed to be scared of HIV anymore. In 2017, the US government changed its website AIDS.gov to HIV.gov, to reflect the fact that now hardly any Americans die from AIDS. Formal entry and travel restrictions for people with HIV have relaxed in most countries, though you will have trouble in Bahrain, Iran, Iraq, and half a dozen others, and you are unlikely to be allowed to settle permanently in Canada and some federal states in Germany. The United States removed entry restrictions in 2010, fourteen years after HAART (highly active antiretroviral therapy) was developed.12 Not only can people living with HIV enter the United States “like anyone else,” according to the Global Database on HIV-specific travel and residence restrictions, but the United States’ visa waiver program no longer considers HIV a communicable disease. This is strange: HIV remains a communicable disease, but now a treatable one. The rule change issued by the Centers for Disease Control and Prevention was more accurate in its language. Its guidelines to physicians about what they must test for in immigrants and refugees read that HIV is no longer “a communicable disease of public health significance.”13 In some places.

  The good news in HIV is still followed by the bad. In 2015, there were 36.7 million people living with HIV and 2.1 million new infections. There were 1.1 million AIDS-related deaths in 2015, no great advance on 1.5 million in 2000.14 The word plateau is now used in HIV/AIDS circles: infections have plateaued; AIDS deaths have plateaued. A better topographical analogy is that HIV has forked. In richer countries, it is again a disease of the niche: men who have sex with men, prostitutes, drug users. It is a chronic, manageable disease with a normal life span. Outside the richer countries of the world, HIV has a different face. The Philippines has the fastest-growing HIV rate in Asia (tied with Afghanistan), mostly in gay or bisexual young men. HIV rates across the Middle East and North Africa are rising, fueled by taboo and silence. AIDS-related deaths in eastern Europe have risen by 50 percent.15

  But South Africa is a puzzle. Other countries in eastern and sub-Saharan Africa are HIV success stories, with dropping rates of infection. South Africa accounts for more than a third of new HIV infections in the southern continent:16 a quarter of a million in 2016.17

  * * *

  They are telling me about the levels. The levels vary according to whom you ask, but the most common version is this: Level 1 gets you lunch money. Level 2 is airtime. Level 3 may be a fancy set of extensions, a Brazilian or a Peruvian, which are worth 2,500 or 3,500 rand ($209 or $292). Level 3 may also be a new smartphone. Level 4 is a trip to Durban. And hardly anyone gets to Level 5: that’s a Benz or a flight to Dubai. Each level requires a woman or girl to pay for it with sex: that is as sure a fact as that they exist. People talk about them as if they are science and fact, even these schoolgirls at COSAT (Center of Science and Technology), a school in the fancier part of Khayelitsha. Fancy in Khayelitsha means some houses are brick and the roads are wider and you won’t see the locked “bucket toilets”—which are what they sound like—that you see in poorer areas. This is a very nice school and has clearly many international supporters and friends. The front yard flower beds are planted with succulents; the main gate is heavy and kept locked; and there is a wellness center staffed by a full-time counselor. The children here have earned their places and are the educational elite of the township. They will go on to further education. They will escape. They talk to me with the tones of youth, kindly yet patronizing. They are adjusting for this white woman who does not know how their world works, who has clearly never been a schoolgirl but was always a person with a notebook, being inquisitive, intrusive, in their faces, disrupting their lunch hour, asking about blessers.

  Blesser. The word arose from young women on social media saying they were “blessed” by boyfriends who bought them things. Blesser is translated differently depending on whom I ask. For a woman who runs an organization helping women to exit prostitution, it is prostitution. It is girls getting compensated by older men for sex. For people working in public health, it is “transactional sex.” For Dr. Genine Josias, who runs Khayelitsha’s sexual assault center Thuthuzela, it is rape and blessers are rapists. “The girls are underage. They cannot consent. It is rape.” For anyone with any sense, it is a spectac
ularly efficient way for HIV to spread.

  For these schoolgirls, sitting around a table during lunch break, chatting, it is part of their life, like airtime and what they call “free Facebook” (a text-only version of Facebook that doesn’t consume data). They talk like they are above such things as blessing, but they know girls at school who have a blesser. One tells me about a school friend who is dropped off at school by a man in a luxury car. “First time I thought it was her father. When they leave, they hug each other. You can see when you hug a father and when you hug a boyfriend.” It’s disgusting, they say, with fantastic contempt. They say, he is old! with emphatic scorn. They disapprove, these girls who are smart and the elite, who will escape. They tell me the rules of blessing: “Don’t have a sugar daddy, if you’re not ready to give them sugar. Because obviously the blessers or sugar daddies want something in return and they don’t want to call it sex so they call it sugar.” In return, the girls get wonderful things: a Peruvian or Brazilian weave, that costs 2,500 rand ($210), a price I would gasp at because my hair is short or my budgeting is thrifty. They get Zara clothes or trips to the malls of the waterfront. One girl had the latest iPhone and then had an even more advanced one couriered to her door. “Couriered!” says the schoolgirl telling this story, with wonder. They act outraged but yet they are indulgent. This is also the attitude of much of South African media to blessing. A blesser named Serge becomes nationally famous when he tells a TV program about his arrangements with young women. He is thought glamorous, not dangerous. There is rapt reporting of an online service named Blesserfinder, defined by Facebook as a “lifestyle service,” if the lifestyle is one that encourages the spread of HIV.

  I don’t feel indulgent of blessers who come to fish for poor girls outside schools and colleges. There is nothing glamorous about the ones who refuse to use condoms, because how can a young woman who wants what you can give resist you? Blesser, blessee: these are new names for something that exists anywhere a young woman exchanges her body for something, but that something is never power. An MSF driver, a local man, gives me a Khayelitsha version of how things work. Level 1 blessers live in shacks. They provide sundries. Level 2s live in the government-provided brick houses, the ones people often sell for cash, then go back to the shacks. Level 3s stay in a township away from here, 4s are even closer to town, and the 5s are probably in Durban. He is laughing when he tells me this. Most people talk about blessing with humor. I doubt Salim Abdool Karim would. At the Durban AIDS conference in 2016, Karim, professor of epidemiology at the Centre for Aids Programme of Research in South Africa, presented research undertaken in KwaZulu-Natal that mapped the movement of the virus through a population of sixteen hundred people by tracking the similarity of certain genetic sequences. They found that HIV was thriving on blesser behavior: young women aged around twenty were being infected by older men aged thirty and above. The young women then passed this on to long-term partners of their own age.18

  Another pathway that suits HIV: young women with blessers will also have a boyfriend of their own age. To have multiple partners is unquestioned. I read that this behavioral norm has grown from history and apartheid. Men forced to work away from home in hostels and mines developed the practice of having concurrent partners. (I think: they were forced to work but not be wanton.) The practice became the norm, enough that the COSAT schoolgirls think there is nothing wrong with having more than one boyfriend and are baffled that I do. They pretend to be disgusted at the idea they would sleep with older men but they are happy to admit to what they call a “backup boyfriend.”

  One girl explains this to me with polite pity and with an appropriate analogy for a writer. “Let’s say you are dating. Boys like to cheat, so girls need a backup plan. So when you drop a book it goes boom and it’s going to hurt. When you have a backup boyfriend, you will have a backup. Catch the book before it falls.” Catch the book, protect your heart. I’m disconcerted by both the poetry she has wrapped around the problem and how the girl speaks with the flatness of the obvious, as if she is telling me the sun is in the sky.

  Backup boyfriends have other names, such as armpit. The woman who tells me this is Nelly, who runs a new MSF program that provides pre-exposure prophylaxis (PrEP) to young women. PrEP involves giving antiretrovirals before infection, to prevent infection. “Armpit sounds better in the vernacular,” she says, and spells the Zulu word, Ikhwapha. I wonder how a boyfriend called an armpit could sound good in any language, but the reasoning is reasonable. An armpit is hidden; a second boyfriend is hidden. They also call it a clutch bag, says Dr. Genine Josias. “You carry a handbag but sometimes you need a clutch bag, too.” Josias knows these things because her daughters tell her but also because of her job. She has worked in Khayelitsha since 2004, when she joined MSF. “We used to take histories from patients,” says Josias. “Some patients became HIV-positive because they were raped and they never accessed post-exposure prophylaxis.” (PEP consists of antiretrovirals given after possible exposure.) This gap in prevention, this rape-size gap, led to the establishment of a dedicated sexual assault center in 2005. It was called Simelela, meaning “to lean on someone.” Simelela was taken over by government in 2009 and renamed Thuthuzela, a Xhosa word that means “to comfort.”

  Thuthuzela has moved to Khayelitsha’s fancy new district hospital (it used to be at the hospital in Site B, where MSF founded its HIV clinic). The new hospital is 325 yards away from the MSF office, but I am not allowed to walk there unaccompanied for safety reasons. Violence here is as common as dust. A staff member told me of acquaintances who have been carjacked, raped, mugged, and robbed at home over the last few months. The robbers also cleared out the fridge. Thuthuzela is meant to offer safety for traumatized people, as well as medical examinations, counseling, statement taking, and forensic investigations. It is open all day, every day, all year, every year. Even so, the number of clients has dropped since the clinic moved: women don’t want to deal with the screening by security guards who want to know their medical problems. Rape rates haven’t dropped. Josias has worked in her field for decades and seen everything. Children raped. Babies raped. Young women. So many young women. Her doctor colleagues raped by doctor colleagues. Rapes so violent the victim must be examined under anesthesia. Nothing surprises her anymore. But at least people understand better about HIV. “They know they need to do something after someone has been raped. They come here and say, I’m not worried about the police or the court, I’m worried about HIV.”

  How can young women fight off HIV as well as male violence? Women in Rwanda, Tanzania, and South Africa who have experienced violence were calculated to be three times as vulnerable to getting HIV as women who have not. Another study estimated that a woman experiencing intimate partner violence has a 1.5 higher risk of being infected.19 Josias is worried. Money is not there for marketing and outreach like it used to be. The children they spent years sensitizing have grown up now. There are new children coming, and they know less: they don’t know there is Thuthuzela; they don’t know there is post-exposure prophylaxis; they don’t know their safety depends on active effort, not luck. They don’t know their risk factors are shaped just like them, that—in the words of Dr. Josias—here (and not only here), “if you have breasts and a vagina, you are unsafe.”

  * * *

  HIV is old. A retrovirus. The retro does not mean old-fashioned but that its creation process is back-to-front. HIV has no DNA, only two strands of RNA, a single strand of ribonucleic acid that existed before DNA. Some scientists believe an RNA world preceded our DNA one. Now, all life-forms are based on DNA except RNA viruses. A retrovirus needs to steal from a DNA cell to survive and to replicate. Inside the target cell, the RNA strands are transformed into DNA by the enzyme reverse transcriptase. Somehow the DNA breaches the cell nucleus by penetrating pores on its surface and splices its DNA into the DNA of the cell. Now it can replicate. Now the T-cell has become a virus factory. New immature virions are created and head to the outer membrane of
the T-cell, where they pass through—this is “budding”—and emerge as new viral particles. Again, again, again.

  This is a successful infection. It begins with a cloud or a swarm of virions being transmitted. But it is not a foregone conclusion. HIV can be transmitted many times without taking root in the body. Many viral particles will be “dead-end” and cause no harm. Many will be dealt with by the immune system. The trouble with HIV is that it needs to infect only one cell. From one infected cell, a person can develop AIDS.

  HIV is flexible. Once inside the body, it can proceed in several ways to infection. Some virions may infect T-cells they encounter in the vagina or anus or blood. Some may cross through the mucous membranes that line these areas into the bloodstream and infect cells there. Some may travel on their own to a lymph node. Others may hitch, often on dendritic cells, another type of leukocyte. I search for images of these and find dreamy shapes with floral folds. A search engine delivers an image of a red rose among the cells and it doesn’t jar. HIV may infect some dendritic cells, but usually it uses them to get where it wants to be. In scientific language, dendritic cells “present” the virus to the lymph node, a debutante at a ball.