While the medical authorities concentrated on the epidemic among white homosexuals, more perceptive doctors realised that a more dangerous heterosexual epidemic threatened. The first African in South Africa definitely known to have suffered from HIV was a man from the DR Congo who apparently sought treatment early in 1985. During that year 522 blood specimens from Africans in Johannesburg were tested and all found negative.48 The first serious alarm emerged in 1986, when tests on African mineworkers found only 0.02 per cent prevalence among South Africans but 3.76 per cent among men from Malawi. ‘In the compounds and at work we were taunted and heckled,’ the Malawians complained, ‘. . . they called us dying people.’ The government ordered compulsory screening of migrant workers, but trade unions, medical officers, and the Malawian authorities all resisted until all recruiting there was abandoned.49 Such Central African migrants certainly helped to introduce the disease. Two of the first black South Africans known to have contracted HIV were infected some time before 1986 by a Malawian mineworker. The only positive case among 240 African women tested in Johannesburg early in 1987 was a Malawian migrant. But none of the 94 ‘self-confessed promiscuous women’ and 1,065 other women in mining areas tested in 1986 was infected and mineworkers did not become a core group spreading infection to the rest of the South African population, whose prevalence levels they generally shared.50 Nor were sex workers an early focus of disease on the scale of Kigali, Nairobi, and Addis Ababa. By the late 1990s they were often heavily infected – 60 per cent in the Hillbrow area of Johannesburg, 56 per cent at truck stops in the Natal Midlands – but this was not the case earlier in the decade and professional sex workers were rare in African townships, where men seldom blamed infection on them.51
The lack of a core group is a striking feature of the initial infection of black South Africans. The infection was rapid: during 1987 blood screening suggested that HIV prevalence was already eight times higher among blacks than whites and was doubling every six months.52 But it was infection by diffusion across a long, much-permeated northern frontier and through individual contacts in many sectors of a mobile, commercialised environment. One indication of this is that even by 1992 the strains of subtype C virus overwhelmingly dominant in the African population were drawn from all parts of Central Africa, with a large element from neighbouring Botswana, in contrast, for example, to the homogeneity of strains in Ethiopia. Among pregnant women who tested positive at Baragwanath Hospital in Soweto in 1991, ‘A strong link was made with African countries to the north of South Africa or partners who travelled.’
Another indication of the complexity of transmission was that the highest HIV prevalence at that time was not in the industrial heartland of the Witwatersrand but in KwaZulu-Natal.53 Among the likely reasons for this predominance, which continued throughout the 1990s, were the region’s dense rural population, the unusually close interaction between the countryside and the major city of Durban, high rates of mobility and migration, equally high levels of sexually transmitted diseases, and the fact that Zulu had abandoned circumcision two centuries before. Even in 1990 some of the province’s highest prevalence rates, over 3 per cent of adults, were in rural areas crossed by truck routes to Swaziland and Mozambique, with concentrations among late teenage women and those who had recently shifted residence. A study there a decade later found that couples with a migrant male were nearly twice as likely to have one or more member infected with HIV than were couples without a migrant, but that in 29 per cent of couples with only one infected member, that member was the woman. Antenatal prevalence at that time in the northern Umkhanyakude rural district was 41 per cent, against 32.5 per cent for the province and 22.4 per cent for South Africa as a whole.54 The current incidence of new infections among women aged 15–49 at Hlabisa, the region’s main hospital, was 17 per cent a year, as high a figure as was recorded anywhere in Africa during the epidemic. The disease was closely associated with tuberculosis, which had been suppressed during the 1950s by chemotherapy but now became the chief opportunistic infection in HIV-positive patients. Tuberculosis cases at Hlabisa multiplied nearly six times between 1990 and 2001. ‘The country,’ wrote the doctor in charge, ‘is busy burying its young.’55
The peak expansion of South Africa’s HIV epidemic lasted from about 1993 to 1998, when the number of new cases began to decline.56 Apart from KwaZulu-Natal, the worst-affected provinces were Gauteng, the Free State, and Mpumalanga, but perhaps the most severe impact was in the independent states of Lesotho and Swaziland, both tied to South Africa by labour migration. The mines were not initially major centres of infection and HIV only slowly penetrated Lesotho. Its statistics are particularly erratic, but prevalence appears to have been low until 1993, when a dramatic increase took place, reaching 31 per cent at urban antenatal sites in 2002. The carriers were returning mineworkers – 48 per cent were estimated to be infected in 2000 – who transmitted the virus to the women who in 2002 were 55 per cent of those infected.57 Swaziland was less dependent on migration to South Africa, but there, too, rapid infection coincided with the acceleration of the South African epidemic around 1993. A year later, 16 per cent of antenatal clinic attenders were HIV-positive and the proportion increased continuously thereafter to nearly 39 per cent in 2003, a figure rivalled only in Botswana. Rural and urban prevalences were almost the same. This rapid, sustained, and widespread growth was probably driven chiefly by mobility within Swaziland and the particular subordination of young women.58
Within South Africa, similarly, high levels of mobility ensured that infection was relatively evenly distributed between town and country. In 2002 the first population survey found 12.4 per cent adult prevalence in African rural areas, 11.3 per cent on commercial farms, and 15.8 per cent in areas of formal urban housing, but a markedly higher prevalence (28.4 per cent) in ‘informal urban areas’, the squatter settlements ringing every town.59 This was the most striking evidence anywhere in Africa that the epidemic had come to concentrate among the poor. One connection was the prevalence of sexually transmitted diseases which were roughly three times as common in informal housing areas as elsewhere. An intensive study in the Carletonville mining area of Gauteng in 1999 found that HSV-2, the main cause of genital ulcers, was the single best predictor of HIV, infecting 91 per cent of HIV-positive women and 65 per cent of HIV-positive men aged 14–24. Among men at an STD clinic in Durban, similarly, HIV prevalence increased between 1991 and 1998 from 5 to 64 per cent and HSV-2 prevalence rose from 10 to 41 per cent.60
A second connection between HIV and poverty concerned gender relationships. While commercial sex was relatively unimportant in the townships, widespread partner exchange like that in Kinshasa and Bangui was markedly more common among the young there than in other contexts.61 Among men it was in part inherited from a polygynous tradition, but it was due also to the collapse of rural restraints on premarital sex (especially its restriction to non-penetrative intercourse), to artificial contraception that reduced the risk of unwanted pregnancy, to the disempowerment of poor young men who could not afford to marry and establish households, and to a reactive machismo that was further stimulated by the violence of the anti-Apartheid struggle.62 Although observers overdramatised the ‘lost generation’ of the early 1990s, many young townsmen of the time aspired to be an isoka, the handsome, popular, and irresponsible hero who displayed his masculinity, in one of the few ways available in a township, by having penetrative sex with girlfriends whom he could not afford to marry. ‘If I were to have many lovers,’ one explained, ‘people . . . would think that I was a playboy, which is a very nice thing to be.’63 Sexual debut came increasingly early, at a median of perhaps sixteen years. Condoms were despised as destroying both pleasure and trust. Many young men had little sense of their own danger: as late as 2003, 62 per cent of HIV-positive people aged 15–24 believed they were at little or no risk of infection. Others accepted the risk as one among many that they faced. ‘We thought that with the new government we could relax, study, plan a future,’ a man of twenty said in the mid 1990s. ‘Now AIDS is here to give us no future, Well, we’ll all just get it and that’s life. We’re cursed; we really are the lost generation.’64
For young township women, the danger could be more immediate. Of those aged 14–24 interviewed at Carletonville in 1999, 16 per cent had been forced to have