Catherine Campbell;The International African Institute, James Currey, Indiana University Press, and Double Storey, 2003, ISBN 0-253-21635-4, £12.95 (Pbk) 224p; ISBN 0-253-34328-3, £40 (Hbk) 214p

This is a sobering, thought-provoking and significant book, of importance to anyone interested in Southern African sociology, psychology, health matters or politics. Author Catherine Campbell, a social psychologist with a specific focus on the local community-level of analysis rather than individual and biomedical perspectives, analyses the results, including disappointments and failures, after three years of a particular HIV-prevention programme, the Summertown Project. ‘Summertown’ is a pseudonym for a small South African community, used to protect respondents' confidentiality. Three particular high-risk sectors of this community were targeted for intervention designed to improve sexual health: migrant mineworkers, commercial sex-workers and schoolchildren. Campbell is at pains to point out that poverty and gender inequalities had an adverse effect on the aims of the project, revealing that rationality is only one factor in decision-making.

Numerous studies, in addition to the shocking escalation of AIDS statistics, support Campbell's assertion that people wittingly participate in risky behaviour. Despite intellectually knowing the dangers of such behaviour, many individuals avoid using condoms, and have sex with multiple partners. No better example could be provided than the case of former Deputy President, Jacob Zuma, also previously leader of the Moral Regeneration Campaign and head of the National AIDS Council. The South African public has been riveted by the 2006 trial of Jacob Zuma (63), accused of rape by a 31-year-old HIV-positive family friend who identifies as a lesbian. Zuma denied the charge of rape, but acknowledged having had sex with the woman without a condom. He testified that he felt he had avoided the possibility of being infected with AIDS as he had taken a shower after having had sex. While many AIDS activists and gender activists have been dismayed by the poor role model Zuma has proved to be, and by the degree of support shown by traditionalists to Zuma, other commentators have been heartened by the public debate which has been sparked by the trial.

One pertinent example of the effects of contrary discourses on opting for unprotected sex that is provided in ‘Letting Them Die’: Why HIV/AIDS Prevention Programmes Fail is the preference for what is locally termed ‘flesh-to-flesh’ sexual contact by miners. These men are pervaded with the ideology of machismo, which stresses fulfilling sexual urges. However, they are migrant workers, mainly removed from contact with their wives and families, and further, they daily face death underground, leading to a fatalistic attitude. In such conditions of powerlessness, unprotected sex represents intimacy and control, which are difficult to achieve elsewhere.

Physical, psychological and social factors are closely interwoven, and attempting to bring about behavioural change in the Project proved to be more fraught than initially conceived. Two major problems concerned the lack of coherent, unified ‘communities’ that could organize around common goals, and major differences in stakeholder groupings. An example of the former problem is provided by the case of sex-workers, who were competitors for a relatively small pool of clients, although they were also in the same situation of vulnerability to the twin scourges of South African life, violence against women and HIV infection. So although the sex-workers were intellectually aware of the dangers facing them if they did not insist on condom use, poverty compelled some to take these risks and meet the demands of clients for ‘flesh-to-flesh’ contact, thus rupturing the united front which was the only possibility for acceptance of condom use. Yet these sex-workers were far from passive victims, and they devised creative strategies of coping with their lack of social respectability and the stigma associated with their work. Further, in certain instances they gave each other significant support. The Project encouraged open discussion of issues of sexual health and a more proactive approach to using condoms and seeking treatment for sexually transmitted infections. Disappointment at measurable results may have been related to unrealistically high aims, and the length of time taken for social change to occur.

Although there is an unfortunate lag of four years between this book's publication and its appearance for review in this journal, many circumstances in South Africa render it pertinent today, such as the Zuma trial and current, local clinical trials of microbicides, which may provide women with a greater measure of empowerment against HIV transmission. Condom usage is problematic, and sex-workers cited in ‘Letting Them Die’ expressed a preference for female condoms; however, these were then, and are still, expensive and unobtainable at government-run clinics. Widespread microbicide trials may lead to a discreet means of protection for women, who are proportionately much more at risk of HIV infection than men in a country where the infection rate is alarming and still rising.

The strength of this book lies in its compelling, lucid writing of a gripping account, and especially of its non-judgmental treatment of nuance, complexity and dialectics. Given this, the sub-title strikes a surprisingly defeatist note, which should not deter the reader, as it is uncharacteristic of an enlightening and worthwhile book.