Changing the Course of AIDS: Peer Education in South Africa and Its Lessons for the Global Crisis (review)

Indisputably, says David Dickinson in the introduction to Changing the Course of AIDS, "a great deal has been written in the last two decades about HIV/ AIDS, especially on the pandemic afflicting Southern Africa" (vii). Much of this work, however, may have gone unread by Africanists who expect accounts of HIV/AIDS prevention and treatment to consist of explanations of sexual practices or of biomedical details that would not be readily accessible to the general reader. But despite its somewhat misleading, overly ambitious, and functionalist title, Dickinson's book should interest all students of social change in southern Africa. This sociological study of HIV/AIDS peer education in diverse South African businesses tries to understand "the web of social relationships that influence behavior" (5), particularly with reference to Erving Goffman's classic framing of social space as "front stage" and "back stage" and Victor Turner's notion of "liminality." So-called front-stage behavior includes that of workplace peer educators who give training sessions to coworkers within vertically structured communication programs run by HIV/AIDS managers; back-stage interventions include educators' participation in informal activities both at work and on the outside (including engagement in coworkers' daily lives, or "slipping out of order" into a liminal space for social change).

Avoiding the superficial framing of South African AIDS that jumps abruptly from the situation under apartheid to the policies of the postapartheid state, Dickinson conducts a clearly reasoned discussion of why the population has been vulnerable to the transmission of HIV and how access to health care has been shaped by larger social and political processes. Thoughtful considerations of race, class, and gender inequalities distinguish this book from others less cognizant of local politics and its divisiveness. The focus on peer educators is also an interesting contribution to a literature that tends to concentrate on physicians or on the more famous grassroots activists. Although peer educators are among the lowest cadre of AIDS workers globally, they are elites locally, since they are part of the 20 to 40 percent of South Africans who actually have a job. Dickinson draws on six years of research in five large companies: a mining company, two automobile manufacturers, a retail group, and a financial institution. He characterizes corporate policies to address AIDS as "a messy outcome of internal activity, social pressures, and a pragmatic recognition from senior management that it is best to make a virtue out of a necessity" (65); these policies range from the most extensive level of engagement to what he calls "cheap and cheerful" measures.

The book's normative agenda is explicit: for example, individuals who have developed AIDS policies in their workplace are labeled "AIDS Champions." The book aims to convince AIDS "experts" that responses from below have value and should be supported as effective strategies in the fight against the disease. This claim is convincingly argued, even if the empirical claim of effectiveness is not. The question of how vertical hierarchies of AIDS interventions can stimulate and not stifle peer engagement is also not resolved.

Individual behavioral change is the focus of peer education—helping people practice safe sex on a consistent basis, reduce the number of sexual partners, utilize HIV testing, and access AIDS treatment. A critical point of the book is that behavioral change requires that the HIV/AIDS epidemic be considered an ordinary topic for conversation in intimate spaces, not exclusively the subject of public lectures and sermons. Another key goal—transforming social relationships so that individuals are mobilized into collective action—is mentioned but dismissed, because "neither marches nor petitions nor legal reform can ensure that people will use condoms" (30).

Horizontal communication, Dickinson argues, is key to changing behavior, yet because these processes are framed within local cultures and consist of face-to-face interaction between peers, he acknowledges that little...