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While working in the public hospital context in Johannesburg, we were confronted with the challenge of thinking about why vertically infected HIV-positive adolescents were consistently defaulting on their antiretroviral (ARV) treatment. By all accounts it was a puzzling question, as taking the medication meant not getting ill - and ultimately staying alive - but this did not seem to matter to this group of patients. It quickly became evident that the clinical room was not going to be the place to offer treatment to the identified 50 adolescents. We simply did not have the resources for individual therapy. Working with the adolescents in small groups proved no less of a challenge and what unfolded was the realization that very complex internal unconscious psychic forces were at play. All the children at this unit were black, from extremely impoverished backgrounds, many had lost their primary maternal caregivers at a young age, many were moved from family to family, some were living in homes for orphans, and many were ostracized in their communities. It became clear that the clinical work with vertically infected HIV-positive adolescents required a new paradigm of thinking, not just of psychoanalysis in the community but psychoanalysis of (and for) the community.
HIV entered into global consciousness in the early 1980s when a report was first published in the United States of America (USA) about five previously healthy homosexual men becoming infected with an immune compromising virus. In Africa, people were dying, unnoticed, from an immune compromising virus for at least a decade before this. Subsequent reports from the USA issued HIV as a disease of risk for a particular kind of person, the 4 H club – hemophiliacs, homosexuals, heroin addicts and Haitians. At the same time, South Africa was entering into the last decade of Apartheid. Black lives had little value in this brutal system of oppression and the Apartheid government did not see the danger of the HIV epidem