Making sense of HIV/AIDS in South Africa: Issues in HIV prevention

Centre for AIDS Development, Research and Evaluation www.cadre.org.za

Warren Parker • warren@cadre.org.za

Variations in antenatal HIV prevalence in Africa

HIV/AIDS in South Africa South Africa has a population of 45 million and a diverse

economy that has wide polarities between rich and poor

Majority of people are poor as a product of under and unemployment, but there is a highly active economic sector including mining, manufacturing and industry that is competitive globally

Approximately 4.5 million South Africans are HIV positive - amongst the highest total number of people living with HIV in any country worldwide

HIV affects all age groups, race groups and economic strata

Mainly heterosexual, very little IDU, generalised

Female risk is exacerbated by factors related to sex (biological vulnerability), gender (power differentials)

Population-based HIV prevalence, 20024%

8%

22% 24

%

14%

12%

12%

5%

7%7%

17%

32%

24%

18% 19

%

11%

8% 7%

0%

5%

10%

15%

20%

25%

30%

35%

40%

15-19 20-24 25-29 30-34 35-39 40-45 45-49 50-54 55+

Males

Females

Antenatal HIV prevalence over time

Antenatal prevalence in <20

Antenatal HIV prevalence amongst youth has remained much the same over the past four years

SA Antenatal data, females < 20

15.4% 14.8%15.8% 16.1%

0.0%

2.0%

4.0%

6.0%

8.0%

10.0%

12.0%

14.0%

16.0%

18.0%

20.0%

2001 2002 2003 2004

<20

Disproportional effects on females

Biological factors increase female risk

Population-based studies show high prevalence, and disproportional effects on young females (2004) Males 15-19 2.5%Females 15-19 7.3%Males 20-24 7.6%Females 20-24 24.5%

Teen pregnancyrates have increased (1998/2004)

2.0%5.2%

10.7%

19.8%

30.2%

1.0%

5.0%

18.0% 19.0%

38.0%

0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

30.0%

35.0%

40.0%

45.0%

15 16 17 18 19

DHS 1998

RHRU 2003

But, progress in condom access

SA public sector condom procurement: 2001-2004

267282

302

346

0

50

100

150

200

250

300

350

400

2001 2002 2003 2004

Millions

Increase in perceived ease of access• 2000, males and females 15-30, 75%• 2002, males and females, 15-24, 95%

And increased condom use Increased public sector procurement

Demand-based logistics system, widespread access (including commercial and social marketing availability)

Quality control of product

Progressive increase in reported last intercourse condom use• 1998, DHS, females, 15-19, 21.2% (unmarried partner)• 2000, BAC, males and females, 15-30, 52%• 2002, NM/HSRC, females 15-24, 46.1%; males, 57.1%• 2003, RHRU, females 15-19, 55%; males, 57%

Factors underpinning high prevalence in South Africa (1) HIV/AIDS response led by left wing health NGOs prior to

1994 (including ANC)

Comprehensive national AIDS plan in place pre-1994

New government slow in implementing systematic response

NGOs marginalised by shifts in funding to bilateral model - many NGOs collapsed

Naïve positions adopted on AIDS including debates about HIV causality, failure to move efficiently to address mother to child HIV transmission, provision of ARVs (legal pressure by the TAC shifted policy)

Some systematic response – efficient condom logistics, increased access to voluntary counselling and testing

Factors underpinning high prevalence in South Africa (2) Rapid growth in prevalence, and high current levels of HIV

mean there is a very high average risk of infection through sex

Consistent condom use hasn’t been widely promoted, and consistent condom use is difficult

Mobility, migration, urbanisation and poverty exacerbate the epidemic

High turnover of sexual partners, late marriage – relationships unstable

Median age of first sex is 18, but highest risk of infection occurs in the over 20 age group

High levels of violence against women - unemployment, alcohol abuse, inadequate justice system

Approaches to understanding behaviour

Cognitive approach assumes that that:• learning is an interactive process• knowledge is objective• ideas can be communicated in a linear way - ie. from sender to receiver in such a way that meaning is easily shared.

Constructivist approach recognises that there is a relationship between the individual and his/her context• knowledge is subjective• communication is multifaceted

Humanist approach assumes that people have a desire to learn• knowledge is seen as a resource that can be sought out• communication is a multifaceted process

Cognitive approach

Centers on the individual and assumes that individuals can mitigate risk through making choices about their sexual practices (eg. when, where, with whom, how, how safely)

Assumes that agency lies with the individual

Assumes that knowledge and and the ability to act on knowledge (self-efficacy) are closely related

Assumes that risk is purely related to individual behaviour

Cognitive approach to sexual behaviour

Assumes sex is a rational activity and overlooks the heightened emotional states of sexual activity

Fails to address the fact that sex occurs with a partner who may determine when and how sex might occur

When applied to sexual behaviour it overlooks power relations that are a product of gender power differences as well as power embedded in cultural values placed on age, differences in economic power, in institutional power, in physical power

Assumes behaviour change is a consistent state

Overlooks structural vulnerability – for example, labour migration breaks up families, poverty creates inequality, inadequate policing and justice systems, inadequate rights frameworks

Limits to cognitive approaches

Sexual risk in the context of the HIV epidemic is about complexity, about limitations of self-efficacy over sexual relationships, about lack of resources, about marginalisation.

Risk is continuous and complex. Simple concepts of Behaviour Change - ‘ABCs’ hide, this complexity because they focus on the individual: • Abstinence (rational control over sexual desire)– but partner may pressurise • Faithfulness (at best, we can control ourselves)– but partner behaviour cannot be controlled• Condom use (negotiated, technical)– but correct and consistent use not always easy• Partner reduction (number of partners can be controlled)– need for affirmation, love, pleasure in contexts where separated from partners or alone

Cognitive approach is dominant in HIV/AIDS campaigns

Most campaigns use mass media

Limitation is that mass media is linear, top down, centralised

Mass media audiences are homogenised - mass media cannot easily adapt to diversity

Communication is broken down into simple messages and imperatives or ‘orders’

Follow a ‘propaganda’ model, and assume direct causal relationship between knowledge and action

HIV/AIDS campaign contexts HIV/AIDS campaigns are formal organised activities,

typically utilising various forms of communication to achieve objectives related to prevention, care, treatment, support and rights

Campaigns represent only one element of the multi-layered discourses that occur in relation to HIV/AIDS

Campaigns contribute to the stimulating individual response, but:- there may be contradictions between campaigns- may contradict regimes of knowledge (eg. Concepts of disease; non-biomedical belief systems; cultural practices; faith-based constructions of the epidemic; fear; stigma)- have a relative meaning in comparison to individual engagement with the epidemic (eg. Being HIV positive, knowing people who have died, volunteering)

Communication exposure

HIV/AIDS communication occurs in various contexts:• Mass media, as a product of purposive HIV/AIDS campaigns (TV, Radio, Print, Outdoor, Electronic)• Mass media, unrelated or indirectly related to purposive campaigns: eg. In news, drama, documentaries, features talk shows, newspaper columns• Small media: eg. Leaflets, posters• Events: eg. Plays, rallys, story-telling• Icons, artifacts: Red ribbon, AIDS quilts, artworks

– Policy discourses: eg. conferences, workshops– Public relations discourses: eg: press releases, anouncements, launches– Structured, interactive: eg. Counselling– Interpersonal: eg. Conversations, arguments

Mass media campaign examples

Number of HIV/AIDS campaigns in South Africa the utilise mass media, and expanded strategies

Integrated model - Soul city (www.soulcity.org.za) Theorised approach combined with non-didactic model -

Tsha Tsha (www.cadre.org.za) Claims making and rhetoric combined with integration of

youth as consumers (www.lovelife.org.za) Incremental impacts can be demonstrated through

evaluations, but massive short-term impacts can only be achieved through a complex of interventions and community-led response

Present emphasis - ABC (limits)A range of important prevention strategies are overlooked by an over-emphasis on ‘ABC’ and sexual behaviour:

Prevention of mother-to-child HIV transmission (PMTCT) Prevention of HIV following rape through post-

exposure prophylaxis (PEP) Prevention of HIV infection through PEP following

occupational or other exposure Prevention of HIV through detecting and treating STIs Prevention of HIV through addressing gender

disempowerment, sexual violence and child sexual abuse Prevention of HIV through addressing abuses of

institutionalised forms of power (e.g. teachers, police, prisons)

Prevention of HIV through addressing economic and structural inequalities

Limits of ABC HIV prevention through ‘universal precautions’ in healthcare

and other settings. Includes exposure to patients and healthcare workers in health care settings (unsterile instruments, dental care, expressed breastmilk)

Risks of breastfeeding and shared breastfeeding HIV prevention through avoiding injecting drugs/needle

sharing Unsterile instruments for tattooing Emphasis on generalised risk – overlooks the importance of

addressing high-risk contexts (sex work, mobile forms of employment, migration, informal urbanisation, gay men)

Horizontal and grassroots forms of communication overlooked

Global emphasis on top-down models but grassroots, community-led approaches that use horizontal communication and organisation have been overlooked and marginalised (constructivist and humanist)

Gay men in the US in the 1980s mobilised around the death of friends and leaders - HIV response included closing down gay bath houses, buddy support to people who were ill, condom distribution, political mobilisation and action, counselling and testing, aesthetic responses

Communities in Uganda mobilised around care, focused on importance of partner reduction, openness

Need to reawaken community action models, yet currently funding is highly centralised, models of response don’t foster community action

Need to think about epidemiological drivers of the epidemic – Early sexual debut

– Age differentials between partners– Multiple partners– Coercion (as a product of power differentials)– Violence (rape, statutory rape)

Need to look at vulnerability– Specific risks to young females– Children affected by HIV/AIDS in their families (orphaning)– Poor promotion of grants and assistance to vulnerable youth– Inadequate promotion of rights and legal framework– Little emphasis on young PLHA

Contexts of risk– mobility– urbanisation and informal settlement

Conclusions

Severe epidemic is very difficult to recover from Prevention needs to be linked to treatment, care, support

and rights Community mobilisation a key model - need to move beyond

top-down approaches Global and local funding models need to be revised to

support community response National leadership is important, but local leadership more

so