Understanding culture and HIV/AIDS in sub-Saharan Africa

Early in the study of HIV/AIDS, culture was invoked to explain differences in the disease patterns between sub-Saharan Africa and Western countries. Unfortunately, in an attempt to explain the statistics, many of the presumed risk factors were impugned in the absence of evidence. Many cultural practices were stripped of their meanings, societal context and historical positioning and transformed into cofactors of disease. Other supposedly beneficial cultural traits were used to explain the absence of disease in certain populations, implicitly blaming victims in other groups. Despite years of study, assumptions about culture as a cofactor in the spread of HIV/AIDS have persisted, despite a lack of empirical evidence. In recent years, more and more ideas about cultural causality have been called into question, and often disproved by studies. Thus, in light of new evidence, a review of purported cultural causes of disease, enhanced by an understanding of the differences between individual and population risks, is both warranted and long overdue. The preponderance of evidence suggests that culture as a singular determinant in the African epidemic of HIV/AIDS falls flat when disabused of its biased and ethnocentric assumptions.     

Caregiver alcohol use and mental health among children orphaned by HIV/AIDS in South Africa

Research in the developed world suggests that parental alcohol use negatively impacts child mental health. However, little research has examined these relations among children in the developing world and no studies to date have done so in the context of AIDS-orphanhood. Therefore, the present study tested the interactive effect of AIDS-orphan status with caregiver alcohol use on child mental health. The sample included 742 children (51.2% female; M_{age ?}=?9.18; age range: 7–11 years; 29.8 AIDS-orphans; 36.8% orphaned by causes other than AIDS; 33.4% non-orphaned) recruited from Mangaung in the Free State Province of South Africa. Child mental health was assessed via child self-report, caregiver, and teacher reports; and caregiver alcohol use via self-report. Path analyses, via structural equation modeling, revealed significant direct effects for AIDS-orphan status on caregiver-reported child mental health; and for caregiver alcohol-use problems on teacher-reported child mental health. However, the interaction effect of AIDS-orphan status with caregiver alcohol use did not reach significance on all three reports of child mental health problems. These results suggest that orphan status and caregiver alcohol use may independently relate to mental health problems in children and that the effects of both should be considered in the context of the mental health needs of children in AIDS-affected countries.     

Perceived Risks of HIV/AIDS and First Sexual Intercourse among Youth in Cape Town, South Africa

The ‘Health Belief Model’ (HBM) identifies perception of HIV/AIDS risks, recognition of its seriousness, and knowledge about prevention as predictors of safer sexual activity. Using data from the Cape Area Panel Survey (CAPS) and hazard models, this study examines the impact of risk perception, considered the first step in HIV prevention, set within the context of the HBM and socio-economic, familial and school factors, on the timing of first sexual intercourse among youth aged 14–22 in Cape Town, South Africa. Of the HBM components, female youth who perceive their risk as ‘very small’ and males with higher knowledge, experience their sexual debut later than comparison groups, net of other influences. For both males and females socio-economic and familial factors also influence timing of sexual debut, confirming the need to consider the social embeddedness of this sexual behavior as well as the rational components of decision making when designing prevention programs.

Social Perceptions of HIV/AIDS among the Wayuu of Colombia

Understanding how Indigenous populations perceive HIV/AIDS is of high relevance for the implementation of culturally appropriate interventions. The study analyzed the ways in which Indigenous Wayuu communities of Colombia socially perceive and respond to HIV/AIDS from their sociocultural realities and their knowledge of the illness. It analyzed qualitative data from 9 focus groups and 29 semi-structured interviews. The Wayuu think of HIV/AIDS as “the illness”, that it is incurable, fatal, transmitted from alijunas (non Wayuu), and beyond their understanding. They seem to perceive HIV/AIDS similarly to the ways Western societies perceived unknown or misunderstood epidemics in the past.     

A novel symptom cluster analysis among ambulatory HIV/AIDS patients in Uganda

Symptom clusters are gaining importance given HIV/AIDS patients experience multiple, concurrent symptoms. This study aimed to: determine clusters of patients with similar symptom combinations; describe symptom combinations distinguishing the clusters; and evaluate the clusters regarding patient socio-demographic, disease and treatment characteristics, quality of life (QOL) and functional performance. This was a cross-sectional study of 302 adult HIV/AIDS outpatients consecutively recruited at two teaching and referral hospitals in Uganda. Socio-demographic and seven-day period symptom prevalence and distress data were self-reported using the Memorial Symptom Assessment Schedule. QOL was assessed using the Medical Outcome Scale and functional performance using the Karnofsky Performance Scale. Symptom clusters were established using hierarchical cluster analysis with squared Euclidean distances using Ward’s clustering methods based on symptom occurrence. Analysis of variance compared clusters on mean QOL and functional performance scores. Patient subgroups were categorised based on symptom occurrence rates. Five symptom occurrence clusters were identified: Cluster 1 (n = 107), high–low for sensory discomfort and eating difficulties symptoms; Cluster 2 (n = 47), high–low for psycho-gastrointestinal symptoms; Cluster 3 (n = 71), high for pain and sensory disturbance symptoms; Cluster 4 (n = 35), all high for general HIV/AIDS symptoms; and Cluster 5 (n = 48), all low for mood-cognitive symptoms. The all high occurrence cluster was associated with worst functional status, poorest QOL scores and highest symptom-associated distress. Use of antiretroviral therapy was associated with all high symptom occurrence rate (Fisher’s exact = 4, P < 0.001). CD4 count group below 200 was associated with the all high occurrence rate symptom cluster (Fisher’s exact = 41, P < 0.001). Symptom clusters have a differential, affect HIV/AIDS patients’ self-reported outcomes, with the subgroup experiencing high-symptom occurrence rates having a higher risk of poorer outcomes. Identification of symptom clusters could provide insights into commonly co-occurring symptoms that should be jointly targeted for management in patients with multiple complaints.     

Changing trends and the impact of alcohol on the HIV/AIDS epidemic in South Africa: Review

The association between increased HIV infection and alcohol use has been extensively studied and is established. South Africa is among one of the sub-Saharan African countries with the highest prevalence and number of people living with HIV/AIDS in the world. Although recent evidence suggests that the epidemic has stabilised, infection rates remain unacceptably high. Alcohol use is on the increase, particularly in the groups most susceptible to HIV infection, namely women and young adults, and informs poor choices with respect to safer sexual practices. This paper reviews the association between alcohol and HIV. More specifically, however, it aims to explore the potential socio-politico-biological and cultural explanations as to the factors that intersect to drive these two epidemic diseases: alcoholism and HIV/AIDS in South Africa. Understanding some of the underlying factors will provide a framework to implement public health measures to curb HIV.     

Poverty and HIV/AIDS in South Africa: an empirical contribution

This study sets out to establish and explain the empirical link between HIV/AIDS and poverty using data collected by the 1998 South African Demographic and Health Survey (SADHS). Analysis is restricted to women of reproductive age (15 – 49 years). The results indicate an increased risk of HIV infection among the poor, due to poverty-related characteristics of low education and low knowledge of the means of avoiding HIV infection, as opposed to the non-poor. Moreover, the poor and the less educated were found to be more likely not to use condoms than the non-poor. The results do not, however, provide the reasons for these relations and as such further research is required. One possible explanation was financial dependence on their partners, as it was found that women who received money from their partners, as well as those who came from households where hunger was a common phenomenon, were more likely not to use condoms because their partners disliked condoms, than those who did not receive money from their partners. The results also hinted at the intricacy of the poverty-HIV/AIDS relationship, so that it was not only low socio-economic status that increased susceptibility to HIV infection but also high socio-economic status.     

Alcohol consumption and HIV/AIDS: the neglected interface

Many countries with heavy HIV and alcohol burdens do not fully recognize these epidemics as intrinsically interconnected. Missed opportunities for synergistic prevention and treatment of HIV and alcohol abound.Few HIV policies, services for HIV prevention or research projects adequately address alcohol-HIV harms or include alcohol use as an HIV risk factor.     

Social support and mental health among adults prior to HIV counseling and testing in Durban,South Africa

Poor social support and mental health may be important modifiable risk factors for HIV acquisition, but they have not been evaluated prior to HIV testing in South Africa. We sought to describe self-perceived mental health and social support and to characterize their independent correlates among adults who presented for voluntary HIV testing in Durban. We conducted a large cross-sectional study of adults (≥18 years of age) who presented for HIV counseling and testing between August 2010 and January 2013 in Durban, South Africa. We enrolled adults presenting for HIV testing and used the Medical Outcomes Study’s Social Support Scale (0 [poor] to 100 [excellent]) and the Mental Health Inventory (MHI-3) to assess social support and mental health. We conducted independent univariate and multivariable linear regression models to determine the correlates of lower self-reported Social Support Index and lower self-reported MCH scores. Among 4874 adults surveyed prior to HIV testing, 1887 (39%) tested HIV-positive. HIV-infected participants reported less social support (mean score 66 ± 22) and worse mental health (mean score 66 ± 16), compared to HIV-negative participants (74 ± 21; 70 ± 18; p < 0.0001). In a multivariable analysis, significant correlates of less social support included presenting for HIV testing at an urban hospital, not having been tested previously, not working outside the home, and being HIV-infected. In a separate multivariable analysis, significant correlates of poor mental health were similar, but also included HIV testing at an urban hospital and being in an intimate relationship less than six months. In this study, HIV-infected adults reported poorer social support and worse mental health than HIV-negative individuals. These findings suggest that interventions to improve poor social support and mental health should be focused on adults who do not work outside the home and those with no previous HIV testing.     

A comprehensive programme addressing HIV/AIDS and gender based violence

A survey was administered to 304 respondents participating from three areas near Welkom, South Africa. Face-toface interviews were conducted with women from randomly selected households to evaluate the impact of a service provision programme targeting women living with HIV/AIDS and gender based violence. Gender based violence (GBV) awareness and knowledge was high. Respondents had high perceived levels of risk. They reported making various behavioural changes to avoid GBV. The respondents were aware of their legal rights pertaining to GBV. HIV/AIDS knowledge levels and attitudes were acceptable. Behavioural changes included condom use, abstinence and being faithful to one partner. Disclosure of HIV was lower than disclosure of GBV.Awareness and knowledge of female condoms were high, yet usage low. Participants reported that they would be able to introduce condoms to a relationship and negotiate usage with relative ease. Perceived levels of GBV and HIV were high, and stigma levels towards the affected women were also relatively high. The awareness and knowledge levels of GBV and HIV of older respondents were lower than younger respondents. The key findings of this study support the notion of using a holistic approach, targeting more than one issue. There is lower stigma levels associated with combined conditions, which might allow easier access to vulnerable groups. Coordination and collaboration of services are however needed to enable this benefit.     

Drug use and HIV in West Africa: a neglected epidemic

Injecting drug use is poorly documented in West Africa. HIV prevalence studies are still rare. Recent studies show that drug injection is on the rise. There is an urgent need to take this component of the HIV epidemic into account and to establish adapted intervention strategies.     

HIV/AIDS: South African women at risk

A previous version of this paper was presented at the AIDS in Context Conference, University of the Witwatersrand, Johannesburg, 4–7 April 2001

This paper engages some aspects of the HIV/AIDS epidemic and the complexities associated with it. It outlines the socio-epidemiological patterns of the epidemic and in doing so identifies the groups with the greatest and fastest growing rates of infection. The pattern of the epidemic in South Africa is as follows: it is primarily a heterosexual one, the rates of infection in the general population are very high, and the percentage of HIV positive women is greater than men. An additional feature is the young age of onset of infection for women. These data demonstrate the need to focus our attention on young African women and the factors underpinning their predicament. In order to shed light on the position of women in the epidemic and the particular risks they face, we examine the long-standing relationship between gender and racial inequalities and health.

Within the constraints of limited and flawed statistical data, the paper argues that a complex interaction of material, social, cultural and behavioural factors shape the nature, process and outcome of the epidemic in South Africa. It concludes with recommendations for the way forward.     

Stigma,discrimination and the implications for people living with HIV/AIDS in South Africa

Stigma and discrimination play significant roles in the development and maintenance of the HIV epidemic. It is well documented that people living with HIV and AIDS experience stigma and discrimination on an ongoing basis. This impact goes beyond individuals infected with HIV to reach broadly into society, both disrupting the functioning of communities and complicating prevention and treatment of HIV. This paper reviews the available scientific literature on HIV/AIDS and stigma in South Africa, as well as press reports on the same subject over a period of 3 years. Analysis of this material indicates that stigma drives HIV out of the public sight, so reducing the pressure for behaviour change. Stigma also introduces a desire not to know one's own status, thus delaying testing and accessing treatment. At an individual level stigma undermines the person's identity and capacity to cope with the disease. Fear of discrimination limits the possibility of disclosure even to potential important sources of support such as family and friends. Finally, stigma impacts on behaviour change as it limits the possibility of using certain safer sexual practices. Behaviour such as wanting to use condoms could be seen as a marker of HIV, leading to rejection and stigma. All interventions need to address stigma as part of their focus. However, the difficulty of the task should not be underestimated, as has been shown by the persistence of discrimination based on factors such as race, gender and sexual orientation.     

Sexually transmitted infections and infectiousness beliefs among people living with HIV/AIDS: implications for HIV treatment as prevention

Objectives

Sexually transmitted infections (STIs) significantly impact the health of people living with HIV/AIDS, increasing HIV infectiousness and therefore transmissibility. The current study examined STIs in a community sample of 490 HIV‐positive men and women.

Methods

Assessments were performed using confidential computerized interviews in a community research setting.

Results

Fourteen per cent of the people living with HIV/AIDS in this study had been diagnosed with a new STI in a 6‐month period. Individuals with a new STI had significantly more sexual partners in that time period, including non‐HIV‐positive partners. Participants who had contracted an STI were significantly more likely to have detectable viral loads and were less likely to know their viral load than participants who did not contract an STI. Multivariate analysis showed that believing an undetectable viral load leads to lower infectiousness was associated with contracting a new STI.

Conclusions

Individuals who believed that having an undetectable viral load reduces HIV transmission risks were more likely to be infectious because of STI coinfection. Programmes that aim to use HIV treatment for HIV prevention must address infectiousness beliefs and aggressively control STIs among people living with HIV/AIDS.     

HIV/AIDS and TB: contextual issues and policy choice in programme relationships

Tuberculosis (TB) and HIV/AIDS affect each other closely. Given the rapid spread of the HIV-driven TB epidemic worldwide, the case for establishing some form of relationship between control activities for HIV/AIDS and TB is clear. However, the question 'how' has not been resolved satisfactorily. TB and HIV/AIDS programmes have traditionally maintained their own management, supervision, funding flows and specialist boundaries. This article explores opportunities and challenges for collaboration between the two, through drawing on the expertise in organization and management, policy analysis and disease control of both TB and HIV/AIDS. Based on an extensive literature review, the article investigates how contextual issues affect the design of a collaboration; what the organizational options are; and what impact a collaboration would have. A universal model for organizational change is unlikely and changes may present as both solutions and contradictions. Careful planning and consultation are required before implementing the changes, in order to avoid jeopardizing the function and effectiveness of both disease control programmes and the health service system.     

在流动人口中开展预防艾滋病工作初探

目的了解流动人口对艾滋病相关知识的知晓情况,尝试如何在流动人口中开展艾滋病预防教育工作.方法对云南省某建筑工地18名建筑工人(均为男性)进行了2小时的艾滋病基本知识培训,培训采用讲解、示教和参与相结合的方法,培训内容注重实用性.结果培训后,培训对象有关艾滋病的知识知晓率明显上升,对艾滋病的警觉性有所提高.结论建议在流动人口中开展灵活多样的艾滋病预防教育工作.     

Risk factors for HIV/AIDS in a low HIV prevalence site of sub-Saharan Africa

We conducted a hospital-based survey on prevalence and risk factors of HIV-1/2 and other viral infections in Zanzibar archipelago. Blood samples, socio-demographic and behavioural data were collected from 2697 patients. The overall HIV prevalence was 2.9%. About 1.4%, 2.1%, 4.2% of antenatal clinic (ANC) attendees and 2.1%, 3.7%, 5.3% of blood donors were, respectively, HIV-Abs-, HTLV-Abs- and HBs-Ag-positive; 5.5% of blood donors were HCV-affected. Co-infections were rare. Exactly 3.4% of the children aged 6-10 years were HIV-positive. People aged 26-35 years [adjusted odds ratio (AOR) 4.4, 95% CI (confidence interval) 1.72-11.22; P = 0.002], illiterate subjects (AOR 3.6, 95% CI 1.65-7.98; P = 0.001) mobile workers (AOR 7.0, 95% CI 1.41-34.62; P = 0.02) and previously operated patients (AOR 1.9, 95% CI 1.02-3.66; P = 0.04) were at higher risk for HIV/AIDS. Any of the examined factors were associated with hepatitis B virus, hepatitis C virus and human T lymphotropic virus type 1/2 transmission. HIV/AIDS prevention strategies must primarily be addressed to traditional high-risk groups and secondarily to unsafe health care procedures in relatively preserved sub-Saharan areas.     

Culture and African contexts of HIV/AIDS prevention,care and support

Culture plays a vital role in determining the level of health of the individual, the family and the community. This is particularly relevant in the context of Africa, where the values of extended family and community significantly influence the behaviour of the individual. The behaviour of the individual in relation to family and community is one major cultural factor that has implications for sexual behaviour and HIV/AIDS prevention and control efforts. As the impact of HIV/AIDS in Africa remains unabated, a culture-centered approach to prevention, care and support is increasingly recognised as a critical strategy. In this article PEN-3, a model developed to centralise culture in health promotion interventions, is presented as a framework to be used in HIV/AIDS prevention, care and support in Africa. The three domains of the PEN-3 model incorporate specific constructs: relationships and expectations, cultural empowerment, and cultural identity.The cultural empowerment and relationships and expectations domains are ‘assessment/appraisal’ domains used for cultural assessment. Community identity is the ‘application/transformation’ domain that helps the public health practitioner assist the community to identify the point of entry of the intervention. In this paper the authors describe PEN-3 and then present examples of how the assessment/appraisal domains can be utilised to frame HIV/AIDS-related concerns in the context of Africa.