Boundaries of care: the role of the school in supporting vulnerable children in the context of HIV and AIDS

This paper is a response to a growing vision of schools as sites of care and support for vulnerable children in the context of HIV and AIDS. The aim is to interrogate this notion and to raise some key issues in considering the role of schools in the context of the epidemic. The paper is based on two research activities. The first was a desk review of projects working in the area of schools in the context of HIV/AIDS and poverty, including a review of the policies underlying these initiatives. The second was the documentation of a particular project in a province of South Africa. The paper begins by outlining some major education policies in South Africa related to the care and support of vulnerable children in the context of HIV and AIDS. The paper then offers three cautionary notes in relation to the thrust of these policies and those programmes attempting to implement them. The first suggests consideration of the context of implementation — the schooling system. The second recommends consideration for resourcing these policies, which is looked at through a case study. The third note considers the policy visions of schools and teachers: how schools and teachers are conceptualised both in policies and programmes is problematised. The misalignment between the policies around schools and vulnerable children, the resourcing of these policies, and their contexts of implementation is brought into relief, as well as the implications for thinking about expanded roles for schools and teachers. The paper offers possible ways forward in considering the role of schools in the context of HIV and AIDS. These include new ways of thinking about resourcing, proper monitoring and evaluation of projects, and a focus on quality teaching and learning.     

HIV- and AIDS-related (mis)perceptions and (non)responses of school principals in the Eastern Cape,South Africa

Despite various HIV and AIDS training programmes offered for educators by the South African Department of Education, little has been achieved at the level of management in terms of creating a wider understanding of the social and cultural complexities of the condition and its impact on the quality of teaching and learning. Specifically, there is a lack of developmental programmes to help school principals provide leadership that can ensure that teachers and children who live in a context affected by the disease will still find themselves in a school environment of quality, care and compassion. With this in mind, we conducted a qualitative research enquiry among a sample of 12 school principals in the Eastern Cape Province in order to discover their perceptions about the impacts of HIV and AIDS on their schools and to learn how they have responded to the corresponding challenges. Our intention was to use the findings primarily to inform the development of an academic programme and short courses to empower school principals and leadership in this regard, but the findings may also be relevant as a guide for research on a larger scale.     

Women's health,HIV/AIDS and the workplace in South Africa

This work explores the connections between gender inequality, HIV/AIDS and women's health in the world of work in South Africa. These connections are located within a context of significant reversals in development, specifically declining life expectancy and premature mortality for South Africans — particularly for women. By relying on the existing literature and interviews with 33 key informants, the paper examines the extent to which South African workplaces are recognising women's social and biological vulnerability to HIV. In particular, the paper considers the potential role of the workplace in responding to growing evidence that links gender and health by establishing targeted HIV/AIDS interventions. The findings suggest that the vast majority of company representatives do not recognise women's social and biological vulnerability and related social norms vis-à-vis HIV and AIDS. Importantly, most workplaces are not initiating programmes that specifically address women's or men's health. The author briefly identifies factors that may help explain the current state of knowledge and practice in the realm of HIV and women's health in the workplace, and puts forward suggestions for future research.     

Appreciative inquiry into lifeskills-based HIV/AIDS education in South African schools

With a steady rise in the prevalence of HIV and AIDS throughout the world it has become vital for programme implementers at all levels to ensure that all HIV intervention programmes are effectively put into practice. The present research used qualitative and quantitative data to evaluate the lifeskills-based HIV/AIDS education programme being implemented in primary and secondary schools in South Africa, with special reference to KwaZulu-Natal. A qualitative questionnaire gathered information from nine respondents at three levels: Department of Education district officials, educators and learners. Six key themes were consequently identified to guide the evaluation: communication, empowerment, resources, networking, motivation, and evaluation and feedback. A quantitative questionnaire completed by 30 educators revealed an overall positive attitude towards the programme, regardless of the educator's gender, age or level of formal education. The results are discussed with special reference to continuation and improvement of the lifeskills-based HIV/AIDS education programme.     

Sex work,reform initiatives and HIV/AIDS in inner-city Johannesburg

The on-going criminalisation of sex work in South Africa, concurrent sexual partnerships, socio-economic vulnerability, migrant status and gender-based violence intensify sex workers' risk of contracting HIV. These factors combine to restrict the skills, ability and resources of sex workers to negotiate safer sex and to access HIV prevention, treatment and healthcare services. The paper situates the living and working conditions of sex workers in Hillbrow, an inner-city area of Johannesburg, within the South African legal context, especially in regard to current law reform initiatives regarding sex work, as well as the increasing anxiety about the influx of (sex) tourists during the 2010 FIFA World Cup. In addition, the paper describes an intervention by the Reproductive Health & HIV Research Unit at the University of the Witwatersrand, Johannesburg, an innovator in providing mobile healthcare services and education to hotel-based sex workers in Hillbrow. The paper contends that a legal-rights-approach to HIV risk and vulnerability, together with powerful public health considerations, render decriminalisation an imperative response to sex workers' material conditions.     

Knowledge,attitudes and perceptions of HIV/AIDS among traditional birth attendants and herbal practitioners in Lagos State,Nigeria

Recognising the widespread role of traditional birth attendants (TBAs) and herbal practitioners (HPs) in health care at community level in Nigeria, we set out to assess their knowledge, attitudes and practices in relation to HIV infection and prevention. Questionnaires were administered to a convenience sample of 189 participants in 20 local government areas of Lagos State. We found that knowledge of modes of transmission of HIV was less than adequate and included lack of knowledge of the existence of HIV/AIDS amongst some practitioners, claims for the ability to treat HIV/AIDS, failure to name major avenues of transmission and confusion of HIV/AIDS with other conditions. The use of measures to prevent infection of clients and themselves showed that normal standards of infection control are not adhered to. Considering that as many as 60% of children born in Nigeria are delivered by traditional birth attendants and that use of the services of herbal practitioners extends across the entire society in both rural and urban settings, this is seen as reason for concern. It is suggested that better incorporation of TBAs/HPs into the well-developed primary health care system offers not only a way of overcoming the risks of infection posed by traditional health practices but also offers an opportunity to extend the reach of voluntary counselling and testing and prevention of mother-to-child infection programmes. The research has shown the need for appropriate training of TBAs, to enable them to recognise the risk of HIV infection in their own practices and to encourage them to adopt universal precautions against spreading infection. We also recommend that they be more extensively integrated as primary health care workers in VCT and PMTCT programmes in Nigeria. We further suggest that referrals made between the traditional practitioners and professional health care providers can be an effective and successful element of HIV/AIDS prevention and control programmes.     

Community-based care of children with HIV in Potchefstroom,South Africa

Children contract HIV infection largely through vertical transmission and are vulnerable to AIDS illness due to an immature immune system. In South Africa, hospitals are often overburdened and thus children with HIV may be directed to the community for care. As a result, non-professional caregivers are a predominant source of care for children living with HIV. Various authors, including the Department of Health, have stipulated the importance of establishing the knowledge and needs of non-professional caregivers of children with HIV. Our research has investigated the extent of non-professional caregivers' knowledge and needs, specifically those within the Potchefstroom district of the North-West Province. The objectives included formulating guidelines for a training programme that can enhance relevant knowledge and skills among these caregivers. Quantitative data were gathered using a questionnaire, which was developed following a literature study. The 109 non-professional caregivers who responded to the questionnaire displayed some knowledge and skills concerning specifically the care of children with HIV or AIDS, although gaps existed concerning their knowledge of community-based referral, caring needs specific to children, and precautionary measures to prevent HIV transmission. Recommendations are made with specific reference to a training programme. We surmise that non-professional caregivers play a pivotal role in the care of children with HIV in the Potchefstroom district — a service that is sometimes rendered in perilous conditions. This study improves our understanding of the support and training needed for non-professional caregivers in their pursuit to care for children with HIV in resource-limited communities, and thus it contributes to the field of nursing science. The findings may generate ideas for future research on this important topic.     

The impact of the HIV epidemic on the composite wellbeing of educators in South Africa: a qualitative study

In South Africa, support is available for educators who are HIV-positive, and there are numerous initiatives to curb further HIV infections. What is lacking though is an understanding of how the HIV epidemic impacts on educators who are affected personally or professionally. For this reason a qualitative study was undertaken with 25 affected educators from the Gauteng and Free State provinces. Semi-structured interviews were conducted to determine how the epidemic is impacting the health of educators who are affected but not HIV infected. The results suggest that affected educators are in need of interventions that target health promotion, since those who participated reported poor physical, emotional, social, spiritual and professional health. The results also suggest that some educators do cope with the overall impact of the epidemic, implying that resilient functioning among affected educators should be promoted.     

HIV/AIDS prevention through peer education and support in secondary schools in South Africa

The implementation and evaluation of a peer education and support programme in secondary schools to prevent and reduce high-risk sexual behaviour amongst adolescents is discussed. The aims of the programme were to provide accurate information about HIV/AIDS, discuss and reconsider peer group norms, and establish support for learners. In the programme that was implemented in 13 secondary schools in Tshwane, South Africa, peer educators were identified, trained and supported to implement the programme in their schools with the assistance of a teacher and postgraduate students as facilitators. Peer educators organised HIV awareness activities, facilitated class discussions on risk behaviour and gender relationships, and supported learners in solving personal problems. Process evaluation included weekly reports and focus group discussions with peer educators and teachers. A quasiexperimental design involving an experimental and control group, as well as pre- and post-assessments, was used to evaluate the impact of the programme on psychological well-being, personal control, school climate and reported high-risk behaviour of learners aged between 13 and 20 years. The results showed that the percentage of learners in the experimental group who were sexually experienced remained unchanged over the time period of 18 months. In contrast, a significantly increased percentage of learners in the control group were sexually experienced after the same time period. The control group also perceived more of their friends to be sexually experienced. No differences were reported in condom use in either of the groups. The findings of this study suggest that peer education can contribute to a delayed onset of sexual activity, and can therefore contribute to the prevention of HIV/AIDS amongst adolescents.     

HIV/AIDS knowledge among adolescent sign-language users in South Africa

People with hearing impairment may have difficulty accessing information about HIV/AIDS, especially those who use sign language. Because adolescence is characterised by sexual maturation, it is important to gauge levels of HIV/ AIDS awareness and knowledge in this age group. For this scoping study, we interviewed seven adolescent South African Sign Language (SASL) users (aged 15 to 21) who were attending a school outside Johannesburg which caters for hearing-impaired learners from limited socioeconomic backgrounds. The responses were transcribed and themes were clustered to extract the essence of what was conveyed. The participants appeared to have basic knowledge about HIV and AIDS (e.g. prevention through the use of condoms); however, gaps in their knowledge included misperceptions about contracting HIV infection (e.g. through touching people with HIV or AIDS, or rejecting a person who was possibly HIV-positive as a preventive measure) and confusing HIV disease with other illnesses (e.g. cancer). Overall, the adolescents appeared to have insufficient information about HIV transmission and did not appear to fully understand the consequences of infection. The findings correlate with other research in Africa showing the difficulties experienced by people with disabilities, including hearing impairment, in accessing HIV/ AIDS information. The article advocates for policymakers to include people with hearing impairment, particularly sign language users, in HIV-prevention programmes.     

Understanding visuals in HIV/AIDS education in South Africa: differences between literate and low-literate audiences

This article reports on a research project aimed at determining the scope and nature of differences in picture comprehension between literate and low-literate audiences in the context of HIV and AIDS. Structured interviews were held with 30 low-literate and 24 literate adult speakers of African languages. The responses were coded and analysed both qualitatively and quantitatively. Consistent with previous research, we found that purely analogical visuals pose relatively few interpretation problems across the literacy spectrum. Literate and low-literate respondents recognised human beings and familiar analogous objects equally successfully. The interpretation of abstract items was problematic for respondents at both literacy levels, but relatively more so for low-literate respondents. Purely symbolic or conventional abstract elements, such as speech and thought balloons, and purely mathematical symbols are difficult for low-literate individuals since they do not have any analogical residue that will trigger relevant meaning aspects of the visual. Metaphors are difficult when they require culture-specific knowledge. The results strongly suggest that designers should exploit the expressive power of the human body in constructing (abstract) meaning. All humans have comparable experiences with associated basic actions and bodily expressions. Therefore, facial expressions and body postures and positions are powerful in transferring complex messages. We advise that pictorial metaphors, art styles that distort objects, complex pictures with partially symbolic content, as well as abstract symbols borrowed from written language should be omitted where possible.     

A study of local government HIV/AIDS projects in South Africa

The primary goal of this study was to survey local government HIV/AIDS projects in South Africa. A total of 240 questionnaires were sent to local municipalities nationally between May and July 2002. A total of 44 municipalities returned their questionnaires, covering 53 projects. Most projects focused on prevention and awareness and the majority had awareness/prevention/information as part of their objectives as well as their activities. Home/community-based care was also prominent. It seems that in the future the focus of programme development will shift in this direction. Major constraints were a lack of funds, transport and trained personnel. Future emphasis must thus be put on these components. In addition government needs to put more resources into local government HIV/AIDS programmes since this tier will be the nodal point for national combatting of the HIV/AIDS epidemic.     

HIV/AIDS,poverty and risky sexual behaviour in South Africa

This paper employs data from the 1998 South African Demographic and Health Survey in exploring the nature of socio-economic inequalities in and determinants of risky sexual behaviour. Risky sexual behaviour was associated with poverty only in the case of multiple partnerships. Affluent women that have engaged in risky sexual behaviour were shown to be more likely to have cited negative perceptions about condom use as main reason for not using a condom at last sex. Poor women in turn were more likely to cite lack of knowledge about condoms and abstinence from condom use as main reason. Poverty plays little part in explaining differences in risky sexual behaviour, although higher education in some cases was associated positively with risky sexual behaviour. Risky sexual behaviour was associated with differences in age, urban residence and marital status. Coloured, Asian and White women were less likely than African women to have engaged in risky sexual behaviour. Violence and coercion were also associated with risky sexual behaviour. Women in affluent households that had engaged in risky sexual behaviour were more likely to have been mistreated by a husband or partner compared to poor women. There is no evidence of a definitive one-way causal relationship between poverty, gender and sexual behaviour and further research is required to elucidate this complex relationship.     

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.     

Gender relations in the context of HIV/AIDS in rural South Africa

As part of the Microbicides Development Programme, we conducted formative research to explore gender relations at a site in rural KwaZulu-Natal. We were interested in gender relations and in assessing their implications for emerging female initiated and controlled HIV prevention methods in the form of microbicides. Eleven focus group discussions were conducted with men and women in the community. Participants were asked about decision making about sex, family planning and the use of condoms in heterosexual relationships. Findings suggest that gender relations in the context of HIV are complex. The findings suggest that both men and women feel that the final decision about child-bearing and the use of contraceptives and rests with women since they are the ones who bear the burden of child care. This implies that it is feasible for couples to use women-initiated and controlled methods of HIV prevention.     

Factors associated with teachers' implementation of HIV/AIDS education in secondary schools in Cape Town, South Africa

This study investigated the factors influencing whether high school teachers implemented HIV/AIDS education. The independent variables included constructs derived from expectancy value theories, teachers' generic dispositions, their training experience, characteristics of their interactive context and the school climate. We conducted a postal survey of 579 teachers responsible for AIDS education in all 193 public high schools in Cape Town. Questionnaires were completed and returned by 324 teachers (56% response rate) from 125 schools. Many teachers (222; 70%) had implemented HIV/AIDS education during 2003, and female teachers were more likely to have implemented than males (74% vs. 58%). The teacher characteristics associated with teaching HIV/AIDS were previous training, self-efficacy, student-centeredness, beliefs about controllability and the outcome of HIV/AIDS education, and their responsibility. The existence of a school HIV/AIDS policy, a climate of equity and fairness, and good school-community relations were the school characteristics associated with teaching HIV/AIDS. These findings demonstrate the value of teacher training and school policy formulation. They also demonstrate the value and importance of interventions that go beyond a sexual health agenda, focussing on broader school development to improve school functioning and school climate.     

Oral health needs of HIV/AIDS orphans in Gauteng, South Africa

To care for HIV/AIDS orphans will put health and social services in South Africa before a major challenge. Published clinical information on South and Southern African HIV-positive children is limited to hospitalized children. A cross-sectional, prospective study was conducted on a convenience sample of HIV-positive children, living in orphanages in Gauteng, South Africa, in order to determine the oral health needs of the children. Five homes for abandoned/orphaned HIV/AIDS children were visited, 11 caregivers, excluding the nursing sisters (registered nurses), were interviewed to determine their knowledge regarding oral health. An oral examination was performed on 87 children who were not receiving antiretroviral treatment. The caregivers were knowledgeable regarding pseudomembranous candidiasis but all lacked knowledge on oral hygiene procedures and the cariogenic potential of a baby bottle. The mean age of the children ranged between 3.2 and 7 years, with one home having children older than 11 years. Rampant early childhood caries in 19 (21.8%) children was the major finding, with 5 children suffering severe pain from multiple carious teeth. In the hospice section of the homes all 12 children had clinically detectable candidiasis, while in 4 (33.3%) there was an associated bleeding and ulceration of the oral mucosa, impairing their ability to eat. The findings indicate a training need among caregivers regarding the oral health of children and a role for health professionals in preventing oral diseases and reducing suffering.     

HIV/AIDS and the South African Bill of Rights,with specific reference to the approach and role of the courts

An outstanding feature of the 1996 South African Constitution is the inclusion of a Bill of Rights, which contains all the categories of human rights that are ordinarily included in most international human rights instruments. Section 27 provides for, among other things, the right to health care services and the right to emergency medical treatment. Several other provisions in the Bill of Rights are quite relevant to the fight against HIV/AIDS and to protecting the rights of those who are infected. The South African courts, particularly the Constitutional Court, have often been called upon to interpret and give effect to some of these rights. Judgements regarding confidentiality, HIV testing, access to medication and related issues have been passed in the courts. In that sense, the courts can and have played a pivotal role in the fight against the HIV/AIDS pandemic. In spite of that, South Africa is still perceived as a country that has failed to address the issue of HIV/AIDS with the urgency that it deserves. This article discusses the extent to which the South African Bill of Rights provides for those rights relevant to persons with HIV/AIDS and it examines some decisions by the courts regarding the enforcement of those rights. The article also explores how and whether or not particular court decisions have been implemented and honoured.