HIV/AIDS in South Africa 25 Years On (eBook)

Foreword 4
Acknowledgments 6
Contents 7
Contributors 10
1 Introduction and Overview 17
1.1 The HIV/AIDS Epidemic in South Africa 18
1.2 Southern Africa Within the Global HIV/AIDS Epidemic 19
1.3 Rationale for this Book 20
1.3.1 Overview of the Book 21
References 24
Part I Psychosocial Issues 26
2 The Sociocultural Aspects of HIV/AIDS in South Africa 27
2.1 Introduction 27
2.2 Contours of the Local Web of Significance 28
2.3 From Contours to Practices 30
2.3.1 Unprotected Sex with Multiple and Age-Disparate Partners 30
2.3.2 Gender Inequalities 31
2.3.3 Stigma, Denial, Exclusion and Discrimination 32
2.3.4 Substance Abuse 32
2.3.5 Dry Sex or Vaginal Douching 33
2.3.6 Cultural Practices and Ritual Activity 33
2.4 Conclusion 36
References 36
3 HIV and Women 40
3.1 Introduction 40
3.2 Legacy of Apartheid, Patriarchy and Urbanisation: Historical Perspectives 41
3.3 Women, Femininities and Sexuality 44
3.4 Men and Control: Gender Inequities and Gender-Based Violence 47
3.5 Prevention of HIV in Women, Challenges and Future Directions 49
References 51
4 Masculinity and HIV/AIDS 54
4.1 Introduction 54
4.2 Introducing Masculinity 54
4.2.1 Masculinity, Risk Behaviour and HIV/AIDS 55
4.3 Changes in Patterns of Masculinity 60
4.4 Conclusion 63
References 64
5 HIV and Youth: A Behavioural Perspective 68
5.1 Introduction 68
5.1.1 Background 68
5.2 Understanding Risk Influences for HIV Infection Through Sexual Transmission in Youth in South Africa 70
5.3 Reviewing the Evidence for Effectiveness of Interventions at Various Levels of Influence for Youth in South Africa 74
5.3.1 Individual Level 75
5.3.2 Interpersonal and Community Levels 75
5.4 Conclusion 77
References 78
6 Infants and Young Children Affected by HIV/AIDS 82
6.1 Introduction 82
6.2 Children Affected by HIV and AIDS 83
6.2.1 HIV Infection in Young Children 83
6.2.1.1 The Virgin Cure and Child Rape 84
6.2.2 Young Children Living with HIV 85
6.2.3 Treatment and Support for Young Children Living with HIV and AIDS 85
6.3 Effects of HIV and AIDS on the Care of Young Children 87
6.3.1 Maternal Mental Health 88
6.3.2 Parenting in the Context of HIV and AIDS 89
6.3.3 Parental Death 90
6.4 Responses to Children Affected by HIV and AIDS in South Africa 90
6.4.1 Policy Responses 91
6.4.2 Programme Activity 93
6.4.3 Developments on the Global Front 94
6.5 Conclusions 94
References 95
7 Poverty and HIV and AIDS 101
7.1 Introduction 101
7.2 Understanding the Relationship Between HIV and AIDS and Poverty 101
7.3 Reasons for Poor People Having Increased Risk of HIV 103
7.4 Is HIV a Function of Poverty or Income Inequality? 105
7.5 Impact of HIV/AIDS and Poverty on Society and Health 106
7.6 How AIDS Exacerbates Poverty and Impacts Negatively on Orphans 108
7.7 The Impact of Poverty on HIV/AIDS Interventions 109
7.7.1 Condom Use 109
7.7.1.1 ARV Treatment and Poverty 110
7.8 Conclusion and Recommendations for Further Research and Interventions 111
References 113
8 HIV and Stigma in South Africa 117
8.1 Introduction 117
8.2 South African Contributions to Stigma Theory 117
8.2.1 Definitions of Stigma 118
8.2.2 Stigma Typologies 119
8.3 South African Stigma Research 119
8.3.1 Developing Stigma Instruments for South Africa 120
8.3.2 Research Findings in South Africa 120
8.4 Stigma Interventions in SA: Politics and Pragmatics 123
8.5 Funding and International Collaborations in Stigma Research 126
8.6 Conclusion 128
References 128
Part II Prevention and Treatment 133
9 The Politics and Psychology of AIDS Denialism 134
9.1 Introduction 134
9.2 Overview of AIDS Denialism 134
9.3 AIDS Denialism and Former President Thabo Mbeki 136
9.4 Possible Explanations for Mbekis Denialism 138
9.5 A Psychological Autopsy of AIDS Denialism 140
9.6 Conclusions 143
References 144
10 Local-Level Responses to HIV/AIDS in South Africa 146
10.1 Introduction 146
10.2 A Local-Level Orientation to HIV Infections and AIDS Responses 146
10.2.1 HIV Prevalence at Human Settlement Level 146
10.2.2 Variation in HIV/AIDS Responses at Community Level 148
10.3 A Review of Local Responses to HIV/AIDS 150
10.3.1 Civil Society Responses to HIV/AIDS at Local Level 150
10.3.1.1 A Regional Orientation 150
10.3.1.2 The South African Context 152
10.3.1.3 Support for Local-Level Responses 155
10.3.2 Local Government Responses 158
10.4 Prospects for Responding to HIV/AIDS at the Local Level 160
10.4.1 What Is Needed? 161
References 162
11 Social Movements and HIV/AIDS in South Africa 165
11.1 Introduction 165
11.2 The Treatment Action Campaign 167
11.3 Rights, Citizenship and Globalisation from Below 169
11.4 Social Movements at the Community Level 171
11.5 The Power of AIDS Dissent 172
References 174
12 Approaches to HIV Counselling and Testing: Strengths and Weaknesses, and Challenges for the Way Forward 175
12.1 Introduction 175
12.1.1 Current Availability and Use of CT Services in South Africa 175
12.1.2 Reasons for and Barriers to CT Uptake 176
12.1.3 The Need to Scale up CT 176
12.2 Client-Initiated Counselling and Testing or VCT 176
12.2.1 Evidence Supporting VCT 177
12.2.2 Criticism of VCT 178
12.2.3 Innovative Approaches to VCT Are Required 178
12.2.3.1 Home-Based VCT 179
12.2.3.2 Evidence that Home-Based VCT Is Effective 179
12.2.3.3 Criticism/Concerns About Home-Based VCT 179
12.2.3.4 Mobile VCT 182
12.2.3.5 Evidence that Mobile VCT Is Effective 182
12.2.3.6 Concerns About Mobile VCT 184
12.3 Provider Initiated Counselling and Testing (PICT) 184
12.3.1 Evidence that PICT Is Effective 185
12.3.2 Concerns About PICT 185
12.3.3 Expanding Paediatric Testing 185
12.3.4 Preliminary Evidence in Support of Paediatric Testing 186
12.3.5 Concerns 186
12.4 Challenges for the Way Forward 186
12.5 Policy and Research Gaps 188
12.6 Conclusions 189
References 189
13 Vertical transmission of HIV Pregnancy and Infant Issues 193
13.1 HIV Prevention in Pregnancy 193
13.2 HIV Transmission to the Baby Vertical Transmission 193
13.3 Antiretroviral Treatment in Pregnancy 194
13.4 Mode of Delivery 195
13.5 Infant Feeding 197
13.6 Contribution of Social Science 197
13.7 HIV Testing as the First Step in Prevention 198
13.8 Situation in Sub-Saharan Africa and South Africa 198
13.9 Psychological Considerations 199
13.10 Reproductive and Sexual Health Counselling for all HIV -Positive women 199
13.11 HIV Counselling for All Pregnant Women 201
13.12 Intervention Pathways and Decision Making 201
13.12.1 Mother/Father and Couple Testing 202
13.12.2 Consent and Result Collection 203
13.12.3 Stigma and Disclosure 204
13.12.4 After Testing HIV Positive 204
13.13 Fathers 206
13.14 Infant Testing 206
13.15 Child Development in the Presence of HIV 207
13.16 Bereavement and HIV 207
13.17 A Way Forward Integrated Provision 208
References 208
14 HIV/AIDS, Nutrition and Structural Interventions in South Africa: A Move in the Right Direction 215
14.1 Introduction 215
14.2 Failure of HIV Prevention 215
14.3 Malnutrition and HIV: A Vicious Cycle 217
14.4 Promising Interventions 220
14.4.1 Structural Contributions to HIV Infection 220
14.4.1.1 A Structural Intervention in South Africa 221
14.4.2 Schools as a Platform for the Delivery of Health Interventions 222
14.4.2.1 HIV, School Health and Nutrition 222
14.4.2.2 Junior Farmer Fields and Life Schools 223
14.4.2.3 School Feeding 225
14.5 Key Lessons 226
14.6 Conclusion 227
References 228
15 Strengthening Community Responses to AIDS: Possibilities and Challenges 231
15.1 Introduction 231
15.2 Conceptualising the AIDS-Competent Community 233
15.2.1 Knowledge and Skills 233
15.2.2 Social Spaces for Dialogue and Critical Thinking 234
15.2.3 Ownership/Responsibility 234
15.2.4 Solidarity and Common Purpose 235
15.2.5 Bridging Social Capital 235
15.3 The Entabeni Project 235
15.4 Building Volunteer Skills 236
15.5 Building Bridges Between Volunteers and External Partners 237
15.6 Building Within-Community Support Networks for the Volunteers 238
15.7 Volunteer Challenges 240
15.8 Conclusion 241
References 243
16 HIV/AIDS, Religion and Spirituality 246
16.1 Introduction 246
16.2 Religion and Society 247
16.2.1 The Value of Faith-Based Organisations (FBOs) 247
16.2.2 The Challenges FBOs Face 248
16.2.3 The Impact of the Compassion vs. the 'Divine Punishment' Doctrines 249
16.3 Religious Institution-Based Initiatives in AIDS Prevention and Care in South Africa for the Past 25 Years 250
16.3.1 Christianity 252
16.3.2 Islam 254
16.3.3 Judaism 254
16.3.4 Hinduism 255
16.3.5 African Tradition 255
16.4 Conclusion 256
References 257
Part III Persons Living with HIV/AIDS 261
17 Experiences of People Living with HIV 262
17.1 Introduction 262
17.2 Common Experiences of Living with HIV 265
17.2.1 Recognising Status 265
17.2.2 'Othering' and Depression 265
17.2.3 Acceptance and 'Living Positively' 268
17.2.4 'Speaking Out' 269
17.3 Heterogeneous HIV Experiences 270
17.4 Signifying HIV 272
17.5 Problems of HIV Experiences 273
17.6 Future Experiences 275
17.7 Experience as Theory 276
References 277
18 Positive Prevention: HIV Risk Reduction for People Living with HIV/AIDS 279
18.1 Introduction 279
18.2 Rationale for Positive Prevention 279
18.3 Parameters of Positive Prevention 281
18.4 Positive Prevention Interventions Tested in the US Clinical Trials 282
18.5 Cultural Adaptation of Two Positive Prevention Interventions for Use in South Africa 283
18.5.1 Healthy Relationships 284
18.5.2 Options for Health 284
18.6 Principles of Positive Prevention 285
18.6.1 Detect HIV Infection Early for Maximal Impact 285
18.6.2 Effectively Intervene Within Risk Contexts 285
18.6.3 Systematically Reduce Institutionalized AIDS Stigma 286
18.6.4 Support HIV-Status Disclosures and Responsible Non-disclosures 286
18.6.5 Debunk the Myth that Undetectable Viral Load Equals Non-infectiousness 287
18.6.6 Aggressively Detect and Treat Co-occurring STI 287
18.6.7 Integrate Positive Prevention Interventions with Routine Clinical and Supportive Services 288
18.7 The Promise of Positive Prevention in South Africa 288
18.8 Why Positive Prevention could Fail South Africa? 289
18.9 Conclusions 290
References 290
Part IV New Directions in HIV Research 293
19 HIV/AIDS and Persons with Disabilities 294
19.1 Introduction 294
19.2 Disability in South Africa 294
19.3 Persons with Disabilities and HIV Risk 296
19.4 The Global HIV/AIDS and Disability Survey 300
19.5 HIV/AIDS and Persons with Disabilities in South Africa 300
19.6 HIV/AIDS and the Disability Grant 302
19.7 Conclusions 304
References 305
20 HIV/Aids and the Prison System 310
20.1 Introduction 310
20.2 Inmates 310
20.2.1 Prisoners Are Part of the Community 310
20.2.2 Reaching High-Risk Demographics of the Prison Population 311
20.2.2.1 Imprisonment, Health Care and Early Mortality 311
20.2.2.2 HIV Prevalence 311
20.2.2.3 Access to ARV 311
20.2.3 High-Risk Behaviours 312
20.2.4 Sex and Sexual Violence in Prisons 313
20.2.5 Managing People Entering the Prison System and People on Parole and Supervision 316
20.2.6 Government's Response to HIV and AIDS in Prisons 318
20.3 HIV and AIDS and Prison Governance 320
20.3.1 The Impact of HIV/AIDS on DCS Officials 320
20.3.2 Fear of Stigmatisation 320
20.3.3 The Impacts of HIV/AIDS on Prison Governance 321
20.3.3.1 Staff Attrition 321
20.3.3.2 The Role of Leadership in Combating HIV/AIDS 322
20.3.4 Remedial Measures 322
20.4 Conclusion 323
References 324
21 HIV and Circumcision 327
21.1 Introduction 327
21.2 Biological Plausibility 327
21.3 Scientific Evidence 328
21.3.1 Ecological and Cross-Sectional Studies 328
21.3.2 Randomised Controlled Trials 329
21.4 Montreux 2007 332
21.5 Implementation and Operations Research 332
21.6 Social Scientists Reaction 337
21.7 Conclusions 338
References 339
22 Participation in HIV Vaccine Trials 341
22.1 Introduction 341
22.1.1 Impact of HIV/AIDS in South Africa 342
22.1.2 Strategies for HIV Prevention 343
22.2 Developing an HIV Vaccine 343
22.2.1 The HIV Vaccine Clinical Trial Context 344
22.2.2 Stakeholders in the Clinical Trial Process 345
22.3 Socio-behavioural Aspects of HIV Vaccine Trials 346
22.3.1 Recruitment, Willingness to Participate (WTP), Retention and Attrition 346
22.3.2 Enrolling Adolescents in HIV Vaccine Trials 347
22.3.3 Social Harms 348
22.3.4 Community Participation in HIV Vaccine Trials 349
22.4 The Future of HIV Vaccine Research in South Africa: Challenges and Opportunities 352
References 353
23 Bridging the Gap Between HIV and Mental Health Services in South Africa 356
23.1 Introduction 356
23.2 Mental Health and HIV/AIDS 357
23.3 Mental Illness and Its Correlates for PLHA 358
23.4 Other Vulnerable Groups and Risk for Mental Illness 360
23.5 Mental Illness and the Course of HIV 360
23.6 HIV Infection and Risk Among People with Mental Illness 361
23.7 Addressing the Mental Health Consequences of HIV 363
23.8 Strengthening Mental Health and HIV Services 365
23.8.1 AIDS and Infrastructure 365
23.8.2 Service Integration 366
23.8.3 Advocacy, Education, and Research 366
23.8.3.1 Advocacy 366
23.8.3.2 Education 370
23.8.3.3 Research 370
References 371
Index 375