Prevention efforts that ignore the broader economic, political and social factors that encourage high-risk sexual practices will be limited in stopping the spread of HIV.
The recent papal visit to the UK was targeted by protestors unhappy with the Vatican’s stance on LBGT rights, women’s equality, the handling of what seems to be systemic child abuse by Catholic priests, as well as the Pope’s views on the role of contraception, which he does not encourage, and claims that it makes the HIV epidemic worse. In the Pope’s view, only the teachings of the Catholic Church, such as abstinence, no sex before marriage and being faithful, can halt the spread.
This stance has been strongly criticised by opponents, who argue that denying that contraception can help stop the spread of HIV, particularly in sub-Saharan Africa, the region in which the vast majority of the world’s people living with HIV/AIDS live, will discourage condom use and lead to greater infection rates. The alternative solution to the epidemic is education, in terms of how the virus is spread, means of protection and general sexual health, to enable people to make informed sexual choices.
The standard package of solutions forwarded by UNAIDS and other health agencies include ABC campaigns (Abstain, if you can’t Be faithful, or use a Condom), and IEC (Information, Education and Communication) campaigns, along with condom distribution, treatment to prevent Mother to Child Transmission, increasing access to general and sexual healthcare services, voluntary counselling and testing services, and treatment in the form of Antiretroviral drugs (ARV’s). However, although there are signs that the epidemic is beginning to stabilise in some countries in sub-Saharan Africa [1], there is broad agreement that results from prevention efforts have been disappointing.
One of the reasons for this lack of success is that the standard package of interventions are only targeted at changing individual behaviour, and form a biomedical/behavioural paradigm[2]. This individualistic paradigm has a narrow view of human behaviour, with individuals seen as largely rational, and able to change their behaviour in relation to desirable aims as new information becomes available. However, a growing body of work in the epidemiological discipline has begun to stress the role of social/structural drivers in the HIV epidemic [3]. This approach does not deny that behaviour change is ultimately the key to prevention, but that human behaviour cannot be understood in isolation from the conditions in which people live.
Current understandings of the HIV epidemic in sub-Saharan Africa are often based on simplistic assumptions. For example, HIV/AIDS is generally seen as a disease of poverty [4, 5]. However, within sub-Saharan Africa, the richest countries in the region, South Africa and Botswana, have amongst the highest prevalence rates, and within countries, it is often the wealthiest classes that have the highest levels of HIV prevalence[6, 7].
A more conservative conclusion is that ‘HIV does not disproportionately affect the poorer in sub-Saharan Africa’[8]. Despite nearly 30 years of prevention efforts on sub-Saharan Africa, HIV prevalence rates are still high within the classes that have the means and knowledge to prevent infection. This suggests that there is more to prevention than education or condom distribution. This is supported by data from Botswana, which shows that people with similar levels of HIV-related knowledge engage in very different sexual practices, something which is ‘consistent with the existence of non-informational barriers to behavioural change’[9], and shows that in Botswana, ‘knowledge is not enough’.
An example of how we can understand HIV transmission from a structural point of view is the case of Migrant Mineworkers in South Africa[10, 11], a group that exhibit high levels of both risky sexual behaviour and HIV infection [12], and also infect partners on their return home. The migrant labour system emerged in colonial times, and was continued in the apartheid era. Miners are employed from all over South Africa and adjoining countries, but are not encouraged to bring their families and settle in the mining areas. Most employment contracts are not permanent, generally renewed on an annual basis, and foreign workers are not granted permanent residence. This creates long periods of separation between miners and their families, with regular trips back between contracts. The living and working conditions are poor, with the male workforce consigned to single-sex hostels that house up to 18 mineworkers per room. The work is physically demanding and dangerous, fostering fatalistic attitudes towards life. Deaths in the mines are common and expected. There is little to do in terms of recreation or stress relief except drink and have sex, readily available from sex workers who are often migrants themselves, living and working in hotpot settlements that have sprung up around the mines [10–12].
When combined, these factors create a highly risky sexual environment, and cannot be ignored when trying to understand the epidemic. As one prominent academic concludes, ‘the most important aspect of slowing down the spread of STI’s and HIV infection … would be to alter the broader social and material conditions that encourage high-risk sexual practices’[10]. Prevention efforts that ignore these conditions will have a limited impact, and encourage a tendency to distract attention from the broader economic, political and social change that is necessary to stop the spread of HIV.
References
[1] UNAIDS, Epidemic Update November 2009. 2009, UNAIDS and WTO: Geneva. p. 100.
[2] Campbell, C. and B. Williams, Beyond the biomedical and behavioural: towards an integrated approach to HIV prevention in the Southern African mining industry. Social Science & Medicine, 1999. 48(11): p. 1625-1639.
[3] Gupta, G.R., et al., Structural approaches to HIV prevention. The Lancet, 2008. 372(9640): p. 764-775.
[4] Poku, N.K., Africa’s AIDS Crisis in Context: ‘How the Poor Are Dying’. Third World Quarterly, 2001. 22(2): p. 191-204.
[5] Whiteside, A., Poverty and HIV/AIDS in Africa. Third World Quarterly, 2002. 23(2): p. 313-332.
[6] WOJCICKI, J.M., SOCIOECONOMIC STATUS AS A RISK FACTOR FOR HIV INFECTION IN WOMEN IN EAST, CENTRAL AND SOUTHERN AFRICA: A SYSTEMATIC REVIEW. Journal of Biosocial Science, 2005. 37(01): p. 1-36.
[7] Parkhurst, J., Understanding the correlation between structural factors of wealth and poverty with HIV in Africa: no single correlation. 2010, WHO.
[8] Mishra, V., et al., HIV infection does not disproportionately affect the poorer in sub-Saharan Africa. AIDS, 2007. 21: p. S17-S28 10.1097/01.aids.0000300532.51860.2a.
[9] Dinkelman, T., J. Levinsohn, and R. Majelantle, When Knowledge is Not Enough: HIV/AIDS Information and Risky Behaviour in Botswana, in Research Seminar in International Economics. 2006: Gerald R.Ford School of Public Policy, The University of Michigan.
[10] Campbell, C., Letting Them Die. 2009, Oxford: James Currey.
[11] Crush, J., et al., Migration and HIV/AIDS in South Africa. Development Southern Africa, 2005. 22(3): p. 293-318.
[12] Lurie, M.N., et al., The impact of migration on HIV-1 transmission in South Africa: a study of migrant and nonmigrant men and their partners. Sex Transm Dis, 2003. 30(2): p. 149-56.
