Donald Skinner

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 ones own status, thus delaying testing and accessing treatment. At an individual level stigma undermines the persons 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.

Epidemiology of health and vulnerability among children orphaned and made vulnerable by HIV / AIDS in sub-Saharan Africa.

Abstract The HIV/AIDS epidemic in sub-Saharan Africa has already orphaned a generation of children, and it is projected that by 2010, 18 million African children under the age of 18 are likely to be orphans from this single cause (UNICEF, 2005, The state of the Worlds Children: Childhood under threat. New York: UNICEF). Results from a Kellogg funded OVC project (Skinner et al., 2004, Definition of orphaned and vulnerable children. Cape Town: HSRC) supported the construct that the loss of either or both parents would indicate a situation of likely vulnerability of children. A key problem in the literature on the impact of orphanhood on the well-being of children, families and communities, is that the focus of assertions and predictions is often on the negative impact on ‘AIDS orphans’, or households. There are hardly any studies that compare the experiences of orphans with non-orphans. This paper thus attempts to fill that gap. It uses epidemiological data to explore the epidemiology of health and vulnerability of children within the context of AIDS in sub-Saharan Africa. Because of data limitations, only the following aspects are examined: (i) orphan status; (ii) household structure (in particular, grandparent headedness and female-headedness); (iii) illness of parents; (iv) poverty; and (v) access to services, especially schooling, health, social services. While recognizing the limitations of the analysis, data presented in this paper indicates that orphans in sub-Saharan Africa are more vulnerable than non-orphans. The authors conclude with some suggestions for policy makers and programme implementers, highlighting the importance of focusing on interventions that will have maximum impact on the health and well-being of children.

Towards a Definition of Orphaned and Vulnerable Children

The HIV epidemic presents challenges including orphans and a large mass of children rendered vulnerable by the epidemic and other societal forces. Focus on orphaned and vulnerable children (OVC) is important, but needs accurate definition. Twelve focus group interviews of service providers, leaders in these communities, OVC and their caretakers were conducted at six project sites across Botswana, South Africa and Zimbabwe to extend this definition. The loss of a parent through death or desertion is an important aspect of vulnerability. Additional factors leading to vulnerability included severe chronic illness of a parent or caregiver, poverty, hunger, lack of access to services, inadequate clothing or shelter, overcrowding, deficient caretakers, and factors specific to the child, including disability, direct experience of physical or sexual violence, or severe chronic illness. Important questions raised in this research include the long-term implications for the child and community, and the contribution of culture systems.

Generalizing a model of health behaviour change and AIDS stigma for use with sexually transmitted infection clinic patients in Cape Town, South Africa.

Abstract We tested the Information–Motivation–Behavioural Skills (IMB) model of AIDS preventive behaviour in South Africa. Prospective path analyses were performed on measures collected from 131 men and 60 women with sexually transmitted infections (STI) in Cape Town. Results showed that IMB constructs collected at baseline predicted risk reduction behaviour 3 months later. Risk reduction intentions were positively associated with risk reduction self-efficacy and self-efficacy was in turn positively associated with protective behaviour 3 months later. In a second model, AIDS-related stigmas correlated inversely with AIDS knowledge and there was a trend toward AIDS stigmas correlating inversely with behavioural intentions. Accounting for AIDS-related stigmas did not improve model fit. These findings parallel similar tests of the IMB model in US samples and suggest that the IMB model may generalize to South Africa and may therefore be useful in guiding HIV risk reduction interventions.

Mental health and HIV sexual risk behavior among patrons of alcohol serving venues in Cape Town, South Africa

Background:Alcohol-serving venues in South Africa provide a location for HIV prevention interventions due to risk factors of patrons in these establishments. Understanding the association between mental health and risk behaviors in these settings may inform interventions that address alcohol use and HIV prevention. Methods:Participants (n = 738) were surveyed in 6 alcohol-serving venues in Cape Town to assess post-traumatic stress disorder (PTSD) and depression symptoms, traumatic experiences, sexual behavior, and substance use. Logistic regression models examined whether traumatic experiences predicted PTSD and depression. Generalized linear models examined whether substance use, PTSD, and depressive symptoms predicted unprotected sexual intercourse. Men and women were analyzed separately. Results:Participants exhibited high rates of traumatic experiences, PTSD, depression, alcohol consumption, and HIV risk behaviors. For men, PTSD was associated with being hit by a sex partner, physical child abuse, sexual child abuse and HIV diagnosis; depression was associated with being hit by a sex partner, forced sex and physical child abuse. For women, both PTSD and depression were associated with being hit by a sex partner, forced sex, and physical child abuse. Unprotected sexual intercourse was associated with age, frequency and quantity of alcohol use, drug use, and PTSD for men and frequency and quantity of alcohol use, depression, and PTSD for women. Conclusion:Mental health in this setting was poor and was associated with sexual risk behavior. Treating mental health and substance-use problems may aid in reducing HIV infection. Sexual assault prevention and treatment after sexual assault may strengthen HIV prevention efforts.

Theory-based HIV risk reduction counseling for sexually transmitted infection clinic patients in Cape Town, South Africa.

Background: South Africa has the world’s fastest growing AIDS epidemic. There is an urgent need for effective HIV risk reduction interventions in South Africa. Objective: The objective of this study was to develop and test the potential efficacy of a brief theory-based HIV prevention counseling intervention for sexually transmitted infection (STI) clinic patients in South Africa. Method: STI clinic patients in Cape Town (N = 228) were assessed at baseline and randomized to receive either: 1) a single 60-minute session motivational/skills-building HIV risk reduction counseling intervention or 2) a 20-minute HIV information/education session. Participants completed 1- and 3-month follow ups with 80% retention. Results: The 60-minute motivational/skills risk reduction counseling demonstrated significantly greater risk reduction practices, lower rates of unprotected intercourse, and greater likelihood of receiving HIV testing after the intervention. Conclusions: Brief theory-based HIV prevention counseling may significantly reduce HIV risk behaviors for STI clinic patients in South Africa.

Because he has bought for her, he wants to sleep with her: alcohol as a currency for sexual exchange in South African drinking venues.

Previous research has documented the practice of transactional sex in sub-Saharan Africa and its association with gender-based violence, gender inequalities and HIV risk. At the same time, it has been suggested that women may use transactional sex to obtain a greater sense of control over their lives and their sexualities, and to garner access to resources. The aim of this study was to better understand the practice of exchanging alcohol for sex in alcohol-serving venues in a township in Cape Town, South Africa. Data were collected between June 2009 and October 2010. Six venues were included and observations were conducted in each for four one-week periods over the course of a year. In-depth qualitative interviews included 31 women and 13 men whom interviewers had observed as regular venue customers. Follow-up interviews were conducted with 24 respondents to explore emerging themes. Interviews were recorded and transcribed. Using a grounded theory approach, Atlas.ti was used to code transcripts, field notes, and analytical memos written about each document. Results revealed that alcohol was commonly used as a currency of sexual exchange in this setting, and both women and men understood that accepting alcohol from a man implied consent for sexual favors. Women reported a sense of agency in participating in the transactional sex dynamic, especially when they were able to manipulate it to meet their own ends without fulfilling the mens sexual expectations. At the same time, data revealed that the norm of transactional sex reinforced the undervaluing and commoditization of women. As identified elsewhere, transactional sex put both women and men at greater risk of HIV through multiple partners and inconsistent use of condoms, and the possibility of rape. Interventions are needed to address sexual risk behaviors and substance use within this context to prevent new HIV infections.

Evaluation of use of cellphones to aid compliance with drug therapy for HIV patients

Abstract Key to the care of people living with HIV is effective data on use of ARVs, their responses to the medication and additional needs. An adaptation of cellphone technology by Cell-Life provides an easy-to-use data capturing devise for use by therapeutic counsellors (home based carers). Individual in-depth interviews were conducted with all the counsellors using the technology at two points in time, six months apart. The technology was found to be easy to use, especially for those who had previously used a cellphone. It eased data collection considerably and reduced fears around loosing notes. Improvements in technology between the two sets of interviews showed responsiveness from Cell-Life to the users of the technology. The patients also responded well to the technology, feeling that it improved their treatment. The major concern for home-based carers was the risk of crime due to having a cellphone, which led to the therapeutic counsellors eventually leaving the cellphones at home when visiting patients and entering the data at a later point. While the carers initially felt that the technology was an intrusion in their lives they later adapted to it.

AIDS-related Stigma, HIV Testing, and Transmission Risk Among Patrons of Informal Drinking Places in Cape Town, South Africa

BackgroundAIDS-related stigma as a barrier to HIV testing has not been examined within the context of high at risk environments such as drinking venues. Of particular importance is whether AIDS-related stigma is associated with HIV transmission risks among people who have never been tested for HIV.PurposeWe examined: (1) AIDS-related stigma as a barrier to testing, controlling for other potential barriers, and (2) whether stigma is associated with HIV risks among HIV-untested individuals.MethodsWe surveyed 2,572 individuals attending informal drinking establishments in Cape Town, South Africa to assess HIV testing status, AIDS-related stigma endorsement, and HIV transmission sexual risk behavior.ResultsEndorsement of AIDS-related stigma was negatively associated with HIV lifetime testing. In addition, stigma endorsement was associated with higher HIV transmission risks.ConclusionAIDS-related stigma must be addressed in HIV prevention campaigns across South Africa. Antistigma messages should be integrated with risk reduction counseling and testing.

Pregnancy, alcohol intake, and intimate partner violence among men and women attending drinking establishments in a Cape Town, South Africa township.

The highest rates of fetal alcohol syndrome worldwide can be found in South Africa. Particularly in impoverished townships in the Western Cape, pregnant women live in environments where alcohol intake during pregnancy has become normalized and interpersonal violence (IPV) is reported at high rates. For the current study we sought to examine how pregnancy, for both men and women, is related to alcohol use behaviors and IPV. We surveyed 2,120 men and women attending drinking establishments in a township located in the Western Cape of South Africa. Among women 13.3% reported being pregnant, and among men 12.0% reported their partner pregnant. For pregnant women, 61% reported attending the bar that evening to drink alcohol and 26% reported both alcohol use and currently experiencing IPV. Daily or almost daily binge drinking was reported twice as often among pregnant women than non-pregnant women (8.4% vs. 4.2%). Men with pregnant partners reported the highest rates of hitting sex partners, forcing a partner to have sex, and being forced to have sex. High rates of alcohol frequency, consumption, binge drinking, consumption and binge drinking were reported across the entire sample. In general, experiencing and perpetrating IPV were associated with alcohol use among all participants except for men with pregnant partners. Alcohol use among pregnant women attending shebeens is alarmingly high. Moreover, alcohol use appears to be an important factor in understanding the relationship between IPV and pregnancy. Intensive, targeted, and effective interventions for both men and women are urgently needed to address high rates of drinking alcohol among pregnant women who attend drinking establishments.