Nicole Angotti

Prevalence of HIV among those 15 and older in rural South Africa

A greater knowledge of the burden of HIV in rural areas of Southern Africa is needed, especially among older adults. We conducted a cross-sectional biomarker survey in the rural South African Agincourt Health and Socio-demographic Surveillance site in 2010–2011 and estimated HIV prevalence and risk factors. Using an age–sex stratified random sample of ages 15+, a total of 5037 (65.7%) of a possible 7662 individuals were located and 4362 (86.6%) consented to HIV testing. HIV prevalence was high (19.4%) and characterized by a large gender gap (10.6% for men and 23.9% for women). Rates peaked at 45.3% among men and 46.1% among women – both at ages 35–39. Compared with a similar study in the rural KwaZulu-Natal Province, South Africa, peak prevalence occurred at later ages, and HIV prevalence was higher among older adults – with rates above 15% for men and 10% for women through to age 70. High prevalence continues to characterize Southern Africa, and recent evidence confirms that older adults cannot be excluded from policy considerations. The high prevalence among older adults suggests likely HIV infection at older ages. Prevention activities need to expand to older adults to reduce new infections. Treatment will be complicated by increased risk of noncommunicable diseases and by increasing numbers of older people living with HIV.

Testing differences: the implementation of Western HIV testing norms in sub-Saharan Africa

This paper examines the implementation of Western HIV testing norms – counselling, consent and confidentiality (‘3Cs’) – in Malawi, a high prevalence, rural African setting. It considers the differential perspectives of three categories of stakeholders: proponents, implementers and intended beneficiaries. The proponents are members of the ‘Counseling and Testing Establishment’. For them, the 3Cs are human rights imports that are worth defending formally, but not always worth prioritising in practice. The implementers are HIV Counsellors. For them, knowledge of the 3Cs as Western biomedical jargon distinguishes them from villagers, but places them in situations where the ethics of testing conflict with their moral concerns for those whom they were trained to help, thus they adapt them in practice. And the intended beneficiaries, the rural Malawians whose rights are meant to be protected by the 3Cs, perceive the norms as protecting themselves as individuals, but as harming rather than benefitting their communities. The case study of Malawi illustrates a tension between Western, individual rights-oriented public health norms and local concerns for the health and wellbeing of the imagined communities that they are meant to benefit.

Cardiometabolic disease risk and HIV status in rural South Africa: establishing a baseline

BackgroundTo inform health care and training, resource and research priorities, it is essential to establish how non-communicable disease risk factors vary by HIV-status in high HIV burden areas; and whether long-term anti-retroviral therapy (ART) plays a modifying role.MethodsAs part of a cohort initiation, we conducted a baseline HIV/cardiometabolic risk factor survey in 2010–2011 using an age-sex stratified random sample of ages 15+ in rural South Africa. We modelled cardiometabolic risk factors and their associations by HIV-status and self-reported ART status for ages 18+ using sex-stratified logistic regression models.ResultsAge-standardised HIV prevalence in women was 26% (95% CI 24-28%) and 19% (95% CI 17–21) in men. People with untreated HIV were less likely to have a high waist circumference in both women (OR 0.67; 95% CI 0.52-0.86) and men (OR 0.42; 95% CI 0.22-0.82). Untreated women were more likely to have low HDL and LDL, and treated women high triglycerides. Cardiometabolic risk factors increased with age except low HDL. The prevalence of hypertension was high (40% in women; 30% in men).ConclusionsSub-Saharan Africa is facing intersecting epidemics of HIV and hypertension. In this setting, around half the adult population require long-term care for at least one of HIV, hypertension or diabetes. Together with the adverse effects that HIV and its treatment have on lipids, this may have serious implications for the South African health care system. Monitoring of the interaction of HIV, ART use, and cardiometabolic disease is needed at both individual and population levels.

HIV after 40 in rural South Africa: A life course approach to HIV vulnerability among middle aged and older adults

South Africa has the highest number of people living with HIV in the world (over 6 million) as well as a rapidly aging population, with 15% of the population aged 50 and over. High HIV prevalence in rural former apartheid homeland areas suggests substantial aging with HIV and acquisition of HIV at older ages. We develop a life course approach to HIV vulnerability, highlighting the rise and fall of risk and protection as people age, as well as the role of contextual density in shaping HIV vulnerability. Using this approach, we draw on an innovative multi-method data set collected within the Agincourt Health and Demographic Surveillance System in South Africa, combining survey data with 60 nested life history interviews and 9 community focus group interviews. We examine HIV risk and protective factors among adults aged 40-80, as well as how and why these factors vary among people at older ages.

Let's talk about sex, maybe: Interviewers, respondents, and sexual behavior reporting in rural South Africa

Researchers are often skeptical of sexual behavior surveys: Respondents may lie or forget details of their intimate lives, and interviewers may exercise authority in how they capture responses. We use data from a 2010–2011 cross-sectional sexual behavior survey in rural South Africa to explore who says what to whom about their sexual lives. Results show an effect of fieldworker age across outcomes: Respondents report “safer,” more “responsible” sexual behavior to older fieldworkers, and an effect of fieldworker sex; men report more sexual partners to female fieldworkers. Understanding fieldworker effects on the production of sexual behavior survey data serves methodological and analytical goals.

Implementing "insider" ethnography: lessons from the Public Conversations about HIV/AIDS project in rural South Africa.

We describe the conceptualization and implementation of a research methodology in which ‘insider’ community members work with ‘outsider’ investigators as participant observers to document everyday conversations taking place in public settings in their communities. Our study took place in a resource-poor area of rural South Africa and focused on HIV/AIDS, yet we aim here to provide a road map for those interested in implementing this approach in other contexts for various empirical ends. Because this approach is unusual, we highlight considerations in selecting a team of ethnographers, describe the training process, and offer ways to ensure the data collected are trustworthy and confidential. We describe the advantages and limitations of utilizing ‘insider ethnography’ in contexts where being indigenous to the study site provides access to perspectives that cannot be obtained through other methods. Finally, we examine how mutuality and the positionality of the research team affect data collection and quality.

Reconsidering Gendered Sexualities in a Generalized AIDS Epidemic

Using the threat of a severe AIDS epidemic in a collection of rural villages in South Africa, we illustrate how men and women reconsider gendered sexualities through conversations and interactions in everyday life. We draw from data collected by local ethnographers and focus on the processes through which men and women collectively respond to the threat posed by AIDS to relationships, families, and communities. Whereas previous research has shown that individuals often reaffirm hegemonic norms about gender and sexuality in response to disruptions to heteronormative gender relations, we find that the threat of AIDS provokes reconsideration of gendered sexualities at the community level. That is, our data demonstrate how men and women—through the interactions and exchanges that make up their daily lives—debate, challenge, make sense of, and attempt to come to terms with social norms circumscribing gendered sexual practices in a context where the threat of a fatal disease transmitted through sex looms large. We argue that ethnographic data are particularly useful for capturing communal responses to events that threaten heteronormative gender relations and reflect on how our findings inform theories of gender relations and processes.

Accurate information as a tool to decrease HIV test refusals in research studies.

It has been argued that researchers conducting surveys that include testing for human immunodeficiency virus (HIV) have a duty to tell potential subjects that they do not have the right to participate if they refuse to receive their HIV test results.1,2 Furthermore, promotion of the routine feedback of such test results has been based on the grounds that knowledge is power and information is liberation.3 However, other researchers argue that, although it is desirable to offer study participants post-test counselling, for practical and ethical reasons some study participants should be given the right to refuse such counselling.4 Although we support the right of participants to opt out of post-test counselling and thus not to receive their test results, we also propose that subjects who are – or may be – tested for HIV should be given information that may decrease their resistance to learning their test results. We draw on data, collected between 1998 and 2013, on rural Malawians’ experience with – and perceptions of – HIV testing. From the perspective of the organizations that promote HIV testing, it is axiomatic that people will benefit from knowing their HIV status. In Maher’s view, such benefit justifies sanctioning those who refuse to receive their test results.2 We disagree, for two reasons. First, the experience of many Malawians is that refusal to consent to testing may have serious consequences. For example, although the policy for antenatal HIV testing in Malawi includes an opt-out provision, accounts from pregnant women attending antenatal clinics show that HIV testing is compulsory if the women are to receive antenatal care.5 Moreover, in population-based HIV surveys, fieldworkers are always under pressure to minimize the numbers of test refusals and may exert undue pressure on individuals who do not want to receive their test results. While exclusion from antenatal services is, presumably, much more serious than exclusion from survey participation, in both of these examples people are sanctioned for not giving consent – which is a clear ethical violation. Second, our ethnographic data depict the anguish that many suffer as they anticipate the future receipt of their test results – an issue that has rarely been discussed in the public health and social science literature.6 Two common misperceptions among rural Malawian adults are that the result of an HIV test will almost always be positive and that a positive result will inevitably be followed by hastening psychological deterioration, suicidal thoughts and death. Yet survey data from people living in rural Malawi show that between 80% and 90% of respondents who believed that they were HIV-positive before they were tested learned that they were HIV-negative.7,8 That so many are convinced, wrongly, that an HIV test will inevitably produce a positive diagnosis is the consequence of rural Malawians’ incorrect understanding of the probabilities of HIV transmission. For example, most of our survey respondents believed that an uninfected individual was certainly or highly likely to be infected with HIV during a single act of unprotected intercourse with an infected person.8 Would it not be preferable to treat those living amidst the HIV epidemic as having an ethical right to accurate information on the probabilities of transmission? Efforts should be made to evaluate the potential benefits of disseminating accurate information on the probabilities of transmission, the approximate prevalence of HIV infection and the probability of a positive result in an HIV test – such that consent for HIV testing in surveys is fully, rather than incompletely, informed. We need to know whether such health education would be a liberation, lead to fewer test refusals in research studies and, importantly, increase the number of people who are willing to know their HIV status.

Making meaning in the time of AIDS: longitudinal narratives from the Malawi Journals Project

The Malawi Journals Project is one of the longest-running observational field studies in rural sub-Saharan Africa, ongoing since 1999. The journals provide real-time accounts of the unfolding epidemic, from the days when AIDS was considered by rural Malawians to be a death sentence, through the advent of international AIDS organisations bearing advice on avoiding infections by self-control, and then the turn to institutionally-based efforts to control infection through HIV testing and antiretroviral medications. This paper examines the epistemological and substantive contributions of the Journals Project, which we and others who have analysed the journals have made to understanding the AIDS epidemic. The paper has three primary aims. The first is to provide evidence of the chasm between the top-down perspectives of global actors with a mandate to address the pandemic and the bottom-up perspectives of local actors trying to avoid dying from AIDS, perspectives that are often contradictory. Second, beyond what can be learned from the journals about individual and collective responses to AIDS, they suggest the value of longitudinal observational field studies as a method for understanding how cultural change occurs. And third, as an example of the potential of longitudinal field studies as a research method on AIDS as well as other topics, we have structured our argument around the broader empirical and theoretical debates in the social sciences featured in published and presented analyses of the Malawi journals data: multiple moral logics, the course of global flows of information and injunctions, and the collective deliberation that produces authoritative local knowledge.

How to “Live a Good Life”: Aging and HIV Testing in Rural South Africa:

Objective: The African HIV epidemic is aging, yet HIV testing behavior studies either exclude older persons or include too few to say much about age differences. Method: Strategically combining focus group interviews (participants in 40s/50s/60s-plus age groups) and survey data from rural South Africa (where HIV prevalence peaks in the late 30s, but continues to be over 10% into the late 60s), we examine gender and life course variation, motivations, and barriers in HIV testing. Results: We find significant gender differences—Women test at higher rates at younger ages, men at older ages. Our qualitative data not only highlight recognition of testing importance but also suggest gendered motivations and perceptions of testing. Men and women report similar barriers, however, including fear of finding out their (positive) HIV status, limited confidentiality, and partner nondisclosure. Discussion: We conclude with recommendations to increase HIV testing uptake among older adults including home testing, couples testing, and HIV testing concurrently with noncommunicable diseases.