Austin J Public Health Epidemiol. 2016; 3(1): 1031.
What Perpetuates the Spread of HIV/AIDS in Rural South African Communities? A Closer Look at Social Factors
Linganiso WS and Gwegweni JMT*
Department of Nursing and Public Health Medicine, University of Kwazulu-Natal, South Africa
*Corresponding author: Tsoka Gwegweni JM, Department of Nursing and Public Health Medicine, University of Kwazulu-Natal, George Campbell, Durban, South Africa
Received: September 21, 2015; Accepted: January 01, 2015; Published: January 04, 2016
HIV/AIDS is highly prevalent in low and middle-income countries, and markedly severe in people of low socioeconomic status in the rural South Africa. The disease has been long treated as more of a biomedical problem rather than preventing it by focusing on the social underlying causes. HIV/AIDS continues to spread because some of the social factors that contribute to its spread are not effectively addressed. Poverty has made the situation more difficult in rural communities, and people engage in sexual relationships not because they want to but for economic reasons and the relationships are basically started in response to economic concerns. Women are the most vulnerable in contracting the disease because of the subordinate positions they hold in the community which deprives them an opportunity to make decisions that affect them during sexual practices. Cultural practices as well have lots of myths involved around the issue of HIV/AIDS where ritual initiation and traditional circumcision is involved; and most of the cultures in rural communities have undermined women and exposed them to the disease. The conditions in which people live have played a big role towards the spread of HIV/AIDS, and unfortunate that the environmental, cultural and social factors are receiving a limited attention when it comes to addressing HIV/AIDS. After reviewing some literature, this study offers six major social factors that have potential in spreading HIV/AIDS in rural South African communities.
Keywords: HIV/AIDS; Social factors; Rural communities; South africa; Poverty
HIV: Human Immuno-deficiency Virus; AIDS: Acquired Immunodeficiency Syndrome; STIs: Sexually Transmitted Infections; IPV: Intimate Partner Violence; MSM: Men who have Sex with Men; PMTCT: Prevention-of-Mother-To-Child-Transmission
The burden of HIV/AIDS is still alarming in some other parts of the world, such as rural communities. ART has been used to try and control the disease, reduce deaths due to HIV/AIDS, and has been reported to prevent the transmission of the virus as well. Current strategies addressing the HIV/AIDS problem use more of a biomedical approach than other approaches. The problem with the biomedical approach is that it aims at reducing deaths and it is individually-focused, whereas its success would be improved when HIV prevention addresses the broader structural factors that have an impact on people’s lives, such as poverty, gender and policy. It is in the interest of this paper therefore, to look at the social factors that perpetuate the spread of HIV/AIDS.
Based on the literature reviewed, six major themes on perpetuators of HIV/AIDS have emerged and these were: sexual partnerships and HIV transmission, circular labour migration, cultural practices and HIV/AIDS, poverty and nutritional status, education and unemployment; and access to health care services. Each one of these themes has been described below.
Some researchers believe that different characteristics of sexual partnerships are associated with the spread of HIV/AIDS in rural communities. These researchers examined the age-mixing and age-asymmetry in sexual partnerships. In the article they further discussed how the two concepts of age-mixing and age asymmetry discourage condom use and influence HIV transmission. The study was focused on the older males and younger females, where the latter become overpowered in the process by males who have a greater capacity to make decisions on condom use and HIV prevention. Further, the article discussed the outcomes of the study, where new HIV infections have been identified amongst girls who dropped out from school and common amongst non-spousal partnerships .
Concurrent and multiple sexual partnerships, including polygamy have also been investigated by Tanser and colleagues. Their article discussed the implications these partnerships have towards the spread of HIV/AIDS. They further warned that due to the fact that sub-Saharan Africa is home to about two-thirds of the world’s HIV-positive population and also considering the fact that more than 70% of all the new HIV infections occurred in 2008, engaging in such partnerships, will perpetuate the spread of HIV . Therefore, education that addresses sexual partnerships and informs people on when to start engaging in such activities will be essential for people in rural areas.
Zuma et al., Looked at circular labour migration as one of the social factors that lead to the spread of HIV/AIDS in rural areas. In their study, they discussed the circular movement done by laborers between rural areas and the urban areas when searching for jobs. They advised that during this process, migrant men get infected with HIV from acquired partners during migration periods and infect their rural partners they return back home . Delany-Moretlwe et al., Discussed how the long distance truck drivers also contribute towards the HIV infections due to the dose-response and casual relationships they are engaged into during their travel . During travelling, the possibility is that the truck drivers do not have any protection in place, hence the relationship is also casual and therefore unplanned sexual practices.
Welz et al., Advised that migration has the same implications for both males and females. In their article they discussed the spread of HIV/AIDS amongst mobile non-residents or mobile individuals in rural areas. The results of the study were that HIV prevalence among non-residents peaked at 63% for women and 56% for men. The study adds to the literature the importance of not overlooking female migration against male migration, as the migration of women plays a big a role in perpetuating the spread of HIV/AIDS . Unanimously, Collinson discovered that migrants who returned more frequently were found to be less exposed to outside partners and less implicated in the HIV epidemic . What the author implies is that the closer the families/or partners are together, the lesser the spread of HIV.
In rural areas, culturally initiated and traditionally circumcised men have a belief that after they went through the transition of boyhood to manhood, they are immune from contacting Sexually Transmitted Infections (STIs) including HIV and because of that, they do not engage themselves in consistent condom use . In the study it has been reported that 92% of the participants believed that circumcision allowed men to practice sexual intercourse without condoms, as the removal of the foreskin is believed to reduce the risk of contracting HIV/AIDS . The study issues a call for a culturally sensitive education, especially of the initiation leaders, initiates and everyone involved in this practice, so as to increase the awareness and prevent the spread of HIV/AIDS.
Three more authors looked at cultural practices that have potential for the spread of HIV/AIDS among women. Buve et al., stated that some traditions and socioeconomic developments have contributed to the spread of HIV-1 infection, including the subordinate position of women. Their study basically warns that not all sexual behaviors are voluntary, but rather determined by the cultural and socioeconomic contexts . Therefore, this calls for the intensive education and awareness of the factors that determine the spread of HIV/AIDS to people in remote areas. Ackermann et al., suggested that a high rate of rape, unfavorable economic position and an inability to assist on condom usage are all some of the factors that render women powerless to protect themselves against HIV infection . Women in rural areas therefore, are really in need of empowerment.
Jewkes et al reported that women who experience Intimate Partner Violence (IPV) havea risk for HIV infection. According to the study, it is mostly young rural women that are prone to IPV and become infected with HIV in the process . Regarding what is referred to in the latter statement, culturally, women in rural areas are still subjected to subordinate positions, where men have every authority or right over women, including the power to beat them up. Due to rural women’s low socioeconomic status, they lack knowledge, education and awareness of what is right and good for them. Everything that their male partners do to them is all treated as acceptable. As a result, rural women are deprived freedom to initiate or suggest condom use during sexual activity.
It has been suggested that people in rural areas generally are of a low socioeconomic status and presumably live below the poverty line. Magadi therefore stated that the adverse future chances of people living with poverty are likely to increase their readiness to take risks today . This supports the belief that most people engage and stay in sexual relationships for the sake of economic concerns, and in that way exposing themselves to HIV/AIDS and perpetuate its spread.
Louria and colleagues were more concerned about some specific nutritional deficiencies that enhance HIV transmission. The study advised that in an HIV-positive person, nutritional deficits may increase viral load, thus increasing potential for HIV transmission during a heterosexual engagement. The article discussed the implications of heterosexual partnerships and the increased risk with nutritional deficits, where HIV is more transmissible . Therefore, poverty and eating what is available and not nutritious due to unaffordability can lead to rapid spread of HIV/AIDS. Furthermore, the authors focused their study on people who have already contracted HIV and may need better nutrition than people who are not affected .
Low or no education and unemployment have been found to have a contributory factor towards the spread of HIV/AIDS. Pettifor et al., reported high HIV infection among young women who had not completed high school despite reporting only having one lifetime partner. Due to poverty, limited education and unemployment, young women end up choosing older male partners for survival. Genderpower inequities may lead to reduced condom use, unwanted sexual practices, transactional sexual relationships and HIV transmission . Two more other researchers also reported on the implications of low education and HIV/AIDS spread.
Barnighausen et al., reported high incidence of HIV among women of low education in rural areas, and maintain that increased educational attainment in general population may lower HIV infections, respectively . Zuma et al., confirmed that evidence suggested urban youths as better informed about HIV and AIDS than their rural peers . The latter implies that the lack of information and enlightenment can expose the youth in rural areas to risks of unplanned pregnancies, STIs and HIV infections.
Education seems to be very important when it comes to knowledge about HIV and it is so unfortunate that it is what most rural people lack and hence there are still new HIV infections coming up. Peltzer et al., found associations between higher educational level, urban setting and knowledge of HIV status compared to HIV-positive, young, lower educated Black African rural men as well . Tladi warned about the implications of lack of education when it comes to HIV/AIDS that it may lead to decreased decision-making power, especially when one has been the victim of poverty .
Access to health care services has always been a problem, including the attitude of staff towards clients, and these factors have had a negative impact on people with HIV/AIDS and other health problems. Imrie et al., reported that Males that have Sex with other Males (MSM) are not only disproportionately affected by HIV, but that MSM behaviour contributes significantly to sustaining the high number of new infections recorded each year. The article discussed the implications of MSM’s contribution to high HIV numbers, which is due to the inability to access health care services in rural areas. MSM encounter stigmatizing comments, abuse and negative attitudes when engaging with health care services .
Access and utilization of health care services remain a challenge particularly in rural areas and are in need of urgent improvement. Kimani-Murage et al., looked at the Prevention-of-Mother-To- Child-Transmission (PMTCT) program in South Africa. The article suggested that since HIV is associated with nutritional deficiencies, the viral load will be high and people in the household may be easily infected through the child and HIV will keep spreading . Therefore, if these children and their mothers are not attended and treated well by staff in a health care service, they will continue to be one of the sources of HIV transmission due to mismanagement. Otwombe et al., Brought up some suggestions on the development of interventions or enhancement of the existing ones for improvement of patient management, and emphasized that the enhancement process will rely on the approach that can be able to inform HIV managers and policy makers .
In summary, people of low socioeconomic status are more vulnerable to being infected with HIV. Looking at all the potential determinants of HIV infections in rural areas, effective strategies on HIV prevention that will focus on the underlying causes, rather than treating HIV as more of a biomedical problem, are of great need in these areas. For example strategies that will priorities the importance of engaging other sectors in achieving optimum health of the rural people as far as HIV prevention is concerned, as nearly all social determinants of health are outside the direct control of the health sector. This can be achieved through inter-sect oral collaboration and prioritization of health in all policies.
HIV has not been effectively controlled and this has been the result of many different factors. Poverty is the most underlying cause of that, especially in rural areas. Poverty increases people’s readiness to take risks today in trying to cope and survive. Therefore, people will be forced to engage in unplanned relationships, and where they do not have power to make decisions on how and when should they embark on sexual practices. Women of all age groups are the most vulnerable in the process as they stay in most of the relationships because of economic reasons and the most of these relationships started in response to economic concerns.
It has been reported that in rural areas, HIV infections keep coming up due to sexual partnerships, especially heterosexual relationships. Although the MSM have potential of spreading more infections, but in rural areas there is not much of these key population groups and not much research has been conducted specifically in rural areas. Circular labour migration, cultural practices, gender violence and inequities, low education and unemployment; and inaccessible health care services and the attitude of the health care staff are some of the determinants of HIV infection, including poverty, in rural areas.
Research has shown that both the public health and the primary health care strategies have not been effective enough to address and control HIV infection in rural areas. It is said that, poor health of the public is strongly linked to underdevelopment. Failing to apply comprehensive and effective strategies; and lack of understanding from the senior management including policymakers, will compromise the development of the country and undermine the international development on the implementation of sustainable development goals, where new HIV infections are expected to be the thing of the past. Therefore, there is a dire need to address poverty and gender inequities; and empower women socially and economically, if positive effect in controlling HIV infections in rural areas is to be achieved.
- Hargreaves JR, Morison LA, Kim JC, Busza J, Phetla G, Porter JD, et al. Characteristics of sexual partnerships, not just of individuals, are associated with condom use and recent HIV infection in rural South Africa. AIDS Care. 2009; 21: 1058-1070.
- Tanser F, Barnighausen T, Hund L, Garnett GP, McGrath N, Newell ML. Effect of concurrent sexual partnerships on rate of new HIV infections in a high-prevalence, rural South African population: a cohort study. Lancet. 2011; 378: 247-255.
- Zuma K, Lurie MN, Williams BG, Mkaya-Mwamburi D, Garnet GP, Sturn AW. Risk factors of sexually transmitted infections among migrant and non-migrant sexual partnerships from rural South Africa. Infectious disease Epidemiology. 2005; 133: 421-428.
- Delany-Moretlwe S, Bello B, Kinross P, Oliff M, Chersich M, Kleinschmidt I, et al. HIV prevalence and risk in long-distance truck drivers in South African: a national cross-sectional survey. International journal of STD & AIDS. 2014; 25: 428-438.
- Welz T, Hosegood V, Jaffar S, Batzing-Feigenbaum J, Herbst K, Newell ML. Continued very high prevalence of HIV infection in rural KwaZulu-Natal, South Africa: a population-based longitudinal study. AIDS. 2007; 21: 1467-1472.
- Collinson MA. Striving against adversity: the dynamics of migration, health and poverty in rural South Africa. Global Health Action. 2010; 3: 1-14.
- Nyembezi A, Rutler RAC, Van den Bome B, Sifunda S, Funani I, Reddy P. Correlates of consistent condom use among recently initiated and traditionally circumcised men in the rural areas of the Eastern Cape Province, South Africa. BMC Public Health. 2014; 14: 2-11.
- Buve A, Bishikwabo-Nsarhaza K, Mutangadura G. The spread and effect of HIV-1 infection in sub-Saharan Africa. Lancet. 2002; 359: 2011-2017.
- Ackermann L, de K. Social factors that make South African women vulnerable to HIV infection. Health Care Women Int. 2002; 23: 163-172.
- Jewkes R, Dunkle K, Nduna M, Levin J, Jama N, Khuzwayo N, et al. Factors associated with HIV sero-status in young rural South African women: Connections between intimate partner violence and HIV. International Journal of Epidemiology. 2006; 35: 1461-1468.
- Magadi MA. The disproportionate high risk of HIV infection among the urban poor in sub-Saharan Africa. AIDS Behav. 2013; 17: 1645-1654.
- Lourie DB, Skurnick JH, Palumbo P, Bogden JD, Rohowsky-Kochan C, Denny TN, et al. HIV Heterosexual Transmission: A hypothesis about an additional potential determinant. International Journal of infectious diseases. 2000; 4: 110-116.
- Pettifor AE, Levandowski BA, MacPhall C, Padian NS, Cohen MS, Rees HV. Keep them in school: the importance of education as a protective factor against HIV infection among young South African women. International journal of Epidemiology. 2008; 37: 1266-1273.
- Barnighausen T, Hosegood V, Timaeus IM, Newell ML. The socioeconomic determinants of HIV incidence: evidence from a longitudinal, population-based study in rural South Africa. AIDS. 2007; 21: 29-38.
- Zuma K, Mzolo T, Makonko E. Determinants of age at sexual debut and associated risks among South African youths. Afr J AIDS Res. 2011; 10: 189-194.
- Peltzer K, Matseke G, Mzolo T, Majaja M. Determinants of knowledge of HIV status in South Africa: results from a population-based HIV survey. BMC Public Health. 2009; 9: 174.
- Tladi LS. Poverty and HIV/AIDS in South Africa: an empirical contribution. SAHARA J. 2006; 3: 369-381.
- Imrie J, Hoddinott G, Fuller S, Oliver S, Newell ML. Why MSM in rural South African communities should be an HIV prevention research priority. AIDS Behav. 2013; 17: 70-76.
- Kimani-Murage EL, Norris SA, Pettifor JM, Tollman SM, Klipstein-Grobusch K, Gomez-Olive XF, et al. Nutritional status and HIV in rural South African children. BMC Paediatrics. 2011; 1: 1-13.
- Otwombe KN, Petzold M, Modisenyane T, Martinson NA, Chirwa T. Factors associated with mortality in HIV-infected people in rural and urban South Africa. Glob Health Action. 2014; 7: 25488.