Socio-cultural drivers of the HIV/AIDS epidemic in sub- Saharan Africa Prof Geoffrey Setswe DrPH 8 May 2010

Overview Why is the HIV/AIDS pandemic not uniform around the world? What are the socio-cultural risk drivers that influence the spread of HIV in sub-Saharan Africa? What does this tell us about our response to the epidemic? 2

Background SADC: epicentre of global HIV pandemic - adult prevalence rate 11% as compared to 1% globally.  By 2009, 33.4 million people living with HIV/AIDS worldwide.  63% in sub-Saharan Africa  37% of new infection in 2008 occurred in the region.  6,000 people in Southern Africa become infected with HIV every day.  People under 25 years = half of all new HIV infections worldwide. Source: UNAIDS (2009) 3

4 Psycho-socio-cultural factors driving the spread of HIV

Human factors that drive the spread of HIV High prevalence of other STIs Knowledge of AIDS and perception of risk Multiple sexual relationships Traditionally low use of condoms, even in high-risk sexual encounters Poverty and the relatively low health status of much of the population, including widespread malnutrition Low status of women - ?ability to negotiate safer sex Settlement patterns and worker migration Cultural practices e.g. Wife adoption Low levels of male circumcision 5

Environmental risk factors driving the spread of HIV Economic and Political Factors - Level of poverty – commercial sex work - War and social conflicts – rapes and sexual abuse - Status of transport and mobility of population - Performance of health care system - Response to epidemic 6

Abstinence and faithfulness as risk factors 83% of young people said that it was possible not to have sex for as long as you can. 78.5% said that not having sex was the best way of preventing infection with HIV. 68.7% of young people said that the media encouraged faithfulness in relationships and 84.6% said that life skills workshops were helpful in encouraging them to remain faithful to one partner. Source: Setswe (2010) Views and perceptions of young people on ABY 7

MCP, MC and condom use as major risk factors SADC Think Tank, Maseru, May 2006 – Multiple and concurrent partnerships with low consistent condom use, in the context of low levels of male circumcision are key drivers of the HIV pandemic in Southern Africa. SADC Regional Consultation: Social Change Communication for HIV Prevention, Swaziland, October 2006 – Recommended partner reduction as a key focus for social change communication interventions both at country and regional levels. 8

Condom use during last sex act, South Africa 2002 and 2005 AgeMale (%) Female (%) yrs yrs yrs

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Reasons for MCP MCPs are common practise Sexual dissatisfaction Emotional and physical dissatisfaction Culture and social norms influence MCPs Money and material possessions Alcohol and MCP Men cannot control sexual desire Pressure Male domination and abuse HIV and AIDS risk and fatalism 11 Soul City (2007)

Social-cultural meanings of MCP For a man: affirms his self-worth, shows generosity, expresses love/appreciation, helps restore pride, validates manhood, asserts & establishes power & authority in relationship. For a woman: affirms her value, an expression of love/appreciation, boost self-esteem & social status, helps builds social networks & capital, gains materially, promotes dependency and vulnerability. (a conundrum for women) (Luke & Kurz 2002, Kelly et al 2003, Hallman 2004, Lary et al 2004, Longfield et al 2004, Luke 2005, Nshindano 2006, Nkosana & Rosenthal 2007). 12

Socio-cultural factors to consider in implementing MC services Sensitivity to cultural and traditional practices should be shown at all times and the government must ensure that MC is promoted and delivered in a culturally appropriate manner that minimises stigma associated with circumcision status. Engagement and participation of key community leaders including Traditional Healers and Leaders to assist in the buy in and filtering of the implications of safe MC to relevant communities will play a critical role in addressing socio-cultural issues and overcoming barriers to safe MC. Cultural neutrality: MC for HIV prevention is not a means of cultural identity, but solely a health intervention. 13 DOH (2009) Male circumcision framework for South Africa (Draft)

Conclusions – Strong views on ABY do not necessarily translate into behaviour change in HIV prevention. – MCP is a key driver of HIV infections in Southern African countries where national HIV prevalence rates among adults exceeds 15%. – MCP is itself driven by various socio-cultural and economic factors including both old and new social cultural norms and values. – There is a need for individual and multi-level interventions as social and structural level through social change communication using the media and community mobilisation or community engagement including the involvement of faith-based organisations. 14