Exploring the syndemic interaction between social, environmental and structural contexts of HIV infection in peri-mining areas in South Africa: a qualitative study

OBJECTIVE

To explore the syndemic interaction between social, environmental, and structural contexts and HIV infection in peri-mining areas in South Africa.

DESIGN

Mixed qualitative methods consisting of in-depth interviews (IDIs) and focus group discussions (FGDs) exploring the interaction between HIV infection and the social, environmental and structural factors affecting people living in the peri-mining areas of South Africa. Themes were analysed following the syndemic theoretical framework.

SETTING

Participants were recruited from three mining companies and locations in the peri-mining communities surrounding the mining companies in Limpopo, Mpumalanga, and Northern Cape provinces.

PARTICIPANTS

Inclusion criteria included mineworkers, healthcare workers, female sex workers (FSWs), injection drug users (IDUs), and other community members, ≥18 years, living in the peri-mining area at the time of participation. Three FGDs were conducted (n=30): 13 men and 17 women aged 18-55 years. IDIs were conducted with 45 participants: mineworkers (n=10), healthcare workers (n=11), FSWs (n=15), truck drivers (n=4) and IDUs (n=5).

RESULTS

The findings from this study indicate that a syndemic of four socio-behavioural factors is associated with HIV acquisition in peri-mining areas. These are migrancy, accessibility to alcohol and substance use, commercial and transactional sex, and uptake of HIV prevention services.

CONCLUSIONS

Our findings have implications for HIV prevention programmes in mining companies, which rely on male condom usage promotion. More emphasis on better education about HIV prevalence, transmission and up-to-date prevention alternatives, such as pre-exposure prophylaxis for mineworkers is recommended. Furthermore, collaboration with community-based organisations is recommended to wholly address the syndemic factors influencing HIV transmission in peri-mining communities.

A qualitative study of migrant-related stressors, psychosocial outcomes and HIV risk behaviour among truck drivers in Zambia

Truck drivers are part of mobile populations which have been noted as a key population at risk of HIV in Zambia. This study was aimed at: (1) determining potentially traumatic events (PTEs), labour migrant-related stressors, psychosocial problems and HIV risk behaviours among truck drivers in Zambia; and (2) examining the relationship between PTEs, migrant-related stressors, psychosocial outcomes and HIV sexual risk behaviour among truck drivers in Zambia. We conducted 15 semi-structured interviews with purposively sampled male truck drivers at trucking companies in Lusaka, Zambia. Findings indicate that truck drivers experience multiple stressors and potentially traumatic incidences, including delays and long waiting hours at borders, exposure to crime and violence, poverty, stress related to resisting temptation of sexual interactions with sex workers or migrant women, and job-related safety concerns. Multiple psychosocial problems such as intimate partner violence, loneliness, anxiety and depression-like symptoms were noted. Transactional sex, coupled with inconsistent condom use, were identified as HIV sexual risk behaviours. Findings suggest the critical need to develop HIV-prevention interventions which account for mobility, potentially traumatic events, psychosocial problems, and the extreme fear of HIV testing among this key population.

Evaluation of HIV/AIDS Prevention in South African Schools

This article reports on the implementation of a schoolbased HIV/AIDS and life-skills training program to prevent the spread of HIV/AIDS among the young people in secondary schools in South Africa. The implementation of the program was evaluated for a period of two years, using process and outcome evaluation and a systems approach to understand the higher-order feedback processes that obstructed the implementation and effectiveness of the intervention. Although HIV/AIDS is a medical condition, this article emphasizes that HIV/AIDS prevention is interrelated with the psychosocial context within the community. Interventions should therefore be conceptualized and implemented in terms of the various levels of interaction in the community.

Danger zone: Men, masculinity and occupational health and safety in high risk occupations

The workplace is a key setting where gender issues and organizational structures may influence occupational health and safety practices. The enactment of dominant norms of masculinity in high risk occupations can be particularly problematic, as it exposes men to significant risks for injuries and fatalities. To encourage multi-disciplinary collaborations and advance knowledge in the intersecting areas of gender studies, men's health, work and workplace health and safety, a national network of thirteen researchers and health and safety stakeholders completed a critical literature review examining the intersection between masculinities and men's workplace health and safety in order to: (i) account for research previously undertaken in this area; (ii) identify themes that may inform our understanding of masculinity and workplace health and safety and; (iii) identify research and practice gaps in relation to men's workplace health and safety. In this paper we present key themes from this review. Recommendations are made regarding: (i) how to define gender; (ii) how to attend to and identify how masculinities may influence workers' identities, perceptions of occupational risks and how institutionalized practices can reinforce norms of masculinity; (iii) the importance of considering how masculinities may intersect with other variables (e.g. historical context, age, class, race, geographical location) and; (iv) the added significance of present-day labour market forces on men's occupational health and safety.

Behavior change communication and mobile populations: the evaluation of a cross-border HIV/AIDS communication strategy amongst migrants from Swaziland

This study investigates the effect of being exposed to the Soul City Southern Africa Regional OneLove campaign, a behavior change communication program, on sexual behavior and condom use among a mobile population in Swaziland. Data for this study come from a nationally representative sample of 845 individuals who reported traveling to neighboring countries for at least two weeks at any time in the previous two years. Respondents were asked about exposure to the campaign through television, radio, booklets, posters, and advertisements both in Swaziland and in the other countries where they had traveled in the previous two years. Odds ratios were used to estimate the relationships between the HIV/AIDS outcomes of interest and program exposure for the full sample as well as separately for males and females. The program had no effect on reducing known risky behaviors such as having multiple sexual partners. However, men exposed in Swaziland only (AOR = 3.4, CI 1.2-9.4) and in Swaziland and another country (AOR = 2.8, CI 1.0-7.7) were more likely to report using a condom at last sex. In the full sample, those exposed in Swaziland were more likely to report using a condom at last sex (AOR = 2.6, CI 1.3-5.3) and a condom at last sex with a regular partner (AOR = 2.3, CI 1.1-4.8). Men who reported multiple sexual partnerships and who were exposed in Swaziland and another country were nine times as likely to report condom at last sex than men with no exposure. Respondents exposed in Swaziland and another country were more likely to have been tested for HIV; this was true for the total population (AOR = 2.9, CI 1.1-7.9) and for men separately (AOR = 3.3, CI 1.1-10.1). These findings provide support for more regional HIV prevention programs in Southern Africa as a way to increase positive behaviors among mobile populations.

Resisting the binarism of victim and agent: Critical reflections on 20 years of scholarship on young women and heterosexual practices in South African contexts

The last 20 years have seen a proliferation of research, spurred by the imperatives of the HIV epidemic and reportedly high rates of gender-based violence, on heterosexual practices in the South African context. Research has focused on how poverty, age and gender within specific cultural contexts shape sexual agency and provide a context for unequal, coercive and violent practices for young women. This paper takes stock of what we currently 'know' about heterosex and critically reflects on the political and ideological effects of such research, specifically in the light of young women's agency. A primary concern is that efforts to address gender inequality and the normative gender practices that shape inequitable heterosexual practices may have functioned to reproduce the very discourses that underpin such inequalities. The paper 'troubles' the victim-agency binarism as it has been played out in South African research on heterosex, raising concerns about how the research may reproduce gendered, classed and raced othering practices and discourses and bolstered regulatory and disciplinary responses to young women's sexualities. The paper argues for critical, feminist self-reflexivity that should extend to re-thinking methodologies entrenched in frameworks of authority and surveillance.

Labor migration and HIV risk: a systematic review of the literature

To inform the development of multilevel strategies for addressing HIV risk among labor migrants, 97 articles from the health and social science literatures were systematically reviewed. The study locations were Africa (23 %), the Americas (26 %), Europe (7 %), South East Asia (21 %), and Western Pacific (24 %). Among the studies meeting inclusion criteria, HIV risk was associated with multilevel determinants at the levels of policy, sociocultural context, health and mental health, and sexual practices. The policy determinants most often associated with HIV risk were: prolonged and/or frequent absence, financial status, and difficult working and housing conditions. The sociocultural context determinants most often associated with HIV risk were: cultural norms, family separation, and low social support. The health and mental health factors most often associated with HIV risk were: substance use, other STIs, mental health problems, no HIV testing, and needle use. The sexual practices most often associated with increased HIV risk were: limited condom use, multiple partnering, clients of sex workers, low HIV knowledge, and low perceived HIV risk. Magnitude of effects through multivariate statistics were demonstrated more for health and mental health and sexual practices, than for policy or sociocultural context. The consistency of these findings across multiple diverse global labor migration sites underlines the need for multilevel intervention strategies. However, to better inform the development, implementation, and evaluation of multilevel interventions, additional research is needed that overcomes prior methodological limitations and focuses on building new contextually tailored interventions and policies.

Density of drinking establishments and HIV prevalence in a migrant town in Namibia

Given the established link between alcohol consumption and risk taking behavior, it is plausible that neighborhoods with higher density of drinking establishments will be associated with increased prevalence of HIV. We conducted an ecological study comparing neighborhoods in Luderitz, Namibia, to evaluate this relationship. We observed increased prevalence of HIV comparing high densities of registered and unregistered shebeens, bars, and total number of drinking establishments, as compared with low densities, were associated with increased prevalence of HIV (PR = 3.02, 95% CI: 2.04-4.47; PR = 1.71, 95% CI: 1.42-2.07; PR = 1.55, 95% CI: 1.19-2.02). Our observation of increased prevalence associated with higher densities of drinking establishment's merits consideration.

Guiones sexuales de la seducción, el erotismo y los encuentros sexuales en el norte de Chile

Este artículo analiza las diversas expresiones que adquieren los encuentros sexuales, la seducción y el erotismo en el norte de Chile. El estudio se realizó usando la Teoría de los scripts sexuales. Se entrevistó a 46 hombres y mujeres de 18 a 69 años de edad de las ciudades de Antofagasta y Calama. Las conclusiones revelan que la construcción de los guiones sexuales se refuerza con los modelos socioculturales inequitativos y jerarquizados existentes en las relaciones de género predominantes en la sociedad chilena, sobretodo en una zona del país donde predomina la minería como principal actividad económica. Además, en los sectores socioeconómicos más bajos se observan, elementos asociados a los modelos más tradicionales, mientras que guiones sexuales con elementos más flexibles y equitativos en los niveles más altos.

Alcohol use and sexual behaviour among risky drinkers and bar and shebeen patrons in Gauteng province, South Africa

This paper describes the South Africa component of a World Health Organization multi-site rapid assessment and response project seeking to develop a methodology for studying factors associated with alcohol use-related sexual risk behaviour in diverse cultural settings. This report focuses on the qualitative assessments that were conducted in order to profile alcohol use and sexual behaviour in the communities concerned, ascertain the relationships between alcohol use and sexual behaviour, and develop a conceptual model of the relationships between alcohol use and sexual risk behaviour. The participants consisted of adults aged between 25 and 44 years in a township and city site in Gauteng province. The assessments involved conducting 18 key informant interviews, observations in seven drinking venues, six focus groups and 16 in-depth interviews of 'risky drinkers' and their partners. Most participants felt that there were high levels of alcohol consumption and unprotected sex among some members of their communities, with the latter occurring mainly among casual sexual partners. The findings also pointed to strong links between alcohol consumption and sexual risk behaviour. A conceptual model of the association between alcohol use and risky sexual behaviour is proposed. This study suggests a need for multi-faceted HIV intervention strategies for reducing levels of alcohol abuse in general, and enhancing protective sexual behaviours among alcohol-using populations.

Sex, Sexuality and Sickness: Discourses of Gender and HIV/AIDS among Kwazulu-Natal Women

Current HIV-prevention work indicates that simply providing HIV-related information plays a limited role in changing sexual practices, and instead stresses the need to address the social and cultural forces shaping individual behaviour. The aim of this study was thus to explore the social influences that shape women's sexual behaviour with specific attention given to discourses of gender and HIV/AIDS. Material was generated through seven focus group discussions with black women living in a peri-urban area in Durban, and was interpreted using discourse analysis. The study clarified the ways in which women are not necessarily in a position to make purely rational, individual decisions about safe sex, since these decisions are intimately linked to social constructions of sexuality and the power relations that operate in cultures. It identified specific cultural practices linked to the organisation of gender roles and how these influence safe sex practices. The analysis then examined the implications of these findings for future HIV/AIDS education interventions.

Beyond the biomedical and behavioural: towards an integrated approach to HIV prevention in the southern African mining industry

While migrant labour is believed to play an important role in the dynamics of HIV-transmission in many of the countries of southern Africa, little has been written about the way in which HIV/AIDS has been dealt with in the industrial settings in which many migrant workers are employed. This paper takes the gold mining industry in the countries of the Southern African Development Community (SADC) as a case study. While many mines made substantial efforts to establish HIV-prevention programmes relatively early on in the epidemic, these appear to have had little impact. The paper analyses the response of key players in the mining industry, in the interests of highlighting the limitations of the way in which both managements and trade unions have responded to HIV. It will be argued that the energy that has been devoted either to biomedical or behavioural prevention programmes or to human rights issues has served to obscure the social and developmental dimensions of HIV-transmission. This argument is supported by means of a case study which seeks to highlight the complexity of the dynamics of disease transmission in this context, a complexity which is not reflected in individualistic responses. An account is given of a new intervention which seeks to develop a more integrated approach to HIV management in an industrial setting.