Mobilising indigenous resources for anthropologically designed HIV-prevention and behaviour-change interventions in southern Africa

Experiences of HIV among global Indigenous populations through the lens of the UN Declaration on the Rights of Indigenous Peoples

Since its introduction in 2007, the UN Declaration on the Rights of Indigenous Peoples (UNDRIP) has been adopted by 144 countries worldwide. In a ten-point statement released in 2017, Indigenous leaders in the HIV and AIDS community established a list of truths and actions to be used for advocacy to end AIDS among Indigenous Peoples through self-determination, justice, and human rights. 15 years after the UNDRIP and 5 years after the 10-point statement, this Review asks where we are in terms of upholding the UNDRIP and the International Indigenous HIV and AIDS Community statement in relation to HIV and AIDS, and what is needed to better uphold and respond to these directives. HIV in Indigenous populations continues to intersect with multiple forms of oppression, racism, and discrimination, which are yet to be eliminated from laws, policies, and practices. Eradicating white supremacy and Indigenous-specific racism across all health systems is a bare minimum requirement to uphold Indigenous rights within health care, and must be accompanied by support for Indigenous, self-determined, culturally tailored, and community-specific health and wellness services.

The relevance of the content of an HIV and AIDS social intervention programme for the youth in the Northern Cape, South Africa

The numbers of people infected with HIV and living with AIDS remain high in South Africa. The youth of the Northern Cape province in South Africa are a vulnerable population in this regard. However, there seems to be a dearth of rigorous evaluations of HIV and AIDS social intervention programmes targeted at the youth. This study aimed to evaluate the relevance of the content of an HIV and AIDS social intervention programme for the youth in the Northern Cape as well as to collect attendees' recommendations with regards to programme content. The data collection method comprised a group-administered questionnaire completed by youth (N = 172) who participated in the Soul City social intervention programme (SCP) implemented for the youth in the Northern Cape, and recruited through stratified random sampling. Based on specific criteria, the results showed that the SCP programme's content was relevant to the communities it served. The youth also forwarded recommendations for the programme content. Recommendations from the study include that youth support should be beyond dialogues; women's rights should be promoted within the context of HIV prevention strategies; the SCP should intensify its condom promotion efforts because it is relevant to the South African government's macro-level plan; relevant community leaders should be visited to explain the rationale for the youth's involvement in programmes; and the programme should focus more pertinently on poverty alleviation strategies.

Re-establishing safer medical-circumcision-integrated initiation ceremonies for HIV prevention in a rural setting in Papua New Guinea. A multi-method acceptability study

Background

Efforts to stem the spread of Human Immunodeficiency Virus (HIV) in Papua New Guinea (PNG) are hampered by multiple interrelated factors including limited health services, extreme diversities in culture and language and highly prevalent gender inequity, domestic violence and poverty. In the rural district of Yangoru-Saussia, a revival of previously ceased male initiation ceremonies (MICs) is being considered for a comprehensive approach to HIV prevention. In this study, we explore the local acceptability of this undertaking including replacing traditional penile cutting practices with medical male circumcision (MMC).

Methods

A multi-method study comprising three phases. Phase one, focus group discussions with male elders to explore locally appropriate approaches to HIV prevention; Phase two, interviews and a cross-sectional survey with community men and women to assess views on MICs that include MMC for HIV prevention; Phase three, interviews with cultural leaders and a cross sectional survey to assess the acceptability of replacing traditional penile bleeding with MMC.

Results

Cultural leaders expressed that re-establishing MICs was locally appropriate for HIV prevention given the focus on character building and cultural preservation. Most surveyed participants (81.5%) supported re-establishing MICs and 92.2% supported adapting MICs with MMC. Changes to penile bleeding emerged as a contentious and contested issue given its cultural significance in symbolizing initiates’ transition from childhood to adulthood. Participants were concerned about potential clash with modern education, introduced religious beliefs and limited government support in leadership and funding.

Conclusions

Most people in this study in Yangoru-Saussia support re-establishing MICs and replacing traditional penile bleeding with MMC. This culturally-sensitive alignment of MMC (and HIV prevention) with revived MICs responds to a national health priority in PNG and acts as an example of providing culturally-sensitive male circumcision for HIV prevention recommended by WHO/UNAIDS. However, the implementation of this undertaking will require considerable effort, especially when modern pursuits in education and religion must be factored and when there is expectation for local authorities to lead and provide funding.

Assessing the Impact of Leveraging Traditional Leadership on Access to Sanitation in Rural Zambia

Open defecation is practiced by more than one billion people throughout the world and leads to significant public health issues including infectious disease transmission and stunted growth in children. Zambia implemented community-led total sanitation (CLTS) as an intervention to eliminate open defecation in rural areas. To support CLTS and the attainment of open defecation free communities, chiefs were considered key agents of change and were empowered to drive CLTS and improve sanitation for their chiefdom. Chiefs were provided with data on access to sanitation in the chiefdom during chiefdom orientations prior to the initiation of CLTS within each community and encouraged to make goals of universal sanitation access within the community. Using a survival regression, we found that where chiefs were orientated and mobilized in CLTS, the probability that a village would achieve 100% coverage of adequate sanitation increased by 23% (hazard ratio = 1.263, 95% confidence interval = 1.080-1.478, P = 0.003). Using an interrupted time series, we found a 30% increase in the number of individuals with access to adequate sanitation following chiefdom orientations (95% confidence interval = 28.8-32.0%). The mobilization and support of chiefs greatly improved the uptake of CLTS, and empowering them with increased CLTS knowledge and authority of the program in their chiefdom allowed chiefs to closely monitor village sanitation progress and follow-up with their headmen/headwomen. These key agents of change are important facilitators of public health goals such as the elimination of open defecation in Zambia by 2020.

'Good culture, bad culture': polygyny, cultural change and structural drivers of HIV in Papua New Guinea

Culture is often problematised as a key structural driver of HIV transmission in Papua New Guinea. Official HIV programmes, as well as church teachings, tend to focus on customary marital practices of polygyny and bride price payments as 'harmful traditions'. This focus can oversimplify the effects of current and historical nuances of cultural, political and economic change on sexual concurrency and gender inequality. Community-based healthcare workers in Southern Highlands Province explain that customary marital practices are now highly reconfigured from their traditional forms. A recent mining boom has financially advantaged local and travelling men, who are driving an increase of sexual concurrency, transactional sex and inflation of bride price payments. Healthcare workers suggest that the erosion of important social relationships and kinship obligations by the expanding cash economy has caused an intensification of individual male power while enhancing the vulnerability of women. Yet without the means to challenge the effects of uneven economic development, healthcare workers are left to target 'culture' as the central influence on individual behaviours. A commitment to address structural inequality by political leadership and in HIV prevention programmes and a careful contextualisation of cultural change is needed.

Traditional healers and the "Fast-Track" HIV response: is success possible without them?

The rapid scale-up of effective HIV prevention strategies is a central theme of the post-2015 health and development agenda. All major global HIV and AIDS funders have aligned their policies and plans to achieve sharp reductions in new HIV infections and reach epidemic control by 2030. In these "fast-track" plans, increased antiretroviral treatment coverage and the attainment of viral suppression are pivotal, and there is firm recognition of the need for countries to mobilise more domestic resources and build stronger community clinic systems. There is little in these bold plans, however, to suggest that the now 30-year-old call by the World Health Organization (WHO) and other organisations to establish systematic collaborations with the traditional health sector will finally be heeded. In the context of sub-Saharan Africa's HIV epidemic, a significant body of literature demonstrates the critical role that traditional healers can play in improving the success of health programmes, including those for HIV prevention. This paper provides a brief history of collaboration with traditional healers for HIV followed by a description of several successful collaborations and discussion of key elements for success. We argue that the traditional health sector is a major resource that has yet to be sufficiently mobilised against HIV. As we shift from a short-term HIV response to a longer-term and more sustainable response, there is an urgent need to accelerate efforts to leverage and partner with the hundreds of thousands of traditional health practitioners who are already providing health services in communities. Failure to better attune our work to the medical pluralism of communities affected by HIV will continue to hinder HIV programming success and help assure that ambitious post-2015 HIV prevention and control goals are not realised.

Framing the impact of culture on health: a systematic review of the PEN-3 cultural model and its application in public health research and interventions

OBJECTIVE

This paper reviews available studies that applied the PEN-3 cultural model to address the impact of culture on health behaviors.

METHODS

We search electronic databases and conducted a thematic analysis of empirical studies that applied the PEN-3 cultural model to address the impact of culture on health behaviors. Studies were mapped to describe their methods, target population and the health behaviors or health outcomes studied. Forty-five studies met the inclusion criteria.

RESULTS

The studies reviewed used the PEN-3 model as a theoretical framework to centralize culture in the study of health behaviors and to integrate culturally relevant factors in the development of interventions. The model was also used as an analysis tool, to sift through text and data in order to separate, define and delineate emerging themes. PEN-3 model was also significant with exploring not only how cultural context shapes health beliefs and practices, but also how family systems play a critical role in enabling or nurturing positive health behaviors and health outcomes. Finally, the studies reviewed highlighted the utility of the model with examining cultural practices that are critical to positive health behaviors, unique practices that have a neutral impact on health and the negative factors that are likely to have an adverse influence on health.

DISCUSSION

The limitations of model and the role for future studies are discussed relative to the importance of using PEN-3 cultural model to explore the influence of culture in promoting positive health behaviors, eliminating health disparities and designing and implementing sustainable public health interventions.