The range of social, economic and political issues concerning HIV and AIDS is vast and complex. The impact of this pandemic will only be known in future generations. It is an established fact that HIV/AIDS has significantly reduced life expectancy, educational gains have been reversed, poverty increased, and it has eroded economic growth.
Other longer-term effects concern urban-rural disparities in terms of all aspects of service and development. Conversely, the concerted efforts to deal with all these issues has increased awareness and efforts concerning gender equity, primary health and capacity, and mobilised diverse organisations in the pursuit of common objectives. If anything else, profound change – both negative and positive – has, and is, occurring as a direct result of HIV/AIDS.
1. In my view, there are a number of options available to not only accelerate the attainment of the various MDG objectives, but also to improve the effectiveness of diverse efforts. Probably the most important is a re-evaluation of the fundamental value bias of primarily Western-based agencies: In Africa specifically, the foundation of social norms is a group-mindedness, whereas Western-based social norms are focused primarily upon attainment of individual actualisation. This may not appear significant, but this bias has impacted upon delivered programs and methods in profound ways: The ethics of confidentiality in individual testing and counseling, versus relationship or group-based procedures, is such an example. Without the structures of individual confidentiality – both in counseling and medical treatment – the scope of efforts could be significantly broadened, and the relational basis of the pandemic could be more effectively – and rapidly – addressed. Recent research concerning concurrent relationships clearly indicates that it is not sexual frequency that is driving the pandemic, but rather the nature of sexual relationship networks. I believe it is time we deal directly with those relationships, versus its’ individual parts, in both testing, prevention, and treatment.
How do you apply group-mindedness in practice? Setting aside the implied legal changes required, what I would like to see is: Couples counseled and tested for HIV, together, not separately; Family units treated medically, such as with ART. Quite literally, a family – such as the husband and wife – going through the medical testing for CD4s and viral load together, knowing each other’s results, and then being treated with the full knowledge (and counseling) of both persons. This should address many of the non-adherence problems, including the rise of drug-resistant strains of HIV. More controversially, the Zero Grazing (Uganda) model should be revived, where family, friends and neighbours are encouraged to name-and-shame community members who are being unfaithful to their primary relationship, thus reducing the ease of engaging in concurrent relationships. Essentially I am proposing behavior-change methodology that focuses upon group and relationship dynamics, versus individual decision-making.
(a) VCT: Redesign/expand protocols to include couple/family HIV testing and pre/post-test counseling. I.e., all stages of the process conducted in the presence of both persons (or family members);
(b) ART: Medical examinations, diagnosis, explanations conducted in the presence of a family member/spouse.
(c) Prevention: Revive/adapt the Zero Grazing model to focus upon reducing multiple concurrent relationships.
(d) Create processes that enhance relationships including but not limited to increasing levels of intimacy, communication, trust and combined future dreams/plans that both partners desire.
(e) Adopt mandatory counseling sessions within the workplace with opt-out testing.
2. Secondly, with exceptions, leadership at the macro-political leadership level is weak or absent in terms of setting the social normative tone for the changes that are required. Instead, leadership tends to be overly concerned with being seen to be cut from the same cloth as their constituents, versus leading those constituents through difficult changes. The need for popularity supercedes the desire for effectiveness. This is partly associated with the post-colonial desire to build identity and esteem through adherence to cultural values, some of which directly impede the attainment of the MDG objectives. This is particularly the case with gender-related social norms, and the role of women in positions of authority. Although great strides – legally and constitutionally – have been made in this regard, it is simply not enough, and certainly not implemented with great vigour.
It is a fact that one of the primary drivers of the spread of HIV is concurrent relationships, which has many roots, some cultural (polygamy), and some economic. However, this form of open-ended polygamy results in a radical increase in transmission of HIV during the acute infection stage, the Window Period. Regardless of our desire to be value-neutral in this regard, we have few options in eliminating this wide-spread practice. We have almost no chance of changing this practice when our leaders openly have multiple partners, some long-term, and some casual. Until they – the leaders – change, the populace will resist monogamy. The alternative is to legalise and normalize multiple partnerships in such a way that the responsibility to economically support and care for a second or third partner is legally enforceable, similar to closed polygamy, but with the emphasis upon full economic responsibility. This approach should resonate with many people who refer to ‘traditional values’ – which included polygamy – with penalties for breaking the rules. This should, if done carefully, reduce the casual sex, and also the Sugar-Daddy (or Sugar-Mommy) and similar situations, which is based upon attaining economic support. A simple avenue to implement this would be to reduce the period of time required for a relationship to be recognized as Common Law marriage, increase the amount of spouses permitted per person, and then implement an advocacy campaign educating people about their rights under this system. The bottom-line with this proposal is: If you want more than one partner, then you’d better be ready for the economic and legal consequences.
(a) Implement a scorecard for politicians and community leaders which includes knowledge level of HIV/AIDS, and also the number of public statements/projects delivered – personally – regarding HIV/AIDS, poverty, and other MDG goals.
(b) Evaluate traditions and customs that enhance and reduce the attainment of MDG goals. Facilitate public discourse on these beliefs, customs and traditions.
(c) Evaluate the existing legal framework regarding multiple partnerships. Consider legal changes to strengthen the economic and legal rights of concurrent partners, to bolster the level of responsibility of the common partner, in order to close what is currently an open polygamous system.
(d) Conduct a public advocacy campaign to make concurrent partners aware of their legal and economic rights, with respect to the common partner.
(e) Revisit current legislation on the paternal laws that hold men accountable for their off-spring to lessen the burden on State systems.
3. The third major factor concerns the urbanisation of our populations, and the economic power of these urban areas: Rural areas are simply neglected or given token attention. The reality is that many governments and businesses are applying an utilitarian approach to the rural areas: It is – per person – more expensive to develop rural areas, compared to the more densely populated and economically active urban areas. The current focus is primarily upon job creation – which mainly focuses upon urban areas – and the needs of urban populations, while the food production, education, medical care in rural areas are given second place, consistently. The general situation – at least in terms of HIV and AIDS – is that if you are employed in an urban area and have HIV, you will be okay. However, if you live in a rural area, the outcome is dire. This does not only apply to HIV and AIDS – it is a generalised scenario in terms of education, medical care, and service delivery of basic services. As a result, the migration from rural to urban areas continues relentlessly, with a resulting decrease in food production, for example. We sorely need greater attention for the development of rural areas to counter this increasing marginalisation and impoverishment of large sections of our populations. Young people in particular would prefer to be unemployed and living in fringe suburbs, than work on land inherited from their family. This is a direct result of social marketing, which depicts farming and food production as the domain of the poor and uneducated. We need the social status of rural areas to be increased and enhanced, making activities such as farming a desired career and future, particularly with younger people.
Africa – with South Africa as an example – is hell-bent on economic development, as this generates the revenues for the various services the government is obliged to provide. However, in this process, the ability of the population to support and feed itself through homestead farming is neglected in favour of commercial farming. Tremendous dependency is being created upon industry and government services, with little attention given to increasing the capacity of individuals and families to take steps to improve their own food security (e.g., home gardens), and entrepreneurship (self-employment). These two areas need a great deal of attention, if we are to uplift both rural and urban areas from unemployment and poverty: The current mind-set is that if you are not employed or on a government grant, your prospects are dim. Although programmes exist for developing entrepreneurship, these are weak, half-hearted, and limited. Entrepreneurship should be a key subject of education in the education system.
The rural areas in particular require far more development in terms of quality education for children, skills development (e.g., improved farming methods, homesteading), and adult literacy programmes. Primary health services are in dire need of improvement and expansion. If we could double – even treble – the number of primary health nurses in these areas, and also capacitate them to assume the responsibilities of diagnosing and prescribing medications such as ART, we may start to address the severe shortages of doctors in these areas, thus stopping the worsening poverty cycle caused by removing children from school to take care of sick family members, and also adults who would be otherwise engaged in food production. We bemoan the poverty and dire circumstances of many communities, and ask how we can ‘save them’. However, we fail to recognize that those communities have the inherent ability to ‘save’ themselves, given the necessary information, education, and start-up resources. We need to end the hand-out era, and start the hand-up process: When dependency decreases, so does poverty. When self-reliance increases, so does pride and productivity.
(a) ‘Create your own job’: Raise awareness and knowledge regarding entrepreneurship at all levels of society, including at secondary schools. Local, regional and national competitions which promote and reward such activities – including in the rural areas – would facilitate such awareness, status, and skills.
(b) Significantly increase the budgets and efforts focusing upon self- and family-sufficiency regarding food security. This would include practical support regarding seed and fertilizer supplies, skills transfer regarding issues such as soil quality, water-wise methods, crop rotation and/or intercropping. Such efforts could be implemented at all primary and secondary schools, not only to provide food to the children, but also to provide the venue for such skills development. Include such activities in annual performance assessments of such schools and personnel.
(c) Expand the role of Dept Agriculture extension workers to support and capacitate homesteads in food security, versus focusing primarily upon commercial farming. Development and research into non-hybrid seed varieties to encourage seed banking, and thus sustainability of such food security methods. Dry-land and permaculture methods (e.g., mulching, recycling used water) to be refined and promoted. I.e., reduce the dependency upon purchasing processed foods of low nutritional value, and increase self-produced home produce.
(d) Raise the awareness of homestead food security methods through the media (television, radio, newspapers), with regular awards to raise the status of homestead food production.
(e) Revise the policy and education structures to expand the capacity of nursing personnel to diagnose and dispense medications such as ART and prophylaxis.
(f) Elevate the status of the nursing and teaching profession to attract more applicants from schools. Make such recruitment a national strategic priority.
(g) Attach conditions to receipt of social grants for the unemployed. For example, attendance of skills training (including entrepreneur-related and food security methods), and demonstrations of application.
(h) Introduce micro-lending systems to stimulate economic activity in rural settings, giving people basic business education to ensure sustainability.
(i) Utilize Post-Test clubs in rural settings to support healthier living through health empowerment programs and education.
It is high time we started having some very challenging, courageous and difficult conversations if we hope to be truly effective. We need to have the courage to challenge so-called ‘norms’ that are sustaining this pandemic once and for all.
A commentary by David Patient- Person living with AIDS since his diagnosis with GRIDS back in March, 1983
David Patient is one of the longest documented people alive in the world today living with HIV.
He was diagnosed with GRIDS, which later became more commonly known as HIV/AIDS.
He has been an activist and advocate for the rights of those living with and affected by HIV/AIDS, initially in the United States from 1983 till 1995, when he returned to Africa where he has worked ever since.
He is an author of several best-selling books and is an international facilitator and program designer in the areas of health, behaviour change and thought leadership.