Preventing and Mitigating AIDS in Sub-Saharan Africa Research and Data Priorities for the Social and Behavioral Sciences (1996) / Chapter Skim
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2 SOCIETAL CONTEXT
2 SOCIETAL CONTEXT
Pages 57-68
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From page 57... ...
Empirical evidence accumulated during more than a decade of prevention work indicates that both proximal and contextual interventions are necessary to reduce the spread of HIV, as well as to mitigate its impact (Mann et al., 19921. It is difficult to overemphasize the importance of contextual intervention as a weapon against HIV; policy makers simply must begin to consider reform of laws and policies outside the health sector as legitimate AIDS-reduction strategies.
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From page 58... ...
Among the more salient features of the societal context that affect the size and shape of the HIV/AIDS epidemic in sub-Saharan Africa are the age and gender composition of the population; the construction of sex roles and expectations within society; inequities in gender roles and power; sexual access to young girls and the acceptance of widespread differentials in the ages of sexual partners; rapid urbanization under conditions of high unemployment; considerable transactional sex fostered by limited earning opportunities for women; and lack of access to health care, particularly treatment for STDs. These factors are often exacerbated by social upheavals related to economic distress, political conflicts, and wars.
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From page 59... ...
In the indigenous cities of West Africa, they frequently did so through trading; as a result, West African women often have their own income and control their own budget without interference from their husbands. In colonial towns concentrated in East and Southern Africa, single women in town were often automatically associated with the exchange of sex for money or other support (Larson, 1989; Standing and Kisekka, 1989~.
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From page 60... ...
Women in West Africa have traditionally enjoyed more autonomy than women in East and Southern Africa, participating in the labor force in a wide range of income-generating activities such as trading. Furthermore, it is claimed that women in West Africa who separate from their husbands can easily return to their families and usually retain their children, even in patrilineal societies
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From page 61... ...
Patterns observed in some African settings of mixing between people in high-risk core groups and others in the general population (as opposed to simple assortative mixing with strong withingroup partner preference, such as pairings confined to well-defined groups) can result in substantial spread of sexually transmitted infections, including HIV, among the general population (see Anderson and May, 19921.
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From page 62... ...
Several factors lend a special character to conjugal bonds in many subSaharan societies: the relatively greater importance placed on lineage and intergenerational links than on marital ties; traditional separation of spousal economic activities and responsibilities; and polygyny (a common feature of married life in many sub-Saharan African populations, although its prevalence varies considerably according to region and ethnic group) , which can result in substantial age differences between husbands and later wives (Caldwell et al., 1989; Goldman and Pebley, 1989; Pebley and Mbugua, 1989; Orubuloye et al., 1990~.
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From page 63... ...
(Orubuloye et al., 1990~. Multiple partnerships, the need for discretion, and unacknowledged commercial sex all militate against the effectiveness of contact tracing or of interventions aimed primarily at "core groups" such as identifiable commercial sex workers.
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From page 64... ...
During the period of rapid urbanization, health officials noted marked increases in sexually transmitted diseases, more recently including HIV-1 infection, within the growing cities (Quinn, 1994~. In addition, the economic recession may have aggravated the transmission of HIV by increasing the population at risk through increased migration, disruption of rural families, and poverty (Quinn, 1994~.
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From page 65... ...
Truck drivers, the military, and female commercial sex workers are all well recognized as high-risk populations for HIV infection, and are all highly mobile (Smallman-Raynor and Cliff, 1991; Orubuloye et al., 1993~. Women involved in commercial sex work frequently move from one locality to another because of economic pressures.
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From page 66... ...
Wars and civil unrest disrupt local authority, creating environments of lawlessness, and disrupt or destroy local economies, pushing people into cities and sex work. MEDICAL AND PROGRAM FACTORS Access to and use of health services (including STD treatment)
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From page 67... ...
In rural Africa, poor transport and communications networks complicate STD control measures. Contact tracing is logistically difficult and potentially highly stigmatizing because household visits represent the principal means of contact.
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From page 68... ...
and the World Bank's structural adjustment programs may have heightened people's risk of HIV infection by (1) reducing the sustainability of a rural subsistence economy, (2)
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