Our third year HIV/AIDS and Global Health module, which explores broader anthropological questions around HIV/AIDS, illness and healing, sexual and reproductive relationships, and global health. As part of the module students are required to design a HIV awareness poster or research proposal. This week, we are featuring a poster assignment by Hovnan Gulbenkian Eayrs on HIV among older adults in South Africa.
Hovnan’s bio: I am an undergraduate anthropology student at the end of my final year. Whilst I have been fascinated by many areas of anthropology over the course of my degree, I have developed a particular interest in material culture and the anthropology of design and visual communication. I am hoping to work in these areas in the future.
The Forgotten Generation: Questioning the Lack of HIV/AIDS Awareness Campaigns for Older Adults in Mpumalanga Province, South Africa
Although there has been a large amount of research on the effects of the HIV epidemic in sub-Saharan Africa, few studies have considered the effects of the epidemic on older adults. Throughout the course of the epidemic so far, it has been understood that the primary role of older people is to provide care for those that are ill and to look after children that have been orphaned (Negin et al., 2016; Angotti et al., 2018). However, given the high prevalence of HIV amongst older adults (those aged 50+), it is clear that more attention needs to be paid to the acquisition and transmission of HIV within this age group.
With over 7 million people living with HIV, South Africa has the largest HIV prevalence of any country in the world. It also has a large and growing aging population. Much like adolescence, old age is a stage in life that often involves many relationship changes, from divorce and remarriage to widowhood. For this reason, many HIV-negative older adults in South Africa are likely to be exposed to a pool of sexual partners that have a high prevalence of HIV (Houle et al., 2018). This factor, taken alongside very low use of condoms, cross-generational sex, extramarital sex and unknown HIV status, has contributed to the high levels of HIV within this age group (Schatz et al., 2019).
One of the worst affected areas of South Africa is the Mpumalanga Province, where at least 16.5% of people aged 50 or older are HIV-positive (Angotti et al., 2018). The overall rate of new infections in Mpumalanga has fluctuated very little in the past 12 years, continuing to stay high despite huge national investment in HIV awareness campaigns and greatly improved access to ART treatment (Winchester & King, 2017). Mpumalanga also has the highest youth rates of infection in the country. However, whilst the new infection rates in young adults (15-24) is starting to slow down, in older adults (50+) the rate is increasing (Houle et al., 2018). Despite this clear cause for concern, little research and intervention has been targeted at older adults in Mpumalanga.
The risk of unsafe sex being associated with contracting the HIV virus is widely understood by older adults in Mpumalanga (Schatz, et al., 2019). However, as Winchester and King (2017) noted, a pervasive public stigma around the virus still exists in some communities, meaning HIV is rarely discussed outside local health clinics. When asking the residents of Ntunda, a village in Mpumalanga Province, about the virus, Winchester and King (2017) found that they were reluctant to discuss any personal experience with it and instead mostly gave general statements. For example, one man in his fifties told the researchers the only thing he knew was that HIV was “healed at the hospital” (p.162) (Winchester & King, 2017) One women, however, acknowledged that the virus was a great problem in the village, explaining that “most people are affected” (p.163), but nothing more. According to Winchester and King (2017), even this kind of acknowledgement of the problem was rare. The denial and stigma that exists in Ntunda, and other areas of Mpumalanga, affects not only the way HIV is discussed in the community but also the way in which external public health messages are received (Angotti et al., 2018).
Unlike the poorer neighbouring countries of Mozambique and Swaziland, in Mpumalanga there are very few public health posters and billboards outside the clinics. (Winchester & King, 2017) Within the clinics, there is much more visible advertising on HIV, with campaigns advising pregnant mothers to get tested and warning young adults about the risks of unsafe sex. However, even then there are no posters that target older adults specifically. It is clear that the focus of HIV prevention is not on this group, despite the strong evidence that suggests it should be (Schatz et al., 2019).
An investigation by Angotti et al. (2018) into the HIV preventions strategies employed by the older South Africans in Mpumalanga, without intervention from the state, revealed how men and women ‘took quite varied approaches. These strategies were understood in the context of a local concept of ageing well, that was embodied by the phase ‘ku ti khoma’, meaning ‘to take care of yourself’ (p.263) (Angotti et al., 2018). This concept encapsulates the expected behaviours and responsibilities of a respectable older person within the community.
Both older men and women interviewed by Angotti et al. (2018) generally acknowledged that the best strategy for ‘taking care of yourself’ in the context of HIV was to remain in a monogamous relationship. However, for men, this strategy was rarely used. The strategy of older men for ‘taking care’ more often involved reducing the risk involved in having multiple sexual relationships or extramarital sex, rather than desisting from those activities entirely. For some men, therefore, this involved choosing sexual partners their own age and avoiding having sex with younger women/men they encountered in bars and clubs. For other men this involved choosing to wear a condom. For example, one man interviewed by Angotti et al. (2018) described how he always went with ‘a condom in his pocket’ if he knew he was seeing a prostitute. Although condoms do offer some protection from getting infected, they are not fail-safe meaning these men are still putting themselves and their partners at risk. Furthermore, as condoms were often considered something only used with sexual partners that were not close or seen as risky, there was an aversion to using them, sometimes by both men and women, in close sexual relationships and with husbands/wives (Schatz et al., 2019).
By contrast, for older unmarried women, refusing sex was often their main strategy for ‘taking care of themselves’ (Schatz et al., 2019; Angotti et al., 2018). Unlike married women, whose main strategy was to say faithful to their partners, unmarried women often found the best course of action was to simply reject unsolicited advances. However, some single women, although not married, still have long-term sexual relationships and find it hard refuse sex. (Houle et al., 2018) Even though they know the person they are with may have other sexual relationships and are worried they may be infected, these sexual relationships often predated the HIV epidemic in South Africa. As such, there is widespread difficulty in these relationships being brought to an end now. Married women often face similar difficulties. In the interviews carried out by Angotti et al. (2018), both older men and women were accused of not staying faithful when their partner was not around, yet the older men tended to have more extramarital relationships.
As there are few formal work opportunities in Mpumalanga, many of the men in the communities travel far to find work. This creates long periods of time when married couples are separate, thereby increasing the chance of extramarital sex taking place. Should this take place, both parties are at risk, even if the partner at home has stayed faithful. One woman expressed her concern about this to Angotti et al. (2018): “I’m at home taking care of myself then he [comes] home and [infects] me. I didn’t misbehave at all, then we all get infected in that way” (p.269). In this way, the lack of employment opportunities in Mpumalanga Province continues to be one of the central issues faced by the people who live there (Houle et al., 2018). Although there is a fast growing physical healthcare infrastructure of clinics and hospitals funded by the government, the very weak local economy means people must still travel far to make any income. Along with the provision of healthcare facilities and access to medicine, systemic issues like unemployment also need to be addressed in order to reduce the prevalence of HIV (Winchester & King, 2017; Negin et al., 2016).
Although the increase in the number of healthcare clinics in the area is considered a positive development by most, some of the older adults interviewed by Angotti et al. (2018) felt their introduction had created a culture of ‘nondisclosure’ and secrecy within the community. Due to the stigma that surrounds HIV, they described how some people were unwilling to go and collect their ART medicine as frequently as they should because they did not want to reveal their HIV status. This then further contributed to the increased prevalence of HIV in the area. As Angotti et al. (2018) highlight, it is precisely in this type of situation that making an effort to ‘take care of yourself’ (by adhering to the ART programme) meant also taking care of the community. One older man interviewed by Angotti et al. (2018) suggested that in order to identify the impact of HIV, there needed to be some community measures that made the HIV status of every member public. In this way, everyone could see whether those that were HIV-positive were adhering to their medicine and taking care of themselves. Whilst also stopping unprotected sex between those that are HIV-negative and those that are HIV-positive, such a process would make it easier for the whole community to care of themselves.
The situation in which my poster sits is an important factor in whether it is seen, read and acted upon. Most older adults in Mpumalanga receive a pension from the government, which is often their only source of income (Winchester & King, 2017). This requires the recipients to go to a specific ‘pay point’ in their village in order to collect their pension each month (Ralston et al., 2016). I think this would be significant place in which my poster could be presented and seen by its target audience. In this position, the poster may sit alongside other informational posters and, as such, I decided to use the striking colours of black and red to make the poster stand out from any others it might be placed alongside. Further, the text is in short, to-the-point sentences and the key phrases are highlighted in order to convey the main message effectively, without it having to be viewed for too long.
The stigma around HIV is still strong in many communities in Mpumalanga (Schatz et al., 2019). However, I believe that asking older adults to consider how HIV prevalence affects not only their own lives, but also the lives of their family and their community, may provoke them to act. From the interviews by Angotti et al. (2018) and Winchester and King (2017), it seemed clear that older adults felt a sense of responsibly for taking care of their community. As elders, they identified that an essential element of their role within the community was to act as the caregivers for those that needed support or were unwell. (Winchester & King, 2017) They are, in return, given a level of respect by others, who bring food and other items they might need. Accordingly, by referring to my target audience as ‘respectable elders’ in my poster, my aim is to evoke this sense of responsibility to their community and the caregiving element of their role.
The main intention of my poster was to utilise the same expression used by older people in Mpumalanga Province, to motivate them to ‘take care of themselves’. However, as I have shown, in the context of HIV/AIDS this expression can be understood in a number of different ways. For this reason, instead of leaving it up to someone’s own discretion, I wanted to convey two simple messages to older adults in Mpumalanga. The first is to inform them that, unlike many previous campaigns in the area that target younger generations, they too are also susceptible to HIV and can pass it on. The second is to encourage them to ‘take care of themselves’ by finding out their HIV status.
Although it may not be considered a preventative method, by knowing their status, older adults in Mpumalanga may be more conscious of either taking care to not get infected or preventing further infection. Furthermore, by going to the clinic and getting tested they will be given more information on how HIV is spread and what they can do to prevent its spread. If they test positive at the clinic, they will be given ART and enrolled in a ‘positive living’ program (Houle et al., 2018; Winchester & King, 2017). This program will teach them how to take care of themselves; maintain their health during the treatment and why they must adhere to the medicine (Schatz et al., 2019). For this reason, I think the action of getting tested will be the important first step in the process of reducing HIV prevalence among older adults in Mpumalanga.
Angotti, N. et al., 2018. ‘Taking care’ in the age of AIDS: older rural South Africans’ strategies for surviving the HIV epidemic. Culture, Health & Sexuality, Volume 20.
Houle, B. et al., 2018. Sexual behavior and HIV risk across the life course in rural South Africa: trends and comparisons. AIDS Care, 30(11).
Negin, J. et al., 2016. Rising Levels of HIV Infection in Older Adults in Eastern Zimbabwe. PLoS ONE, Volume 11, p. e0162967.
Ralston, M. et al., 2016. Who Benefits—Or Does not—From South Africa’s Old Age Pension? Evidence from Characteristics of Rural Pensioners and Non-Pensioners. International Journal of Environmental Research and Public Health, Volume 13.
Schatz, E. et al., 2019. How to “Live a Good Life”: Aging and HIV Testing in Rural South Africa. Journal of Aging and Health, Volume 31, p. 709–732.
Winchester, M. & King, B., 2017. Constructing landscapes: Health care contexts in rural South Africa. Medicine Anthropology Theory, 4(1).