Education as an HIV Prevention and Intervention Strategy in South Africa
Author: Eric Seng, 2017
“Transformation is a key component of the modern human experience, whether it be changing political systems, ideologies, or other frameworks…”
Image is of Eric Seng, center, with members of loveLife Orange Farm Y-Centre Academy in Johannesburg, South Africa. Photo provided by Eric Seng.
Transformation is a key component of the modern human experience, whether it be changing political systems, ideologies, or other frameworks. Ideally, this would be a smooth and painless process. However, this is seldom the case. Rather, transformation has often led to varying degrees of pain and suffering. While South Africa’s transformation from apartheid to democracy was overwhelmingly peaceful and averted major conflict, it has not been immune to major crises. One such crisis is that of the HIV/AIDS epidemic.
The HIV/AIDS epidemic in South Africa is nothing short of an ongoing national emergency, much like a continuously rising flood. South Africa is not the only country grappling with this disease, but, the emergence of HIV during the transition from apartheid to democracy exacerbated its destructive power and lethality. This was due to a plethora of competing priorities deemed more urgent by a new government, that was attempting to build an entirely new country. HIV prevention and intervention strategies were put on the backburner as the new government navigated its way through such pressing agenda items as writing a new constitution and ensuring a peaceful transition to democracy. HIV, always the opportunist, did not wait until the new government was established and prepared to fight this new enemy. Instead, the disease kept spreading. By the time the government began to act, it was already too late: HIV/AIDS developed into a full-blown epidemic. In order to stem and ultimately prevent new infections, effective prevention and intervention strategies are needed. These can take many forms and be implemented in a variety of ways. One such area of interest is education. This paper will explore the effectiveness of various methods of education practiced in South Africa as HIV/AIDS prevention and intervention strategies by examining their impacts on key statistics related to HIV/AIDS.
Overview of HIV Epidemic in South Africa
Before discussing HIV prevention and intervention strategies, an understanding of the HIV/AIDS epidemic in South Africa is required. The South African Human Sciences Research Council (HSRC), along with its various partners, conducted four national surveys to track and report on the epidemic. These surveys, conducted in 2002, 2005, 2008, and 2012, provide vital information on the epidemic, such as changes in its prevalence and incidence, risk behaviors over time, and the use of antiretroviral therapy (ART). Prevalence indicates how widespread a disease is while incidence conveys information about contracting the disease, such as the rate of new or newly diagnosed cases of the disease. This data is critical for contributing to a greater understanding of the epidemic, highlighting areas of concern and identifying trends that can subsequently steer policy decisions that relate to prevention and intervention strategies (Zuma et al., 2016).
These surveys conducted by the HSRC collected behavior and biomedical data from people of all ages through representative samples of households throughout South Africa. In the National HIV Prevalence, Incidence, and Behavior Survey of 2012, the most recently published survey, 38,341 respondents were interviewed from 11,079 households and 28,997 (67.5%) of 42,950 people that met certain eligibility criteria provided blood specimens. The collected data indicated the latest trends relating to the epidemic, such as the prevalence and incidence of the disease by racial and gender groups, the use of ARTs, condom usage at last sex, sexual debut before age 15, and levels of accurate HIV knowledge (Zuma et al., 2016). For the purposes of this paper, survey data relating to prevalence and behavioral determinants of HIV will be examined.
Prevalence of HIV demonstrated a statistically significant increase from 10.6% in 2008 to 12.2% in 2012. In a population of 52.3 million people, this translates to 6.4 million people living with HIV. Females experienced a statistically significant higher prevalence than males, 14.4% to 9.9%, respectively. However, the peak prevalence for both males and females shifted to an older age group between 2008 and 2012. The peak age group for females shifted from 25-29 to 30-34 years of age, and for males it shifted from the 30-34 age group to the 35-39 age group (Zuma et al., 2016). While this shift in prevalence accounts for the time lapse between the 2008 and 2012 surveys, it also demonstrates that the prevalence of the younger age groups in 2008 did not overtake the 25-29 years of age female group or the 30-34 years of age male group. This is possibly indicative of effective HIV prevention and intervention strategies.
The 2012 survey also demonstrated a statistically significant disparity in HIV prevalence between different racial groups, with Black Africans experiencing a 15% HIV prevalence, followed by 3.1% for Coloreds, 0.8% for Indians/Asians, and 0.3% for Whites. People living in informal urban and rural areas demonstrated a statistically significant higher HIV prevalence—19.9% and 13.4%, respectively—than those living in formal urban and rural areas—10.1% and 10.4%, respectively. Provincially, KwaZulu-Natal had the highest statistically significant prevalence—16.9%, while the Western Cape had the lowest with 5.0% (Zuma et al., 2016).
The four HSRC surveys identified four high risk sexual behaviors reported by demographic variables. The behaviors included early sexual debut (having sex before age 15), age-disparate relationships (having a sexual relationship with someone who is five or more years older than the index person), non-condom use during the last sex act, and having multiple sexual partners within the last year. Early sexual debut increased slightly from 10% in 2008 to 11% in 2012. Also in 2012, 19.9% of adolescent respondents between 15-19 years of age reported being involved in age-disparate sexual relationships. It is important to note that there is a statistically significant difference between the sexes in this behavior, with 33.6% of all female adolescents reporting involvement in age-disparate sexual relationships compared to just 4.1% of male adolescents. Additionally, the rates of adolescents, aged 15-19 years, reporting involvement in age-disparate sexual relationships increased for both females and males between 2008 and 2012, 6.0% and 3.7%, respectively (Zuma et al., 2016).
Also in the 2012 HSRC survey, 12.6% of adult respondents aged 15 years and older reported having multiple sexual partners. Again, there was a statistically significant difference between the sexes, with 20.1% of males reporting having multiple sexual partners compared to 4.6% of females. Condom usage during the last sex act was reported by 36.2% of all respondents while 52.9% reported that they never used condoms. Additionally, there was a statistically significant increase in condom usage between 2002 and 2008, followed by a decrease of 8.9% in 2012. Survey data also revealed that condom usage during the last sex act peaked among those between 15-24 years of age, decreased with age, and was highest among males (Zuma et al., 2016).
The 2012 HSRC survey highlights various areas of concern and trends regarding the HIV epidemic in South Africa, notably the increasing prevalence and high risk sexual behaviors that perpetuate new infections. As Zuma et al. (2016) point out, the survey results “suggest that there is a need to scale up prevention methods that integrate biomedical, behavioral, social and structural prevention interventions to reverse the tide in the fight against HIV (67).” Indeed, any strategy to combat HIV would need to incorporate these various elements. An intervention or prevention strategy that focuses only on one element, such as biomedical, without consideration of socioeconomic factors would be doomed to fail. Whereas the biomedical nature of HIV is generally uniform across locations, the same cannot be said for each population’s socioeconomic environment. The socioeconomic environment of South Africa plays a significant role in the ongoing perpetuation of the HIV epidemic and will be examined in the next section.
Socioeconomic Status and HIV
When discussing HIV intervention and prevention strategies for South Africa, one must consider the country’s various socioeconomic environments and the roles they play in the spread of the disease. Some have argued, including a former president of South Africa, that poverty causes HIV. While poverty can indeed be a contributing factor to the spread of the disease, it alone is not responsible for the epidemic. Rather, socioeconomic inequality and vulnerability have been shown to be strongly associated with HIV incidence in sub-Saharan Africa.
Previous studies have revealed that African countries with high Gini coefficient scores were also the countries most devastated by HIV. As Wabiri and Taffa (2013) point out, a reason for the inaccurate causal link between poverty and HIV lies in methodological shortcomings in measuring income and poverty at both individual and household levels. Previous studies utilizing cluster sample surveys, such as population-based Demographic and Health Surveys (DHS) and AIDS Impact Surveys (AIS), use various indicators to determine a population’s level of poverty based on ownership of such items as radios, refrigerators, and phones as well as the availability of utilities such as water, electricity, and toilets. However, possessing or lacking these items and utilities does not accurately discriminate between poor and non-poor households in rural Africa.
To counter such measurement shortcomings, Wabiri and Taffa (2013) used a socio-economic index (SEI) score calculated using Multiple Correspondence Analysis of measures of ownership of durable assets by a sample of 14,383 adults 15 years or older in South Africa. The distribution of HIV outcomes across three SEI categories of Low (poorest), Middle, and Upper (not so poor) was assessed using weighted data. These HIV outcomes included HIV prevalence, access to HIV/AIDS information, level of stigma towards HIV/AIDS, and perceived HIV risk and sexual behavior. Using univariate and multivariate logistic regression, the researchers assessed the covariates of the HIV outcomes across the socioeconomic groups (Wabiri et al., 2013).
Their analysis resulted in statistically significant findings: women (57.5%) outnumbered men (42.3%) in the Low SEI group. Additionally, HIV prevalence was highest in the Low SEI group (20.8%) and was highest among women (19.7%) compared to men (11.4%). Black Africans also demonstrated higher HIV prevalence (20.2%) compared to other racial groups. Those in the Upper SEI reported a higher frequency of HIV testing (59.3%) than those in the Low SEI (47.7%). Access to HIV/AIDS information also varied along SEI lines, with only 20.6% of those in the Low SEI group reporting good access compared to 80.0% of those in the Upper SEI. Of particular interest for this study was the revelation that 84% of those in the Low SEI group had no formal education or completed only up to primary level compared with 31% in the Upper SEI group. Additionally, 68.2% of those in the Upper SEI group and 36.3% of those in the Middle SEI group completed matric exam or tertiary education. According to the logistic regression results, level of education was statistically significant in its association with perceived HIV risk across all SEI groups, with the common belief that an increase in education level corresponds to a perceived decrease in risk. Those lacking a secondary school education believed they were at an increased risk of HIV infection (Wabiri et al., 2013).
Peltzer et al. (2009) maintain that HIV Counseling and Testing (HCT) is necessary for HIV prevention and treatment, because people need to know their HIV status before they can seek out treatment and prevention strategies. As such, HCT must be available to the entire public. HCT uptake factors include socioeconomic factors such as age, marital status, educational level, occupation, household wealth, and area of residence; social factors such as fear of stigma and discrimination, proximity and access to HCT sites, and HIV risk behavior; and health status. Using a multivariate analysis of a sample of 16,395 South Africans aged 15 and up, the researchers determined that residing in a rural area, being in the Black African population group, having a lower educational level, and being unemployed were associated at a statistically significant level with not knowing one’s HIV status. Conversely, the researchers found that being a female between the ages of 25 to 34, of the Black African population group, possessing higher educational levels, having employment, and living in an urban area were associated with knowledge of one’s HIV status (Peltzer et al., 2009).
The above findings clearly demonstrate that socioeconomic inequality and vulnerability, not simply poverty, have direct impacts on the perpetuation of the HIV epidemic in South Africa. Although only brief overviews of each study were presented, it is clear that the socioeconomic factor of education is intimately entrenched in the HIV epidemic. Thus, education, employed in various methods, can be used as an intervention and prevention tool to not only stem the flow but ultimately reverse the tide of new HIV infections. Although studies conducted in Sub-Saharan African countries prior to 1996 suggest that increased education was correlated with increased HIV infection, this trend reversed itself in the late 1990s. HIV prevalence among the most educated decreased at a more consistent rate than for less educated populations. Hargreaves et al. (2008) go on to suggest that, in the early 21st century, the least educated populations in many countries in sub-Saharan Africa have disproportionately more new HIV infections.
Education as an HIV Intervention
In the fight against HIV, there are many weapons in the arsenal that can be employed to combat the epidemic. These can take many forms, such as biomedical programs focusing on treatment of the disease with ART. One weapon that has the potential to be extremely effective if employed correctly is that of education. Education has several advantages over other intervention and prevention strategies, such as its versatility and ability to be adaptable to different situations. It also comes in various forms, such as traditional classroom education, peer education, and education through sport. This section will examine education as an HIV intervention and prevention tool, recent studies into the effects of education on the spread of HIV in South Africa, and several types of education programs utilized in South Africa to counter the HIV epidemic.
Education can be a powerful weapon in the fight against a phenomenon such as the HIV epidemic in South Africa; however, many challenges must be overcome. Contextual factors such as pervasive gender stereotypes and inequalities, cultural and religious beliefs and traditions, under-resourced schools, teacher and student absenteeism, and sexual bullying and violence present significant obstacles to effective educational practices. Additionally, a conducive environment for effective education should not be characterized by, “the absence or uneven distribution of clear policy frameworks and guidelines, the absence of HIV from most school and education sector plans, yearly action plans and education budgets, lack of training for teachers in teaching about HIV and AIDS, and the absence of good-quality curricular materials” (Aggleton et al., 2011). Unfortunately, this is the environment many developing countries are faced with, including South Africa.
Despite such challenges, education has been shown to have positive impacts on the HIV epidemic through various forms of treatment education, education for prevention, and education for a positive response. Treatment education is education aimed at preparing people for ART treatment, advocating engagement at both the individual and community levels in learning about ART, as well as instilling the importance of knowing one’s HIV status. Prevention education is education aimed at preventing new HIV infections and has become a mainstay in the fight against HIV, as evidenced by 20-30% declines in new HIV infections in over 20 sub-Saharan countries (Aggleton et al., 2011). In the prevention capacity, education not only can provide individuals with the knowledge necessary to prevent infection, but shift individual attitudes towards risk reduction and behavior change. Education for a positive response is education at the community or societal levels. It aims at fostering environments built on trust resulting in high levels of social capital. Within these contexts, education can exert its effects through the mechanisms of school-based HIV and AIDS education, the broader psychosocial benefits derived from an education, the economic and lifestyle impacts of education, education’s potential to influence power within sexual relationships, and education’s capacity to affect social and sexual networks (Aggleton et al., 2011).
General education, not specifically geared towards HIV prevention or treatment, also has the potential to prevent new infections. In a 2003 study involving a nationally representative sample of 12,000 South Africans aged 15-24 years old, bivariate and multivariate analyses were conducted to determine any correlation between HIV prevalence and identified HIV risk factors such as education level, location of residence, current age, and other factors. Bivariate analysis revealed that only education level and age were significantly associated with HIV infection while multivariate analysis controlling for other risk factors determined that women who had not completed high school had 3.75 greater odds of being infected compared with women who had completed high school (Pettifor et al., 2008).
In a 2001 study investigating the association between school attendance, HIV infection, and other outcome variables representing high HIV risk, Hargreaves et al. (2008) determined that school attendance may reduce HIV risk by affecting the structure of sexual networks and communication within those networks. These structural and communication changes may possibly result in improved self-confidence, self-efficacy, and the adoption of less risky sexual practices. Hargreaves et al. (2008) go on to state that maximizing school attendance may halt the spread of HIV among young people.
Various lessons have been learned from a systematic and analytic review of eight HIV intervention and prevention programs aimed at South African youth since 2000. These interventions were mainly successful in their ability to effectively address social and structural factors impacting HIV risk as opposed to focusing solely on individual-level behaviors (Harrison et al., 2010). Another lesson was the value of utilizing personnel, other than teachers, to deliver interventions. It was found that teachers often resist teaching sex education and, although peer education was popular with students, it was not shown to be effective due to the lack of authority the peer educators had. A viable alternative to teachers and peer educators, was the use of class mentors who are older youth but still able to command the respect of the students (Harrison et al., 2010).
The use of educators other than teachers is an important aspect of education as an intervention and prevention tool in the fight against HIV in South Africa. For example, the use of peer educators to teach sex workers about HIV prevention is an example of the versatility of education to reach multiple target populations. However, as previously stated, education requires a conducive environment in order to be effective. In a study comparing peer education of sex workers in India and South Africa in HIV prevention methods, the South African results were shown to be less effective than those of their Indian counterparts due to a lack of infrastructure, a relatively new political context, a lack of support for the peer educator coordinator, and a management that does not have sex worker representation. Conversely, the Indian example has been relatively successful in advancing HIV prevention among sex workers as well as improving their overall health and living conditions. Improvements targeting the aforementioned issues in the operating environment could potentially improve the effectiveness of South Africa’s peer educators in educating sex workers in HIV prevention (Cornish et al., 2009).
Africaid Trust, a South African grassroots non-profit organization, developed and employed an innovative HIV education prevention program utilizing the popularity of soccer with South Africa’s youth. This program, WhizzKids United (WKU), is based on the social cognitive theory of behavior and operates 12-week programs for boys and girls in elementary schools in Pietermaritzburg, South Africa, where knowledge and life skills critical to HIV prevention are taught (Balfour et al. 2013). WKU builds off previous studies which suggest that proactive HIV prevention is most effective when targeting younger audiences prior to their sexual debut, and thus, it influence safer sexual behavior. In a study comparing the attitudes and behaviors as they related to HIV of a sample of 972 youth, 267 of whom completed the WKU program, revealed that the WKU alumni had statistically significant higher levels of HIV knowledge and lower levels of HIV stigma. According to Balfour et al. (2013), “(t)hese results demonstrate the potential impact of interactive HIV education and prevention programs such as WKU OTB (On The Ball) and point to their added value over existing classroom-based HIV education as an HIV prevention strategy.”
Witnessing Education in Action
There are numerous community groups and non-profit organizations operating in South Africa that are employing various forms of education to prevent the continuing spread of HIV/AIDS in the country, especially amongst the youth. During a recent visit to South Africa, a group of NYU graduate students met with several of these groups. One such community group that actively plays a significant role in the prevention of HIV/AIDS in its community is the Kliptown Youth Program (KYP). Mr. Thando Bezana, KYP’s cofounder and Operations Manager, briefed the NYU students on KYP’s mission, which is to provide opportunities to help the youth of Kliptown. To understand the challenges faced by Kliptown’s youth, some general information on the community is required.
Kliptown is a community located in the Soweto township outside of Johannesburg. Like many townships, Soweto is characterized by abject poverty, lacking proper housing, schools, medical facilities, and infrastructure. As a result of this environment, Mr. Bezana explained that opportunities for upward mobility are lacking at best and that many of Kliptown’s youth turn toward drugs, alcohol, and other risky activities, some of which could potentially lead to the spread of HIV/AIDS. In order to counter this, KYP works to provide Kliptown’s youth with educational and training resources to assist young people in advancing their education and obtaining employment. Many of these educational and training resources are delivered via the Internet in KYP’s computer lab. Having access to the internet and to the internet’s educational materials, including those dealing with HIV/AIDS, is absolutely vital in assisting Kliptown’s youth educate themselves and rise above the poverty that surrounds them.
NYU graduate students also met with LoveLife Orange Farm Y-Centre Academy Program Coordinator Mr. Gilbert Buthelezi and his staff. LoveLife is a non-profit organization that operates numerous offices and centers throughout South Africa with the mission of improving the lives of South Africa’s youth through preventing new HIV/AIDS infections, reducing teen pregnancy, keeping young girls in school, and assisting young people gain employment. This organization utilizes peer educators, called mpintshis and groundBREAKERs, to educate youth about safe sexual practices and behavior in order to prevent the spread of HIV/AIDS. These peer educators utilize group discussions, athletics, musical and dramatic performances to mentor and educate community youth on topics such as safe sexual practices and behavior to prevent STIs and pregnancy as well as maintaining healthy relationships that are not exploitive. The use of peers that a community’s youth can relate to is absolutely critical in providing youth valuable information and enabling discussions that otherwise would not take place due to cultural norms.
Summary and Conclusion
The onslaught of the HIV epidemic in South Africa could not have appeared at a worse time than it did during that country’s transformation from an oppressive apartheid government to an inclusive democracy. Competing priorities associated with the formation of a new government and limited resources prevented the South African government from adequately responding to the looming crisis. These factors, coupled with a lack of strong leadership on the issue from the government, led to the disease spreading like wildfire throughout the country. Even now, with considerable government attention and dedication of resources to curb the epidemic, intervention and prevention are stymied by socioeconomic inequality and vulnerability, which only perpetuate the epidemic.
Education, in its various forms, can be a powerful weapon in South Africa’s war on HIV. As demonstrated previously through multiple studies, a negative relationship between the level of education attained and HIV infection exists. Innovative education programs like WKU demonstrate the effectiveness proactive prevention education can have on vulnerable populations. Given that peer education programs are managed appropriately and operate in a supportive environment, these programs can effectively prevent HIV. Education alone, however, will not defeat this epidemic. Substantial attention and effort must be made to improve the socioeconomic status of South Africans and narrow the inequality gap. Should that happen, education will be a force multiplier in turning the tide of South Africa’s HIV epidemic.
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