South Africa is considered to be one of the countries worst affected by HIV/Aids in the world. The reasons for this are complex; nevertheless, certain sociocultural factors have been identified as responsible for the rapid spread of the disease. These include the following:
- Gender inequality and male dominance
- Violence and sexual violence
- Political transition and the legacy of apartheid
- Stigma and discrimination
- Commercialisation of sex
- Lack of knowledge and misconceptions about HIV/Aids
- Cultural beliefs and practices
Gender inequality and male dominance
South African culture is generally male-dominated, with women accorded a lower status than men are. Men are socialised to believe that women are inferior and should be under their control; women are socialised to over-respect men and act submissively towards them. The resulting unequal power relation between the sexes, particularly when negotiating sexual encounters, increases women’s vulnerability to HIV infection and accelerates the epidemic.
Women’s inferior status affords them little or no power to protect themselves by insisting on condom use or refusing sex.
Many women also lack economic power and feel they cannot risk losing their partners, and thus their source of financial support, by denying them sex or deciding to leave an abusive relationship.
Entrenched ideas about suitably “masculine” or “feminine” behaviour enforce gender inequality and sexual double standards, and lead to unsafe sexual practices. Abstinence and monogamy are often seen as unnatural for men, who try to prove themselves “manly” by frequent sexual encounters, and often the aggressive initiation of these.
Examples of other prevalent ideas which result in sexually unsafe behaviour include the following: sex on demand is part of the marriage “deal”; sexual violence is a sign of passion and affection; men have natural sexual urges that cannot be controlled in the face of women’s powerful attractions; sex is necessary to maintain health and gender identity.
These views serve to justify men’s sexual behaviour to some extent: men are given license to be sexually adventurous and aggressive, without taking responsibility for their actions.
Women’s respectability is derived from the traditional roles of wife, home-maker and mother. Childbearing and satisfying her husband, sexually and otherwise, are key expectations for a wife - even if she is aware that her husband is unfaithful. Refusing a husband sex can result in rejection and violence.
The low status accorded to a woman without a male partner may be an additional reason for making women less likely to leave an abusive relationship. Too much knowledge about sex in women is seen as a sign of immorality, thus insisting on condom use may make women appear distastefully well-informed. Married women who request safer sex may be suspected of having extra-marital affairs or of accusing their husbands of being unfaithful.
Physical and sexual violence
Violence against women is a major problem in South Africa, and is linked to its male-dominated culture. Men often use violence in an attempt to maintain their status in society and prove that they are “real men” by keeping women under their control. Physically abusive relationships limit women’s ability to negotiate safer sex: many men still do not want to use condoms, and some become violent if women insist on safer sex. Women may not even raise the issue of safer sex for fear of a violent response.
One result of apartheid-era violence by the state and the armed resistance movement is that violence came to be seen as a familiar, acceptable way of solving conflicts and wielding power. In addition to heterosexual relationships, violence pervades a wide range of social relations, including same-gender sexual relationships such as those between male prisoners.
South Africa, where a woman has about a one in three chance of being raped in her lifetime, has among the highest sexual violence statistics in the world – with obvious implications for the spread of HIV/Aids. The genital injuries that result from forced sex increase the likelihood of HIV infection; when virgins and children are raped, the trauma is more severe, and risk of infection even higher.
In cases of gang rape, exposure to multiple assailants further increases risk of transmission.
Increasing numbers of rapes of female children may represent men’s attempts to seek sexual relations with young girls to avoid HIV infection or because of the belief that sex with a virgin will cure Aids.
Women with a history of being sexually abused are more likely to risk unsafe sex, have multiple partners, and trade sex for money. Men who are violent to their partners are also more likely to have sexually transmitted infections (STIs). These factors combine to put women who suffer sexual violence at very high risk of contracting HIV/Aids.
Political transition and the legacy of apartheid
The early years of the HIV/Aids epidemic in South Africa coincided with the end of the apartheid era, a period of complex political transition and societal instability. Leadership was distracted by the then more immediate concerns of the struggle towards democracy, with the result that crucial time was lost in the fight against Aids.
Elements of the apartheid regime - such as migrant labour, the homelands system, the Group Areas Act and forced removals - contributed to the widespread poverty, gender inequality, social instability and unsafe sexual practices that now continue to influence the spread of HIV/Aids.
The migrant labour system has been particularly important as a vehicle for HIV transmission. Labourers were prevented from settling where they worked in the urban areas, but maintained links with their families in rural parts, and moved between the two. This to-and-fro migration has been a major factor in the spread of HIV and other STIs (which, in turn, increase the risk of HIV infection). Migrant labour patterns persist because of uneven development and employment opportunities, both within the country and in neighbouring African states.
People separated for long periods tend to seek sex outside their stable relationships, which, in the single-sex hostels accommodating migrant labourers, has often been in the form of unsafe male-to-male sex, and making use of the sex-work industry that developed in the vicinity. Men frequently become HIV-infected at their place of work, and then carry the infection back home and pass it on to their wives and unborn children.
Another form of migration occurred when the former revolutionary cadres, such as umKhonto weSizwe, returned from the north of South Africa’s borders in 1994 and were incorporated into the national defence force. Their return, from areas of high HIV prevalence, contributed to the rapid growth of the epidemic. Refugees from neighbouring African states also entered the country, often bringing new strains of the virus with them.
Stigma and discrimination
The stigma attached to HIV seriously hinders prevention efforts, and makes HIV-positive people wary to seek care and support for fear of discrimination. People who are infected may also be reluctant to adopt behaviour that might signal their HIV-positive status to others. For example, a married HIV-positive man may not use a condom to have sex with his wife; an HIV-positive mother may continue to breastfeed her baby. Many people might not want to get tested for fear of their community finding out.
Homosexuality is also stigmatised in South Africa. There is still significant denial of the existence of homosexuality in the black community and a history of poor government interventions focused on gay people. The violence often suffered by young homosexuals as a result of social stigma may cause them to hide their sexuality and not access information that could help protect them against HIV infection.
High levels of unemployment and an inadequate welfare system have lead to widespread poverty, which renders people more vulnerable to contracting HIV because of the following factors:
- The daily struggle for survival overrides any concerns people living in poverty might have about contracting HIV.
- Strategies adopted by people made desperate by poverty, such as migration in search of work and “survival” sex-work, are particularly conducive to the spread of HIV/Aids.
- People living in deprived communities where death through violence or disease is commonplace tend to become fatalistic: the incentive to protect oneself against infection is low when HIV is only one of many threats to health and life. Poverty may also breed low levels of respect for self and others, and thus a lack of incentive to value and protect lives.
- Poverty is generally associated with low levels of formal education and literacy. Knowledge about HIV and how to prevent it, as well as access to information sources such as schools or clinics, is subsequently low in poor communities.
Ironically, socio-economic development and poverty relief can, in fact, sometimes drive the epidemic. This is particularly the case when development is linked to labour migration, rapid urbanisation, and cultural modernisation – all of which occur to a significant extent in South Africa. Thus, although poverty contributes to the spread of HIV/Aids, alleviating poverty can do likewise. For example, improved infrastructure such as new transport routes and improved access are seen as positive developmental goals. However, this often results in a larger migrant population, and facilitates the spread of Aids to previously inaccessible parts of the country.
Commercialisation of sex
A prominent aspect of South African culture that undoubtedly contributes to the HIV/Aids epidemic is that sexuality is frequently seen as a resource that can be used to gain economic benefits.
The country has seen the rapid development of a relatively affluent black middle class with a desire for material goods, and a sexual culture that associates sex with gifts. Men gain social prestige by showing off material possessions and being associated with several women.
Young women are often persuaded to have sex with “sugar daddies” – older, wealthier men – in exchange for money or gifts. Some girls enter the sex industry for similar reasons. Young women infected with HIV by sugar daddies then infect younger men, who in turn infect other young women and in time become HIV-positive older men themselves – and so the cycle continues. Older men also infect older women, usually their wives. Both younger and older women give birth to children, some of whom will be HIV-positive.
Lack of knowledge and misconceptions about HIV/Aids
It appears that the majority of South Africans have heard about Aids, and have a fairly good level of knowledge of the basic facts i.e. that the disease is spread sexually, and that condoms reduce risk. Nevertheless, there are still many people, especially those with low levels of formal education and who lack access to accurate, relevant information on HIV/Aids and sexuality, who are unaware of the risks.
Women in particular have high rates of illiteracy, and many girls do not complete basic education. Also, women may be unaware of risks because their time is taken up with tending the home, and they have limited links with the outside world.
Added to this is the problem that dangerous myths and misconceptions about HIV/Aids abound. These include believing that the virus can be contracted by sharing food, that infected people can be recognised by their symptoms, and, perhaps the most notorious of all, the belief that sex with a virgin can cure the disease. Beliefs such as this give people a false sense of their level of risk, and contribute to confusion about how HIV is transmitted.
People who do possess some knowledge about HIV often do not protect themselves because they lack the skills, support or incentives to adopt safe behaviours. High levels of awareness among the youth, a population group particularly vulnerable and significant as regards the spread of HIV/Aids, have not led, in many cases, to sufficient behavioural change. Young people may lack the skills to negotiate abstinence or condom use, or be fearful or embarrassed to talk with their partner about sex. Lack of open discussion and guidance about sexuality is often lacking in the home, and many young people pick up misinformation from their peers instead.
Cultural norms and practices
Certain prevalent cultural norms and practices related to sexuality contribute to the risk of HIV infection, for example:
- Negative attitudes towards condoms, as well as difficulties negotiating and following through with their use. Men in southern Africa regularly do not want to use condoms, because of beliefs such that “flesh to flesh” sex is equated with masculinity and is necessary for male health. Condoms also have strong associations of unfaithfulness, lack of trust and love, and disease.
- Certain sexual practices, such as dry sex (where the vagina is expected to be small and dry), and unprotected anal sex, carry a high risk of HIV because they cause abrasions to the lining of the vagina or anus.
- In cultures where virginity is a condition for marriage, girls may protect their virginity by engaging in unprotected anal sex.
- The importance of fertility in African communities may hinder the practice of safer sex. Young women under pressure to prove their fertility prior to marriage may try to fall pregnant, and therefore do not use condoms or abstain from sex. Fathering many children is also seen as a sign of virile masculinity.
- Polygamy is practised in some parts of southern Africa. Even where traditional polygamy is no longer the norm, men tend to have more sexual partners and to use the services of sex workers. This is condoned by the widespread belief that males are biologically programmed to need sex with more than one woman.
- Urbanisation and migrant labour expose people to a variety of new cultural influences, with the result that traditional and modern values often co-exist. Certain traditional values that could serve to protect people from HIV infection, such as abstinence from sex before marriage, are being eroded by cultural modernisation.
(Olivia Rose-Innes, Health24, October 2006)
Information sources used for this article include:
- Annual Report (2004/05) of the Human Sciences Research Council of South Africa
- Centre for Aids Development, Research and Evaluation. Gender-based violence and HIV/Aids in South Africa. 2003.
- The AIDS Foundation of South Africa, official website
- The Medical Research Foundation of South Africa, official website