From "Rights" to "Ritual": AIDS Activism in South Africa

In this article, I investigate how the moral politics of HIV/AIDS activism in South Africa is contributing toward new forms of citizenship that are concerned with both rights-based struggles and with creating collectively shared meanings of the extreme experiences of illness and stigmatization of individual HIV/AIDS sufferers. I argue that it is precisely the extremity of the "near death" experiences of full-blown AIDS, and the profound stigma and "social death" associated with the later stages of the disease, that produce the conditions for HIV/AIDS survivors' commitment to "new life" and social activism. It is the activist mediation and retelling of these traumatic experiences that facilitates HIV/AIDS activist commitment and grassroots mobilization. It is also the profound negativity of stigma and social death that animates the activist's construction of a new positive HIV-positive identity and understanding of what it means to be a citizen–activist and member of a social movement.     

Drug companies cut HIV drug prices in the developing world

The UN has reported that five multinational pharmaceutical companies would cut down HIV drug prices in the developing world. One of these drug companies is GlaxoWellcome, which has promised to reduce the price of zidovudine and lamivudine to US$2 in the poorest nations, a fifth of its price in the US. Although Peter Piot, director of the UN Program on HIV/AIDS, welcomed the companies' promises, he warned that price cuts alone will not curb the epidemic. He stated that this initiative is only one critical factor in what must become a much broader and more urgent effort to help people living with HIV/AIDS. Moreover, health and development agencies expressed concern that AIDS drugs will still be unaffordable for the vast majority of those in need in developing countries. In addition, poor countries lack the infrastructure to deliver these drugs safely and effectively. During the time of the UN announcement, US President Bill Clinton also signed an executive order allowing sub-Saharan Africa to adopt legal measures to obtain cheap HIV drugs. Meanwhile, South Africa's reaction to the offer to cut antiretroviral drug prices has been lukewarm.     

HIV Self-Testing Could “Revolutionize Testing in South Africa,but It Has Got to Be Done Properly”: Perceptions of Key Stakeholders

South Africa bears the world’s largest burden of HIV with over 6.4 million people living with the virus. The South African government’s response to HIV has yielded remarkable results in recent years; over 13 million South Africans tested in a 2012 campaign and over 2 million people are on antiretroviral treatment. However, with an HIV & AIDS and STI National Strategic Plan aiming to get 80 percent of the population to know their HIV status by 2016, activists and public health policy makers argue that non-invasive HIV self-testing should be incorporated into the country HIV Counseling and Testing [HCT] portfolios. In-depth qualitative interviews (N = 12) with key stakeholders were conducted from June to July 2013 in South Africa. These included two government officials, four non-governmental stakeholders, two donors, three academic researchers, and one international stakeholder. All stakeholders were involved in HIV prevention and treatment and influenced HCT policy and research in South Africa and beyond. The interviews explored: interest in HIV self-testing; potential distribution channels for HIV self-tests to target groups; perception of requirements for diagnostic technologies that would be most amenable to HIV self-testing and opinions on barriers and opportunities for HIV-linkage to care after receiving positive test results. While there is currently no HIV self-testing policy in South Africa, and several barriers exist, participants in the study expressed enthusiasm and willingness for scale-up and urgent need for further research, planning, establishment of HIV Self-testing policy and programming to complement existing facility-based and community-based HIV testing systems. Introduction of HIV self-testing could have far-reaching positive effects on holistic HIV testing uptake, giving people autonomy to decide which approach they want to use for HIV testing, early diagnosis, treatment and care for HIV particularly among hard-to reach groups, including men.     

Oral candidiasis and oral yeast carriage among institutionalised South African paediatric HIV/AIDS patients

South Africa currently has an estimated 500,000 AIDS orphans, many of whom are HIV-positive. Oral candidiasis commonly occurs in both adult and paediatric HIV/AIDS patients. Published information on HIV-positive children in Africa mainly concerns hospitalised patients. The objective of this study was to determine the prevalence of oral candidiasis and oral yeast carriage among paediatric HIV/AIDS patients residing in orphanages in Gauteng, South Africa, and to compare the prevalence of isolated yeast species with species obtained from adult HIV/AIDS patients. Eighty-seven paediatric HIV/AIDS patients residing in five homes were examined and a swab taken from the dorsal surface of the tongue, cultured on CHROMagar and yeast isolates identified with the ATB 32C commercial system. The species prevalence of 57 identified isolates was compared with that of 330 isolates from adult HIV/AIDS patients. Twelve (13.8%) children presented with clinically detectable candidiasis. Yeasts were isolated from 0% to 53% of children in the individual homes, with Candida albicans (40.4%) and C. dubliniensis (26.3%) constituting the most frequently isolated species. Gentian violet prophylaxis was administered in one particular home and a higher carriage rate (66.6%) of non-C. albicans and non-C. dubliniensis was observed among these children. The prevalence of C. albicans was lower while the prevalence of C. dubliniensis, C. glabrata and C. tropicalis was significantly higher (p ≤ 0.001) among the children than among adult HIV/AIDS patients. These findings indicate a role for yeast culture and species determination in cases with candidiasis in institutionalized paediatric HIV/AIDS patients.     

Constitutional values and HIV/AIDS in the workplace: reflections on Hoffman v. South African Airways

South Africa is experiencing an HIV/AIDS epidemic of enormous proportions. The workplace, like all the other sectors, is adversely affected. The tendency of a significant proportion of employers has been to discriminate against employees and job applicants living with HIV/AIDS through use of HIV testing to exclude those that are HIV-positive. In the case of Hoffmann v South African Airways, the Constitutional Court was asked to determine the constitutionality of excluding a job applicant on account of an HIV-positive status. The Court ruled in favour of the applicant and ordered instatement. Through an analysis of Hoffmann v South African Airways, the article examines how constitutional values are impacting on HIV/AIDS-related ethics in the workplace.     

Development,Calibration and Performance of an HIV Transmission Model Incorporating Natural History and Behavioral Patterns: Application in South Africa

Understanding HIV transmission dynamics is critical to estimating the potential population-wide impact of HIV prevention and treatment interventions. We developed an individual-based simulation model of the heterosexual HIV epidemic in South Africa and linked it to the previously published Cost-Effectiveness of Preventing AIDS Complications (CEPAC) International Model, which simulates the natural history and treatment of HIV. In this new model, the CEPAC Dynamic Model (CDM), the probability of HIV transmission per sexual encounter between short-term, long-term and commercial sex worker partners depends upon the HIV RNA and disease stage of the infected partner, condom use, and the circumcision status of the uninfected male partner. We included behavioral, demographic and biological values in the CDM and calibrated to HIV prevalence in South Africa pre-antiretroviral therapy. Using a multi-step fitting procedure based on Bayesian melding methodology, we performed 264,225 simulations of the HIV epidemic in South Africa and identified 3,750 parameter sets that created an epidemic and had behavioral characteristics representative of a South African population pre-ART. Of these parameter sets, 564 contributed 90% of the likelihood weight to the fit, and closely reproduced the UNAIDS HIV prevalence curve in South Africa from 1990–2002. The calibration was sensitive to changes in the rate of formation of short-duration partnerships and to the partnership acquisition rate among high-risk individuals, both of which impacted concurrency. Runs that closely fit to historical HIV prevalence reflect diverse ranges for individual parameter values and predict a wide range of possible steady-state prevalence in the absence of interventions, illustrating the value of the calibration procedure and utility of the model for evaluating interventions. This model, which includes detailed behavioral patterns and HIV natural history, closely fits HIV prevalence estimates.     

Understanding the Impact of Hazardous and Harmful Use of Alcohol and/or Other Drugs on ARV Adherence and Disease Progression

The objective of this study was to understand the impact of hazardous and harmful use of alcohol and/or other drugs on ARV adherence and disease progression among HIV patients. A cross-sectional study design was used. A total of 1503 patients attending HIV clinics in Cape Town, South Africa were screened for problematic substance use. A sub-sample of 607 patients (303 patients who screened positive for problematic substance use and 304 who did not) participated in this study. Hazardous or harmful alcohol use and problematic drug use predicted missing and stopping ARVs which, in turn, was associated with a decrease in CD4 counts and more rapid HIV-disease progression and poorer health outcomes in people living with HIV/AIDS (PLWHA). The findings of this study underscore the need for an integrated approach to managing substance-use disorders in PLWHA.     

Virginity Testing: Managing Sexuality in a Maturing HIV/AIDS Epidemic

KwaZulu-Natal province in South Africa is currently the site of the world's fastest growing HIV/AIDS epidemic, where it is estimated that between 30 and 40 percent of the adult population is seropositive for HIV. With support from local politicians and members of various government ministries, several self-styled guardians of tradition have emerged to form organizations that advocate and conduct regular virginity testing of girls. Reference to the current HIV/AIDS epidemic is central to calls for greater support of this practice. Drawing on original research among Zulu-speaking people in the periurban communities of Durban, this article examines the sociocultural construction of HIV/AIDS and locates the growing popularity of virginity testing within a gendered meaning-making process consistent with commonly held beliefs that the epidemic is the result of women being sexually "out of control." With the social impact of AIDS starting to take its toll in the forms of increasing AIDS-related deaths and a growing population of orphans, I argue that virginity testing is an attempt to manage the epidemic by exerting greater control over women and their sexuality. In addition, virginity testing of girls helps to draw attention away from the role of men in the maturing epidemic, consideration of which has been conspicuously absent in the popular discourse on AIDS at all levels of South African society.     

Mandela restores morale of AIDS conference

During the 13th international AIDS conference in Durban, former president Nelson Mandela pulled the morale of the conference highlighting the need to confront the needs and concerns of those suffering and dying of HIV/AIDS in South Africa, mostly in sub-Saharan. He also stated that to challenge the grave threat posed by HIV and AIDS, efforts should be combined to save the people. This concluding remark was in direct contrast to the opening words of South Africa's current president, Thabo Mbeki, who failed to deal with the impression he has created internationally that he has doubts about the etiology of AIDS. In addition, the need to focus on the accessibility and affordability of treatment for HIV/AIDS or the opportunistic infections associated with it was highlighted. The conference focused on this issue with the help of AIDS activists, who emphasized that pharmaceutical companies needed to address how their drugs could reach those who most need them.     

Mbeki appoints team to look at cause of AIDS

South African president, Thabo Mbeki, hosted a meeting of more than 30 scientists for a 2-day discussion on HIV and AIDS, particularly on the etiology of AIDS. At least half of the members of the Presidential Advisory Panel on AIDS disputed the orthodox views on AIDS, and many of them do not believe HIV causes AIDS. At the end of the 2-day session, a four-person team was appointed (two ?orthodox? scientists and two dissenting ones). This team and panel will work in a closed Internet session and will review scientific data and construct experiments to deal with questions that may yet be unanswered. The meeting took place against the background of a letter written by President Mbeki to President Clinton, Prime Minister Tony Blair, and several other world leaders, expressing his views on HIV and AIDS. Both in the letter and at the meeting, President Mbeki construed the reaction to his views as similar to the tyranny experienced by the oppressed in South Africa during the apartheid era.     

AIDS Research and Its Role in China＇s AIDS Prevention and Control Policies

By the end of 2005, the estimated number of HIV infected people in China was 650,000. The seriousness of the epidemic calls for effective control measures to tackle the problems in order to avoid the tragedy in Africa from happening in China. ＂Prevention First＂ is the cornerstone of the country＇s health policy. On 2003 World AIDS Day, Premier Jiabao Wen announced a new national AIDS control policy, ＂Four Frees and One Care＂. This policy clearly shows that the Chinese government has once again taken full responsibility to solve public health problems and has profound impact far beyond the AIDS field. In early 2006, the central government put scientific and technology innovation as a national priority and set the target to build an innovative China by year 2020. Since then, the government has been increasing investment in science and technology with major emphasis on both infectious diseases control and new drug research and development. For the first time, development of 100 new drugs and control of major infectious diseases （AIDS, HBV, TB and other emerging infectious diseases） have been selected as national key scientific projects. China＇s best minds in related fields will be pooled to work together in order to remove the technical barriers blocking efficient control of the major infectious disease in China. Knowledge on molecular epidemiology, immunology, pathogenesis, HAART, as well as HIVDR strains will certainly provide urgently needed scientific information for China＇s AIDS control program. Only evidence-based strategy from good research will provide long-term effective control of AIDS.     

Wording effects and the factor structure of the Hospital Anxiety & Depression Scale in HIV/AIDS patients on antiretroviral treatment in South Africa

Background

Given the immense burden of HIV/AIDS on health systems in sub-Saharan Africa and the intricate link between HIV/AIDS and mental health problems, health care providers need a valid and reliable instrument to assess mental health rapidly. The Hospital Anxiety and Depression Scale (HADS) may constitute such an instrument. The aims of this study were to: (1) examine the factor structure of the HADS in a population of South African HIV/AIDS patients on antiretroviral treatment (ART); and (2) identify and control the disturbing influence of systematic wording effects in vulnerable respondent groups.

Methodology/Principal Findings

The translated scale was administered to 716 HIV/AIDS patients enrolled in the public sector ART program in South Africa. A combined confirmatory factor analysis and correlated-traits-correlated-methods framework was used to determine the preferred factor structure of the HADS, while controlling for the disturbing influence of systematic wording effects. When assessing the structure without a negative wording factor, all three factor structures displayed an acceptable fit to the data. The three-factor solution best fitted the data. Addition of a method factor significantly improved the fit of all three factor solutions. Using χ² difference testing, Razavi''s one-factor solution displayed a superior fit compared to the other two factor solutions.

Conclusions

The study outcomes support the use of the HADS as a valid and reliable means to screen for mental health problems in HIV/AIDS patients enrolled in a public-sector ART program in a resource-limited context. The results demonstrate the importance of evaluating and correcting for wording effects when examining the factor structure of the screening instrument in vulnerable patient groups. In light of the inter-relationships between HIV/AIDS and mental health problems and the scarcity of adequate screening tools, additional studies on this topic are required.     

Kunyenga, "real sex," and survival: assessing the risk of HIV infection among urban street boys in Tanzania

This article examines possible avenues of HIV infection among urban street boys in Tanzania. In doing so, it questions the ways that AIDS researchers have defined and approached the phenomenon of "survival sex" in East and Central Africa. The article specifically examines the boys' sexual networks, sexual practices, and attitudes regarding their own sexual behavior, including their perceived risk of HIV/AIDS infection. Seventy-five street boys aged eight to 20 from the city of Mwanza were interviewed. Results suggest that almost all street boys are involved in a sexual network in which homosexual and heterosexual behavior occurs. Homosexual practices are rooted in a complex set of behaviors and ideologies known as kunyenga, which is a situated aspect of life on the streets and helps maintain the boys' strong dependence on one another. A key aspect of the boys' sexual careers involves a decrease in kunyenga activity as they approach the age of 18 and an increase in heterosexual encounters after the age of 11. There appears to be a critical period between these ages in which heterosexual and kunyenga activities overlap. It is suggested that boys between these ages represent a potential bridge for HIV/AIDS infection between the general population and the relatively enclosed sexual network of street boys.     

Getting the Message Across: Art and Craft in the Service of HIV/AIDS Awareness in South Africa

The struggle against the HIV/AIDS pandemic is one of the most serious challenges South Africa faces today. Great efforts have been and are being made to create awareness of the disease, utilizing a variety of strategies that range from straightforward educational messages in magazines, billboards, and radio/TV broadcasts, to more creative or artistic approaches in media such as film, drama, music, art, and crafts. Many of these projects (notably the Sarafina II drama production) have drawn criticism of some sort, usually focused on the perceived efficacy of the project, especially in relation to its cost or usage of resources. There sometimes appears to be an implicit expectation that HIV/AIDS awareness projects must state the “message” in simple, blunt, or easily comprehensible terms to “reach” people. This can be argued not only to be patronizing, but to disregard the complex ways in which visual stimuli are received and processed by diverse audiences.

In this article, I will investigate three different creative visual art/craft initiatives that have been employed in South Africa in the past few years to create HIV/AIDS awareness. They comprise: first, HIV/AIDS community murals, sponsored by the Department of Health and painted primarily in townships and on university campuses throughout the country; secondly, a print portfolio/billboard project, involving local and international artists whose “fine art” prints are enlarged to billboard size and placed in high traffic areas in cities and townships; and thirdly, a craft project employing rural women in KwaZulu-Natal who produce beaded dolls, badges and wire baskets (imbenge) with an HIV/AIDS awareness message.

The theoretical framework for this study is informed by semiotics and post-structuralism. It presumes that meaning is always constructed—both by the author/artist and by the recipient/viewer. Artists may want to convey clear educational messages, using seemingly unambiguous symbols and metaphors. However, as every signifier has multiple meanings, which constantly shift and slide, an artist cannot control how individual viewers will decode the message. In view of this, I will argue that it may be short-sighted to dismiss certain types of creative art projects around HIV/AIDS as incomprehensible or inaccessible and therefore ineffective in raising awareness of the disease and associated issues such as stigmatization.     

African Kaposi’s Sarcoma in the Light of Global AIDS: Antiblackness and Viral Visibility

Drawing on the theoretical frameworks of antiblackness and intersectionality and the concept of viral visibility, this essay attends to the considerable archive of research about endemic Kaposi’s sarcoma (KS) in sub-Saharan Africa accrued during the mid-20th century. This body of data was inexplicably overlooked in Western research into KS during the first decade of the AIDS epidemic, during which period European and Mediterranean KS cases were most often cited as precedents despite the volume of African data available. This paper returns to the research on KS conducted in Africa during the colonial and postcolonial period to consider visibility, racial erasure, and discourses of global epidemiology, suggesting that the dynamics of medical research on HIV/AIDS have proceeded according to a tacit paradigm of antiblackness manifest in multiple exclusions of Africa from global health agendas—most recently the exclusion of the region from antiretroviral (ARV) drug therapy during the first decades of the treatment’s availability. During that decade KS all but disappeared among people with access to ARV therapy while KS became even more prevalent in sub-Saharan Africa, escalating along with HIV.     

Randomized controlled trials of HIV/AIDS prevention and treatment in Africa: results from the Cochrane HIV/AIDS Specialized Register

Introduction

To effectively address HIV/AIDS in Africa, evidence on preventing new infections and providing effective treatment is needed. Ideally, decisions on which interventions are effective should be based on evidence from randomized controlled trials (RCTs). Our previous research described African RCTs of HIV/AIDS reported between 1987 and 2003. This study updates that analysis with RCTs published between 2004 and 2008.

Objectives

To describe RCTs of HIV/AIDS conducted in Africa and reported between 2004 and 2008.

Methods

We searched the Cochrane HIV/AIDS Specialized Register in September 2009. Two researchers independently evaluated studies for inclusion and extracted data using standardized forms. Details included location of trials, interventions, methodological quality, location of principal investigators and funders.

Results

Our search identified 834 RCTs, with 68 conducted in Africa. Forty-three assessed prevention-interventions and 25 treatment-interventions. Fifteen of the 43 prevention RCTs focused on preventing mother-to-child HIV transmission. Thirteen of the 25 treatment trials focused on opportunistic infections. Trials were conducted in 16 countries with most in South Africa (20), Zambia (12) and Zimbabwe (9). The median sample size was 628 (range 33-9645). Methods used for the generation of the allocation sequence and allocation concealment were adequate in 38 and 32 trials, respectively, and 58 reports included a CONSORT recommended flow diagram. Twenty-nine principal investigators resided in the United States of America (USA) and 18 were from African countries. Trials were co-funded by different agencies with most of the funding obtained from USA governmental and non-governmental agencies. Nineteen pharmaceutical companies provided partial funding to 15 RCTs and African agencies co-funded 17 RCTs. Ethical approval was reported in 65 trials and informed consent in 61 trials.

Conclusion

Prevention trials dominate the trial landscape in Africa. Of note, few principal investigators and funders are from Africa. These findings mirror our previous work and continue to indicate a need for strengthening trial research capacity in Africa.     

AN UNEQUAL ACTIVISM FOR AN UNEQUAL EPIDEMIC?1

This paper observes that a substantially large moral duty of dealing with the AIDS situation in Africa has been placed on the drug companies and argues that this approach is inequitable. Using the poverty-AIDS relationship and the human rights framework it argues for a more balanced AIDS activism, which puts equal pressure on all potential stakeholders in the war against AIDS. It argues that this redistribution of the HIV/AIDS moral burden is perhaps the only hope for curbing the African AIDS epidemic that continues to ravage communities on that continent.     

From the Zulu medicine to the European phytomedicine Umckaloabo®

Among the Zulus of South Africa a crude root drug of initially unknown botanical origin was used for the treatment of pulmonary diseases and tuberculosis (TB). An English TB patient called “Stevens” heard about it and travelled to South Africa where, according to his account, he was cured by taking an extract of the crude drug. It was extremely difficult to establish the imported crude herbal drug as a “new TB medicine”, as neither the plant from which the drug originated was identified nor were the constituents and pharmacological effects known at that time.It was only after a professional search and initial chemical and taxonomic investigations enabled the identity of the plant to be determined that the requirements were met for comprehensive chemical, pharmacological and clinical research into the crude drug.The following report traces the long and difficult path of this “mystery drug” from the Zululand of South Africa to the laboratories of Europe.     

Care of HIV-infected patients in China

Compared with high infection areas of the world, the total HIV infection rate in China is relatively low. Nonetheless, because of China's vast territory and large population, the potential infection risk must be taken seriously. In the next few years, needle sharing among injection drug users will remain the most common route of transmission for the HIV/AIDS epidemic in China. Unprotected sex is gradually becoming a major route of transmission. China began to implement HAART in 1999 according to international standards. Prior to 2003, there were only about 150 HIV/AIDS patients were treated with HAART in some clinical trials and about 100 HIV/AIDS patients were treated by private sources. Results of those treatments are the scientific basis for development of the therapeutic strategies in China. In March of 2003, the Chinese government initiated China CARES program. In November of 2003, the Chinese Ministry of Health announced a national policy of free ARV treatment to all HIV+ Chinese citizens who were in poverty and required ARV therapy. There are total of 19,456 HIV/AIDS patients received free ARV drugs to date in 159 regions and 441 towns. Current challenges are how to follow-up and evaluate those patients in the clinical settings. The longer the therapy is postponed, the more side effects and the higher probability of drug resistance are going to occur. It remains unclear, therefore, when HAART regimen should be started in the HIV/AIDS population in China.