Hope of a nation - experiences of social exclusion giving rise to spaces of inclusion for people living with HIV and AIDs in South Africa : a reflection

South Africa has one of the highest rates of HIV/AIDS in the world. No one particular group is affected by the virus – rather, it is indiscriminate. Responses to HIV are diverse, and can be starkly contradictory. This author lived among the Xhosa people in rural Eastern Cape, working in community development. The program was a population-based youth empowerment program around HIV prevention. The work involved engaging youth in a range of civic participation activities, and networking with other community based groups and organisations, health and social services, and government departments. This reflection out a narrative of the lived experiences of social exclusion and social connectedness for people living with HIV/AIDS in rural Eastern Cape. It draws out the paradox of how the high prevalence of stigma and discrimination towards those with the illness, and their subsequent experience of social exclusion, actually creates opportunities for social connectedness through support group participation. This in turn is fashioning an emerging social movement breaking down barriers of stigma, and contributing to broader social change to support HIV action.

The reflection begins by outlining the current context and underlying determinants of the proliferation of HIV in the Eastern Cape, including a discussion of exclusion as a determinant. An exploration of how exclusion is also experienced as an outcome of positive HIV status follows. Finally, an explanation of how the experience of exclusion can be transformed into spaces of connectedness, and implications for health promotion practice in this context is also presented.

Churches, mosques, and condoms : understanding successful HIV and AIDS interventions by faith-based organisations

There are an estimated 33 million people living with the Human Immunodeficiency Virus (HIV) worldwide. While national education campaigns have been successful in providing a broad platform of awareness of HIV and AIDS, within some countries faith-based organisations (FBOs) have assumed an important role in educating and supporting local communities to reduce HIV transmission. This article conceptualises the successful characteristics of a Christian organisation in West Papua and a Muslim organisation in Thailand. The ability of both these FBOs to engage successfully with their communities on issues of sexual practice provides important lessons for other FBOs seeking to reduce HIV transmission.

From exclusion to agency in Papua: Pagar Adat Papua (the Papuan Customary Framework) as a culture- centred approach to HIV and AIDS communication

 This thesis examines the existing constructions, multiple discourses and framings of the HIV and AIDS epidemic in the Mee community of Papua, Indonesia, through the lens of a culture-centred approach to HIV and AIDS communication.

Commercial sex work, survival sex, sexual violence and HIV/AIDS prevention in Arumeru District, Arusha region Of Tanzania

Objective: To examine the knowledge and practices about HIV/AIDS among female Tanzanian commercial sex workers (CSWs) and assess the contextual dynamics that prevent safer sexual behaviours.

Method: The study used mixed methods and was implemented in two phases. Phase one assessed the knowledge and practices about HIV/AIDS among CSWs. Data were obtained with 54 CSWs, who were selected by using a snowball sampling approach. Semi-structured, face-to-face interviews with the CSWs were undertaken to allow the research participants to describe and discuss their lived realities as they perceive and experience them. In phase two, three discrete focus group discussions, each comprising 6-10 women, were carried out with 26 of the 54 CSWs who were interviewed in phase one.

Results: There was exploitation and inequity in the women's lives due to the multiple and overlapping oppressions of poverty and patriarchy. Sexual violence was framed, legitimised and reinforced by structural and cultural inequities. Such exploitation impacted not only on CSWs' lives as sex workers, but on their previous and/or simultaneous lives as mothers, wives, girlfriends and daughters. The women practised ‘survival sex’ as CSWs and/or sexual partners of men, and experienced sexual violence from their clients/partners. This violence was either culturally legitimised within a patriarchal framework or manifested itself as ‘displaced aggressive sex’ by men experiencing marginalisation in socio-economic spheres.

Lived experience of gay men caring for others with HIV/AIDS : living, loving and dying in the era of HIV/AIDS

This thesis explored gay male carers’ experience of caring for their partner, brother or friend who had HIV/AIDS. Through using phenomenological methodology (van Manen, 1990), the day-to-day caring experiences were uncovered. The data gathered were then analysed through a nursing ‘lens’, with the concept of stigma as an anchoring point. The dual stigmas of homophobia and AIDS phobia impacted on the daily lives of these men as they cared for their loved one. The research identified six themes. These were: 1) the relationship; 2) coping with HIV and AIDS; 3) the corporal impact of HIV/AIDS; 4) experiences of carers including the absence of others; 5) living daily with the virus: Demands of people living with HIV/AIDS (PLWHA); and 6) saying goodbye, but wanting to keep the memory alive. The caring these men undertook, for which they were frequently unprepared, was intensive and complex, but because of their commitment and love they battled on. Because of a sense of shame associated with AIDS phobia on the part of the PLWHA, the carer often had to undertake this care in isolation, without support from family, friends or home health care agencies. The carers struggled with not only the demands of day-to-day care, but also with non-acceptance from family, both of the nature of the relationship with their partner and of their homosexuality. Family members were forced, often with great difficulty, to acknowledge the close commitment the men had to each other. Recognition that one had a terminal disease, HIV/AIDS was also required. The fear of potential transmission was high among carers, friends and family members. Notably, there was an absence of blame on the part of the carer towards his partner for contracting HIV/AIDS. The physical decline and marking of the body further stigmatised the PLWHA, which added to carers’ burdens. They endeavoured to minimise the physical decline in their partner, so he could continue to pass as healthy, and attempted to make the day-to-day living as normal as possible. The methods of combating weight loss and opportunistic infections meant frequent medical appointments, complex intensive medical procedures and help with personal care, which was undertaken at home largely without support from health care staff. Carers frequently struggled also with their partner’s denial of being ill. One strategy all carers used was to escape with their partners from their everyday life in Melbourne and attempt metaphorically to leave the HIV/AIDS behind; this was a time when they could rekindle their life together as it was before HIV/AIDS came into their lives. Some carers chose to holiday without their partner, to give themselves a break from the day-to-day caring, while others planned and took holidays with their partner. The decline of the health in the PLWHA meant that family members had to recognise and accept both the nature of the relationship and the presence of the disease. This recognition and acceptance often came only when the partner was very ill, even at the point of dying. Carers and their partners discussed the potential use of euthanasia, as a means of ending the final phase of life with some dignity. One carer and his partner used euthanasia, despite its illegal status. The main concern for all carers was providing comfort and a reduction in the pain associated with HIV/AIDS for the partner. The widespread grief associated with HIV/AIDS was evident amongst these carers. All had known other gay men who had died, some carers own partner had died, or was about to die. There was an overwhelming sense of grief, which at times was repressed as a means of coping day-to-day. All carers felt it was important and necessary to remember those lost to HIV/AIDS through the various public memorials, as they did not want their partner to be just another faceless person lost to this disease. This phenomenological study of carers’ experience highlights the need for health care workers to be aware of the differing strategies that gay men use to cope with HIV/AIDS. While it may seem that the carers are coping with care of their partner, the outer façade is not always an accurate portrayal of the true situation. Health care workers should enquire as to the assistance these carers need from health care services in order to continue to care for their loved one. Such assistance can be the simple recognition of the partner and acceptance of them as part of the PLWHA’s network; this inclusion and acceptance is half the battle.

Reconstructing the incidence of human immunodeficiency virus (HIV) in Hong Kong by using data from HIV positive tests and diagnoses of acquired immune deficiency syndrome

The human immunodeficiency virus–acquired immune deficiency syndrome (HIV–AIDS) epidemic in Hong Kong has been under surveillance in the form of voluntary reporting since 1984. However, there has been little discussion or research on the reconstruction of the HIV incidence curve. This paper is the first to use a modified back-projection method to estimate the incidence of HIV in Hong Kong on the basis of the number of positive HIV tests only. The model proposed has several advantages over the original back-projection method based on AIDS data only. First, not all HIV-infected individuals will develop AIDS by the time of analysis, but some of them may undertake an HIV test; therefore, the HIV data set contains more information than the AIDS data set. Second, the HIV diagnosis curve usually has a smoother pattern than the AIDS diagnosis curve, as it is not affected by redefinition of AIDS. Third, the time to positive HIV diagnosis is unlikely to be affected by treatment effects, as it is unlikely that an individual receives medication before the diagnosis of HIV. Fourth, the induction period from HIV infection to the first HIV positive test is usually shorter than the incubation period which is from HIV infection to diagnosis of AIDS. With a shorter induction period, more information becomes available for estimating the HIV incidence curve. Finally, this method requires the number of positive HIV diagnoses only, which is readily available from HIV–AIDS surveillance systems in many countries. It is estimated that, in Hong Kong, the cumulative number of HIV infections during the period 1979–2000 is about 2600, whereas an estimate based only on AIDS data seems to give an underestimate.

Achieving behaviour change: three generations of HIV/AIDS programming and jargon in Thailand

NGOs have played an important role worldwide in the fight to prevent the spread of HIV/AIDS through achieving behaviour change. NGOs have often been at the forefront of innovative changes, influencing government and international programming activities. This paper identifies and analyses the evolution of the HIV/AIDS programmes of one NGO in Thailand over a period of ten years. Three generations of programming are identified both through distinct approaches to this area of work and through the changing jargon used to describe the people the programmes are aimed at.

Stigmatization of patients with AIDS : understanding the interrelationships between Thai nurses' attitudes towards HIV/AIDS, drug use and commercial sex

There is currently a scarcity of research on the nature of HIV/AIDS stigma within the Thai health context. This is problematic given the negative role of stigma in hindering the provision of patient care and treatment. This study used a mixed-method approach to investigate the interrelationships between the stigma of HIV/AIDS and the stigmas relating to its various modes of disease transmission including injection drug use (IDU). Twenty interviews were conducted with trainees and qualified nurses from a Bangkok college. Participants were presented with vignettes describing a hypothetical person varying in disease diagnoses (AIDS, leukemia, no disease) and co-characteristics (IDU,  commercial sex (CS), blood transfusion, no co-characteristic). Using a Q-sort task, participants arranged the vignettes along a bipolar scale according to their willingness to interact with the persons, and were asked to explain their decisions. Univariate and multivariate regression analyses showed that IDU, AIDS, and CS were all individually stigmatizing. Strong interactions were found between the stigmas of HIV/AIDS, IDU, and CS. Interview data also showed clear biases toward patients according to their IDU and CS habits. The findings  suggest that addressing these co-stigmas could be vital to the success of efforts aimed at reducing the disease stigma of HIV/AIDS.

Disentangling the stigma of HIV/AIDS from the stigmas of drugs use, commercial sex and commercial blood donation - a factorial survey of medical students in China

Background
HIV/AIDS related stigma interferes with the provision of appropriate care and support for people living with HIV/AIDS. Currently, programs to address the stigma approach it as if it occurs in isolation, separate from the co-stigmas related to the various modes of disease transmission including injection drug use (IDU) and commercial sex (CS). In order to develop better programs to address HIV/AIDS related stigma, the inter-relationship (or 'layering') between HIV/AIDS stigma and the co-stigmas needs to be better understood. This paper describes an experimental study for disentangling the layering of HIV/AIDS related stigmas.

Methods
The study used a factorial survey design. 352 medical students from Guangzhou were presented with four random vignettes each describing a hypothetical male. The vignettes were identical except for the presence of a disease diagnosis (AIDS, leukaemia, or no disease) and a co-characteristic (IDU, CS, commercial blood donation (CBD), blood transfusion or no co-characteristic). After reading each vignette, participants completed a measure of social distance that assessed the level of stigmatising attitudes.

Results
Bivariate and multivariable analyses revealed statistically significant levels of stigma associated with AIDS, IDU, CS and CBD. The layering of stigma was explored using a recently developed technique. Strong interactions between the stigmas of AIDS and the co-characteristics were also found. AIDS was significantly less stigmatising than IDU or CS. Critically, the stigma of AIDS in combination with either the stigmas of IDU or CS was significantly less than the stigma of IDU alone or CS alone.

Conclusion
The findings pose several surprising challenges to conventional beliefs about HIV/AIDS related stigma and stigma interventions that have focused exclusively on the disease stigma. Contrary to the belief that having a co-stigma would add to the intensity of stigma attached to people with HIV/AIDS, the findings indicate the presence of an illness might have a moderating effect on the stigma of certain co-characteristics like IDU. The strong interdependence between the stigmas of HIV/AIDS and the co-stigmas of IDU and CS suggest that reducing the co-stigmas should be an integral part of HIV/AIDS stigma intervention within this context.

Stigmatization of AIDS patients : disentangling Thai nursing students' attitudes towards HIV/AIDS, drug use and commercial sex

This paper analyzes the interrelationships between the stigma of HIV/AIDS stigma and the co-stigmas of commercial sex (CS) and injecting drug use (IDU). Students of a Bangkok nursing college (N = 144) were presented with vignettes describing a person varying in the disease diagnoses (AIDS, leukemia, no disease) and co-characteristics (IDU, CS, blood transfusion, no co-characteristic). For each vignette, participants completed a social distance measure assessing their attitudes towards the hypothetical person portrayed. Multivariate analyses showed strong interactions between the stigmas of AIDS and IDU but not between AIDS and CS. Although AIDS was shown to be stigmatizing in and of itself, it was significantly less stigmatizing than IDU. The findings highlight the need to consider the non-disease-related stigmas associated with HIV as well as the actual stigma of HIV/AIDS in treatment and care settings. Methodological strengths and limitations were evaluated and implications for future research discussed.

Risk factors for HIV/AIDS and hepatitis C among the chronic mentally ill

The objective of this study was to document the prevalence of risk factors for HIV/AIDS and hepatitis C among people with chronic mental illness treated in a community setting.