Socio-cultural drivers of the
HIV/AIDS epidemic in subSaharan Africa
Prof Geoffrey Setswe DrPH
8 May 2010
Overview
• Why is the HIV/AIDS pandemic not uniform around the
world?
• What are the socio-cultural risk drivers that influence the
spread of HIV in sub-Saharan Africa?
• What does this tell us about our response to the
epidemic?
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Background
• SADC: epicentre of global HIV pandemic - adult prevalence rate 11%
as compared to 1% globally.
 By 2009, 33.4 million people living with HIV/AIDS worldwide .
 63% in sub-Saharan Africa
 37% of new infection in 2008 occurred in the region.
 6,000 people in Southern Africa become infected with HIV every
day.
 People under 25 years = half of all new HIV infections worldwide.
Source: UNAIDS (2009)
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Psycho-socio-cultural factors driving the
spread of HIV
Major Areas of Need
Sociocultural
Cultural Identity
Social Stigma
Psychosocial
School
Mental Health
Family
Poverty
Recreation
Psychomedical
Peers
Sexual Health
Multiple
Diagnoses
Medications
Nutrition
Future Planning
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Human factors that drive the spread of
HIV
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High prevalence of other STIs
Knowledge of AIDS and perception of risk
Multiple sexual relationships
Traditionally low use of condoms, even in high-risk
sexual encounters
Poverty and the relatively low health status of much of
the population, including widespread malnutrition
Low status of women - ?ability to negotiate safer sex
Settlement patterns and worker migration
Cultural practices e.g. Wife adoption
Low levels of male circumcision
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Environmental risk factors driving the
spread of HIV
Economic and Political Factors
- Level of poverty – commercial sex work
- War and social conflicts – rapes and sexual abuse
- Status of transport and mobility of population
- Performance of health care system
- Response to epidemic
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Abstinence and faithfulness as risk factors
• 83% of young people said that it was possible not to have sex
for as long as you can. 78.5% said that not having sex was the
best way of preventing infection with HIV.
• 68.7% of young people said that the media encouraged
faithfulness in relationships and 84.6% said that life skills
workshops were helpful in encouraging them to remain
faithful to one partner.
Source: Setswe (2010) Views and perceptions of young people on ABY
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MCP, MC and condom use as major risk factors
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SADC Think Tank, Maseru, May 2006
– Multiple and concurrent partnerships with low consistent condom
use, in the context of low levels of male circumcision are key drivers of
the HIV pandemic in Southern Africa.
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SADC Regional Consultation: Social Change Communication for HIV Prevention,
Swaziland, October 2006
– Recommended partner reduction as a key focus for social change
communication interventions both at country and regional levels.
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Condom use during last sex act, South
Africa 2002 and 2005
Age
Male (%)
2002
2005
Female (%)
2002 2005
15-24 yrs
57.1
84.8
46.0
73.0
25-49 yrs
26.7
53.4
19.7
55.3
50 yrs+
8.2
25.2
5.6
18.7
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Reasons for MCP
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MCPs are common practise
Sexual dissatisfaction
Emotional and physical dissatisfaction
Culture and social norms influence MCPs
Money and material possessions
Alcohol and MCP
Men cannot control sexual desire
Pressure
Male domination and abuse
HIV and AIDS risk and fatalism
Soul City (2007)
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Social-cultural meanings of MCP
• For a man: affirms his self-worth, shows generosity,
expresses love/appreciation, helps restore pride,
validates manhood, asserts & establishes power &
authority in relationship.
• For a woman: affirms her value, an expression of
love/appreciation, boost self-esteem & social status,
helps builds social networks & capital, gains
materially, promotes dependency and vulnerability.
(a conundrum for women)
(Luke & Kurz 2002, Kelly et al 2003, Hallman 2004, Lary et al 2004, Longfield et al 2004,
Luke 2005, Nshindano 2006, Nkosana & Rosenthal 2007).
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Socio-cultural factors to consider in
implementing MC services
• Sensitivity to cultural and traditional
practices should be shown at all times and
the government must ensure that MC is
promoted and delivered in a culturally
appropriate manner that minimises stigma
associated with circumcision status.
• Engagement and participation of key
community leaders including Traditional
Healers and Leaders to assist in the buy in
and filtering of the implications of safe MC to
relevant communities will play a critical role
in addressing socio-cultural issues and
overcoming barriers to safe MC.
• Cultural neutrality: MC for HIV prevention is
not a means of cultural identity, but solely a
health intervention.
DOH (2009) Male circumcision framework for South Africa (Draft)
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Conclusions
– Strong views on ABY do not necessarily translate into behaviour
change in HIV prevention.
– MCP is a key driver of HIV infections in Southern African countries
where national HIV prevalence rates among adults exceeds 15%.
– MCP is itself driven by various socio-cultural and economic factors
including both old and new social cultural norms and values.
– There is a need for individual and multi-level interventions as social
and structural level through social change communication using the
media and community mobilisation or community engagement
including the involvement of faith-based organisations.
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