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OPINION

WHY HAVE SOCIO-ECONOMIC EXPLANATIONS BEEN FAVOURED OVER CULTURAL ONES IN EXPLAINING THE EXTENSIVE SPREAD OF HIV IN SOUTH AFRICA?

Chris Kenyon,
MB ChB, MA, MPH

Sizwe Zondo,
MA

Robert Colebunders,
MD, PhD

Sipho Dlamini,
MB ChB, FCP (SA)

Corresponding author: C Kenyon (chriskenyon0@gmail.com)

The HIV prevalence in South Africa’s various racial/ethnic
groups differs by more than an order of magnitude. These differences
are determined not by the lifetime number of sexual partners, but by
how these partnerships are more likely to be arranged concurrently in
African communities. The available evidence demonstrates that neither
HIV nor concurrency rates are determined by socio-economic factors.
Rather, high concurrency rates are maintained by a culturally
sanctioned tolerance of concurrency. Why then do socio-economic
explanations trump cultural ones in the South African HIV aetiological
literature? In this article, we explore how three factors (a belief in
monogamy as a universal norm, HIV’s emergence in a time of the
construction of non-racialism, and a simplified understanding of HIV
epidemiology) have intersected to produce this bias and therefore
continue to hinder the country’s HIV prevention efforts.

‘Whereas individual-level parameters may
influence which individuals in a given population acquire infection, it
is population-level parameters that affect the prevalence of
infection.’ Aral, Lipshutz, Blanchard (2007)1

Sexually transmitted infections (STIs) are transmitted via sexual
networks, and differences in the structure of these networks constitute
the key population-level parameter that determines differences in HIV
prevalence.1 The differences
in HIV prevalence between South Africa’s racial/ethnic groups
(19.9%, 3.2% and 0.5% for 15 - 49-year-old blacks, coloureds and whites
respectively2 are as big as
those between the highest- and lowest-prevalence countries in the
world. These large racial/ethnic differences are not related to
individual level risk factors such as lifetime number of sexual
partners, but are more likely determined by different sexual network
structures.3 In African
networks, sexual partnerships are more likely to be arranged
concurrently, and this increases the interconnectedness of the sexual
network in a non-linear fashion.3
Evidence from numerous sources and disciplines shows that these high
concurrency rates are a key factor in driving high HIV transmission
rates in southern and eastern Africa.4

Two main categories of factors have been advanced as being important
in the promotion of these high concurrency rates: cultural and
socio-economic factors. Socio-economic factors are unlikely to be the
predominant determinants since neither HIV nor concurrency are
contoured along the lines of poverty, at the level of countries or
individuals. One of the few quantitative studies looking at the
determinants of concurrency in South Africa found no relationship
between income quintile and concurrency, but concurrency was more
commonly practiced and accepted in black communities than among whites
and coloureds.5

A literature review of the explanations for the striking differences
in HIV spread by race in South Africa concluded that there was a strong
bias favouring socio-economic explanations.6 As
an example, one of the premier textbooks on the epidemiology of
HIV/AIDS in South Africa argues that the reason why HIV prevalence
rates differ between races is that ‘marginalisation and
discrimination on the basis of race and/or ethnicity are key factors
influencing vulnerability to HIV infection.’7
No evidence however was provided to back up this assertion. What is the
explication for this bias? We argue that the playing down of cultural
factors in the South African HIV aetiological literature is the result
of an intersection of three factors.

EXPLAINING THE UNDER-APPRECIATION OF CULTURAL FACTORS

HIV’s emergence in a time of the resonance and construction of non-racialism

The first factor relates to the post-apartheid context of the
emergence of HIV. Notions of white racial and cultural superiority were
central pillars of the apartheid ideology. An uncritical use of race as
an analytical variable and on occasion frankly racist views would
characterise much South African medical and public health enquiry
during the apartheid period. HIV then emerged into prominence during
the difficult period while South Africa was attempting to build a new
dispensation based on non-racialism. Given this backdrop and the fact
that HIV was sexually transmitted, deeply stigmatised and then found to
disproportionately affect black South Africans, it is not difficult to
see why many of the investigating experts downplayed the racial
differentials in HIV spread and biased their assessments of aetiology
towards socioeconomic factors. To have suggested that culturally backed
norms were important in HIV spread might well have been construed as
racist. An example of the ongoing reluctance to use race or ethnicity
as an analytical variable in regard to HIV in South Africa, is the 2008
Human Sciences Research Council HIV Survey. Despite it being South
Africa’s only nationally representative HIV-serolinked survey, it
does not mention racial differentials in HIV rates anywhere except in
one small table in the appendix.8

Monogamy as a universal norm

The second factor derives from the unacknowledged post-Christian
ethical foundation of much of the South African HIV epidemiology. One
dimension of this is the subtle way that monogamy (either lifetime or
serial) is assumed to be normative for all humans. Little consideration
is given to the wealth of anthropological and historical evidence as to
the normative nature of polygamy in stratified societies across place
and time,9 and more
pertinently, the fact that polygamy is still far more widely acceptable
in sub-Saharan Africa than elsewhere in the world.10
The spread of Christianity in South Africa led to the suppression of
polygamy. The historical record is clear that this did not lead to a
reduction in the total number of concurrent partners, but only to the
non-main partners being kept secret.11
Having main and more or less secret-extra partners is still widely
practised and tolerated in the region. Authors who have provided
evidence that these high concurrency rates lead to high-risk sexual
networks in the region have, however, been portrayed as racist and
‘crypto-racist’.12
If these authors label as racist the argument that monogamy is less
prevalent in parts of Africa, then it necessarily follows that these
authors regard monogamy as more ethical. Even if this belief in
mononormativity exists at a fairly subliminal level, then the cultural
explanation for generalised HIV epidemics in Africa may clash with
one’s principles of non-racialism – one is stating that
Africans are more likely to engage in unethical behaviour. Given that
mononormativism is protected by its unacknowledged status, this clash
should lead to the triumph of the commitment to non-racialism. The
theory of cognitive dissonance predicts that given this scenario the
mind should then actively search for other theories, such as
socio-economic and biological ones, to explain the higher HIV
prevalences in Africa (see Fig. 1).

Poorly developed conceptual framework for HIV spread

High-risk networks characterised by high concurrency rates are now
recognized to be key to the generation of generalised HIV epidemics.
Evaluating the strength of these network level effects requires
network-level analyses. One of the most dramatic limitations of much of
the aetiological literature on HIV epidemiology in South Africa, is the
absence of network levels of analysis. A recent example is a study that
compared individual level sexual behaviours between South African and
United States youth surveys.13
Based on little difference between these parameters in the two
countries the authors conclude that differences in sexual behaviour are
unlikely to explain South Africa’s generalised HIV epidemic. They
ignore network level factors in their analysis and the literature which
shows that network level factors are able to explain the magnitude and
patterning of South Africa’s epidemic.3 The conclusions of the paper and the accompanying editorial14
are that HIV prevention efforts need to shift away from focussing on
sexual behaviour and the norms which underpin these, and instead
campaign for conditional cash transfers and a range of biological
measures of proven efficacy for HIV prevention.

Technical interventions as the new panacea for HIV prevention

In the absence of a national consensus ever having been attained
that a culturally sanctioned norm is driving HIV-spread in the country,
the majority of contemporary papers on HIV prevention in South Africa
continue to focus on socio-economic and technical inventions. The
currently favoured interventions include vaginal microbicides,
Test-and-Treat, increased condom usage or STI vaccines.13-15 Some argue
against behaviour change campaigns owing to their futility,14 while
others argue that further research on this topic is immoral.16 One
prominent paper that does mention dealing with high concurrency rates
(albeit as one of a long list of factors) goes on to state that
conditions created by apartheid were responsible for the genesis and
maintenance of high concurrency rates.15 The authors then claim that
South Africa’s HIV Strategic Plan ‘is comprehensive’
and ‘highlights that South Africa is not deficient in
policy’ (p. 926). Unfortunately, this national plan does not
mention the urgency of dealing with concurrency. In fact there is still
little more than a few small ad hoc programmes in South Africa to
effect the mass social mobilisation necessary to lead to norm and
behaviour change in this regard.

Conclusion

The key to Uganda’s success in rapidly bringing down HIV rates
was the way Uganda fairly rapidly recognised the importance of
encouraging ‘zero grazing’ or reducing extra partners.17
Unfortunately, HIV is still viewed by too many in South Africa as being
a disease of poverty and inequality. Where concurrency is acknowledged
to be important, it is too often regarded as being driven by
socio-economic factors. The net effect has been that insufficient focus
and research has been directed at the normative cultural factors that
sustain the high concurrency rates in South Africa. As a result, there
has not been the same pressure brought to bear on effecting the
necessary changes in tolerance of extra partners in South Africa as has
been the case in Uganda.

REFERENCES

1. Aral S, Lipshutz J, Blanchard J. Drivers of STD/HIV
epidemiology and the timing and targets of STD/HIV prevention. Sex
Transm Infect 2007;83 (s1):1-4.

2. Shisana O, Rehle T, Simbayi L, Parker W, Zuma K. South
African National HIV Prevalence, HIV incidence, Behaviour and
Communication Survey. Pretoria: HSRC Press, 2005:90-92.

3. Kenyon C, Dlamini S, Boulle A, White R, Badri M. A
network-level explanation for the differences in HIV prevalence in
South Africa’s racial/ethnic groups. African Journal of AIDS
Research 2009;8:243-254.

4. Mah T, Shelton J. Concurrency revisited: increasing and
compelling epidemiological evidence. Journal of the International AIDS
Society 2011;14:33-39.

5. Kenyon C, Boulle A, Badri M, Asselman V. ‘I
don’t use a condom [with my regular partner] because I know that
I’m faithful, but with everyone else I do’: The cultural
and socioeconomic determinants of sexual partner concurrency in young
South Africans. Journal of Social Aspects of HIV/AIDS 2010;7:35-43.

6. Kenyon C. “Differential poverty rates are responsible
for the racial differentials in HIV prevalence in South Africa”;
an enduring and dangerous epidemiological urban legend? Southern
African Journal of HIV Medicine 2010;11:22-27.

7. Gouws E, Abdool Karim Q. HIV Infection in South Africa: the
Evolving Epidemic. In: Abdool Karim SS. HIV/AIDS in South Africa.
Cambridge: Cambridge University Press, 2005:63.

8. Shisana O, Rehle T, Simbayi L, Zuma K, Jooste S. South
African National HIV Prevalence, Incidence, Behaviour and Communication
Survey 2008: A Turning Tide among Teenagers? Pretoria: HSRC Press, 2009.

9. Macdonald K. The establishment and maintenance of socially
imposed monogamy in western Europe. Politics and the Life Sciences
1995;14:3-23.

10. Cleland J, Scott C, Whitelegge D. The World Fertility Survey: An Assessment. Oxford: Clarendon Press, 1987.

11. Delius P, Glaser C. The myths of polygamy: a history of
extra-marital and multi-partnership sex in South Africa. South African
Historical Journal 2004;50:84-114.

12. Stillwaggon E. Racial metaphors: Interpreting Sex and AIDS in Africa. Development and Change 2003;35:809-832.

13. Pettifor A, Levandowski B, Macphail C, Miller W, Tabor J. A
tale of two countries: rethinking sexual risk for HIV among young
people in South Africa and the United States. J Adolesc Health 2011;
49:237-243.

14. Jaspan H. The wrong place at the wrong time: geographic
disparities in young people’s HIV Risk. J Adolesc Health
2011;49:227-229.

15. Abdool Karim S, Churchyard G, Abdool Karim Q, Lawn S. HIV
infection and tuberculosis in South Africa: an urgent need to escalate
the public health response. Lancet 2009;374:921-933.

16. Sawers L, Stillwaggon E. Concurrent sexual partnerships do
not explain the HIV epidemics in Africa: a systematic review of the
evidence. Journal of the International AIDS Society 2010;13:34.

17. Kirby D. Changes in sexual behaviour leading to the decline
in the prevalence of HIV in Uganda: confirmation from multiple sources
of evidence. Sex Transm Infect 2008;84 (supplement 2):ii35-ii41.

Fig. 1. The cognitive processes involved in evaluating two competing
theories for why HIV has spread so extensively in some racial groups in
South Africa. As illustrated here, the lack of evidence to support the
socio-economic thesis should lead to its dismissal (red arrow), while
the validity of the evidence to support the cultural hypothesis should
serve to strengthen it as an explanatory cognition (yellow arrow). In
the setting of the strong ideologies of class-determinism and
monogamy-as-a-universal norm and the anchor cognition of wanting to
present oneself as antiracist, however, the cultural thesis generates
considerable cognitive dissonance (one is implying that Africans are
more likely to engage in unethical behaviour), and the theory is
therefore rejected (green arrows). Likewise, if one is sufficiently
committed to class as the explanation for differing HIV rates, then the
dissonance produced by the lack of evidence to back one’s ideologically
determined theory up can be reduced by the selective interpretation of
evidence to back it up (orange arrows).