Gender and HIV in South Africa

423 Pages·2018·4.162 MB·English

by  Courtenay Sprague

GLOBAL
RESEARCH
IN
GENDER,
SEXUALITY
AND
HEALTH
GENDER
AND
HIV
IN SOUTH
AFRICA
Advancing women’s
health & capabilities
COURTENAY SPRAGUE
Global Research in Gender, Sexuality and Health
Series Editors
Ellen Annandale
Department of Sociology
University of York
York, UK
Xiaodong Lin
Department of Sociology
University of York
York, UK
Global Research in Gender, Sexuality and Health brings together original,
forward-looking research on gender, sexuality and health at a time of far-
reaching and complex global transformations in each of these areas. The
associations between these realms are being reconfigured by global social
change in different ways and with different consequences for the experi-
ence of illness and delivery of healthcare in local and national contexts.
New experiences of health and illness are also being driven by the
increased global mobility of bodies and illnesses and the growing securi-
tization of illness. In turn, these are challenging conventional ways of
thinking about gender, gender, sexualities and the body and call for novel
conceptual approaches that are a better fit for an understanding of health
in a ‘global age’. This interdisciplinary series aims to showcase original
research monographs and edited collections of interest to an international
readership. Studies from the Global South are particularly encouraged, to
help reflect on and revise knowledge of gender, sexuality and health
beyond a Eurocentric perspective.
More information about this series at
http://www.palgrave.com/gp/series/15916
Courtenay Sprague
Gender and HIV in
South Africa
Advancing Women’s Health
and Capabilities
Courtenay Sprague
University of Massachusetts
Boston, USA
University of the Witwatersrand
Johannesburg, South Africa
Global Research in Gender, Sexuality and Health
ISBN 978-1-137-55996-8 ISBN 978-1-137-55997-5 (eBook)
https://doi.org/10.1057/978-1-137-55997-5
Library of Congress Control Number: 2017964726
© The Editor(s) (if applicable) and The Author(s) 2018
The author(s) has/have asserted their right(s) to be identified as the author(s) of this work in accordance
with the Copyright, Designs and Patents Act 1988.
This work is subject to copyright. All rights are solely and exclusively licensed by the Publisher, whether
the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of
illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and trans-
mission or information storage and retrieval, electronic adaptation, computer software, or by similar or
dissimilar methodology now known or hereafter developed.
The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication
does not imply, even in the absence of a specific statement, that such names are exempt from the relevant
protective laws and regulations and therefore free for general use.
The publisher, the authors and the editors are safe to assume that the advice and information in this book
are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or
the editors give a warranty, express or implied, with respect to the material contained herein or for any
errors or omissions that may have been made. The publisher remains neutral with regard to jurisdictional
claims in published maps and institutional affiliations.
Cover illustration: © Gideon Mendel
Printed on acid-free paper
This Palgrave Macmillan imprint is published by Springer Nature
The registered company is Macmillan Publishers Ltd.
The registered company address is: The Campus, 4 Crinan Street, London, N1 9XW, United Kingdom
Eyabo bonke abesifazane base Ningizimu Afrika abaphila noma
abasengozini yesandulela-ngculazi.
(For all South African women living with or at risk of HIV)
Samkelisiwe with her son at her mother’s home in KwaZulu-Natal shortly before
her death. Source: Mendel 2001, image 10/35. Reprinted with permission
vii
Preface
The three photographs that appear in this work, including the arresting
cover photo, are by the acclaimed South African-born photographer,
Gideon Mendel. Gideon’s photographs are distinctive, not only for their
raw emotion and haunting beauty, but for their ability to portray the
lived experience of families at key moments during the unfolding AIDS
epidemic in sub-Saharan Africa. Gideon was one of the first photogra-
phers to cross the threshold into African homes and communities, and
with their permission, to train his lens on individuals and families at the
HIV epidemic’s epicentre: calling attention to ‘health as social justice’ in
the African Continent. In doing so, he was building on the practice of
‘documentary genre’ used by Peter Magubane and others (post-1976
Soweto uprising and earlier) to capture the bald brutality and cold-
blooded injustice of the Nationalist government’s apartheid regime (see
Badsha, 1986).
Gideon’s images powerfully render, not just the faces of people affected
by HIV, but their stories. Each photograph has a caption that conveys
what those individuals wanted to share at a time when the African AIDS
(acquired immunodeficiency syndrome) epidemic was being ignored and
the rising death toll uncounted. As Gideon writes in his work, A Broken
Landscape: HIV/AIDS in Africa:
ix
x Preface
I first began documenting HIV/AIDS in sub-Saharan Africa in the early
1990s. At the time, three-quarters of the world’s 36 million people living
with HIV/AIDS were in Africa. It was a slow burning tragedy on a monu-
mental scale; one that was quietly decimating some of the poorest nations
on Earth. (2001, p. 1)
I thank Gideon for his generous permission to reprint these moving
photos. The full collection can be seen here: http://gideonmendel.com/a-
broken-landscape/. As with Gideon’s photo narratives—what people felt,
the anxieties that gripped them—must continue to be located in the fore-
ground as the HIV epidemic evolves.
Today 22.3% of all women in South Africa are living with HIV
(Statistics South Africa [StatsSA], 2016a). Despite a massive HIV treat-
ment programme in the public health system since 2004, South Africa
leads the world in global HIV incidence in young women aged 15–24 years
(UNAIDS, 2016a, 2016b). Moreover, HIV prevalence in South African
pregnant women has stood at a constant 29–30% since 2004, while new
HIV infections in women aged 50 and above are increasingly docu-
mented (see Fig. 1.1) (Government of South Africa, 2015a; Sprague &
Brown, 2016; UNAIDS, 2013). These statistics are powered by quantita-
tive techniques using large samples and they effectively tell a powerful
story of the sustained high HIV prevalence and incidence in South
African women and its pernicious effects on women’s health as part of
long-term trends. It is, however, the narratives and voices of women—the
qualitative, lived experience—that is perhaps most important in inform-
ing how the research and policy community can gain greater purchase on
HIV in women in particular social contexts.
The research presented in these pages adopts a joint public health and
social justice lens to capture the complex dimensions of HIV in South
African women. It investigates the opportunities to be healthy or ‘capa-
bilities’ and agency of black South African women living with HIV. The
central question asked by Amartya Sen’s Capabilities Approach (CA) to
human development (1999) is: what are people able to do and be? (1999).
Martha Nussbaum rightly presses that question, asking, are women ‘really
able to do and to be these things, or are there impediments, evident or
hidden, to their real and substantial freedom?’ (2008, p. 1). In this work,
Prefac e xi
the impediments to and enablers of women’s health, agency and wellbe-
ing are elicited through in-depth interviews (IDIs) conducted with 89
women living with HIV, and supplemented by interviews with 44 key
informants. Spanning more than a decade, my research on black South
African women living with the virus has primarily been qualitative in
nature to elevate a needed focus on women’s lived and social experiences
of health and illness. It thus complements the large body of quantitative
biomedical and epidemiological research on HIV in women—some of it
analysed here—to inform social science understandings of the effects of
HIV on women. Attention to some of the essential moral and social
aspects of women’s experiences of living with HIV are also captured but
these continue to require further articulation by South African women
and by women affected by HIV in other parts of the world.
Of note, the original findings, particularly when supplemented by the
results from numerous other South African studies, underscore the prin-
cipal role of structural constraints—especially intimate partner vio-
lence—to undermine black South African women’s agency, and their
process and opportunity freedoms. The manner by which these structural
health determinants, notably adverse gender norms, interact with other
influential factors to inhibit women’s HIV care and adherence are docu-
mented here. These add to the growing body of evidence about social
health inequalities, and how women experience systematic health differ-
ences in their daily world. The possibilities for promoting and protecting
women’s health while advancing their capabilities are also emphasised.
The principal need for women to be able to exercise the rights they are
afforded in South African law remains paramount, as do social policies
and inter- sectoral action. Notably, two gender-transformative interven-
tions (GTIs) undertaken in community-based settings illustrate that
structural-level changes can be achieved (Chap. 7). Indeed, the core thesis
of this work is that HIV in South African women constitutes a social
justice problem, and one that is changeable.
Significantly, the women most at risk of acquiring HIV in South
Africa, and most likely to die from HIV-related causes, are black women.
Despite the process of social transformation that has been unfolding
since the introduction of democracy in 1994, black women’s health and
prospects for human development have been—and continue to be—