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Introduction to the special issue — HIV prevention in the world of work in sub-Saharan Africa: research and practice

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Introduction to the special issue — HIV prevention in the world of work in sub-Saharan Africa: research and practice
   African Journal of AIDS Research 2011, 10(supplement): 291–300 Printed in South Africa — All rights reserved Copyright © NISC (Pty) Ltd  AJAR ISSN 1608–5906 EISSN 1727–9445 doi: 10.2989/16085906.2011.637725   African Journal of AIDS Research   is co-published by NISC (Pty) Ltd and Routledge, Taylor & Francis Group — Introduction to the special issue —HIV prevention in the world of work in sub-Saharan Africa: research and practice * Gavin George 1  and Courtenay Sprague 2 1 Health Economics and HIV and AIDS Research Division (HEARD), University of KwaZulu-Natal, Westville Campus, Private Bag X54001, Durban 4000, South Africa; e-mail: 2  University of the Witwatersrand, Graduate School of Business Administration, 2 St David’s Place, Parktown 2193, Johannesburg, South Africa; e-mail: Keywords: health research, HIV/AIDS, interventions, policy development, prevention and control, private sector, strategic planning, workplace Context and role of the private sector Unlike some diseases that affect the vulnerable (such as children), HIV primarily affects those most productive in the population. Within this context the private sector has a considerable role to play in managing HIV and AIDS and in contributing to comprehensive national responses. As the HIV epidemic expanded in sub-Saharan Africa, it threatened to weaken an already fragile skills base in many countries, placing pressure on worker recruitment and replacement costs, aggravating absenteeism, and contributing to the direct and indirect costs of production and performance (International Finance Corporation, 2002; Ellis & Terwin, 2005; Global Business Coalition on HIV/AIDS & Booz Allen Hamilton, 2006). In South Africa, amid debate over the motivations of company responses to the HIV epidemic and in a context of inaction and denial by the government, large firms took the lead in the provision of antiretroviral therapy (ART) to all employees with HIV who qualified for treatment; they did so well before the South African public health sector made the treatment available in 2004 (Dickinson, 2004). Debswana Diamond Company (De Beers’s operation in Botswana) led this initiative in 2001, followed by Anglo American in 2002 ( The Economist  , 2002; Van der Walt, 2007). Since then, many corporate firms on the continent have developed well-established programmatic responses to HIV and AIDS (Family Health International, 2002; Dickinson, 2009).National business coalitions have also played a major role in responding to HIV epidemics in sub-Saharan Africa by facilitating the development of workplace policies and programmes, establishing public–private and community partnerships, and generating dialogue between sectors, with businesses providing in-kind contributions and donations (UNAIDS, 2011a). Against this backdrop, company efforts to address HIV in the workplace have been at the forefront of the global response (Sprague & Dickinson, 2008). The need to document and replicate successful HIV/AIDS responses has been repeatedly stressed by all stakeholders. Indeed, national strategic plans in African countries priori-tise the dissemination of a growing body of experience and innovation in HIV-related care, treatment and support strategies, across public, private and non-profit sectors (see Government of Botswana, 2003; Government of Lesotho, 2007; Government of South Africa, 2007; Government of Uganda, 2007). While a range of HIV/AIDS-related activities takes place in the world of work in African countries every day, gaps in our knowledge remain. Since 2004, African researchers have come together to create a platform for high-quality applied research on HIV in the workplace, among academics, business people and other interested partners. The aim has been to build on and formalise the network of researchers, particularly new and younger researchers; to signal the importance of supporting university-based research on HIV in the world of work; to conduct quality, evidence-based research on this topic; to inform workplace policies and practices; and, to dissemi-nate the findings of research among other researchers and decision-makers responsible for addressing HIV and AIDS in their organisations. To this end, the South *Anonymous peer review of this article was independently managed by the  AJAR   Managing Editor, since the authors were guest editors of this issue.  George and Sprague292  African Business Coalition on HIV/AIDS (SABCOHA), the Foundation for Professional Development (FPD), the Health Economics and HIV/AIDS Research Division (HEARD), and the University of the Witwatersrand (Wits) hosted the 3rd HIV/AIDS in the Workplace Research Conference, held in Johannesburg, South Africa, in November 2010, with the theme of ‘HIV prevention and possibility.’ From HIV treatment to prevention Considering the sheer loss of human life extracted by  AIDS across the continent, many critics agree that actors at all levels — governments, key leaders and prominent non-governmental organisations (NGOs) — have “failed to respond to the epidemic decisively, which allowed it to fester and spread” (Kalipeni & Mbugua, 2005). As happened elsewhere, many early HIV/AIDS responses in  Africa were characterised by fears of promiscuity, homosex-uality, stigma, denial, blame, inaction and delay (see Shilts, 1988; Mann, 1999; De Cock, Mbori-Ngacha, 2002; Herek & Capitanio, 1993;  AJAR  , 2003; Beyrer, 2010). Because of weak national and institutional responses, the death toll due to AIDS, and some governments’ contention that antiretro-viral (ARV) drugs for Africans were simply unaffordable, the fight for access to ART in Africa has been one of the hallmarks of the HIV/AIDS response (Lindsey, 2001; Mbali, 2003; Altman, 2008). Led by civil society, together with the United Nations and other international organisations, the campaign for access to affordable HIV treatment has been a galvanising symbol of social justice in Africa and globally, denoting hope for the management of a seemingly invincible disease (Jong-wook, 2003; World Health Organization, 2003). As a consequence, in the evolution of the response to HIV and AIDS in Africa, much of the focus has been on affordable treatment, not prevention (Mbali, 2003; Power, 2003). The HIV epidemics in sub-Saharan Africa vary in their timing, drivers and severity. As of 2008, seven southern  African countries became home to generalised HIV epidemics, with national adult HIV prevalence exceeding 10% in Botswana, Lesotho, Namibia, South Africa, Swaziland, Zambia and Zimbabwe (UNAIDS, 2010; cf. Celentano & Beyrer, 2008). As many as 30 million Africans have died of AIDS since the early 1980s (Cook, 2008). By 2002, sub-Saharan Africa had captured over 77% of global  AIDS deaths (De Cock et al  ., 2002). With over 28 million still living with HIV in sub-Saharan Africa (UNAIDS, 2010), the impact and burden on the public health sector and on health personnel has been incalculable. In this context, the private sector has employed its own resources to keep employees healthy. Much of the sector’s effort has been focused on strategic planning to manage the risks and impacts of HIV and AIDS on companies. This includes workplace policy formulation based on agreement among company stakeholders (Global Business Coalition on HIV/AIDS & Booz Allen Hamilton, 2006). Most workplace HIV/AIDS policies communicate the common princi-ples of non-discrimination and non-stigmatisation towards individuals living with HIV and maintaining confidentiality of their HIV status. These principles are in keeping with the International Labour Organization (ILO) (2010), the United Nations (2001 and 2006), and other international and national legal conventions and standards (cf. Global Reporting Initiative, 2003; Global Business Coalition on HIV/AIDS, 2006). Beyond this, most organisations’ policies spell out the organisation’s position on HIV/AIDS; indicate employee benefits and assistance, including different types of leave of absence for illness or to attend funerals and other forms of reasonable accommodation (e.g. work restructuring due to illness, flexible work schedules, opportunities for rest breaks); outline in-house HIV/AIDS programme goals and focus (such as HIV prevention, treatment, care and support); describe the performance management aspects of the programme, including any monitoring and evalua-tion; and outline the organisation’s communication strategy (International Finance Corporation, 2002; Ellis & Terwin, 2005; Whelan, 2007). Within companies, much HIV prevention has come in the form of HIV/AIDS education and awareness campaigns targeted to staff, but more recently extended to key business partners such as suppliers, contractors, distribu-tors and communities. Workplace education sessions or workshops generally include content such as the main modes of HIV transmission, HIV prevention methods and the prevention and treatment of sexually transmitted infections (STIs), safer sexual behaviour versus HIV-risk behaviour, voluntary HIV testing and counselling, and resources that can be accessed for additional informa-tion and support within or outside the workplace (such as peer educators or social workers) (Dickinson, 2009; ILO, 2010). As part of their HIV-prevention interven-tions, organisations normally provide free condoms, STI treatment, post-exposure prophylaxis for HIV, and preven-tion-of-mother-to-child-HIV-transmission (PMTCT) services in medical stations throughout firm operations in Africa (Family Health International, 2002; ILO, 2010). In many  African countries, these services have progressively been made more available in the public health system as well. Historically, companies have been weak on targeting the particular health needs of women, biological and social vulnerability related to HIV acquisition, and gender norms related to masculinity and gender relations (power and negotiation during sex) (Sprague, 2008). Equally, attention to individuals’ sexual orientation has not been a feature, though this may change if NGOs begin to partner more actively with the private sector. There is some anecdotal evidence of this (see Sonke Gender Justice Network, 2011).Ultimately, HIV and AIDS interventions in the world of work and outside have tried to contain and mitigate the impact of the epidemic through HIV prevention, treatment, care and support. Often, however, HIV-prevention efforts have not changed behaviour. Even so, in recent years the focus has returned to HIV prevention due to a number of key factors: in light of the 2008 global economic recession and many research and technological advances in HIV-prevention interventions, international and African organisations have begun an earnest dialogue on the ‘prevention revolution,’ with UNAIDS (2011b) putting forward the target of zero new infections in its 2011–2015 strategy ‘Getting to Zero.’ Indeed, with more than 7 000 new HIV infections per day   African Journal of AIDS Research 2011, 10(supplement): 291–300293 globally (UNAIDS, 2011b), there is a dire need to institute universal, comprehensive HIV-prevention strategies to avert new HIV infections. But HIV-prevention efforts in southern  Africa, in particular, have been less than successful (Dworkin & Erhardt, 2007). In addition, in the face of the global economic crisis there has been a shortfall in international HIV/AIDS funding, with businesses, government and taxpayers attempting to cover some of the losses. Meanwhile, the fact that new HIV infections outpace the number of individuals initiating ART (UNAIDS, 2011b) places emphasis on scaling-up HIV preven-tion to reduce premature morbidity and mortality in African populations (Jamison, Feachem, Makgoba, Bos, Baingana, Hofman & Rog, 2006; Celentano & Beyrer, 2008). Several HIV-prevention strategies have gained prominence on the continent. The traditional public-health paradigm has emphasised the three established pillars of HIV prevention: condom promotion and distribution, voluntary HIV counselling and testing (VCT), and treatment of other STIs (De Cock et al  ., 2002; Potts, Halperin, Kirby, Swindler, Marseille, Klausner et al  ., 2008). In contrast, experts and United Nations agencies have argued for a longer-term focus on the structural determinants that increase vulnerability to HIV acquisition (Merson, O’Malley, Serwadda & Apisuk, 2008). With regard to HIV testing, Potts et al  . (2008) contend that there has not been sufficient evidence of a general reduction in higher-risk behaviour among individuals testing HIV-negative, although there has been some degree of reduction in risk behaviour among those who test HIV-positive. Those authors therefore suggest that “HIV testing is…unlikely to substantially alter the epidem-ic’s course,” although HIV testing remains the key entry point into prevention, care, treatment and support (Potts et al  ., 2008, p. 749). The third pillar of HIV prevention is the treatment of STIs. Although the success of treating STIs as a method for averting new HIV infections has not been demonstrated at the population level, the evidence base indicates that at the level of individual STI management it is essential in reducing susceptibility to HIV transmission (Centers for Disease Control and Prevention, 1998; Fleming & Wasserheit, 1999).Given the relatively limited success gained by previous HIV-prevention methods, researchers and practitioners have long pushed for a shift from emphasis on individual behaviours to so-called structural factors. This effort seeks to address the physical, cultural, social, community, economic, legal or other policy features that impact on HIV transmission — for example, by delaying the age of sexual debut, addressing people’s underlying vulnerability due to gender and poverty, increasing the proportion of protected sex acts, and encouraging adherence to HIV treatment (Coates, Richter & Caceres, 2008; Rao Gupta, Parkhurst, Ogden, Aggleton & Mahal, 2008; Rotheram-Borous, Swendeman & Chovnick, 2009). Structural strategies may be combined with biomedical interventions to reduce risk and vulnerability to HIV. Combining consideration for biomedical, behavioural, and structural factors in interven-tions is referred to as ‘combination prevention’ (Rotheram-Borous et al  ., 2009). The 2010 conference in South Africa With HIV prevention being a key priority area for national and international HIV/AIDS responses, the Graduate School of Business Administration at the University of the Witwatersrand (Wits Business School), the Health Economics and HIV and AIDS Research Division (HEARD) at the University of KwaZulu-Natal, together with the South  African Business Coalition on HIV/AIDS (SABCOHA), hosted the 3rd HIV and AIDS in the Workplace Research Conference,   in Johannesburg, from 9–11 November 2010. Delegates reflected on the intersection of workplace HIV responses, academic research, and surveillance, with a particular focus on strengthening HIV-prevention interven-tions in Africa and linking HIV-prevention research to workplace practices. The conference offered an opportu-nity for business stakeholders to step back and reflect on their HIV/AIDS programmes, using the lens of research and practice to consider what has worked and what lessons could be extracted, with the representatives keen to understand the latest trends in HIV-prevention research and their feasibility for workplace implementation. The conference committee reviewed 78 abstracts, with 28 selected for oral presentation and a further seven prominent researchers invited to present their pioneering research during the plenary sessions. The prevailing themes of the conference presentations are captured below. Partnerships for HIV prevention: public, private, community Extending an organisation’s workplace HIV/AIDS programme beyond its employees presents financial and logistical challenges, including raising fundamental questions about the organising principle and purpose underlying such programmes. Past conference discussions included the topics of whether to extend treatment to one spouse or two, how to address sex workers working in mining communi-ties in relation to HIV prevention, and determining where a company’s responsibility for healthcare begins and ends. Research in this area has included the roles of companies in responding to HIV and AIDS in communities, partnerships across sectors, traditional healers in relation to workplace programmes, and community and workplace peer education (see Dickinson, 2008 and 2009). Gender, women’s health, and HIV and AIDS With the feminisation of HIV epidemics (approximately 60% of people with HIV are female), much attention has been paid in recent years to the factors that create an enabling environment for women to acquire HIV disproportionately compared to men. The conference speakers and submis-sions considered the social constructions and meaning of gender, gender stereotyping, sexual identities and norms, intimate partner and sexual violence, and the impact of sexual risk behaviour on women’s greater biological and social vulnerability to HIV acquisition. Intimate partner violence, gender as a social relation, and individuals’ perceptions of gender received much attention, as did the linkages between youths, gender and HIV-risk behaviour (see Pronyk, Hargreaves, Kim, Morison, Phetla, Watts et al  ., 2006; Jewkes, Dunkle, Nduna & Shai, 2010).  George and Sprague294 Migration Growing globalisation and urbanisation has brought the cross-border movement of populations in Africa. This phenomenon is taking place together with internal migration within African countries where individuals search for improved livelihoods and job security. Migrants to urban areas are often attracted to the informal economy, with the informal sector being a neglected space in African national and global legislation concerning workplace responses to health and HIV. The health implications and HIV-programming possibilities that have emerged in this area have become a focus of investigation, as revealed by the last conference and this one. Increasingly, experts argue that migration should be viewed as a process driven by economic and social factors, and not as a ‘problem’ to be addressed by punitive measures. Thus, research has explored the informal workplaces in which migrants do business and the opportunities for HIV-prevention program-ming therein (see Richter, 2008; Vearey, 2008). Treatment Many workplaces now run or support HIV-treatment programmes that complement the public provision of ART. The continuing barriers to optimal treatment provision (e.g. the structure of delivery) and uptake (e.g. psychosocial issues and confidentiality concerns) are ongoing areas of investigation and debate. More recently the World Health Organization’s emphasis on treatment as an HIV-prevention method is an important approach. The prevention of new HIV infections in children through PMTCT is an obvious example of this paradigm: individuals on ART become less infectious, with a range of well-documented benefits to their health and survival. Notably, HIV transmission can be dramatically reduced when HIV-positive individuals are treated and if their partners undergo counselling and testing, with couples receiving HIV-prevention counselling and HIV-positive partners receiving treatment adherence support to maintain an undetectable viral load. ‘Treatment as prevention,’ however, is not fully understood nor widely accepted (see The Lancet  , 2011). While the conference received no papers on ART as HIV prevention, maximising the effects of ART for primary HIV prevention while consid-ering evidence-based combination strategies was a lively area of debate. Youths Young people are the future drivers of the economy and society. One-fifth of the global population comprises young people aged 15 to 24, and the majority of these individ-uals are living in middle- and lower-income countries (UNAIDS, 2011c). Youths have always been an ideal target for HIV prevention. Many specific HIV-programming efforts, such as addressing multiple concurrent partner-ships, intergenerational sex and safe medical male circum-cision, have implications for youths. Yet, in reality, youths are seldom engaged in intervention designs. Issues raised for discussion and follow up at the conference included: the HIV-related knowledge, attitudes and behaviours of youths; the community, school and other structures that can be used for improving outreach to youths; understanding the association between medical circumcision and HIV risk, which varies greatly across contexts and countries; how to ensure that sexual concurrency is addressed according to the contexts and priorities of young people; and the involve-ment and participation of young people in the planning and deployment of HIV/AIDS interventions (see Halperin & Epstein, 2007; AIDSTAR-One, 2009; UNAIDS Reference Group on Estimates, Modelling and Projections, 2009). HIV prevention, broadly  This conference category included biomedical and structural HIV/AIDS interventions, particularly those that have effectively linked theory to an evidence base; research on workplace programmes that have been evaluated and shown to be effective; and, methods for monitoring, measuring and reporting on successes in organisations. The paper submissions included the topics of biomedical interventions to prevent HIV infections (male and female condoms, male circumcision, and microbicides), as well as combination HIV prevention. Also included was research in the behavioural sciences, including structural approaches to HIV prevention (see Rao Gupta et al  ., 2008; Rotheram-Borous et al  ., 2009). Not all the conference submissions underwent peer review for publication in this special issue of the  African Journal of AIDS Research . While some of the promising research presented at the plenary sessions (mentioned in this introduction), such as studies on microbicides, safe male medical circumcision, HIV and TB co-infection, and intimate partner violence, does not appear as articles here, the presentations did inform and generate considerable conference debate. Selected research presented during the plenary sessions The need for comprehensive combination HIV prevention was echoed throughout the conference, suggesting that any single approach may be frustrated by its own limitations, one of which may be the inability to prompt prolonged behaviour change or to prevent target populations from negating the HIV protection gained by way of increased sexual risk behaviour. The latest biomedical HIV-prevention research presented focused on safe medical male circumcision and female microbicides. Dr Neil Martinson of the Perinatal HIV Research Unit (a research unit of the University of the Witwatersrand) shared the outcomes of a noteworthy study conducted in South Africa in 2005 which demonstrated the HIV-prevention effectiveness of male circumcision (the randomised trial showed a 65% reduction in risk of HIV infection among circumcised men). Similar results were achieved in trials in Kenya and Uganda. Although there is no direct protective effect for women, there is evidence to suggest that women will experience lower STI rates as a result (De Bruyn, Martinson, Nkala, Tshabangu, Shilaluka, Kubin et al., 2009).Koleka Mlisana, the director at one of the sites involved in microbicide trials by the Centre for the AIDS Programme of Research in South Africa (CAPRISA) at the University of KwaZulu-Natal, shared details of the CAPRISA 004 tenofovir gel trial involving 889 women at higher risk of HIV   African Journal of AIDS Research 2011, 10(supplement): 291–300295 infection, conducted at an urban and a rural site in KwaZulu-Natal Province. The reduced rates of HIV and herpes (HSV2) infections among the women who used the tenofovir gel were statistically significant. Over the 30-month trial, the microbicide was found to be 39% effective in reducing a woman’s risk of acquiring HIV. This figure was higher at 12 months (50% effective), but it was noted that the partic-ipants’ use of the gel was reduced over time. A safe and effective microbicide is critically important for HIV preven-tion and in empowering women to take control of their own HIV-infection risk (Abdool Karim, Abdool Karim, Frohlich, Grobler, Baxter, Mansoor et al  ., 2010). Overview of the articles Moving to the articles published in this special issue of  AJAR  , the range and types of research methods used are striking. These incorporate anthropology, public health, bioethics, development studies, economic modelling, political science, human rights and psychology. The selection of articles reveals the skill of some researchers in accessing and engaging hard-to-reach marginalised and key HIV-affected populations, such as youths, migrants, women and employees in the informal sector, using mainly qualitative methods. Vearey, Richter, Núñez and Moyo  use three qualita-tive case studies of migrants engaged in informal trades, together with existing literature, to explore the HIV-programming implications for migrant groups in the informal sector in urban South Africa. South Africa is remarkable for its high population mobility, with an estimated 3.6 million people working in the informal (non-agricul-tural) sector, many of them migrants. However, HIV-related responses among informal enterprises fall far short of those established in the formal sector. This is in spite of calls made by national frameworks and the ILO for HIV/AIDS responses to encompass informal workplaces. Findings from the first case study by Vearey and colleagues indicate that migrants labouring as waste-pickers at city dumpsites form a sizeable group in an established, viable industry, yet they have not benefited from exposure to HIV/AIDS education and programming. Those migrants in the sample who were already living with HIV reported that they had not received public health messaging outside of their attend-ance at a clinic. As informal entrepreneurs and migrants, this group would likely face greater difficulties in accessing HIV treatment, care and support. The second case study of men who work in bars in inner-city Johannesburg indicates that despite being a high-risk environment where transac-tional sex routinely takes place, combined with frequent alcohol use, bar employees did not benefit from internal HIV-prevention programmes or external campaigns from other stakeholders (e.g. government, community-based organisations or NGOs). The third case study of migrants who are members of burial societies demonstrates that such organisations could easily provide health-related informa-tion, education and resources to members (while they are still alive). The authors stress that in a generalised HIV epidemic, such as in South Africa, where migration across borders is common, the association between HIV and migration is complex. If national HIV/AIDS responses are to be comprehensive, as embedded in national strategic plans, then they must engage with the  process of migration, rather than simply focusing on migrants as a key affected popula-tion; furthermore, informal workplaces must become a focal point for programmatic interventions. Vearey and colleagues conclude that the informal sector remains one of South  Africa’s critical points of entry for HIV prevention, treatment, care and support for migrants in particular.  A qualitative investigation by Casale, Rogan, Hynie, Flicker, Nixon and Rubincam  addresses one key driver of HIV transmission in South Africa: sexual risk behaviour rooted in constructions of gender and sexuality. With a focus on young people, the authors sought to understand the relationship between gendered sexual identities and vulnerability to HIV infection. Against a background of literature that views sexual risk behaviour as an outcome of established gender inequalities, the authors explore gendered perceptions of HIV risk among male and female youths in a high-HIV- prevalence community in KwaZulu-Natal. The authors investigate how gendered perspectives are linked to HIV-risk behaviour in particular, and to health behaviour more generally. They found that the important theme of ‘responsibility for spreading HIV’ was embedded in certain perceptions among these youths, including varied understandings of the gendered culpability for the spread of HIV and the relationships between gender roles and HIV transmission. The authors conclude that HIV-prevention interventions need to sufficiently engage with gender and sexuality. They recommend using school-based programmes as a vehicle for HIV/AIDS education in order to engage youths in discussions about perceptions of gender and HIV, and to overturn stereotypes and misinformation concerning HIV-risk behaviour. Gilbert and Selikow   use a review of the academic litera-ture and relevant documents to consider the contex-tual factors underpinning the differential vulnerabilities of women and men in South Africa. Their analysis finds that a perilous mix of economic, political, biomedical and cultural forces has combined to produce today’s feminised HIV epidemic. They identify the most common ingredients in this mix as patriarchy, sexual norms (such as intergen-erational sex and having multiple sexual partners), high levels of violence against women and women’s subordinate position to men, as well as inadequate material resources. The authors argue that intervention strategies, particularly in the sphere of HIV prevention, must therefore be gendered, taking into account the specific social and cultural contexts in which women’s sexual risk behaviour and health-seeking behaviour is rooted. They put forward a gender-inclusive approach to HIV prevention, treatment and care which includes: addressing women’s economic dependence on men, challenging social and cultural norms of masculinity and violence, understanding the social constructions of gender, and incorporating men into HIV/AIDS responses. Chawana and Knapp van Bogaert   use South Africa’s current challenge to scale up universal, free HIV treatment to all who require it as the very real situational context for their study. They construct a Markov model to project the economic outcomes of providing treatment to a hypothetical
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