African Journal of AIDS Research 2014, 13(3): 237–246 Printed in South Africa — All rights reserved

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ISSN 1608-5906 EISSN 1727-9445 http://dx.doi.org/10.2989/16085906.2014.952648

Obstacles to HIV prevention, treatment and care in selected public universities in South Africa Blessing Mbatha Department of Communication Science, P/Bag x 392, University of South Africa, Pretoria, 0003, South Africa Email: [email protected] South Africa, like the rest of Southern Africa, is ravaged by AIDS. Higher education in South Africa has a significant role to play in the fight against the spread of HIV and AIDS. This article reports the factors contributing to the spread of HIV and AIDS in three selected public universities in South Africa. To achieve the stated aim, the study answered the following research question: What are the factors contributing to the spread of HIV and AIDS in South African public universities? The problem in this study stems from South Africa’s HIV and AIDS infection rate, one of the highest in the world, especially in KwaZulu-Natal. A qualitative approach was adopted by conducting focus group interviews with the students. The data were analysed using axial coding and open coding, where dominant themes from the discussions were identified and discussed in detail. The findings show that barriers to HIV and AIDS prevention, care and treatment exist in the tertiary institutions under study. Social and economic interventions are needed to stem the spread of HIV and AIDS at tertiary institutions. A range of recommendations for halting the spread of HIV and AIDS in these institutions is provided. Keywords: AIDS pandemic, barriers to HIV prevention, HIV and AIDS, HIV treatment and care, KwaZulu-Natal province, sexually transmitted diseases, South African public universities, tertiary institutions

Introduction and background South Africa, like the rest of Southern Africa, is ravaged by AIDS. AIDS is one of the most serious, deadly diseases in human history. Since AIDS was first identified in the early 1980s, an unprecedented number of people have been affected (Mann 1989, Mbatha 2009, UNAIDS 2010, Vearey et al. 2011). The number of people living with HIV rose from around 8 million in 1990 to 34 million by the end of 2011 (UNAIDS 2012). However, the overall growth of the epidemic has stabilised in recent years. Furthermore, the annual number of new HIV infections has steadily declined and due to the significant increase in people receiving antiretroviral therapy, the number of AIDS-related deaths has also declined (UNAIDS 2012). Since the beginning of the epidemic, nearly 30 million people have died from AIDS-related causes (UNAIDS 2012). An estimated 5.6 million people were living with HIV and AIDS in South Africa in 2009, more than in any other country (UNAIDS 2010). In 2009 an estimated 310 000 South Africans died of AIDS (UNAIDS 2010). Prevalence is 17.8% among those aged 15–49 years old with some age groups being particularly affected (UNAIDS 2010). Almost 1 in 3 women aged 25–29 and over a quarter of men aged 30–34 were living with HIV in 2009 (UNAIDS 2010). Also of note is that HIV prevalence among those aged two and older varies by province with the Western Cape (3.8%) and Northern Cape (5.9%) being least affected, and Mpumulanga (15.4%) and KwaZuluNatal (15.8%) at the upper end of the scale (HSRC 2009).

Around 2.7 million people were infected with HIV in 2010. Sub-Saharan Africa has been hardest hit by the epidemic; in 2010 over two-thirds of all AIDS deaths were in this region (SANAC 2010). This study examined factors contributing to the spread of HIV and AIDS in three out of five South African public universities located in KwaZulu-Natal. Much has been said about HIV and AIDS and its dangers, however, far less attention has been paid to the obstacles to HIV treatment, care and support in South African public universities. The study sought to provide government, education sector, policy makers, AIDS activists, researchers and health professionals with information to assist them in their decision-making processes and help them take appropriate actions in intervention programmes. To achieve the stated aim, the study answered the following research question: What are the factors contributing to the spread of HIV and AIDS in South African public universities? The problem in this study stems from South Africa’s HIV and AIDS infection rate, which is one of the highest in the world. This was confirmed by many researchers (such as Mbatha 2009, Vearey et al. 2011) who note that South Africa has the largest population of people living with HIV globally and that this can be associated with high population mobility. Higher education in South Africa has a significant role to play in the fight against the spread of HIV and AIDS. Firstly, HIV and AIDS have a direct influence on human resource development, and secondly, HEAIDS (2009) reports that students represent a source of the future skills and knowledge base of the country. According

African Journal of AIDS Research is co-published by NISC (Pty) Ltd and Routledge, Taylor & Francis Group

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to HEAIDS (2009), since universities stand at the forefront of education, they are strategically positioned to be the best social response against the epidemic. The sector has a responsibility to inform and empower its communities including students, who represent future leaders and staff as the valuable human capital responsible for producing knowledge in the country. It is therefore deemed necessary for students to be mobilised to become part of the response against HIV and AIDS. In their study, Rogan et al. (2010) caution that HIV and AIDS remain one of the most serious problems facing youths in many sub-Saharan African countries. After outlining previous relevant literature on HIV and AIDS, this paper reports the methodology that was adopted to conduct the study. The article further reports the results, discusses them and, ends with concluding remarks and recommendations. Literature review Current statistics show that over 1 200 people are infected with HIV every day in South Africa. This staggering number has contributed to an epidemic where today 5.6 million South Africans (10.9% of the population) are living with HIV (SANAC 2010). Students in their productive years are the most at-risk population. Furthermore, many countries, including South Africa, have faced a slow-down in economic growth and an increase in household poverty. Thus it is befitting to pay attention to the barriers to HIV prevention, care and treatment in South African institutions of higher learning, more especially in KwaZulu-Natal due to its high number of HIV infections. Although there is no cure for AIDS, HIV infection can be prevented, and those living with HIV can take antiretroviral drugs to prevent or delay the onset of AIDS. On a positive note though, a study published in 2010 (Rehle et al. 2010) shows that HIV incidence is declining and that the impact of antiretroviral treatment is having an effect on the South African epidemic). Rehle et al. (2010) present evidence for a shift in the epidemic and a decline in the rate of new HIV infections in South Africa. Gains continue to be made in response to the global HIV epidemic. The number of new HIV infections is falling, fewer people are dying of AIDS-related causes and more people with HIV are living longer (Rehle et al. 2010). However, these achievements should not lead to complacent attitudes. In South Africa, people living with HIV still face AIDS-related stigma and discrimination. Studies indicate that there is an exceptional HIV and AIDS vulnerability among students in the institutions of higher learning in South Africa (Mkhize 2008, Mbatha 2009). This is also evident in the high pregnancy rate in South African tertiary institutions. Many researchers have written extensively on HIV prevalence in the world and have established that South Africa is one of the most affected countries (Mkhize 2008, Rehle et al. 2010, UNAIDS 2011). These studies further report that the youth is the most infected with the virus. Thus, more focus should be directed to this group. The high pregnancy rate among students simply shows that they are not using precautionary measures of combating the spread of HIV and AIDS. Since the population is very high in the institutions which participated in the study there is fear that more students would

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be infected and affected with the virus. The numbers of HIV infection in South Africa, more especially in KwaZuluNatal, are overwhelming, yet they can only describe the quantitative dimension of the epidemic. The reality behind the figures is one of individual human suffering and whole societies affected by AIDS (Kober and Van Damme 2004). Research methodology The study targeted students in three out of five purposively selected South African public universities in KwaZulu-Natal. A qualitative approach was adopted by conducting focus group interviews with the targeted population. This was done to engage and encapsulate the different viewpoints of the target population. Using purposive sampling, 50 students from each university were selected. Five groups per institution were selected for the interviews. These interviews provided the students with an opportunity to share and reflect on their experiences with regard to HIV and AIDS. These audio-taped interviews lasted between 90 minutes and 2 hours, and were held within the premises of the universities. The data were analysed using axial coding and open coding, where dominant themes from the discussions were identified and discussed in detail. Data analysis was divided into two phases. In the first phase, the researcher engaged in ‘open coding’ to generate thematic categories thereby reducing large passages of text to principal concepts. In the second phase, the researcher engaged in ‘axial coding’, which focused on relating concepts to subcategories and to each other, forming more concrete codes for analysis. The validity of the data collection instruments used in this study was enhanced by the fact that questions were derived from the objectives of the study. Each question was checked to determine whether it contributes to the research objectives. The interview guide was pre-tested for clarity, completeness, relevance and shortcomings in a pilot study. The aim of the pilot study was to establish the interview guide’s effectiveness, reliability and validity before the actual study. Most importantly, the pilot survey aimed at testing the subject matter of the current research, the population it was to cover, its spatial variability, and the possible reactions to questions by the participants. The researcher ensured that he used simple, direct and unbiased wording. Findings from the pilot study revealed that the initial interview guide had too many questions, as participants had to spend more than an hour trying to answer them. The guide was therefore redesigned to make it less cumbersome for both the participants and the researcher. In terms of ethical considerations, informed consent was obtained from each participant in the study to ensure that they understood what they were doing and verify their willingness to participate. The respondents were assured of their rights, including the right of consent, protection from disclosure of information, and respect for their privacy. All the research participants voluntarily participated and were not forced to take part in the study. With regard to protection from harm, the researcher ensured that the participants were not at any risk and would not be exposed to embarrassment, unusual stress, or any demeaning

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Demographic profile of the respondents The findings indicate that the sample was racially biased, with 111 (74%) being blacks, and 39 (26%) Indians. The sample also represented a broad spectrum of ages with 109 participants (73%) between 15 and 22 years of age; 24 (16%) between 23 and 25 years of age; 9 (6%) indicating they were between 26 and 30 years of age; and only 8 (5%) were aged 31 years and above. Furthermore, a significant number of participants, 101 (67%), were from urban areas; 49 (33%) were from rural areas. The study was female dominant with a significant number 97 (65%) being females; 53 (35%) were males.

• ‘If you do not have any financial support you are doomed for starvation.’ • ‘Days are not the same, sometimes I go to bed on an empty stomach and I am used to it.’ • ‘I grab whatever that fills my stomach, even unhealthy stuff due to financial constraints.’ • ‘Some students suffer from food insecurity, which then affects their treatment uptake.’ • ‘I only eat supper due to financial constraints.’ • ‘I joined this university as a student 8 years ago and currently I am pursuing a PhD. Starvation is the main problem facing many students and they end up involved in bad relationships due to financial needs.’ What is immediately clear from the findings above is that students have different experiences with regard to hunger in their institutions. The findings show that some respondents had experienced hunger and some had not. A study by Jamison et al. (2006) reports that hunger and AIDS work in tandem at both the individual and the societal levels. Infection with HIV increases the risk of malnutrition in the individual, while malnutrition worsens the impact of HIV and AIDS. Likewise, Vanek et al. (1953) conducted a study on plasma cell pneumonia in infants and established that protein deficiency is a cause of cell-mediated immunodeficiency. Thus it is strongly recommended that HIV-infected individuals need to consume more energy than uninfected individuals: as much as 10% greater consumption for asymptomatic individuals and 20% to 30% more for symptomatic individuals. In support of the latter views, Gillespie et al. (2001) also opine that malnutrition alters the susceptibility of individuals to HIV infection and their vulnerability to its various sequelae, increases the risk of HIV transmission from mothers to babies, and accelerates the progression of HIV infection. Fawzi et al. (2004) note that daily micronutrient supplementation increases bodyweight, reduces HIV RNA levels, improves CD4 counts and reduces the incidence of opportunistic infections.

Hunger Hunger, along with many other effects causes the immune system to weaken, making the body more susceptible to other diseases. One of the objectives of the study was to establish whether the respondents were experiencing any hunger problems in their campuses. Some of the responses from the respondents during the interviews were: • ‘Food is expensive here, sometimes I eat unhealthy food.’ • ‘Not at all, I have a bursary that pays for my meals and I eat whatever I want.’ • ‘Oh no, my parents are currently taking good care of me and they buy me groceries.’ • ‘My parents taught me how important it is to eat healthy food, so I make sure that I eat healthy stuff.’ • ‘I have been in this university for 7 years now and what I have witnessed here is not good at all. The problem is that most students can’t afford to buy food on a daily basis, let alone 3 meals per day.’ • ‘In my first year of study, I would go to bed without food and it was a common thing. It was very sad because you become vulnerable – you know what I mean.’

Condom usage Poor condom usage is considered by many as one of the factors that contribute to the spread of HIV. Thus, it was vital for this study to establish whether or not the participants were constantly using condoms as a precautionary measure in the fight against the spread of the pandemic. Below it is what the respondents had to say: • ‘Oh yes I always use a condom.’ • ‘Eish, I sometimes forget to use a condom.’ • ‘Sometimes I run out of condoms.’ • ‘We started well with condoms but after three months or so we just forgot about them, it was not even our decision, it just happened.’ • ‘I don’t use government condoms because they easily break during sexual activity.’ • ‘My girlfriend doesn’t want us to use a condom.’ • ‘I only use branded condoms like lovers plus, rough riders.’ • ‘My girlfriend prefers only branded condoms and such condoms are expensive to me since I am a student, thus sometimes we have unprotected sex because I could not always have condoms.’

treatment. Anonymity and confidentiality were promised and maintained. The information they provided was not made available to anyone else who was not directly involved in the study and cannot be traced to/ identified with the participants. The researcher also ensured that the participants remained anonymous throughout the study. In terms of professional standards, the researcher ensured that the findings were gathered in a professional manner without misrepresenting anyone and/or intentionally misleading the respondents about the nature of the study. The researcher ensured that the findings were presented honestly without fabricating any data to support any particular finding. Findings The findings are discussed under the following headings: demographic profile of the respondents; hunger; condom use; gender and prevalence of violence; HIV-related stigma; internalised AIDS stigma; access to HIV prevention, treatment, care and support; and poverty. These factors have been considered by many researchers as some of the barriers to the fight against the spread of HIV and AIDS (Jewkes 2009, Bastien 2011, Campbell et al. 2011, Tomaszewski 2012, Ramirez-Valles et al. 2013).

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• ‘I told my partner to use a condom and the response I got was like: “oh you don’t trust me, so do you think I have HIV?”’ • ‘Let’s face it, although it is not impossible, but it is very difficult to use a condom with a person you have dated for more than five years — what I mean is that for a long time.’ The findings above show that respondents had mixed experiences with regard to condom usage. Kirby (2000) asserts that condoms, when used consistently and correctly, are the only form of protection that can help stop the transmission of sexually transmitted diseases (STDs) such as HIV, and prevent pregnancy. However, Myer et al. (2002) argue that although the South African government has increased the number of male condoms distributed free to the public, there is no understanding of whether these are being used effectively to prevent the spread of STDs, including HIV infection. The evidence for the effectiveness of condoms is clearest in studies of couples in which one person is infected with HIV and the other is not (discordant couples). In a study of discordant couples in Europe, among 123 couples who reported consistently using condoms, none of the uninfected partners became infected (Weller et al. 2007). In contrast, among the 122 couples who used condoms inconsistently, 12 of the uninfected partners became infected. A review of 14 studies involving discordant couples concluded that consistent use of condoms led to an 80% reduction in HIV incidence (Weller et al. 2007). Gender inequalities Many studies have shown that violence against women, including sexual violence, is widespread in South Africa (Dunkle et al. 2004, Shelton et al. 2005, Jewkes 2009). Thus the study set out to establish whether or not the respondents had experienced any gender-related sexual violence on their campuses. The following list provides participants’ responses: • ‘I have never experienced any gender imbalance-related abuse from my boyfriend.’ • ‘My boyfriend is a good person, he can’t do such a thing to me or anyone for that matter.’ • ‘I once had a fight with my boyfriend, he forced me to have sex with him, anyway we had had sex before the incident, but on that day I was very tired’. • ‘Ya, it does happen but you know I just let it go because he is my future husband I guess.’ • ‘Yes it happened on countless occasions, I moved in with my boyfriend because I could not stay off campus due to financial constraints, it is dangerous at night, so I rather stay with him.’ • ‘It happens to many girls here, but they don’t say a thing, until they are fit to stand on their own, I mean financial-wise.’ • ‘These things do happen here but we as girls don’t take them as abuse or something that can lead us to contract viruses. This is due to known reasons, such as financial dependence from our boyfriends.’ These responses show that some respondents had experienced gender-based violence from their partners. The study established that females were the only participants

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who reported experiencing gender-related violence. These findings are in parallel with those of Jewkes (2009) who also established that more than 4 in 10 South African men reported being physically violent to an intimate partner. This also clearly justifies the high HIV prevalence among females in South Africa. In their study on gender-based violence, relationship power and risk of HIV infection in women attending antenatal clinics in South Africa, Dunkle et al. (2004) established that women who have been physically and sexually assaulted by their partners, and those who are in relationships with men who have a greater degree of control over them, are at a higher risk of HIV infection. Similarly, Shelton et al. (2005) are of the view that the poor, especially women, are vulnerable to sexual exploitation because HIV prevalence is partly a function of survival. Further, Lugalla et al. (1999) caution that gender inequality and poverty deprive women of their ability to fulfil their socially designated responsibilities, thus debasing them, and often forcing them into prostitution. HIV-related stigma HIV-related stigma and discrimination is one of the obstacles that severely hampers efforts to effectively fight the HIV and AIDS epidemic. Fear of discrimination often prevents people from seeking treatment for AIDS or from publicly admitting their HIV status. Thus, this study set out to establish whether this was the case at all tertiary institutions under investigation. The respondents had this to say: • ‘It is well known that some people usually discriminate against the one who is sick and has disclosed his/her status.’ • ‘A friend of mine disclosed her status to her roommate, then her roommate stopped sharing things with her, such as utensils.’ • ‘Some do not even want to enter your room.’ • ‘I have never tested on this campus because I am scared of stigma.’ • ‘Some students hide their status because they fear that people will laugh at them.’ • ‘If you are HIV-positive people think that you are immoral.’ • ‘If you are HIV-positive people think that you contracted it through sleeping around.’ • ‘It’s because it’s perceived as a sexually transmitted disease. Therefore when we talk about HIV people, we always refer to this as a disease of someone who flirts.’ • ‘People fear to disclose as this disease is contracted through sex. People’s perception is that people who are infected with the HIV virus are not well behaved.’ • ‘Eish it is difficult here, if you visit the clinic people think you are HIV-positive.’ • ‘Even if I were HIV-positive I would not visit the campus clinic due to stigma.’ • ‘If you visit the campus clinic here, students think that you have a problem or maybe you have developed HIV symptoms in your body’.’ • ‘The nurses who are working here are gossiping about people who come to the clinic, it is even worse because some are student assistants, so they see us from residence.’

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• ‘If you do an HIV test, students think that you sleep around and maybe you also saw some HIV symptoms, then they start gossiping about you and it is even worse if you are a Christian as some people think that Christians cannot be infected.’ • ‘Some health workers are nursing students, so a friend of mine who is living with HIV was reluctant to visit the campus health services out of concerns for confidentiality.’ • ‘Here many students prefer to go to off-campus clinics for HIV test or anything related to STIs rather than risk being identified as HIV-positive on this campus.’ • ‘The main problem here is that students don’t want to disclose their HIV status because they are afraid that other students will discriminate against them.’ • ‘I heard that a student tried to commit suicide after knowing that he was HIV-positive, when the warden asked him why he was killing himself, he said he was afraid that other students were going to judge him.’ The findings above concur with those of the study by Simbayi et al. (2007), who caution that AIDS-related stigma can lead to discrimination such as negative treatment and denied opportunities on the basis of HIV status. This discrimination can affect all aspects of a person’s daily life, for example, when they wish to travel, use healthcare facilities or seek employment (Petros et al. 2006, Bastien 2011). Internalised AIDS stigma HIV and the AIDS pandemic form perhaps the most stigmatised medical condition in the world. Therefore, the respondents were asked to comment on their experiences on internalised AIDS stigma they had experienced on their campuses. This is what they had to say: • ‘If I were HIV-positive, I think it would be difficult for me to reveal my HIV infection.’ • ‘ I would feel like I am irresponsible for myself and to my loved ones.’ • ‘Being HIV-positive makes me feel dirty.’ • ‘I would have to be responsible of my actions and do the right think, which is to stay healthy.’ • ‘I feel guilty that I am HIV-positive.’ • ‘My parents have invested a lot in me and that is why I am here, maybe I would just kill myself.’ • ‘My parents taught me a lot on how I should behave here because I am now responsible for myself and they are not around, so I would be a disgrace to them.’ • ‘I would feel worthless if I happen to be HIV-positive.’ • ‘It would be my own fault that I am HIV-positive, so I will have to face it and not hide it.’ • ‘With fear of discrimination and stigma, I would definitely hide my HIV status from others.’ The findings above show that some respondents had experienced internalised AIDS stigma. In their study on internalised stigma, Simbayi et al. (2007) established that AIDS stigmas interfere with HIV prevention, diagnosis and treatment, and can become internalised by people living with HIV and AIDS. Sharing similar sentiments, Herek (1999) is of the view that people with HIV infection are often ascribed responsibility for their condition because HIV is contracted from behaviours that are considered avoidable, namely unsafe sex and drug use practices. Many

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researchers such as Crandall and Coleman (1992), Wenger et al. (1994), Lewis (1998), Chesney and Smith (1999) have written extensively on internalised AIDS stigmas and caution that these stigmas have the potential for adverse behavioural and emotional ramifications, including not seeking treatment and care services, engaging in unsafe sex practices, fostering a sense of isolation and emotional distress, and self-hatred. In strengthening these views, Parker and Aggleton (2003) report that AIDS stigmas also reproduce inequalities of class, race and gender. In their study on internalised AIDS stigma, Kalichman and Simbayi (2003), supported by Petros et al. (2006), established that AIDS stigmas also create a barrier to HIV prevention, including HIV testing and counselling, in South Africa. Access to HIV prevention, treatment, care and support Lack of access to HIV treatment, care and support contributes to the spread of HIV and AIDS. The study set out to establish whether or not the participants were experiencing such challenges on their campuses. Participants responded as follows: • ‘We do have a campus clinic and that is where we get all the information we want on HIV and AIDS.’ • ‘There is an HIV office in this institution.’ • ‘I don’t know whether our clinic here does provide HIV and AIDS treatment, I only know that they provide HIV testing.’ • ‘We do have counsellors on this campus, so if you are HIV-positive they advise and tell you where to get treatment.’ • ‘Condoms are only available at the campus clinic which is a challenge for many students.’ • ‘I am not sure whether our campus clinic provides ARVs.’ • ‘I am afraid to take condoms in front of other students.’ • ‘The problem is that our clinic does not provide ARVs, you have to travel long distance for such treatment and we don’t have money.’ • ‘Condoms are all over the campus.’ • ‘I am afraid to take condoms in front of the nurses.’ • ‘The university distributes condoms in the student residences, but in a short be space of time you find that condoms are finished and you end-up engaging in unprotected sex.’ The findings above show that access to HIV prevention, treatment, care and support was a huge problem to some of the students. Jamison et al. (2006) are of the view that, notwithstanding the treatment strides, global efforts have not proved sufficient to control the spread of the pandemic or to extend the lives of most of those infected. The desired level of success has not yet been achieved for several reasons. Most people who could benefit from available control strategies, including treatment, do not have access to them. The literature shows that behavioural change is the most significant part of the problem in preventing HIV and AIDS transmission and that basic condom availability is still an issue in some countries (USAID 2000, Mbatha 2009). The South African National Department of Health procures millions of condoms, but their distribution to local health departments is inefficient, leading to large over-stocks in some areas and shortage in others (Mbatha 2009). Marking a welcome change from South

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Africa’s history of HIV, the South African Government launched a major HIV Counselling and Testing Campaign (HCT campaign) in 2010. Since its implementation the HCT campaign has had a notable impact on the availability and uptake of HIV testing and treatment (SANAC 2010). In many countries across the world, access to prevention and treatment services is limited. Global leaders have pledged to work towards universal access to HIV prevention and care, so that millions of deaths can be averted (UNAIDS 2011). Poverty This study sought to ascertain whether any socio-economic factors were affecting turning the tide against the spread of HIV and AIDS in South African public universities. This was important to establish, because most students in these universities are from poor backgrounds. Moreover, as students their primary use of money is for studies and that not all of them have bursaries. Some bursaries do not cover all the student costs and most bursaries only finance tuition, which makes students vulnerable and prone to exploitation. Respondents were required to comment on poverty-based experiences that had put them at risk of contracting HIV. The respondents generally noted the following: • ‘Eish, things are happening here, you find a young student dating an old man because she needs money.’ • ‘In my first year of study here, I dated an old man because I needed money to pay for my accommodation.’ • ‘Most of us here we are from poor backgrounds, so we need somebody to take care of us while we are here.’ • ‘Here it seems as if young girls don’t think about contracting HIV. It is very painful to see five girls from the same campus dating the same man because of his money. These students know each other and they seem to be cool with it. I am sure that one of them is HIV-positive. The man they are dating is a well-known person in Durban and for sure he is got other sexual partners in other universities or elsewhere.’ • ‘Trust me I am not proud about this, currently I am dating a very old woman because I need money and she is giving money that I need as a student. Once I complete my degree, it would be the end of our relationship and we have been dating for two years and we don’t know each other’s HIV status. We started using condoms but after five or six months we automatically stopped using condoms.’ • ‘My bursary could only pay for my tuition and accommodation, then I had to feed myself and my parents died long ago, so there was this guy who liked me. Trust me, I did not like him at all, but because he had money and he used to take me out for dinner, I dated him so that he could buy me food. After 13 days of our relationship he said we must stop using condoms because he was not enjoying it, I refused, telling him that I don’t want to fall pregnant and he became livid and disappeared for 17 days. It was difficult for me because the person who was feeding me had gone. I ended up calling him and told him that we could have sex without a condom.’ The findings indicate that there are positive elements of poverty that have put students at risk of contracting STDs. Understanding poverty within the context of HIV

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and AIDS is critical, as this paper views it as both a risk factor for and the consequence of HIV infection. As a risk factor, poverty is associated with a lack of money to buy food and other necessities that a university student needs. These findings concur with the study conducted by Mbatha (2009) who argues that poor people usually have less access to information about HIV and AIDS and are often less able to protect themselves from the infection. In contrast though, all participants had access to HIV information. Therefore, to them it was not the issue of a lack of access to HIV and AIDS information, but rather resistance to a change in behaviour. Poor people may depend on unsafe sexual relationships for economic security or entertainment (Mbatha 2009). In support of these findings, UNAIDS (2011) indicates that poverty can be a risk factor for and a consequence of HIV infection. The poor frequently live in high-risk social environments and HIV-infected persons experience adverse economic impacts. GanyazaTwalo and Seager (2005) also share similar sentiments, namely that the relationship between HIV and AIDS and poverty is synergistic and symmetrical. As much as HIV and AIDS exacerbate poverty through morbidity and mortality of productive adults, poverty facilitates the transmission of HIV. Discussion The findings show that much still needs to be done to fight the spread of HIV and AIDS in tertiary institutions. Clearly, in their institutions of higher learning students face plenty of obstacles to HIV treatment, support and care. Hunger has emerged as one the major challenges that some of the students experienced in their institution. As indicated in the findings, due to hunger some of the students end up getting involved in risky behaviours that put them at risk of contracting HIV. In line with these findings, Jamison et al. (2006) are of the view that hunger and AIDS work in tandem at both the individual and the societal levels. Furthermore, hunger does not only put a person at risk of contracting HIV, but also a person who has HIV can develop AIDS due to hunger. As the findings show that some of the students revealed that due to hunger they sometimes eat unhealthy food which may affect their immune systems. In support of these findings, Vanek et al. (1953) conducted a study on plasma cell pneumonia in infants and established that protein deficiency is a cause of cell-mediated immunodeficiency. Thus it is strongly recommended that HIV-infected individuals need to consume more energy than uninfected individuals: as much as 10% greater consumption for asymptomatic individuals and 20% to 30% more for symptomatic individuals. Similarly, Gillespie et al. (2001) also reported that malnutrition alters the susceptibility of individuals to HIV infection and their vulnerability to its various sequelae, increases the risk of HIV transmission from mothers to babies, and accelerates the progression of HIV infection. The literature shows that condoms have been buttressed by numerous researchers as the major tool available for the effective prevention of sexually transmitted infections, including HIV transmission (Pulerwitz et al. 2002). Poor and lack of uptake of precautionary measures for curbing

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the spread of sexually transmitted infections is regarded as one of the major hindrances to the fight against the spread of HIV. Hence it was equally important for this study to establish whether or not the participants were consistently using condoms to prevent contracting HIV. Given the current statistics on people who are HIV-positive in South Africa, it was not surprising to find that respondents had mixed experiences with regard to condom usage. This should be a cause for concern because one would expect university students to take more responsibility when it comes to living an HIV-free life since they have access to a lot of information. The survey established that some respondents were not using condoms consistently, which put them at risk of contracting the virus. Some respondents revealed that condoms were only available at the clinics. For condoms to be effective, they should be made available in the students’ residences not only at the clinics as some respondents indicated. On a positive note though, the findings further revealed that some respondents consistently used condoms when engaging in sex. Kirby (2000) is of the view that condoms are the only form of protection that can be used to curb the spread of STDs. Clearly, the number of HIV infections around the world, and more especially in Southern Africa, signifies that it is not easy for people to sustain changes in sexual behaviour. The findings of this study concur with the results of the study conducted by Celum et al. (2008) who established that young people often have difficulty remaining abstinent and condoms are often associated with promiscuity or lack of trust. Their study further revealed that women in male-dominated societies are frequently unable to negotiate condom use, let alone abstinence. Woman are not empowered to demand condom use from their partners, who are most likely at risk of contracting HIV and AIDS and other STDs (USAID 2000). Gender inequality is one of the major factors contributing to the spread of STIs. Pulerwitz et al. (2002) established that attention to women’s ability to negotiate safer sexual practices, particularly condom use, has become a vital component of HIV/STD prevention strategies and reproductive health promotion efforts. Hence one of the objectives of this study was to establish whether the respondents had experienced any genderrelated sexual violence on their campuses. This objective was based on the fact that different studies have shown that violence against women, including sexual violence, is widespread in South Africa (Dunkle et al. 2004, Shelton et al. 2005, Jewkes 2009). The findings of this study showed that some participants had experienced gender-based violence from their partners. Interestingly, the findings showed that females were the only participants who reported experiencing gender-related violence. In line with these findings, Jewkes (2009) established that more than 4 in 10 South African men reported they had been physically violent to an intimate partner. Pulerwitz et al. (2002) further argue that gender-based power imbalances may constrain women’s negotiation ability, yet few empirical studies have tested the hypothesis that sexual relationship power constitutes a key factor in condom use negotiation. Dixon-Mueller (1993) argues that differences between women and men’s access to power can influence interpersonal decisions about sex, including the type and frequency of sexual

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practices. Blumstein and Schwartz (1983) are of the view that greater male power may result in control over sexual initiation and refusal. Pulerwitz et al. (2002) caution that this power differential may also render some women incapable of successfully negotiating condom use. The findings of this study suggest that HIV-related stigma and discrimination are among the obstacles that severely hamper efforts to effectively fight the HIV and AIDS epidemic. The findings further depict that fear of discrimination often prevents students from seeking treatment for AIDS or from admitting their HIV status publicly. In support of these findings, the literature shows that AIDS-related stigma has been reported to be a major factor contributing to the spread of HIV (Campbell et al. 2011, Tomaszewski 2012, Ramirez-Valles et al. 2013). The study established that HIV and AIDS is a highly stigmatised disease in tertiary institutions. Thus, stigma is considered to be a key barrier to HIV and AIDS care, treatment and prevention programmes. The stigma associated with HIV was reported to derive from the view that it is contracted from ‘sleeping around’ and that it is considered a dirty, discreditable, disgraceful disease. Some students expressed the view that accessing antiretrovirals (ARVs) is extremely difficult and expensive because they are not available at their campuses, and students who need ARVs are expected to travel long distances to health facilities, yet they do not have money for transport. Many researchers have written extensively on AIDS-related stigma and concur that, over the past several years, diverse and often confused concepts of this stigma have been invoked in discussions on AIDS (Castro and Farmer 2005, Parker and Aggleton 2003). Some researchers have argued compellingly that AIDS-related stigma acts as a barrier to voluntary counselling and testing (Parker and Aggleton 2003). Likewise, Goffman (1963) contends that both the fear of people who are different and the fear of disease can lead to social stigmatisation. Similarly, Parker and Aggleton (2003) point out that a recent global resurgence of interest in HIV and AIDS-related stigma and discrimination has been triggered at least in part by growing recognition that negative social responses to the epidemic remain pervasive even in seriously affected communities. Conclusion The aim of this study was to establish obstacles to HIV prevention, care and treatment in selected South African public universities in KwaZulu-Natal. The results showed that barriers to HIV and AIDS prevention, care and treatment do exist in the tertiary institutions studied. However, their nature and scope still require rigorous investigation. Due to poverty, HIV-related stigmas, hunger and gender-based violence some students engage in unsafe sex. KwaZuluNatal province therefore has most HIV infections in South Africa. It may be accurate to estimate that, given this trend, and if the status quo remains, there will be 60 million new HIV infections by the end of 2014 in the whole world. Social and economic interventions are needed to stem the spread of HIV and AIDS at tertiary institutions. In these institutions some students are still afraid of undergoing HIV testing due to fear of AIDS-related stigma and discrimination.

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Commitments to the fight against the spread of HIV and AIDS from national governments right down to the institutions of higher learning and community level need to be intensified and subsequently met. HIV-related stigma and discrimination clearly hamper efforts to effectively combat the HIV and AIDS epidemic. Fear of discrimination often prevents people from seeking treatment for AIDS or from admitting their HIV status publicly. Combating stigma and discrimination against people who are infected and affected by HIV and AIDS is vital to preventing and controlling the global epidemic. The AIDS epidemic is different from any other epidemic the world has faced. As such, it requires a response from the global community broader and deeper than has ever before been mobilised against a disease. The fact that AIDS-related stigma exists and needs redress is incontestable. The findings of this study show that stigmatisation of people living with AIDS is a key obstacle to HIV prevention and AIDS care. Indeed, it should now generally be accepted that efforts to reduce stigma be an integral part of all HIV and AIDS programming in tertiary institutions. The findings also show that HIV and AIDS-related stigma places a major psychosocial burden on patients. Therefore, stigma and discrimination should be addressed through strong protection being put in place to ensure confidentiality, and through emotional support and cultural sensitivity. In each of the universities targeted, stigma was also reported to be strongly associated with visiting certain health facilities, including voluntary counselling and testing and ARV treatment sites. Fear of stigma and discrimination were shown to be deterring people from undergoing testing and consultation. This, in turn, was shown to be resulting in delays in patients knowing their HIV status and in commencing with treatment where treatment was necessary. Without decisive and sustained action against the disease in South Africa, the scale of the human tragedy will increase, and economic and social progress will be hampered. The epidemic has left no institution in South Africa untouched. Consequently, this poses a challenge to everyone to come up with new applicable ideas and to work together to combat the spread of HIV and AIDS. The South African workforce, especially the youth, must be equipped with the skills they need to meet the challenges posed by the epidemic. If not, South Africa will be facing major socioeconomic and political uncertainties. Institutional and other monitoring mechanisms can enforce the rights of people with HIV and provide powerful means of mitigating the worst effects of discrimination and stigma. Having said this, it is also true that no policy or law can, by itself, combat HIVand AIDS-related discrimination. Stigma and discrimination will continue to exist as long as societies as a whole have a poor understanding of HIV and AIDS and the pain and suffering caused by negative attitudes and discriminatory practices. In response to HIV and AIDS in tertiary institutions, students and staff need to be empowered about health issues; students need to be mobilised to solve health problems; policies and plans need to be developed in support of those individuals living with HIV and AIDS; and research needs to be conducted to find innovative solutions to health problems.

Mbatha

Recommendations Based on the findings of this study, a range of general recommendations for combating the spread of HIV and AIDS in tertiary institutions are provided. These recommendations aim to stimulate thoughts and discussions about the ways in which HIV and AIDS should be addressed in South African public universities, which would then filter through to the whole country. • The study established that some students were unhappy with the current condom distribution system on their campuses. The study therefore recommends that condoms be made available 24 hours in all students’ residences, including all private spaces such as toilets and bathrooms where students could privately take condoms without anyone judging them. • AIDS-related stigmas hamper prevention, treatment and care at tertiary institutions. These institutions must therefore provide education to all students to enable them to challenge the discrimination, stigma and denial that they encounter. Institutional and other monitoring mechanisms can enforce the rights of people with HIV and provide powerful means of mitigating the worst effects of discrimination and stigma. In extreme cases, enforcing rights may be achieved through the legal process. People with HIV should be aware of their rights and use them where necessary. • Rolling out ARVs on campuses could help students who need them. Thus, students would not have to travel long distances to health facilities to collect ARVs. • Given that malnutrition is a function of poverty, there is a valid rationale to presuppose that poverty helped hasten the spread of HIV in the campuses under investigation. Therefore, it cannot be over-emphasised that students need to have enough food so they can fight disease. The government should consider expanding the National Student Financial Aid Scheme (NSFAS) to cover all student fees, including food, and not only tuition and accommodation. NSFAS is the South African Government student loan and bursary scheme. This would assist students who cannot afford to pay for their meals. • The state, policy makers and relevant stakeholders need to address the issue of gender imbalances to prevent HIV transmission among students. Gender imbalance refers to unequal treatment or perceptions of individuals based on their gender. Genderbased violence is indeed a factor in the country’s HIV epidemic. Women who are unable to negotiate safer sex and the use of condoms would inescapably be at peril of contracting HIV. Recommendations for further research This study focused only in three universities in South Africa. Therefore, it would be necessary for a broader study to be undertaken which would sample more institutions from across South Africa. The author — Blessing Mbatha (PhD) is lecturing at the University of South Africa in the Department of Communication Science.

African Journal of AIDS Research 2014, 13(3): 237–246

His research and teaching interests are broad and include: new media studies; Information and Communication Technology, e-government, e-commerce, e-learning, public relations, organisational communication, information needs and seeking, computer mediated communication, HIV and AIDS, information and knowledge management, and research methods.

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Obstacles to HIV prevention, treatment and care in selected public universities in South Africa.

South Africa, like the rest of Southern Africa, is ravaged by AIDS. Higher education in South Africa has a significant role to play in the fight again...
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