‘Taking care’ in the age of AIDS: older rural South Africans’ strategies for surviving the HIV epidemic

Abstract

Older adults have been largely overlooked in community studies of HIV in highly endemic African countries. In our rural study site in Mpumalanga Province, South Africa, HIV prevalence among those aged 50 and older is 16.5%, suggesting that older adults are at risk of both acquiring and transmitting HIV. This paper utilises community-based focus-group interviews with older rural South African men and women to better understand the normative environment in which they come to understand and make decisions about their health as they age in an HIV endemic setting. We analyse the dimensions of an inductively emerging theme: ku ti hlayisa (to take care of yourself). For older adults, ‘taking care’ in an age of AIDS represented: (1) an individualised pathway to achieving old-age respectability through the taking up of responsibilities and behaviours that characterise being an older person, (2) a set of gendered norms and strategies for reducing one’s HIV risk, and (3) a shared responsibility for attenuating the impact of the HIV epidemic in the local community. Findings reflect the individual, interdependent and communal ways in which older rural South Africans understand HIV risk and prevention, ways that also map onto current epidemiological thinking for improving HIV-related outcomes in high-prevalence settings.

Résumé

Les adultes qui prennent de l’âge sont largement ignorés par les études communautaires sur le VIH dans les pays d’Afrique où l’endémie est la plus forte. Sur notre site rural de la province de Mpumalanga, en Afrique du Sud, la prévalence du VIH parmi les personnes de 50 ans et plus est de 16,5 %, ce qui laisse entendre que les adultes les plus âgés sont à risque à la fois de contracter et de transmettre le VIH. Cet article exploite des entretiens conduits dans des groupes communautaires de discussion thématique, avec des hommes et des femmes ruraux et âgés, pour mieux expliquer l’environnement normatif dans lequel ces individus finissent par comprendre leur état de santé et prendre des décisions le concernant, alors qu’ils vieillissent dans un contexte endémique pour le VIH. Nous analysons les dimensions d’un thème émergent de manière inductive : ku ti hlayisa (prendre soin de soi). Pour les adultes prenant de l’âge, « prendre soin » à l’ère du sida représentait (1) un parcours individuel pour atteindre la respectabilité liée à l’âge mûr, à travers l’adoption de responsabilités et de comportements qui caractérisent cette tranche d’âge, (2) un ensemble de normes et de stratégies de genre pour diminuer leurs propres prises de risques liés au VIH, et (3) une responsabilité partagée dans l’atténuation de l’impact de l’épidémie de VIH dans la communauté. Les résultats reflètent les moyens individuels, interdépendants et collectifs par lesquels les Sud-Africains âgés comprennent le risque et la prévention du VIH, moyens qui nourrissent aussi la réflexion épidémiologique autour de l’amélioration des résultats de la prise en charge du VIH dans des environnements à forte prévalence.

Resumen

Los estudios comunitarios sobre el vih realizados en países africanos altamente endémicos pocas veces han contemplado a los adultos mayores. En la provincia de Mpumalanga, Sudáfrica —sitio rural seleccionado por los autores para realizar su estudio— la prevalencia del vih entre las personas de 50 años o más alcanza 16.5%, lo cual sugiere que los adultos mayores acusan un alto riesgo no solo de adquirir el virus sino también de transmitirlo. Con el fin de comprender mejor las decisiones relativas a su salud tomadas por estas personas a medida que envejecen en un entorno endémico del vih, se realizaron grupos focales comunitarios para entrevistar hombres y mujeres mayores, sudafricanos, residentes en el ámbito rural. Por otra parte, los autores analizan las dimensiones abarcadas por un tema que emerge inductivamente: el ku ti hlayisa (cuidarse a sí mismo). En este sentido, se constata que para los adultos mayores “cuidarse” en tiempos del sida tiene que ver con (1) una trayectoria individualizada destinada a lograr respetabilidad en la ancianidad, asumiendo las responsabilidades y los comportamientos que caracterizan a la persona mayor; (2) un conjunto de normas y estrategias de género que disminuyen el riesgo de contraer el vih; y (3) una responsabilidad compartida destinada a atenuar el impacto de la epidemia por vih en la comunidad. En este sentido, los resultados reflejan las formas individuales, interdependientes y comunitarias a partir de las cuales los sudafricanos mayores comprenden el riesgo de contraer el vih y prevenirlo. Asimismo, estas maneras se corresponden con el pensamiento epidemiológico actual, orientado a mejorar los resultados vinculados a la infección por vih en ámbitos de alta prevalencia.

Keywords:

• Ageing
• rural South Africa
• HIV prevention
• ubuntu
• community-based focus-group interviews

Acknowledgements

We thank all the respondents who participated in this study. We also thank the Izindaba za Badala field team as well as the people of Agincourt for their long involvement with the AHDSS study. For additional research assistance, we thank Vusimusi G. Dlamini and Laurie Hawkins; for their helpful comments, we thank Mike Bader, Ernesto Castaneda, Vusimusi G. Dlamini, Chodziwadziwa Whiteson Kabudula, Sangeetha Madhavan, Rachel Sullivan Robinson, Randa Serhan, Kirsten Stoebenau, Nina Yamanis, and the anonymous reviewers.

Notes

1. Ku ti hlayisa is an expression in the local XiTsonga/Shangaan language that has context-specific meaning. In this paper we analyse it specifically as invoked in relation to HIV.

2. The local study name is isiZulu for ‘matters that concern older people’, which assumes a topic intended only for ‘mature’ ears (like sex).

3. For further details on the larger study, see Mojola et al. (2015).

4. We included mixed gender FGIs to allow for differences in participant responses by gender composition of the group.

5. In Shangaan ‘Baba’ means ‘father’ and ‘Mhaki’ means ‘mother’. Their use is common outside the family context to demonstrate respect, similar to the use of ‘Mister’ or ‘Madam’ in English.

6. See Sennott and Mojola (2017) for standards of respectability in the transition to adulthood for women in the same setting.

7. For older women, taking care also included wearing hand gloves to avoid exposure to infected bodily fluids when caring for sick loved ones. We do not discuss this at length; care-taking risk (as observed in healthcare settings) is rare (https://www.cdc.gov/hai/organisms/hiv/hiv.html).

8. Labour-related migration and mobility in Agincourt is considerable: approximately 60% of men and 20% of women between the ages of 20–60 are regular circular labour migrants (Clark et al. 2007).

9. Lurie et al. (2003) found that it is not only migrant men who infect rural partners with HIV, but also rural women who infect their migrant partners.

10. Hillbrow is a neighbourhood in Johannesburg reputed for vices like prostitution.

11. ART is also understood as veiling one’s HIV status by restoring a healthy bodily appearance, thus contributing to community perceptions that it creates an unsafe sexual environment (Kaler, Angotti, and Ramaiya 2016).

12. Shebeens – private homes that sell alcohol – are a form of entrepreneurship in South Africa.