Counselling clients to follow ‘the rules’ of safe sex and ARV treatment

Abstract

Ideas of ‘responsible sexuality’ are located at the centre of counselling in current antiretroviral treatment (ART) programmes. This paper analyses counselling practices in three HIV/AIDS clinics in Uganda on the basis of participant observation of counselling sessions and interviews with counsellors. The paper illustrates how counsellors concentrate on giving general behavioural instructions, while clients tend to demonstrate their compliance to these ‘rules’ rather than sharing their more intimate thoughts. This is especially the case in the contested terrain of sexual and reproductive behaviour. To explore this phenomenon, the paper analyses a number of dynamics characterising HIV counselling in Uganda, including the pressures of the global bio-political project to ‘save lives’ with ART, the counsellors' working conditions in resource-constrained clinics, the professional authority of counsellors and the clients' challenges to following the rules.

Los programas de tratamiento con antirretrovirales (tar) empleados actualmente se centran en promover ideas de “sexualidad responsable” durante las sesiones de asesoramiento. El presente artículo analiza las prácticas llevadas a cabo durante el asesoramiento brindado en tres clínicas de vih/sida en Uganda, apoyándose en la observación de los participantes en las sesiones de asesoramiento y en la realización de entrevistas a los asesores. El artículo destaca cómo los asesores ponen mayor atención en proporcionar instrucciones de comportamiento generales al mismo tiempo que los clientes muestran mayor tendencia a demostrar su acatamiento de estas “reglas” que a compartir sus ideas más íntimas. Dicha tendencia se agudiza a la hora de abordar el polémico terreno del comportamiento sexual y reproductivo. Con el fin de examinar este fenómeno, el presente artículo analiza varias dinámicas que caracterizan el asesoramiento sobre el vih en Uganda, incluyendo las presiones del proyecto mundial biopolítico de “salvar vidas” a través del tar, las condiciones de trabajo experimentadas por los asesores en clínicas que cuentan con pocos recursos, la autoridad profesional de los asesores y los retos enfrentados por los clientes para acatar las reglas.

Les notions de « sexualité responsable » sont centrales au counselling dans les programmes actuels d’accès au traitement antirétroviral. Cet article analyse les pratiques de counselling dans trois centres de soins du VIH/sida en Ouganda en se basant sur une observation participative des sessions de counselling et des entretiens avec des conseillers. Il montre comment ces derniers se concentrent sur la délivrance d’instructions relevant des comportements en général, alors que les usagers ont une tendance à démontrer qu’ils observent ces « règles », plutôt qu’à faire part de leurs sentiments les plus intimes. Cela est particulièrement vrai dans le domaine controversé des comportements sexuels et reproductifs. Afin d’explorer ce phénomène, l’article analyse un certain nombre de dynamiques propres au counselling sur le VIH en Ouganda, incluant les pressions émanant du projet biopolitique mondial qui a pour objectif de « sauver des vies » avec la thérapie antirétrovirale, les conditions de travail des conseillers dans les centres de soins dont les ressources sont restreintes, l’autorité professionnelle des conseillers et les difficultés rencontrées par les usagers pour respecter les règles.

Keywords::

• HIV/AIDS
• antiretroviral treatment
• counselling
• sexual responsibility
• Uganda

Acknowledgements

This paper is based on studies done during my time as a doctoral student at the Centre of African Studies, University of Copenhagen. The fieldwork in Uganda was funded by the Danish Council for Development Research, the Nordic Africa Institute and the University of Copenhagen's fund for Theology Students and Candidates. This paper could not have been written without the counsellors and clients in Uganda who agreed to share their time and personal experiences with me. During the fieldwork, I also relied on the invaluable assistance of Norah Kirabo, Nelly Arikuru and Jimmy Candia. Earlier versions of this paper were presented at the Fourth European Conference on African Studies, in Leipzig in June 2009, and at the workshop on Counselling and Cultural Change in Africa, at the Amsterdam School of Social Science Research in February 2010. I am extremely grateful for comments and suggestions made by participants in these two conferences. I am also thankful for the useful comments provided by Marian Burchardt, Eileen Moyer, Lisa Ann Richey, Ishmail Nyanzi, and the anonymous reviewers and to Cecilie Thorsted Flo for language editing.

Notes

^1. ‘Client’ is the term widely used for people living with HIV in Uganda. It is connected to the initial opposition to the term ‘patient’ and to the importance of counselling in HIV-related interventions.

^2. The third Catholic organisation was a volunteer-driven home-based care programme. It is not included in this paper, because there was no clinically-based counselling provided in this programme.

^3. In recent years, there has been greater emphasis on provider-initiated testing in many African countries, in response to what was seen as a slow uptake of HIV testing and ART.