‘Sometimes it is not about men’: Gendered and generational discourses of caregiving HIV transmission in a rural South African setting

ABSTRACT

In this paper, we examine a prominent interpretation of HIV risk in a rural South African setting experiencing a severe HIV epidemic well into older ages: the discourse of caregiving HIV transmission. By caregiving transmission, we refer to HIV infection resulting from caring for family members who are living with HIV and may be sick with AIDS-related illnesses. We draw on individual life history and community focus group interviews with men and women aged 40–80+, as well as interviews with health workers providing HIV counselling and testing services at local health facilities in their communities. We illustrate the social and strategic role caregiving HIV transmission discourses play in re-signifying HIV as a sexless infection for older women, thereby promoting HIV testing as well as blameless acceptance of an HIV diagnosis. We further highlight the role of rural health workers who serve as medical epistemic bricoleurs, vernacularising global HIV counselling and prevention messages by blending ideas of gender, generation, and local lived experiences and practices so that they resonate with community norms, values and understandings. Our study highlights the gendered and generational complexities and challenges experienced by rural South Africans aging in a community over-burdened by an HIV epidemic and AIDS-related mortality.

KEYWORDS:

• Caregiving
• HIV transmission
• older women
• rural South Africa

Acknowledgements

Authors are listed in reverse alphabetical order; each author contributed equally to the manuscript. This article is part of a special issue on ‘African Voices in Global Health: Knowledge, Creativity, and Accountability’ edited by Mandisa Mbali and Jessica Rucell. We are indebted to all the respondents who participated in this study. We also thank the ‘HIV after 40’ (Izindaba za Badala) research and field teams, as well as the people of Agincourt, for their long involvement with the AHDSS study. We gratefully acknowledge Jill Williams for her significant contributions to the design, data collection and intellectual underpinnings of the project, and Laurie Hawkins, Moira Nolan, Allison O’Rourke and Miriam Counterman for their research assistance. We also thank Vusumuzi G. Dlamini, F. Xavier Gómez-Olivé, Jane Menken and the anonymous reviewers for their helpful comments, and Erin Ice for her editorial assistance. We are grateful for funding support from: the National Institute on Aging – HIV after 40 in rural South Africa: Aging in the Context of an HIV epidemic [R01 AG049634] (PI Sanyu Mojola); the National Institutes of Health – Partnership for Social Science AIDS Research in South Africa's Era of ART Rollout [R24 AG032112-05] (PI Jane Menken); the University of Colorado Innovative Seed Grant (PI Sanyu Mojola) and the William and Flora Hewlett Foundation African Population Research and Training Program [2009-4060] (PI Jane Menken). The MRC/Wits Agincourt Unit is supported by the South African Medical Research Council and the University of the Witwatersrand, as well as the Wellcome Trust, UK (grants 058893/Z/99/A, 069683/Z/02/Z, and 085477/B/08/Z – PI Stephen Tollman). We further acknowledge support for services and resources provided by the District of Columbia Center for AIDS Research, an NIH-funded program (AI117970), the Center on Health, Risk, and Society (CHRS) at American University, as well as the Office of Population Research (OPR) at Princeton University, which is supported by The Eunice Kennedy Shriver National Institute of Child Health & Human Development of the National Institutes of Health under Award Number P2CHD047879. The content of this paper is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

Disclosure statement

No potential conflict of interest was reported by the authors.

Notes

1 For comparison, among younger women, 32% in their 20s, 44% in their 30s, and 34% in their 40s were living with HIV (Gómez-Olivé et al., 2013), while 84% in their 20s, 82% in their 30s, and 64% in their 40s had ever been tested (Schatz et al., 2019).

2 While risk of infection varies by type of exposure and the viral-load of infected blood, the average risk of HIV transmission through occupational exposure (the closest proxy for caregiving transmission) is estimated at 0.3% after a needle stick or cut exposure, 0.1% through exposure of the eye, nose or mouth, and less than 0.1% after exposure of non-intact skin (Centers for Disease Control and Prevention, 2003). Our aim here is not to debate the plausibility of this mode of transmission. Rather, we aim to examine the socio-cultural work and public health goals caregiving HIV transmission discourses accomplish by making HIV risk for older women appear sexless.

3 Other non-sexual modes of HIV transmission mentioned by respondents included sharing razors, needles and nail clippers, and excessive blood exposure, such as during a car accident.

Additional information

Funding

This work was supported by William and Flora Hewlett Foundation: [Grant Number 2009-4060]; National Institute on Aging: [Grant Number R01 AG049634]; Wellcome Trust: [Grant Number 058893/Z/99/A,069683/Z/02/Z,085477/B/08/Z]; National Institutes of Health: [Grant Number AI117970,R24 AG032112-05,P2CHD047879].