5.4 Knowledge and comprehension of HIV/AIDS: A focus on prevention
5.4.1 HIV/AIDS: Transmission and prevention
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of HIV incidence through use of VMMC and condoms. The themes are presented according to the chronological order presented above. The sequencing of the themes was a deliberate process in pursuit of coherence since the themes are closely related. In terms of focus group discussion (FGD) responses, these are presented in the following pattern; FGD: 1B and FGD:
1G, indicating the sequence of the schools and composition of interviews; boys (B) and girls (G), while categories FGD 1–2 and FGD 3–4 represent Zvishavane and Mberengwa, respectively.
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It is a viral infection that is usually transmitted through sexual intercourse with an infected partner. However, HIV can also be transmitted through contact with fluids from the human body such as blood, say in the event of an accident. Sharing of sharp objects can also expose a person to the risk of contracting HIV even if they have abstained from sexual activity (FGD: 3B, Mberengwa).
A general observation is that most participants were well informed about what HIV is, both as a microbe and as a disease. Although it is not clearly stated in the interview, participants referred to HIV and AIDS as one and the same thing. Their conception of the two (HIV and AIDS) was clearly convoluted. However, more significantly, participants had a satisfactory grasp of the several modes of HIV transmission. In this regard, sex (heterosexual) was identified as the dominant mode of HIV transmission, and this is clearly encapsulated in the above excerpts.
However, fewer participants demonstrated lack of understanding in their conceptualisation of risk. HIV risk is intricately linked to transmission. The following is a demonstration of limited awareness:
HIV is a sexually transmitted disease. It is caused by engaging in unprotected sex and failure to wash off the dirt from the act… I am not very sure, but I believe you won’t get HIV if you wash because it is transmitted through dirt such as sperms and these are usually harboured in the foreskin, leading to HIV infection (FGD: 4B, Mberengwa).
In the above quote, the participant establishes a naïve causal relationship between the post- coital process of washing the genitalia and HIV transmission. Although the former part is correct, the latter is erroneous, displaying a clear lack of concrete understanding which could be interpreted as clear testimony of ignorance. Participants with superficial knowledge or who lack in-depth understanding of HIV/AIDS were generally few.
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Furthermore, in line with the sub-theme of an HIV/AIDS knowledge deficit, another participant responding to a question on whether medical male circumcision should be promoted as an HIV preventative strategy in secondary schools or not, had the following to say:
Circumcision should be promoted in schools. It is important because at times young people engage in sexual activities so if they are circumcised, it will be an advantage for them. If he is circumcised, he does not have HIV (FGD: 4G, Mberengwa).
The above line of thinking is understandable, given that the modus operandi for providing VMMC for HIV prevention in Zimbabwe is characterised by HIV testing and counselling (HTC). HCT is also a prerequisite for access to routine health services such as anti-retroviral therapy (ART), pre-ART care and support, and for most of the biomedical interventions including prevention of mother to child transmission (PMTCT) and VMMC (GoZ, 2015).
Given that a negative sero-status is the licence to get medically circumcised, some adolescents run the risk of assuming that being circumcised automatically translates to being HIV- free, which is not always the case as sero-status can change post-circumcision.
The other aspect central to the discussion was prevention of HIV transmission. As a matter of principle, successful prevention is premised on ensuring that exposure to disease is minimised, and when there are chances for infection, susceptibility is significantly reduced.
According to Barnett and Whiteside (2002) “the principle of successful prevention is in ensuring that people are not exposed to the disease or, if they are, that they are not susceptible to infection” (p.40). This study is firmly anchored on the first part of Barnett and Whiteside’s (2002) definition of prevention. When asked whether there is need for medically circumcised males to use condoms, one participant said:
He must wear a condom; may be either partner would be HIV positive, so it helps to prevent its transmission from one infected partner to the other. This also helps to prevent the woman from falling pregnant. The condom can also prevent sexually
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transmitted infections (STIs). If one partner is infected and no condom is used, then the other partner will be infected too (FGD: 4G, Mberengwa).
This participant is very clear about the transmission and prevention of HIV. Despite the significant reduction in susceptibility due to a circumcision status, it can be observed that participants were clear that in as much as VMMC reduces chances of contracting HIV by an estimated 60%, the strategy does not benefit the female partner, hence the need for condom use. The following was said;
Fine, he might be circumcised, but might be already HIV positive, and then he tells you that he is circumcised; that doesn’t protect you as a woman and ultimately you get infected….It is also possible that some are circumcised while they are already positive [HIV sero-positive], so it is not safe not to use a condom (FG1: 3G, Mberengwa).
Circumcised or not, a condom remains necessary. However, the problem is that for us as girls it’s difficult to insist on a condom, it’s difficult because you will be judged as a prostitute…yeah, it’s tricky (FGD: 4G, Mberengwa).
Secondly it is clear that participants didn’t view HIV as an STI. This is perhaps a result of mother tongue intervention as STIs are referred to as siki and HIV/AIDS is different from these since it takes longer to manifest, unlike syphilis and gonorrhoea, and mostly importantly that infection with HIV doesn’t leave signs on the genitals.
In another focus group discussion (FGD), one participant collectively blamed both oral contraceptives and condoms for promoting a culture of promiscuity among adolescent girls based on the pretext of an increased protection against falling pregnant. Such behaviour is technically referred to as risk compensation. Risk compensation refers to an increase in risk behaviour resulting from an individual’s perceptions of reduced risk (culminating from the adoption of a protective measure such as medically circumcising for HIV prevention) (Grund
& Hennink, 2012). The following response was offered as a counter argument in favour of condoms, when contraceptive methods were collectively castigated:
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No, it’s different. Condoms are better in that they prevent both diseases and pregnancy;
a condom is a paper that you use and dispose of, but some of these birth control measures include injectable contraceptives such as Depo which can last long, and while on them you tend to relax and do whatever you feel like doing, knowing that you won’t fall pregnant and at the end you may contract HIV (FGD: 3G, Mberengwa).
The above can be interpreted as a duly informed position regarding HIV transmission. This finding does not only demonstrate knowledge per se, but an in- depth understanding of the context within which HIV is transmitted, and possibly prevented.
In a bid to elaborate on how total protection against HIV infection can be achieved by a circumcised male, since VMMC provides partial protection, FGD participants had the following to say:
We must complement circumcision with other methods of HIV prevention such as abstinence, use of condoms and reducing the number of sexual partners. If pupils are [medically] circumcised, they must be taught that this method is not 100% effective, and that they must use other ways of preventing infection when they decide to be sexually active. Before marriage, they must have a blood test, and [additionally] being faithful to one [uninfected] partner is another way of preventing HIV (FGD: 3B, Mberengwa).
You must condomise. His being circumcised doesn’t help prevent transmission and acquisition of HIV by the female. However, demanding that he use a condom is not easy since it’s difficult for a girl to show a boy that she wants sex (FGD: 1G, Zvishavane).
Medical male circumcision and condom use are biomedical approaches to HIV prevention. In this finding, the participant provided an array of prevention strategies to tackle the epidemic from the preventative side, thereby epitomising Tatoud’s (2011) ‘HIV prevention buffet’. This finding encompasses different, but compatible approaches, foregrounding behaviour change as a rich ingredient to HIV prevention. Importantly, the primacy of combination preventions illustrated in this study resonates with relevant literature within the trajectory of HIV prevention (Baxter & Abdool Karim, 2016). Prevention of new infections
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occupies the centre-stage of the current global response and to the HIV/AIDS epidemic (UNAIDS, 2014b). Precisely, it is envisaged that this ambitious target can be achieved through the deployment of tailor-made combination HIV prevention strategies (Baxter & Abdool Karim, 2016).