1. Key Concepts Anthropology 393 – Cultural Construction of HIV/AIDS Josephine MacIntosh April 5-8, 2005

2. Ethnocentrism & Cultural Relativism Ethnocentrism: the practice of judging another society by the values and standards of one’s own society Cultural relativism: the view that cultural traditions must be understood within the context of a particular society’s responses to problems and opportunities

3. Cultural Relativism The values of one culture should NOT be used as standards to evaluate the behaviour of persons from outside that culture A society’s custom and beliefs should by described objectively Modern approach Strive for objectivity and do not be too quick to judge

4. Important Points The two main goals of anthropology are: To understand uniqueness and diversity To discover fundamental similarities The focus of cultural anthropology: Contemporary societies and cultures throughout the world The goal of applied anthropology: To find practical solutions to cultural problems

5. Recall… Culture includes Physical aspects Objects Actions Mental aspects Thoughts Beliefs Values Inventions Rules

6. Language Transmits Culture Culture is a key concept in anthropology Culture is the learned, shared way of life that is transmitted from generation to generation in a society Humans learn through Experience (situational learning) Observation (social learning) Symbols (symbolic learning)

7. Blood transfusion is the most efficient route for HIV infection Sexual transmission is the most common route of infection 75% of all HIV infections are sexually transmitted HIV Transmission Routes

8. Epidemic Curves Classical epidemic curve is bell-shaped Steepness of slope is a measure of infectivity or contagion Length of the curve describes duration of epidemic Highly infectious diseases (like measles): Short period of infectiousness (generally 2 weeks) Relatively short duration (typically 6 months to a year)

9. Epidemic Curves Not so with HIV/AIDS Marked by elongated curve Lengthy period of infectivity, enduring over generations Several distinct peaks As it moves through different populations (MSMs, IDUs, etc)

10. Doing the Math Using this mathematical model and assuming: Exponential growth A doubling time of 3 years It would take: 30 years for the prevalence of HIV to change from 0.001% to a detectable level of 1% 3 years to change from 10 to 20 percent (Anderson & May, 1992:59)

11. Doing the Math Currently, the epidemic is spreading at twice the initial predicted rate Between 1999 & 2002, infection rates have: DOUBLED in East Asia & the Pacific Increased 2 ½ times in North Africa & Middle East Almost TRIPLED in Eastern Europe & Central Asia Eastern Europe & Central Asia currently have the fastest-growing epidemic in the world

12. Reponses to Infectious Disease Biologically appropriate interventions: Eliminate source of infection and/or Eliminate contact with source and/or Reduce infectivity and/or Reduce susceptibility Socially appropriate interventions: Limit social and economic disruption Promote stability along prevention/care continuum (McGrath, 1991; 1992)

13. Deviance and Immorality Historically, STIs have been stigmatized Because of the connection with deviant or immoral behaviour Moral judgments are made based on culpability Lifestyles at fault?  Pronounced ‘guilty’ Naïve partners of the guilty  pronounced ‘innocent’ Children of innocents  pronounced ‘defenseless victims’

14. Fear of moral judgment isolates Infected Affected ‘At risk’ Can preclude health preserving behaviours Busza, 1999; Gilmore & Sommerville, 1994; Goldin, 1994 Probable result  accelerated epidemic Deviance and Immorality

15. Social Construction of HIV Negative moral judgments Especially probable with HIV because stigma of the illness is layered upon pre-existing stigmas Does not encourage interventions which are, at the same time, biologically and socially appropriate Seriously disrupts social systems Obstacle to prevention/care/treatment

16. Scope of the Problem HIV is spreading at twice the predicted rate Limiting exposure to STIs is complex Many social responses to HIV increase stigma Fear of stigma is problematic because many: Dissociate themselves from risk groups Avoid testing & counseling Avoid accessing health care Resist behaviour change

17. Scope of the Problem Incidence of HIV/AIDS will continue to increase without appropriate interventions Current public health response is inadequate Need to address stigma Need to provide affordable drugs by implementing the WHO ‘3 by 5 plan’ Need concentrated social action to normalize prevention/care/treatment

18. Gender Roles & HIV Prevailing gender roles Considered by many to be the most pervasive and universal problem associated with HIV prevention One of the few ethnographic commonalities between women as a group Globally, may present the largest obstacle to HIV prevention

19. Social & Sexual Equity Integral to HIV/AIDS prevention It is important to change Accepted patterns of male behaviour Expected patterns of female behaviour Then, women can be in a position to protect themselves from the very real threat of HIV infection -- which leads ultimately, to death

20. Coming to Grips With the Challenges Successful programs must: Improve and provide health information, care and other services Be culturally appropriate and gender-sensitive Develop sex-specific, gender-balanced information about HIV/AIDS and other STIs Address different audiences in different settings

21. A New Challenge Multi- Drug Resistant HIV

22. Defining Attributes of Culture Culture includes ideas & beliefs that shape & interpret any behaviour Culture is different from society Culture = the meaning of behaviour Society = the patterns of behaviour Patterns of behaviour can be observed, but the meaning is not apparent Although meaning can be inferred, analyzed, or derived from asking the participants to interpret their behaviour

23. Crucial Distinction Behaviour (social aspect) Beliefs, ideas, & knowledge (cultural aspect) Not necessarily consistent with each other For example: a couple may know (a cultural factor) that they should use condoms But they do not use a condom (a social factor) In this case, knowledge does not translate to behaviour.

24. Theories of Change Popular theoretical models for HIV/STI risk reduction highlight importance of Motivating target audiences think & talk about own need for behaviour change (Peterson & Di Clemente, 2000) Providing information, behavioural skills, removal of perceived barriers integral to the maintenance of individual-level behaviour change But… w/o personal motivation to integrate risk reduction strategies, little changes

25. Individual-level Models Health Belief Model AIDS Risk Reduction Model Social Cognitive Theory Theory of Reasoned Action Theory of Planned Behaviour Information-Motivation-Behavioural Skills Transtheoretical Model

26. Individual-level Models Individual-level theoretical models for HIV/STI risk reduction highlight the importance of Accurate information Motivation Behavioural skills social norms which support safer behaviours BUT… individual-level theories offer little insight into how to shift social norms to support safer behaviour

27. Social-level Models of Change Diffusion Theory Leadership Models Social Movement Theory

28. Social-level Models of Change Social models can shape the norms, values, & interests of at-risk social groups Necessary adjuncts to any large-scale intervention Norms and referents have a strong influence on individual intention to act HIV highlights issues that are social Individual-level risk-reduction enhanced by addressing group and subcultural norms Capitalizing on existing community and interpersonal networks to improve public health delivery Removing social barriers that hinder safer behaviours

29. Effective HIV & Pregnancy Prevention Programming Focus on reducing one or more specific HRSB Theory-based Advocate avoiding sexual risk-taking Provide accurate information Attend to social pressures Model sexual communication & negotiation skills Use interactive teaching methods Appropriately targeted: age, sexual & cultural exp Adequate in length Include and train teachers and peer leaders Kirby, 2001

30. Challenges and Barriers Community level barriers Social norms surrounding sexuality and drug use Patient level barriers Does person perceive that s/he is at risk? Can they integrate change? Motivations = pleasure seeking Substance use Can impede intervention efforts two ways Associated with increased risk-taking behaviour Associated w/ reduced ability to implement risk-reduction

31. Challenges and Barriers Mental illness Alcohol and HIV risk behaviours Heavy alcohol use associated with General increases in risky sexual behaviour Decreased condom use Increased risk of relapse into risky sexual behaviour Contextual substance use appears to have the highest risk Non-injecting drug use (e.g., Crack cocaine) Related to associated sexual behaviour Especially drug-related prostitution activities