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PLEASE CITE AS THE FOLLOWING:
Niele, S., & Liamputtong, P. (2016). HIV/AIDS Knowledge and Risk of HIV/AIDS Among Youth in
South Africa. In P. Liamputtong (Ed.), Children and Young People Living with HIV/AIDS: A Cross-
Cultural Perspective (pp. 169-190). Cham: Springer International Publishing.
Chapter 9
HIV/AIDS knowledge and risk of HIV/AIDS among youth in South Africa
Sylvia Niele & Pranee Liamputtong
Sylvia Niele
Psychologist & Independent Researcher
c/- P O Box 633
Black Rock, Victoria, Australia 3193
Email: sniele@ozemail.com.au
Pranee Liamputtong
Personal Chair in Public Health
Department of Public Health
School of Psychology and Public Health
College of Science, Health and Engineering
La Trobe University
Bundoora, Victoria, Australia 3086
Email: pranee@latrobe.edu.au
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Abstract
The vast majority of the global population living with Human Immunodeficiency Virus (HIV) and
Acquired Immunodeficiency Syndrome (AIDS) are found in South Africa. The literature suggests
these HIV prevalence and AIDS mortality statistics may be underestimated. In South Africa
HIV/AIDS has resulted in devastating social and economic repercussions, impacting the most
productive members of society; those aged 15-49 years. Interventions for prevention and treatment
used successfully in developed countries do not appear to be as effective in South Africa. Street youth
are often omitted from research samples and are at considerably higher risk for contracting HIV. This
chapter is based on our study and involved 18 street youth and staff at a registered non-government,
non-profit shelter who completed semi-structured qualitative interviews or a focus group in early
January 2012. Results showed many participants had limited understandings of HIV and its link to
AIDS. The pervasive effect of stigma appeared to undermine knowledge and disclosure of HIV status,
and included descriptions of negative attributions, ostracism and suicide. Appearance was viewed as
an important outward indicator of health, whilst socio-economic risk factors leading to street life
increased HIV/AIDS risk. Street youth reported engaging in crime, violence, sexual activity and
substance use. Our findings offer implications for HIV/AIDS prevention and treatment in South
Africa. Numerous recommendations included greater dissemination of accurate knowledge, and
interventions that target males, misinformation and stigma.
Keywords: HIV/AIDS, street youth, stigma, prevention, treatment, culture, gender inequality, multiple
partners, risk, knowledge
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Table of Contents
1. Introduction
2. Factors Undermining Prevention and Treatment of HIV/AIDS in South Africa
3. Cultural Practices and HIV/AIDS
4. South African Street Youth at Higher Risk for HIV/AIDS
5. The Study
6. Knowledge About HIV/AIDS
6.1 General knowledge about HIV/AIDS
6.2 How HIV/AIDS knowledge was first acquired
6.3 Knowledge related to transmission
6.4 Knowledge related to prevention and testing
6.5 Knowledge related to treatment
6.6 Positive outcomes of HIV/AIDS knowledge
7. Risk Factors Associated With HIV/AIDS
7.1 Social and familial factors
7.2 Street life
7.3 Psychological issues
8. Discussion and Recommendations
9. Conclusion
References
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1. Introduction
Human Immunodeficiency Virus is a retrovirus that eventually causes Acquired Immunodeficiency
Syndrome (AIDS), the stage in which there is a severe loss of the body's cellular immunity, and without
antiretroviral (ARV) treatment, inevitable death. At the end of 2013, 35 million people globally were
living with HIV with the greatest proportion (24.7 million) in Sub-Saharan Africa, with 67% of men and
57% of women living with HIV are not receiving antiretroviral therapy (UNAIDS, 2014). An additional
consideration is that defaulting on the ARV regimen, risks drug resistant strains of HIV being spread
(Kallings, 2008). Consequently those with HIV or AIDS experience considerable suffering with over
3,000 people dying daily in Sub-Saharan Africa (UNAIDS, 2014), and this affects the most productive
in society, those aged 15 – 49 years, and the AIDS epidemic is the leading cause of death in South
Africa (UNAIDS, 2014) with an estimated 2.5 million South African children as at 2012 being orphaned
by HIV/AIDS (UNICEF, 2013).
HIV/AIDS continues to be perceived as a devastating and debilitating illness in developing
countries, and South Africa has encountered additional risks affiliated with this disease. For example,
HIV/AIDS is associated with increased risk of suicide in South Africa (Govender & Schlebusch, 2012;
Schlebusch & Govender, 2012), and in KwaZulu-Natal, the region with the highest HIV/AIDS
prevalence (UNGASS, 2012), the occurrence of suicidal ideation in HIV-positive individuals was
25.4% (Bertolote, Fleischmann, Leo, & Wasserman, 2009). Even pregnancy is not protective against
suicidal thoughts (Rochat, Bland, Tomlinson, & Stein, 2013). Because HIV/AIDS continues to
represent a serious threat to public health in South Africa, and particularly younger people, greater
empirical understanding of the drivers of the epidemic is urgently needed.
2. Factors Undermining Prevention and Treatment of HIV/AIDS in South Africa
A number of factors have been proposed which may have hampered South Africa’s response to the
HIV/AIDS epidemic. The South African government has been widely criticized (Nattrass, 2004) for
initial denial of the link between HIV and AIDS, and an early ban on life-extending ARV treatment
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believing it to be toxic (Tomaselli, 2009). This delay was estimated to have cost 330,000 lives (Abdool
Karim, Churchyard, Abdool Karim, & Lawn, 2009) and may partially explain low uptake of ARV
treatment (Adam & Johnson, 2009).
Globally, proposed factors undermining HIV/AIDS prevention include a resistance to behavior
change and beliefs regarding gender, sexuality, and culture (Coates, Richter, & Caceres, 2008). In
South Africa, popular patriarchal notions of masculinity encourage men to have multiple wives and
sexual partners, engage in frequent intercourse, emphasize procreation, and discourage sexual abstinence
and condom use (Jordaan, 2005; Simpson, 2009), with women having little power to negotiate safe sex.
In addition, extremely high rates of rape and violence, with 1 in 3 South African women reporting being
raped in their lifetime (Moffett, 2006) differentiates Western and South African cultures, and increases
the risk of HIV transmission as condom use is unlikely.
Other pivotal practices which have been linked to HIV spread include transactional sex and the
Virgin Myth. Transactional sex, where sex is exchanged for cash or material goods, is prevalent in
South Africa. A cross-sectional study in Soweto found the practice was associated with violence, socio-
economic disadvantage, and substance use, shaping women’s behavior and their risk for HIV (Dunkle et
al., 2004). A cluster randomized control trial in the Eastern Cape also found transactional sex increased
young women’s HIV risk (Jewkes, Dunkle, Nduna, & Jama Shai, 2012). The Virgin Myth, where
sexual intercourse with a young girl is believed to cure HIV/AIDS, is considered responsible for child
rape increases and HIV spread amongst children in South Africa (Meel, 2003; Ndlovu, 2005). Structural
inequities in South Africa have also been proposed to contribute towards, and exacerbate, HIV
transmission by necessitating practices such as transactional sex (Jewkes et al., 2012) and with
unemployment in South African townships estimated at 75% (Stokes, 2007), poverty, and transactional
sex, may be increasing HIV risk. See also Chapters 4, 7 and 15 in this volume.
3. Cultural Practices and HIV/AIDS
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Few studies have explored the link between specific African cultural practices and HIV/AIDS. An
anthropological study by Mchunu (2005) revealed that ‘respect’ in Zulu culture prohibited children
discussing sexual matters with their parents. Mchunu also suggested that apartheid necessitated Zulu
men to work in cities, and that the cultural practice of ‘cleansing’, sex with another woman to avoid
bringing witchcraft back to their wives, may be proliferating the virus. Similar to Zulus, Xhosa culture
is purported to consider HIV/AIDS a curse from the ancestors (Barr, 2008). Circumcision is a common
ritual in South Africa, usually amongst adolescents already sexually active, and may spread HIV if the
same traditional knife is used (Peltzer, Nqeketo, Petros, & Kanta, 2008). Consequently, numerous
randomized control trials are promoting that earlier medical circumcision could reduce HIV
transmission (Auvert et al., 2005; Bailey et al., 2007; Gray et al., 2007). If such factors are contributing
to HIV spread, culturally sensitive HIV/AIDS interventions are needed (Teitelman, Seloilwe, &
Campbell, 2009), therefore more research exploring possible links between South African cultural
beliefs and practices and HIV/AIDS is urgently required.
4. South African Street Youth and Risk for HIV/AIDS
A subgroup identified at particularly high risk for HIV/AIDS in South Africa are street youth who are
generally aged between 11 and 17 years (Kruger & Richter, 2003). The street youth population is
considered to be increasing due to the familial impact of AIDS reducing the number of caregivers, and
due to their homelessness, exact prevalence of street youth can only be estimated (Ward & Seager,
2010). Based on a report by outreach workers in contact with street youth in Zimbabwe (Dube, 1997),
and a qualitative study with South African street youth (Richter & Swart-Kruger, 1995), increased risks
for contracting HIV have been suggested. These included, earlier sexual activity, engagement in
consensual or survival sex, rare use or misconceptions regarding condom effectiveness, a high
incidence of sexually transmitted diseases (STDs), and substance use. There also appears to be a lack
of knowledge amongst street youth regarding HIV/AIDS and how it is spread (Bryan, Kagee, &
Broaddus, 2006; Kruger & Richter, 2003; Mufune, 2000; Snell, 2003) with a study of male street youth
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in Ethiopia suggesting day-to-day survival concerns were considered more pressing than the problem
of HIV/AIDS (Tadele, 2003). It is important to understand whether access to information and
education regarding HIV/AIDS could play a significant role in addressing knowledge gaps and
misconceptions amongst street youth.
5. The Study
The study on which this chapter is based investigated the knowledge, attitudes and cultural beliefs of
South African street youth with respect to HIV/AIDS transmission, sequelae and treatments to address
the significant current gaps in the literature. We utilized a qualitative semi-structured interview
framework to: 1) ascertain current knowledge regarding HIV/AIDS in street youth in South Africa; 2)
ascertain if participants consider HIV and AIDS to be linked; 3) ascertain cultural beliefs associated
with HIV/AIDS; 4) further explore street youth attitudes towards HIV/AIDS; and 5) determine the part
stigma plays in HIV/AIDS prevention and treatment behaviors. In addition, implications for
HIV/AIDS prevention and treatment behaviors in South Africa were considered in respect of both the
community generally and street youth in particular.
The final sample consisted of 7 female and 7 male street youth (n = 14) and 1 female and 3
male staff members (n = 4), aged 15 - 34 working or residing at Umthombo, a non-profit street youth
shelter (See Results for details). An additional participant did not complete the entire interview, and
his data was subsequently excluded from analysis.
The research was conducted at Umthombo, a South African non-government and fully
registered non-profit organization that empowers street children towards leaving street life. Umthombo
is situated in the central business district of Durban and provides meals, and ongoing or transient
accommodation for 40-60 street youth ranging in age from 11 years to early 20s. At the time the
research was undertaken, Umthombo employed 35 staff who were an amalgamation of trained former
street children and social working professionals. Interviews occurred in early 2012.
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Participants were recruited by staff announcing to street youth the opportunity to participate in
research. To minimize feelings of coercion, potential participants were approached by an independent
volunteer to ascertain interest and answer any questions. Eligibility criteria for participants included,
being over 14 years of age (and for those 14 to less than 18 years, willingness to have an Umthombo
staff member present during the interview), and sufficient English proficiency to communicate and
understand exchanges with us.
Semi-structured interviews, including ascertaining family of origin details using a genogram,
and observation were conducted. Before interviews commenced all participants read, or had read to
them, the Explanatory Statement and Consent Form. Questions pertaining to stigma were taken from
The AIDS-Related Stigma Scale (Kalichman et al., 2005), the only reliable and valid stigma scale
developed for Africa. It consisted of 9 items asked as open questions to elicit greater depth of
information. All other questions were developed based on the literature.
The interviews were opportunistic, taking place at a time and place convenient to the
interviewee and would occur in various rooms at Umthombo based on availability. Measures were
taken to ensure privacy with the interview being suspended when interruptions occurred. To facilitate
confidentiality, all participants chose a pseudonym, used in place of their actual name in this report.
Interviewed staff members reported having been street youth themselves and/or having spent
time as a child or adolescent in a shelter away from their family. Participant welfare was paramount
and the researcher was sensitive to any distress or discomfort participants may have experienced,
provided an option to not disclose information if this caused discomfort, reassured them regarding
confidentiality and initiated interventions where necessary. Participants were invited to provide
opinions or feedback, and street youth were encouraged to speak English as much as possible.
An Umthombo staff member was usually present during street youth interviews. Three staff
members assisted including a social worker (1 interview), shelter staffer (1 interview) and youth
worker/medical officer (7 interviews) and would also assist in translation as required. Due to the
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possibility of translator bias, it was decided to only include data directly provided, or confirmed by
participants. One 17 year old female participant (pseudonym Latifa) refused to be interviewed with a
staff member present because no staff members she trusted were available. Based on our assessment it
was decided to conduct the interview without a staff member present.
Table 1 summarizes the demographic characteristics of all participants interviewed.
Table 1: Demographic characteristics of participants
Participant No. Pseudonym Age Gender Street youth or Culture Parents still
staff member alive
1 Vavavoom 28 Male Staff member Xhosa Father
2 James 34 Male Staff member Xhosa Mother
3 Sindi 27 Female Staff member Sotho None
4 Sbu 21 Male Street youth Zulu Fathera
5 Latifa 17 Female Street youth Zulu Mothera
6 Mike 19 Male Street youth Zulu None
7 Thabo 29 Male Staff member Xhosa Mother
8 Fridayb 14 Male Street youth Zulu Mother
9 Sabelo 15 Male Street youth Zulu Mother
10 Thamqasa 15 Male Street youth Zulu Mother
11 Sboniso 17 Male Street youth Zulu Mother/Father
12 Sphiwe 19 Male Street youth Zulu Father
13 Princess 16 Female Street youth Zulu None
14 Brian 19 Male Street youth Zulu Mother/Fathera
15 Rethabile 18 Female Street youth Zulu Unknown
16 Olga 18 Female Street youth Zulu Father
17 Sharon 18 Female Street youth Zulu Mother/Father
18 Doris 18 Female Street youth Zulu Father
19 Carol 17 Female Street youth Zulu None
aMortality status unknown as parent has been absent since participant was young.
bDid not complete interview.
The mean ages for street youth and staff members were 17.6 and 29.5 years respectively. Of
the remaining total sample (n = 18), 8 were female and 11 were male, with participants 15 to 19
participating in a focus group. Zulu was the predominant culture amongst street youth whilst most staff
members were Xhosa. Only 3 participants indicated that both their parents were still alive, although 1
of these participants was unsure as their parent left when they were very young.
6. Knowledge About HIV/AIDS
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This theme elicited general information regarding HIV/AIDS and where it was learnt. Knowledge
pertaining to HIV transmission, prevention and testing, AIDS treatment, and positive outcomes as a
result of this knowledge are also described.
6.1 General knowledge about HIV/AIDS
Knowledge regarding HIV/AIDS varied across participants. Most knew about the virus and some had
extensive knowledge (e.g., low CD4 count indicates AIDS, KwaZulu Natal has highest HIV rate in
South Africa). Whilst some participants were able to differentiate between HIV and AIDS, many could
not and used the terms interchangeably or considered them the same. Preferences regarding use of the
term HIV or AIDS revealed that 55% of participants preferred the term HIV, for 22% it did not matter,
6% did not know what HIV was, 6% did not know what AIDS was, and 11% knew neither about HIV
or AIDS.
Participants acquired new information about HIV during interviews, particularly during the
intervention, which confirmed knowledge gaps previously identified in the literature (Bryan et al.,
2006; Eaton, Flisher, & Aarø, 2003; Swart-Kruger & Richter, 1997). For example, Sphiwe was
unaware of the link between HIV and AIDS and how HIV undermines immunity, Princess did not
know that HIV was a virus passed on through bodily fluids, and Brian did not realize people who are
HIV-positive can look and feel well yet still be spreading HIV. All focus group participants were
unaware that HIV was a small germ, subsequently becoming aware of the importance of condom use
during the focus group. James was aware that an unborn baby could be protected from HIV but not the
mother once she was infected. Sabelo did not know any intervention information, and both Sbu and
Thamqasa were unaware of South Africa having the highest HIV/AIDS prevalence in the world, nor
that HIV is spread primarily via heterosexual intercourse.
The difference between a street youth’s awareness of HIV/AIDS, and their behaviour, was also
salient. For example, Brian emphasised the importance of HIV testing yet later revealed: “I haven’t
checked it”.
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Sbu stated post intervention that he would use a condom in future but earlier in the interview
had indicated that he already used them, as did Princess who said she would now use gloves and
condoms but had also attested to their merits earlier. It is unclear whether these answers reflect a
willingness to please, significant change, or an inability to translate increased knowledge into safer
sexual practices (MacPhail & Campbell, 2001; Marston & King, 2006; Snell, 2003).
Beliefs about level of infection in the community may also increase risk. Mike was aware of
HIV and AIDS and that it was spread by not using a condom, but considered there was low prevalence
in the community: “It’s not in a lot of people”. This may result in not practicing safe sex based on the
belief that the chances of acquiring the virus are low.
6.2 How HIV/AIDS knowledge was first acquired
Most participants learnt about HIV and AIDS during adolescence at school although some, (such as
Princess) had ceased schooling after Year 8, and had consequently developed little knowledge. Other
identified sources of knowledge regarding HIV/AIDS included doctors and nurses at clinics and
hospitals, shelters, Xhosa initiation school, community outreach door to door, staff training at a
hospital, and through outside organizations attending Umthombo such as on World AIDS Day.
Shelter staff rarely discussed HIV/AIDS with street youth. Sindi explained: “We prefer visitors
because from us they [street youth] don’t want to hear”.
No exposure to external AIDS educators at the shelter, may explain why several street youth,
such as Sabelo, did not know about HIV, AIDS or both. Shelter staff, such as James, believed that
parents will need to begin discussing HIV/AIDS with their children, something that has not previously
been common:
But now the challenge is, we’ve got kids and they’re growing. We also have
to teach them about this thing. Our parents never taught us.
Traditions, such as parental respect in Zulu culture (Mchunu, 2005), may explain why young people are
unable to speak freely regarding issues that pertain to sex out of deference to adults. This affected
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interviews on several occasions and was overcome by asking impersonal questions (‘they’ rather than
‘you’). The implication for HIV/AIDS is that if young people in South Africa are unable to discuss
such matters with their parents, then their access to such knowledge is restricted to schools, which they
no longer attend after becoming street youth. Therefore street youth or adolescents who do not attend
school may have little or no access to HIV/AIDS information on the streets or in townships, apart from
peers (Selikow, Ahmed, Flisher, Mathews, & Mukoma, 2009).
6.3 Knowledge related to transmission
Participant knowledge regarding ways of contracting HIV/AIDS emphasized blood to blood
transmission through, injury/violence, piercings, tattoos, intravenous drug use, injections, and
heterosexual intercourse. Misinformation regarding HIV transmission methods included: penetration
through fingernails, sweat, touch, just knowing someone, stepping on a rusty nail, sharing the same
utensils, and kissing if gums were bleeding.
Regarding the question of whether a HIV-positive mother would transfer HIV to her baby,
opinion and confidence of participants generally varied. The baby could become infected at birth or
through breast milk, could remain naturally free of HIV or be protected through medication:
The baby can be protected from that…I don’t know how…the mother is not allowed to breast
feed. (Vavavoom)
As procreation is an important expression of masculinity (Jordaan, 2005; Simpson, 2009) and most
street youth are sexually active earlier (Kruger & Richter, 2003; Swart-Kruger & Richter, 1997), it
seems that greater education for street youth regarding mother-to-child transmission (and the
importance of testing and treatment) is warranted.
Information provided by some medical authorities may increase risk taking behavior among
street youth. Sindi, when attending training about HIV/AIDS at a local hospital, was told that unless
there was a cut during sexual intercourse, the partner cannot be infected. Proliferation of such
information may justify unprotected sex, and incorrectly minimize estimation of risk. An emphasis on
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cuts may cause people to overlook possible transmission as a result of STDs or the micro tears that can
occur during intercourse.
6.4 Knowledge related to prevention and testing
Condom use, colloquially known as “condomise” was advocated by all participants that knew about
HIV/AIDS although not all linked condom use with HIV/AIDS. Condoms were described as enabling
“safe sex”, “protecting you”, “pieces of plastic”, “prevent disease”, and being used for contraception.
Most knew that they were freely available from clinics and hospitals, and focus group participants also
obtained condoms from the medical officer. This raises questions of whether condom use is practical
for street youth who may have spontaneous or forced sexual encounters (Dube, 1997; Lockhart, 2008).
Street youth have few possessions, clothes or places to store condoms on their person. However, most
street youth knew about condoms and where to access them.
All staff interviewed voiced concerns regarding the reliability of free government provided
condoms:
They do protect you in a way, but not one hundred percent, cos [sic] they can break. (Thabo)
Others found that witnessing the suffering of friends with advanced AIDS, motivated prevention:
The stage they are in, it’s kind of bad…it makes someone to think twice… before you do things.
(James)
Abstinence, marriage or monogamy was the only other form of prevention mentioned, mainly by staff.
Whilst abstinence was supported in the focus group, another street youth, sharing her response to a
nurse’s abstinence recommendation, considered it unrealistic:
As we’re living…they know that people…they get married and sleep and get a child. (Latifa)
HIV/AIDS testing was advocated overall, with some participants considering it a fast way of
confirming the HIV status of oneself or prospective partners, whilst others reported themselves or
others being afraid to learn their status and subsequently avoiding being tested or waiting until
symptoms occur:
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Other people they said no, if I get sick, then there’s no cure for my sickness, then I check (Sindi)
Because Sindi considers men play a major part in the spread of HIV, she believes males should be
targeted for prevention and testing education. This is also a perspective emerging in the literature
(Betron, Barker, Contreras, & Peacock, 2011; Jordaan, 2005).
I think they (men) are the ones who really, really, really need more education than other
people…and they are the ones that don’t want to go and check.
Some participants reported being tested when external educators accompanied by doctors visited and
testing was also promoted prior to Xhosa initiation. Quarterly testing to ensure early detection was also
recommended.
6.5 Knowledge related to treatment
Most participants who knew about ARVs, perceived them to be beneficial, and that they maintained a
person’s health and increased their life expectancy. Some ARV knowledge was sophisticated, such as
ARV use being linked to one’s CD4 count (number of helper T cells per cubic millimetre of blood):
You have to find the CD4 count…to find out if they have to start the ARVs. (Sindi)
A healthy diet was considered an important aspect of HIV/AIDS treatment, particularly when taking
ARVs. Special foods were recommended such as fruit, vegetables, and drinking water, whilst foods to
be avoided included: junk food, onion, and oil. Some participants, such as Sboniso, believed that
healthy food and exercise alone could stop the outward appearance of AIDS for up to 30 years:
Let’s say I got HIV positive when I was two years. I can even go and be thirty one years and tell
my children that I have that, how long I’ve live with this virus.
Even staff with extensive HIV/AIDS knowledge, such as Thabo, believed that it would be possible to
have the virus, live for an extended period of time and even have children if ARVs were adhered to:
You must live for the next twenty to thirty years…you might still get kids, if you love children.
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No participant indicated that ARVs or any other intervention could cure HIV/AIDS, with the exception
of James citing that a baby who shares their mother’s blood can be protected from HIV even if the
mother is HIV-positive:
I am sure there is a cure for HIV and AIDS. I don’t know why them people they are not
releasing it if it is there. How can you save the kid and you don’t save the mother?
James attributed his beliefs to population control and apartheid in books he read about the origin of
AIDS:
They say, all over the world we are populated…so now people need to die because of this so
that we can decrease them…In the beginning we were killing them but today they are killing
themselves through sex.
AIDS and the implementation of Western scientific and medical interventions may inadvertently
trigger recollections of apartheid oppression (Mbali, 2004; Nattrass, 2008). This was reflected in the
data with repeated references to freedom, humanity and equal rights when discussing HIV
stigmatization:
They still a human being...we all mutually have equal freedom, irrespective of sickness.
(Vavavoom)
A return to African traditions may attempt to offset perceptions of Western intervention (Maluleke,
2012):
African doctors will say they can cure AIDS but, for my understanding, there is no cure. (Sindi)
Our data showed knowledge regarding ARVs was mixed. Several participants made a consistent link
between taking ARVs and the importance of eating healthy food, that ARVs control the proliferation of
AIDS in the body, and that ARVs increase life expectancy. Others such as Thamqasa had not heard of
ARVs, and Sboniso considered ARVs to be medication to treat TB, unaware of the link between AIDS
and TB (Abdool Karim et al., 2009).
6.6 Positive outcomes of HIV/AIDS knowledge
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Data highlighted how knowledge about HIV/AIDS was put into practice by the participants. Thamqasa
volunteered that he promotes condom use amongst the other street youth: “I said to the other ones you
have to use a condom”. As an intern at Umthombo, and considering that staff generally to not discuss
HIV/AIDS with street youth, Thamqasa plays a significant role in promoting safe sex amongst his
peers. Sboniso’s positive interaction with AIDS patients met through a shelter program was a
normalising and stigma reducing experience: “They are friendly, kind, anything that you can think”.
Others argued for promoting community spirit and reciprocity when coping with the realities of
HIV/AIDS:
You need to be friends with people, take care of people so that they can be able to take care of
you…if you treat people like shit, then they will treat you like shit. (James)
A celebrity disclosing their HIV status via the media can play a powerful educative role, especially in
negating stigma:
There’s a guy who used to play basketball back in the days cos I used to love basketball, Magic
Johnson…from there I kind of changed my mind and said OK, even famous people you know
can get this. It doesn’t mean that because we are poor or because he or she is rich, they can’t
get this thing. It affects everyone. (Thabo)
Such disclosures humanise the condition, engender sympathy, and highlight that HIV/AIDS is an
illness that does not discriminate.
7 Risk Factors Associated with HIV/AIDS
This theme elicited a number of discrete factors leading to street life which culminate in direct risks for
acquiring HIV. Discrete factors were social and familial in nature, whilst direct risks were associated
with street life and psychological issues.
7.1 Social and familial factors
For many street youth a disintegration of the family unit has been a significant factor in choosing the
streets where the risk for contracting HIV is high (Foster, 2004; Grassly, Lewis, Mahy, Walker, &
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Timaeus, 2004; Robbins et al., 2010; Ward & Seager, 2010). Of the 13 participants who completed
genograms, earlier death of family members was reported by all but 2 participants, some lost up to 4
members of their immediate family, 7 had suffered the death of one parent with another 3 orphaned.
Additional deaths were reported by focus group members who did not complete genograms. Where
mentioned, causes of death included undisclosed illness, suicide, shooting, stroke, HIV/AIDS or
cancer. Most street youth had been exposed to the death of a family member at a young age, or
witnessed their parent slowly dying, most due to AIDS. For some the experience was particularly
visceral:
I was suffering too much when my mother was next to me and she was dying…then… my sister
died, it was very bad. (Sphiwe)
Many street youth reported being neglected by family members who were dependent on alcohol.
Abuse and maltreatment was frequently reported by participants. Examples included a female street
youth molested by her grandfather, a male street youth raped and starved by his stepmother, adoption
because of an auntie’s mistreatment, being beaten by their ‘granny’, or abandonment by a parent.
Some participants reported leaving for the streets as early as 8 years of age.
Fragmented families were frequently reported with several participants having little or no
involvement from their fathers who often established new families elsewhere. This was highlighted in
genograms where participants mentioned same aged siblings:
My father was a policeman so he moved around a lot, so… he had girlfriends, in many places.
(Thabo)
Mothers were usually responsible for bringing up children but the loss of either parent tended to
exacerbate family fragmentation with children then staying with extended family. This is epitomised
by Olga’s story of her father denying her parentage: “He denied me when I was young…my mother…
she kill herself”.
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Economic factors placed families under additional strain with street youth and staff citing
unemployment, poverty, lack of food and poor living conditions (See Figure 1) which likely aggravated
family divisions and discrimination.
Figure 1. Where street youth come from - a typical township home.
Latifa was taken by a social worker from her family and adopted despite having extended
family because: “all of them got their own childrens…and…they are not working”. In several cases
family conditions remained so dire that when returned to their homes, street youth immediately left for
the streets.
Social changes such as increased freedom and rights were also considered to increase young
people’s exposure to HIV risk. Sindi highlighted government changes to the Children’s Act in South
Africa, now enabling children from 12 years to access contraception and abortion without parental
consent, possibly leading young people to an earlier introduction to unprotected sex. Thamqasa agreed
that street life also offered freedom in the form of “entertainment, disco, girls, unlimited hours” which
played a significant role in his return to the streets.
Physical discipline of children both within the home and by the community is expected, but
providing moral guidance and judgement can be difficult to differentiate from abuse.
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Sometimes they give you a speech…sometimes they beat you….if a child is not beaten down, I
can tell you it is not respectful. (Sboniso)
In some cases community justice can be taken to the extreme such as when Sboniso’s family
rejected him for his own protection:
The reason for them to chase me out it’s not that they doesn’t like me...I did wrong in the
community, the community when it beats you…it beats you to death. (Sboniso)
Although family fragmentation, abuse, and neglect motivated many participants to turn to the streets,
others missed their friends, enjoyed having freedom or thought it would be fun compared to life at
home. Other possible factors based on our observation included: conduct disorder; learning
difficulties; trauma; grief; and other mental health issues.
7.2 Street life
All participants agreed that street life (See Figure 2) was difficult and dangerous. To escape the
stresses of street life, numerous participants indicated they had used (or continue to use) various
substances including cigarettes, dagga (marijuana), glue sniffing, heroin and whoonga. This made
them vulnerable to HIV through sexual exploitation whilst high, and the likelihood of taking greater
risks when engaging in crime and violence to support their habit risking blood to blood transmission.
Staff discussions revealed that whoonga consisted of marijuana, chlorine, rat poison and ARVs and was
sprinkled on a cigarette and smoked, resulting in immediate addiction. Whoonga was reported to cause
death in those with HIV and staff claimed people had deliberately become infected with HIV to access
ARVs, on-selling them to drug dealers to fund their habit. This finding builds on what little is known
about whoonga, also known as nyoape, in the literature which implicates the incorporation of ARVs
into the drug (Moodley, Matjila, & Moosa, 2012; TF Market Research, 2011).
Princess and Latifa reported that female street youth smoked dagga inside the toilet at the
shelter and Brian admitted previously using glue. Mike continues to use dagga but explained why he
gave up whoonga:
20
Whoonga…it’s no good for me…I decided to quit it…because it makes you thin…it makes
you steal a lot.
Others gave up one substance only to substitute it with another:
I did smoke glue… I smoke it a lot…well I stop it and then I start smoking heroin. (Sbu)
Figure 2. A street in Durban close to the shelter.
Reliance on substances often lead to crime and made street youth vulnerable to exploitation,
violence (See Figure 3), prostitution, begging and subsequently HIV, with shelters offering only
temporary refuge from the streets until street youth reached 18 years of age (Umthombo offered
extended age accommodation). Thamqasa explains his involvement in crime before living at
Umthombo:
I was stealing too much, I was robbing people outside, stealing money, see now I am not doing
that.
Participants described street youth engaging in violent behaviours such as hitting smaller children,
carrying knives, threatening staff, accusations of child rape, and the researcher witnessed a volunteer
being attacked with a knife.
21
Figure 3. Violence is a common risk on the streets – a street youth with infected stab wounds.
Several participants reported police brutality during round-ups, describing being beaten, and
even the use of pepper spray.
I was sleeping and the Metro coming and they hit us and take us far away…with…pepper
spray, yar. (Thamqasa)
For most participants, families are not a safe haven in South Africa with exposure to death and
emotional and physical abuse often precipitating going to the streets. Street life offers ongoing
vulnerability for acquiring HIV through substance use, violence, and crime with only shelters
offering limited protection. Therefore, improving family functioning and homeless support are
important aspects of reducing HIV and has been supported in previous research (Snell, 2003; Swart-
Kruger & Richter 1997).
7.3 Psychological issues
Difficult family and socio-economic circumstances had a marked impact on street youth
psychologically. Many participants cited reactions of being stressed, “sad” (depressed), whilst others
cited boredom, loneliness, embarrassment and ostracism. Some had detached themselves socially and
22
struggled with feelings of despair. When asked about the happiest time in his life, Sphiwe corroborated
the translator’s description: “He doesn’t have it, been terrible (emphasised) abuse in his life”.
Survival on the streets involved regular exposure to violence, likely to result in hypervigilance
and aggressive responses to threat. James described a recent incident where a street youth at the shelter
pulled a knife on him to which he responded violently:
I was stabbed twice in my life, almost died…it was just my mind, it just went mad
immediately…because he was coming straight to me…that’s life on the street, so I’ve been
there you know…because the minute you pull a knife on me, you want to kill me.
James’ response not only reflects his childhood on the streets, but also how violence is a daily threat on
the streets of Durban, thus increasing the risk of blood to blood HIV transmission.
‘Living in the moment’ represents a way of escaping from daily hardship and consequences.
When asked why some people risk having unprotected sex, Sindi explained:
Because there are a lot of things that happened…they lost interest in everything in life…they
just want to enjoy themselves for that moment.
This suggests a sense of hopelessness about the future which is understandable in the context of risk
factors such as unemployment, poverty, high rates of rape and violence and poor nutrition: all daily
challenges for street youth and many South Africans. Consequently, enjoyment of immediate pleasures
such as substances and sex may represent a welcome escape from daily survival struggles. Therefore,
protecting against HIV, whose problematic symptoms manifest many years into the future, is unlikely
to be a priority for street youth or South Africans struggling in cities or townships.
8. Discussion and Recommendations
The purpose of our research was to give street youth, one of the most disenfranchized groups in South
Africa, a voice and ascertain their knowledge about, and vulnerability to acquiring, HIV/AIDS. The
following summary of the main themes of our findings also has implications for addressing HIV/AIDS
prevention and treatment across South Africa.
23
Knowledge regarding HIV/AIDS amongst street youth varied and numerous knowledge gaps
were identified (e.g., that HIV is mainly spread through heterosexual intercourse), and many
participants could not differentiate between HIV and AIDS. Beliefs regarding low prevalence are
likely to increase risk, and exposure to outside educators in a shelter environment may increase
knowledge about the virus. Cultural beliefs, such as not discussing sex in deference to adults, are likely
to compromise HIV/AIDS knowledge acquisition. Misinformation regarding transmission, and
preventative interventions such as abstinence and condoms, clashes with cultural beliefs such as the
importance of procreation in expressing masculinity. HIV/AIDS stigma could lead to avoidance of
HIV testing and men were identified as playing a major part in disease spread. ARVs were correctly
linked by some to the need for a healthy diet and mistakenly as a treatment for TB. AIDS was also
negatively linked to a Western interference and apartheid but numerous positives were also identified
with HIV/AIDS understandings, such as increased compassion and sympathy, and the positive impact
of celebrity disclosure, highlighted how the virus does not discriminate.
Discrete risk factors leading to street life and increased risk of acquiring HIV, included
disintegration of the family unit through substance use, polygamy, death (often due to AIDS), and also
through economic factors such as unemployment, and poverty, which could lead to neglect and abuse.
Direct risks associated with street life, which is difficult and dangerous, often leads to ‘self medication’
via substance use. This results in increased vulnerability to sexual exploitation, crime, exposure to
violence and consequently psychological issues such as depression, trauma related disorders and
ultimately increased exposure to HIV transmission.
From a sexuality perspective, this study highlighted gender inequality and the need to empower
women to be more active agents in negotiating safe sex, which cannot be done without the support of
government regulated infrastructures such as police and courts to act against violence, crime and rape
(Jewkes, Sikweyiya, Morrell, & Dunkle, 2009; Moffett, 2006) which place women at risk for HIV
infection. Prevention is further compromised and chances of transmission increased, when current
24
interventions are contradicted by South African culture and beliefs such as polygamy, multiple
partners, transaction sex and provider relationships, gender inequalities, and perceptions of masculinity
which can drive unprotected intercourse and high rates of rape.
HIV/AIDS knowledge was inextricably linked with culture and beliefs. For example, outside
educators could play a valuable and effective educative role in promoting accurate knowledge about
HIV/AIDS but differences identified between what participants say and do in regarding HIV/AIDS
practices indicates that other factors need to be identified that may mediate reluctance to take
preventative action such as culture and beliefs about the disease. Data confirmed that suicide can occur
in anticipation of a HIV/AIDS diagnosis, challenging recent findings (Govender & Schlebusch, 2012;
Schlebusch & Govender, 2012) because suicide may not be solely linked to depression. Whilst medical
circumcision is seen as a significant preventative intervention (Peltzer et al., 2008; Wilcken, Keil, &
Dick, 2010) this study progresses previous findings (Barr, 2008) that practices such as using the same
circumcision knife across initiates poses considerable risk irrespective of prior HIV testing and the
importance of cultural consideration in developing interventions. Abstinence appears unrealistic in the
South African context, and interventions need to reconcile cultural ideals, social reality and HIV risk in
a sensitive and practical way, particularly if there is a resurgence of such traditions post-apartheid
(Maluleke, 2012).
In respect of treatment, whilst ARVs were viewed optimistically overall, efficacy and adherence
can be compromised by HIV/AIDS stigma, structural inequities and inaccessibility to nutritious food.
The poor uptake of ARVs generally (Adam & Johnson, 2009) is exacerbated in the HIV positive street
youth population where attendance at a shelter risks transmission to others through violence, lack of
knowledge, unprotected sex, and being kept unaware of their HIV status, whilst freedom to return to
the streets negates ARV compliance and increases disease spread.
25
This chapter culminates in the following general recommendations (see Table 2) that address
issues raised by the data. These are conditional upon being developed in consultation with health
professionals and interest groups familiar with the diverse social and cultural traditions within South
Africa to ensure appropriateness and maximize outcomes.
Table 2
Recommendations regarding HIV/AIDS research and interventions for South Africa
No. Recommendation
1. Emphasise the link between HIV and AIDS and how HIV can be unwittingly spread for up to ten years before
AIDS symptoms become apparent.
2. More education for street youth, regarding mother to child transmission, and the importance of testing and
treatment, is warranted.
3. Promotion of accurate knowledge is essential in reducing transmission and dispelling myths and misinformation.
4. Obstacles to prevention, testing and how to connect HIV to AIDS, especially targeting males, needs to be
better understood as the risk of waiting until symptoms occur before testing can mean the virus is spread for many
years prior to diagnosis and ARV efficacy and life expectancy is undermined.
5. Promoting the benefits of ARVs because of their ability to increase life expectancy and visibly improve health,
could have an important impact against stigma which is often associated with outward appearance.
6. Further research into whoonga, or nyaope, to ascertain the veracity of reports about its ingredients, effects,
dangers and the role of ARVs.
7. Consideration of media-based HIV/AIDS education campaigns headed by well-known public figures disclosing
their HIV/AIDS status to counter stigma, acknowledge how cultural norms and gender inequity have contributed
to the spread of HIV, and educational campaigns that address specific stigma beliefs, e.g., you cannot get HIVAIDS
from touching someone, using the same crockery or cutlery.
8. Further implementation of the Living Positively intervention in South Africa as it reduces stigma, HIV re-
infection, promotes self-care, medication adherence, and condom use.
9. Need for educational interventions that link HIV and AIDS, and early intervention for ARV treatment to extend
life and combat beliefs that HIV/AIDS is a death sentence.
10. Criminal acts such as rape and violence against women need to be reported and prosecuted.
11. Use of education to dispel previous negative perceptions of AIDS death, when no treatment regime was available,
by emphasizing that ARVs prolong life and its quality if taken as directed. A blanket campaign could instill hope
for the future; reduce stigma, fear of testing and suicide.
12. Importance of educating and promoting the life extending benefits of ARVs to address the fearful recollection
of the devastation of AIDS before ARVs became available. This may reduce suicidal ideation and completion.
13. Educational campaigns aimed at associating condoms with trust, rather than mistrust.
26
14. Incorporation of HIV prevention and intervention strategies that require community consultation and
cooperation in practices such as traditional circumcision rituals and masculinity and procreation.
15. Encouragement of early ARV interventions and adherence and greater government intervention in
addressing
structural inequalities that compromise HIV/AIDS interventions.
16. Greater funding and implementation of HIV/AIDS educative interventions directed to street youth, who are at
high-risk for HIV, via not-for-profit shelters who have direct contact with this population.
9. Conclusion
In this study we found that the links between HIV and AIDS for some street youth are unclear
and HIV testing may only occur after developing AIDS symptoms. If this belief is widespread, HIV-
positive people in South Africa may be undermining their health, limiting their life expectancy, and the
effectiveness of ARVs, but most disturbingly, have been unwittingly spreading the virus for up to ten
years before becoming symptomatic. In the context of polygamy and culturally sanctioned multiple
partner relationships this could explain why the virus has spread so rapidly. Without intervention, the
major factor likely to reduce the current HIV/AIDS prevalence figures in South Africa will be mortality.
Halting the spread of HIV, in street youth in particular and South Africa in general, appears to be
hampered by cultural and traditional norms and stigma and further compounded by a reluctance to use
condoms which represent population control and have postcolonial/apartheid overtones. Whilst a
biomedical approach is at the forefront of fighting this pandemic, it will need to collaboratively identify
and incorporate culturally sensitive interventions or there will be no halting HIV’s spread in South
Africa.
27
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