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AIDS fatigue and university students’ talk about HIV risk a
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Tamara Shefer , Anna Strebel & Joachim Jacobs
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Women's and Gender Studies , University of the Western Cape , Private Bag X17, Cape Town , 7535 , South Africa b
HIV/AIDS Programme , University of the Western Cape , Private Bag X17, Cape Town , 7535 , South Africa Published online: 22 Jun 2012.
To cite this article: Tamara Shefer , Anna Strebel & Joachim Jacobs (2012) AIDS fatigue and university students’ talk about HIV risk, African Journal of AIDS Research, 11:2, 113-121, DOI: 10.2989/16085906.2012.698078 To link to this article: http://dx.doi.org/10.2989/16085906.2012.698078
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ISSN 1608-5906 EISSN 1727-9445 http://dx.doi.org/10.2989/16085906.2012.698078
AIDS fatigue and university students’ talk about HIV risk Tamara Shefer1*, Anna Strebel1 and Joachim Jacobs2 University of the Western Cape, Women’s and Gender Studies, Private Bag X17, Cape Town 7535, South Africa University of the Western Cape, HIV/AIDS Programme, Private Bag X17, Cape Town 7535, South Africa *Corresponding author, e-mail: [email protected]
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Drawing on a qualitative study that included 20 focus group discussions with male and female students at an urban-based university in South Africa, this article reports on perceptions, attitudes and reported behaviour with respect to HIV and AIDS and safer sex in the campus setting, with an aim to better understand how young people are responding to the challenges of HIV and AIDS in contemporary South Africa. The findings demonstrate the gap between reported HIV-prevention knowledge and safer-sex practices among a group of young and educated South Africans. Although the participants reported that students were knowledgeable about HIV and had easy access to condoms on campus, a range of factors mediated their capacity to apply this knowledge to safer-sex practices. Besides the usual set of complex social-cultural dynamics, including normative gender roles and power inequalities between men and women, socioeconomic challenges, and differences in age and status between sexual partners, the findings reveal substantial denial, stigma and HIV/AIDS ‘fatigue.’ The findings point to the importance of seeking creative ways to impart HIV-prevention and safer-sex messages that are not explicitly referent to HIV but link rather with broader issues concerning relationships, lifestyle and identity, and hence are responsive to the particular cultural context of university campuses. Keywords: attitudes, condom use, gender issues, HIV prevention, risk perceptions, sexual behaviour, stigma
Introduction The results of social science research and HIV/AIDS interventions in South Africa over the last 15 to 20 years have proven the complex dynamics of the country’s HIV epidemic as it powerfully intersects with social inequalities concerning age, poverty and gender (Harrison, Xaba, Kunene & Ntuli, 2001; Harrison, 2008; Abdool Karim, 2011; UNICEF, 2011). Accordingly, young people’s degree of HIV risk may be viewed as ‘raced,’ classed and gendered. The latest survey by the Human Sciences Research Council (Shisana, Rehle, Simbayi, Zuma, Jooste, Pillay-Van Wyk et al., 2009) shows that black females between the ages of 20 and 34 years are the most at-risk population, with 32.7% HIV prevalence in this group. HIV prevalence particularly among women in this age group has remained high, at around 33%, as estimated in all three national HSRC surveys to date (see Shisana & Simbayi, 2002; Shisana, Rehle, Simbayi, Parker, Zuma, Bhana et al., 2005; Shinana et al., 2009). The link between poverty and HIV risk and prevalence has also been well illustrated; Hunter (2007) points out that estimated HIV prevalence in the informal settlements of South Africa is almost twice as high as estimated levels of prevalence in rural and urban areas. It has become increasingly clear that changing the behavioural practices contributing to the high rate of HIV infections cannot be achieved without addressing the larger issues of power and material inequalities that shape young people’s normative sexual practices. Young people, from school-going adolescents to young adults, are a target group for researchers and
practitioners in terms of HIV-prevention interventions (see National Progressive Primary Health Care Network, 1995; Department of Basic Education, 2010; Harrison, 2010; UNICEF, 2011). While few local studies have specifically examined university settings and campus life, numerous international and local studies have highlighted the salience of considering sexuality and casual sexual practices on university campuses (e.g. Page, Hammermeister & Scanlan, 2000; Ergene, Çok, Tümer & Ünal, 2005; Seloilwe, 2005; Adam & Mutungi, 2007; Clowes, Shefer, Fouten, Vergnani & Jacobs, 2009; Shefer, 2009a). Research by the South African Higher Education HIV and AIDS Programme (HEAIDS) (2010) has shown that sexual activity on university campuses increases in a linear fashion with students’ academic year of study. South African studies by Oxlund (2009) and Shefer (2009a) show how campuses are sexualised spaces where peer pressure to be sexually active is evident and reportedly exacerbated by alcohol and other substance use. It is notable that a review of literature on the topic of trends in alcohol use (Peltzer & Ramlagan, 2009) showed that alcohol trends among university students indicate higher levels of drinking than that shown in national surveys of the general population. Moreover, research has foregrounded the link between substance use and higherrisk sexual practices (Wechsberg, Jones, Zule, Myers, Browne, Kaufman et al., 2010; Staras, Tobler, MalonadoMolina & Cook, 2011). Other research in southern Africa has examined the occurrence of unequal, coercive and transactional sexual practices on university campuses (Oxlund, 2009; Masvawure, 2010; Shefer, Clowes & Vergnani,
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2012). All of these subcultural contextual dynamics clearly play a role in facilitating unsafe sexual practices. Yet the HEAIDS (2010) study estimated 3.4% HIV prevalence among students at South African universities, based on a sample size of 15 291 students from 21 universities; even the highest prevalence of 6.4% at an Eastern Cape site was substantially lower than expected in comparison with the figures given in the national surveys by Shisana et al. (2009) and the Department of Health (2008). Nonetheless, these are significant proportions in a grouping of young people who are expected to contribute significantly to civil society once they have graduated. In light of the considerable amount of research and concerted efforts by the state and civil society to impact on high HIV incidence among young people (cf. Holmes, 2005), levels of HIV incidence and prevalence in South Africa remain among the highest in the world. Moreover, the extent to which young people are responding to national HIV-prevention campaigns (such as a high volume of public HIV/AIDS educational material, and the increasing accessibility of condoms) has not been widely investigated. Some authors have discussed how the prolific public discourse on HIV and AIDS may be facilitating a sense of ‘AIDS fatigue’ among young people (Mitchell & Smith, 2001a and 2001b; Holmes, 2005). Mitchell & Smith (2001a, p. 60) argue that “an internalized AIDS fatigue on the part of those most affected (at least potentially) by the epidemic” also links to a sense of fatality that, given the high rate of new infections, one will contract the virus at some point. They suggest that “both of these ‘dead-end’ attitudes may be a function of information overload, something that might be described as an ‘AIDS fatigue barrier’” (Mitchell & Smith, 2001a, p. 60). This article draws on a qualitative study with a group of university students at an urban South African campus which documented reported behaviour and perceptions of sexual practices on campus. We present the findings with respect to attitudes about HIV and AIDS and reported practices of higher-risk or safer sex, to achieve a better understanding of how young people are responding to the challenges of the HIV epidemic in contemporary South Africa. Methods Qualitative methods, including focus group discussions, were utilised. Purposive sampling at the selected university targeted both male and female students who were recruited across all academic levels (from first-year to postgraduate) to represent the diversity of students across the faculties, nationalities, races, socioeconomic classes and cultures represented at the university. These are suggested as salient features by the literature, and had also emerged in the educational work of HIV programmes at this university. The university where the study was conducted is located in an urban area. In 2009 the student population was 48% coloured, 39% black, 7% Asian and 4% white. Considered a ‘disadvantaged’ institution prior to 1994, many students at the university remain disadvantaged both materially and educationally (Bozalek, 2012). A study examining the throughput of graduates in higher education institutions
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in South Africa (Letseka, Cosser, Breier & Visser, 2010) reported that this university had a high proportion of graduates in the lowest socioeconomic category (approximately three-quarters), compared to an average of 56% across the seven institutions studied. Twenty focus group discussions guided by a semi-structured interview guide were conducted. Only students who were over 18 years of age were included in the study. Each focus group included six to 10 participants, and the groups were variously mixed-gender, women’sonly or men’s-only. Participants were identified in advance through convenient forums, such as tutorial groups and lecture classes. A skilled facilitator regarded as acceptable and appropriate with respect to age, gender and cultural/ language background facilitated each group. The discussions were largely conducted in English, lasted 1–1.5 hours, and were audio-recorded with the participants’ permission. A demographic questionnaire was administered at the start of the discussions to collect information on the participants’ gender, age, programme/degree of study, years on campus, urban or rural background, and residence on or off campus. The larger study looked at reported sexual behaviour and the dynamics of sexual negotiation on campus, including students’ responses to the imperative of safer sex in light of HIV risk. The research was undertaken to gather rich qualitative data that would give those engaged in HIV prevention and education a better understanding of the particular and current context in which sexual practices and relationships take place on campus. Thus, the semi-structured interview guide asked questions about the nature and dynamics of sexual relationships on campus, with a focus on challenges to safe sex and equitable sexual practices. The participants were not asked to elaborate on their personal experiences but asked about what generally happens on campus. We specifically employed this thirdperson interviewing technique because prior experience (and other research on sexuality and other potentially sensitive topics: Strebel, 1995) suggested that it is more comfortable for participants to ‘distance’ themselves from the stories they tell. Speaking in the third-person, even if the experience is one’s own, arguably facilitates sharing, more than if directly asked about one’s own behaviour and experience. All standard ethical procedures were maintained, with particular sensitivity to issues of confidentiality and anonymity, given the focus on sexual behaviour and the link with HIV (which is still highly stigmatised in South Africa). Ethical clearance was obtained through the university’s research and ethics committees. A qualitative thematic analysis was conducted on the transcripts, which were transcribed verbatim from the audio recordings. The analytical software package ATLAS.ti was used to process and analyse the data. Qualitative research, which is “concerned with making sense of human experience from within the context and perspective of human experience” (Kelly, 2006, p. 346), has been widely applied in the pursuit of rich data within socially engaged research for the purpose of generating a deeper understanding of the particular social problem being researched. Drawing
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on the work of Braun & Clarke (2006, p. 81), our analysis involved identifying patterns or themes across the dataset “within a social constructionist epistemology (i.e. where patterns are identified as socially produced)….” Since the study was specifically commissioned to serve the purpose of informing HIV-prevention and educational interventions on the campus, we were concerned with the multiplicity of meanings in students’ perceptions and reported behaviour in relation to HIV and safer sex rather than attempting to ascertain the extent and ‘truth’ about actual practices. Notably, the study did serve to inform such interventions and led to the formulation of a range of novel and alternative messages for behaviour-change communication material on this campus.
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Findings The larger study generated a wide range of themes relating to sexual practices on the campus. Here, we draw out key themes concerning the extent to which the participants reported safer-sex practices among students, and constructions of students’ perceptions of HIV risk in light of their HIV knowledge and the extensive HIV-prevention messages in South Africa. The findings are presented in three sections: the participants’ reflections on students’ general knowledge about HIV and how this relates to safer-sex practices (particularly condom use); identification of challenges to practising safer sex, especially given university students’ knowledge of HIV and higher-risk behaviour; and perceptions about the risk of contracting HIV, including denial of the risk and AIDS ‘fatigue.’ HIV knowledge and condom use There was a strong sentiment that students were well-informed about HIV and safer sexual practices and that condoms were readily available on campus: ‘I think, in general, we are quite educated as to AIDS’ (mixed-gender group). ‘They’re aware of HIV and AIDS. They know everything…because I know there’s a lot of educational programmes, condoms everywhere you go; there’s posters everywhere, everybody knows about it’ (mixed-gender group). It is not surprising that students should report being knowledgeable about HIV and AIDS and well-versed in safer-sex practices, given the proliferation of interventions and the public promotion of HIV-prevention messages. Such findings are reflected in other studies in southern African university contexts (i.e. Harding, Anadu, Gray & Champeau, 1999; Peltzer, 2005; Ntata, Muula, Siziya & Kayambazinthu, 2008). For example, Ntata et al. (2008) found that almost 70% of students at a Malawian university felt they knew enough about HIV and AIDS, 67% knew where to find condoms on the campus, and over 80% knew where to access HIV testing on campus. However, despite university students’ HIV awareness, the participants reported that higher-risk sexual practices are common, and their narratives, elaborated in the next theme, highlight the complexity of factors that impact on young people’s heterosexual relationships and sexual negotiation:
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‘By the way they behave, I don’t think [students are practising safer sex]. Because all the information is there, it’s on TV, there’s condoms in every toilet, it’s on radio everywhere, but everyone’s pulling a blind eye, they just act like they don’t hear it, like they don’t know of it’ (mixed-gender group). ‘They [condoms] are all over but they are not being used. ’Cuz you can see in our toilets they are being used to close the taps. So they are using them but not for the right thing’ (women’s group). ‘People meet in the [student bar], they drink together, one is speculating, or one of them or both of them are thinking of having sex afterwards. All of a sudden they’re drunk and they find themselves having sex. So how is it possible, two of you, once you are in the room, you are excited, you want to have sex, I don’t think people will think about using condoms and HIV and AIDS. People have knowledge of HIV, people do know HIV is a deadly disease and everything, but how sex happens most of the time, it’s not something that is really planned’ (men’s group). ‘Ja, but I think the more they do it, the more extreme they become, you know. Sometimes it’s once without a condom and then they do it the whole time without a [condom], you know, it gets more extreme the more you do it. You don’t learn from it, you become, you actually do worse stuff than you did before’ (mixed-gender group). Similarly, Nigerian students reported good HIV knowledge, yet engaged in higher-risk sex (Harding et al., 1999); and only about half of Malawian first-year students reported using a condom at last sexual intercourse (Ntata et al., 2008). Notwithstanding the reported high prevalence of unsafe sex among students, there were also constructive and responsive narratives that revealed shifts in students’ behaviour and increased sexual responsibility. Alongside the reported practices of unsafe sex were perceptions that condoms are more widely used than in the past, and that safer sex with condoms is viewed positively and even responded to in congratulatory terms: ‘I don’t know for other people, but for me both times I was drunk and both times we did use condoms; I had the condoms [clapping]’ (mixed-gender group). ‘With me, that will be, it will show somebody who knows what they want, somebody who is serious about their life. They don’t want to get pregnant, AIDS or anything. They know what they want; they focus on what they want. Even if you are in a serious relationship, they still insist on using protection’ (women’s group). The participants talked about taking responsibility for one’s own behaviour, revealing an incorporation of messages about safer-sex practices and the importance of agency, and they made suggestions about how to improve communication about HIV risk and safer-sex messages to students: ‘I used to have unprotected sex with my partner and someone asked me — What about safe sex,
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aren’t you afraid of AIDS? And I was like — But I am faithful. But now the thing is, how can you be sure if he is faithful? And I am responsible for myself. I can’t just blame him. I must take responsibility for myself. I don’t want to know if he’s faithful or not, but let me just look out for myself. Let me use protection just in case’ (women’s group). ‘Maybe teach people how to talk about sex and how to negotiate sex, not in terms of condom use or whatever, but just the actual sex and [how to] say — I want to have sex with you — so that somebody can prepare, because I’m actually going to have sex and agree on that…and if it has maybe been spoken about, and if we can start teaching people that it is important to start talking to people about sex before we have sex, then somehow it might help to actually think about using condoms’ (men’s group). Reported challenges to safer-sex practices The participants suggested various reasons why they felt condoms are not used and why safer sex is not practised frequently despite reportedly widespread knowledge of HIV. They regarded higher-risk behaviour among students, especially difficulties in negotiating condom use, as a reflection of gendered power relations, as has been extensively reported in local and international studies exploring the dynamics of sexual negotiation (e.g. Varga & Makhubalo, 1996; Terry, Mhloyi, Masvawure & Adlis, 2006; Shefer & Foster, 2009): ‘Girls are really pressurised into not using condoms — actually easily pressurised’ (women’s group). ‘My point of view is, the point remains that both parties, the male and the female, need that pleasure, but now it’s as if the female part is denied the strategies. The ground is not levelled for both parties. Here is a man given all the potential to negotiate sex — he has access to a male condom, the opposite party doesn’t have — and here there are two people who need that transaction, that act. In other words, both of you are being pushed to get into that activity, but one has got more negotiating power, more facilities than the other’ (men’s group). ‘Most girls will keep quiet because they do not want their man to run away. If they raise such issues such as HIV testing, let’s do this, let’s do that, yes. Um, the males are more dominating in relationships, and most girls lack self-esteem’ (mixed-gender group). ‘Uhm, they [women] don’t have that strength or that power to initiate condom use and negotiate condoms. They just, they just, ja, too soft and, you know, I think they are the ones who are much at risk. Because a girl who goes [there], they know what’s going around in parties and the [student bar], and whatever; they know that guys sleep around, so I protect myself’ (women’s group). Similar to the findings of other local studies on condom usage (MacPhail & Campbell, 2001; Eaton, Flischer & Aaro,
2003), the participants highlighted the complex social and interpersonal contexts that impact on the dynamics of sexual behaviour and influence decisions about condom use. In this study, substance abuse and notions of uncontrollability ‘in the heat of the moment’ (as referred to above) were seen to lower students’ inhibitions and militate against the use of condoms, for example: ‘I have a friend, like when we’re at the [student bar] she leaves with guys, like every week it’s different guys. Because she drinks, she’s out of it, she doesn’t remember a thing, she’s out of control. I speak to her when she is sober and say — Listen do you use protection? She doesn’t care, because she’s on contraceptives. They’re just too drunk and they lose control, they don’t really care’ (mixedgender group). ‘I was at the point that in [your residence], yes, you might have the condoms on you, then you use it, but there’s also in the heat of the moment. This and that happens and you just don’t have it on you, and then you have that guilt you didn’t use a condom’ (mixed-gender group). Other issues relating to normative practices in heterosexual relationships, particularly men’s resistance to using condoms, also emerged frequently, including reports of men’s preference for ‘skin-on-skin’ sex, peer pressure, the coercion of women to not use condoms, and men’s threats to leave women who insist on condom use: ‘A lot of boys, they do that pull-out technique, to have sex skin on skin’ (women’s group). ‘And sometimes I actually wonder if it’s maybe, if it’s a little thing too with peer pressure. Maybe, what their friends are doing, they want to be, this or go on like that, but it’s like — Come on, get a life, let’s go. And, or sometimes you just want to fit in, maybe’ (women’s group). ‘Guys, most of them, if you are in a relationship with them they want to control you. Even if they want to come to your place and you are studying you can’t say you are studying, they want to come ’cuz they are like almighty. If you don’t want them to come, they’ll find somebody else to go to, and they’ll tell you — Is it how you want it to be? Then I’ll find somebody else. And you’ll feel guilty, like, ooh, he’s gonna find somebody else now’ (women’s group). As constructed by both men and women, the idea of condom use as inappropriate in long-term relationships where faithfulness is assumed also emerged (Shefer, 2009b). Perceptions of a need for condoms only with one-night stands and not with regular partners, and condom use as evidence of non-trust between partners, were reported by the participants as barriers to condom use: ‘Like the HIV issue, we know that it’s there, but I mean the girl would say — No, but I love him. I don’t want him to go to another girl because he insists that we don’t use condoms, because if we do condoms then he’ll go, that means I don’t trust him, so he will go to the person that I’m suspecting that he is having an affair with, and stuff like that’ (mixedgender group).
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‘But I’m just saying, with sex partners I’m sure they do use condoms, because they do have their own girlfriends and boyfriends, so they need [condoms] just for that one time’ (women’s group). ‘[It’s] linked to trust, too. You’re maybe in a relationship, maybe for one or two months, then you think, ok, now we trust each other, we can leave the condoms. I only have sex with you, so it’s fine. They develop that trust and that’s very dangerous’ (mixedgender group). Embarrassment at procuring condoms (even though readily available on campus) was also viewed as a barrier to condom use, especially for women. This points to the normative construction of female sexuality as passive and focused on having a relationship rather than enjoying sex, and therefore denotes the continued repression of positive discourses on female sexual desires, as identified in the international and South African literature (Holland, Ramazanoglu, Scott, Thompson & Sharpe, 1990; Lesch, 2000; Harrison, 2008; Kahn, 2008; Shefer & Foster, 2009). For example, one participant commented: ‘But you mentioned the condoms dispenser — no one wants to be seen go fetching a condom. Even if you have sex, you don’t want people knowing or seeing you with a condom. Like, I don’t want people knowing I’m having sex’ (mixed-gender group). While women were often seen as responsible for HIV infections and prevention methods, there was a perception that women are reluctant to use or carry condoms. Moreover, there seemed to be greater concern for unplanned pregnancy, so that if a woman was taking oral contraception this seemed to remove the need for using condoms as well: ‘And we are assuming that HIV and AIDS is the woman’s responsibility, and actually we are putting responsibility on the women more than the men; and yet it involves two people, you know what I mean?’ (men’s group) ‘It needs to become okay for a nice girl to carry a condom around…because I’ve heard it a million times, where girls don’t want to carry condoms around with them because people will see it and think that they are slutty’ (mixed-gender group). ‘It then makes me wonder, when a person is on contraceptives, right, then they are more, like, worried about them not getting pregnant. My question would then come, when they are on contraceptives, this tells me, then this tells me, that they will forego the condom, which means that they put them on high risk’ (women’s group). ‘Because I think that reputation of having a baby is much bigger than [HIV] status, because, I mean, [HIV] status is not something you can see, but obviously pregnancy is something people can see. So if you’re judged for something that people can see through, what would you really stop? Your pregnancy, probably’ (mixed-gender group). Denial and AIDS fatigue Discussion in the focus groups revealed a perception that many students are in denial of personal risk of infection, and
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the sense that HIV and AIDS was still largely unreal and invisible to most students: ‘I think that they do know the risks, but they tend to ignore them, since they think — Fine, I’m still young, and there are girls here and guys here that also study — Where could they possibly get the virus? They, like, tend to distance the virus from themselves and people surrounding them. So they totally ignore them, ignore the risks’ (mixed-gender group). ‘I don’t think they believe they are at risk. Most of the time they are thinking — Oh, it can’t happen to me. Some students you hear them saying they had sex with somebody, like at a party, and you say, like — Aren’t you scared of AIDS? — and they [say] like — No, it’s just AIDS, it won’t happen to me — and they are not like worried. Somebody once said to me — It’s like once you have AIDS, it’s like you’re a celebrity!’ (mixed-gender group). These comments are similar to the responses of students in other studies: for example, an early study among South African university students (Perkel, 1992) found that 63% thought it was ‘not likely at all’ that they were at risk of HIV infection; more recently, Ntata et al. (2008) found that among first-year Malawian students as many as 68% felt they were not at risk of acquiring HIV; and, Peltzer (2005) found that over 80% of both female and male students at a South African university indicated they had never worried about the risk of HIV infection. The participants also conveyed that talk about AIDS is widespread, although the thought of the HIV epidemic remained abstract to them; this possibly serves as a way of legitimising HIV-risk denial. Also evident was a sense of information overload: ‘For me, I think AIDS has become like this abstract thing. You hear about it. You see it on TV, and blah, blah, blah. But you don’t see it. You don’t see people suffering from it. Because there is no one near you who has [the disease] and you don’t see the effect it has on their families and stuff like that’ (women’s group). ‘I’ve never seen a real person with AIDS’ (mixedgender group). The argument among some participants that they had ‘never seen a real person with AIDS’ is somewhat unexpected in the South African context, where over 5.5 million people are living with HIV (UNAIDS, 2010), yet it may be serving to legitimate a denial of risk through a denial of the public presence of those who are ill. Interestingly, in a study of youths in an urban South African environment, Motsemme (2007, p. 75) found that young women avoided naming HIV and AIDS directly; they “put it at the back of their minds and chose to forget” that it could affect them, while at the same time experiencing “fatigue at the constancy of deaths taking place around them.” The negative stigmatisation of AIDS and those who are living with HIV, which has been of much concern in South Africa (cf. Bollinger, 2002; The POLICY Project, 2002 and 2003; Shisana et al., 2005; Shisana et al., 2009), was likewise reflected in the students’ comments:
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‘Ja, almost like, they portray the virus as like…an evil, a evil being; and in that way they, it’s easier to stigmatise people with HIV/AIDS. So they contribute to the stigma, stigmatising HIV/AIDS, people who have AIDS — they contribute’ (men’s group). ‘Uhm, well, you know people will still say that it could be sort of a stigma attached going for an HIV test’ (mixed-gender group). The student’s denial of HIV risk also drew on ‘othering’ discourses in racial terms, whereby mostly certain communities were viewed as at-risk (cf. Mitchell & Smith, 2001b; Deacon, Stephney & Prosalendis, 2005; Airhihenbuwa, Okoror, Shefer, Brown, Iwelunmor, Smith et al., 2009): ‘That’s the main thing, everyone’s like — Ag, man, it only happens to like, black people, it happens to poor coloured people — or something like that’ (mixed-gender group). ‘I’ve met one coloured person who…came to speak at our school. So, it was one coloured person that we know who has AIDS.… But he also said that he slept around and he was a womaniser, and all that stuff’ (mixed-gender group). ‘And it’s, it’s normally when they show people that have AIDS, it’s Africans. They don’t show coloured people. They don’t show whites. I don’t know why. But it’s what I’ve seen’ (women’s group). ‘You know I noticed that as much [as] we are being taught that HIV/AIDS is there, but every year we hear that the rates of HIV/AIDS are increasing. It’s not like that people don’t know that HIV/AIDS is there, it’s just that people are like —No, it won’t happen to me, no, it will happen to, you know, to black people, or you know these other people that are there’ (mixed-gender group). Closely associated was a sentiment that young people are experiencing AIDS fatigue, a situation similarly described by Holmes (2005). Moreover, some participants stated a perception of HIV fatalism and commented that the availability of antiretroviral (ARV) drugs had possibly reduced individuals’ fear of becoming HIV-infected: ‘We have become too comfortable with AIDS’ (women’s group). ‘But the prospect of getting another assignment on HIV and AIDS, I think that’s the thing. It’s another assignment…there’s no shock value to HIV and AIDS anymore’ (women’s group). ‘They brush it off now, because they’ve heard so much about it in school, and whatever, that now they think — Oh, it’s just another one of those posters again’ (mixed-gender group). ‘I don’t think students are even aware of what happens, ’cuz the thing is this other friend once told me we are all going to die someday, you’re just gonna die sooner [laughter], so what’s the big fuss about it? You get sick, they will provide for you, you will get ARVs. We’re not gonna be here forever, so you just gonna die sooner’ (women’s group). One participant’s suggestion of what is needed regarding HIV education highlights the information-saturation that
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reportedly has facilitated emotional exhaustion leading to apathy about practicing safer sex: ‘I think, like, people have heard enough of AIDS. Like what she said, they all know that. I think now we should just focus on teaching them self-esteem, like how to say — No. Support groups on motivation, not on HIV, HIV, HIV — because it’s tiring’ (mixed-gender group). Conclusions The findings highlight the continuing gap between knowledge and behaviour with respect to safer sex and HIV prevention among young and educated South Africans. In the time since early research conducted on university students’ attitudes and knowledge relating to HIV (see Strebel & Perkel, 1991; Perkel, 1992), young people have become largely familiar with HIV and the need for safer-sex practices, and they have easy access to condoms. In spite of this changed context, with increased access to information and resources as well as exposure to constant HIV-prevention messages, young people evidently remain at risk for contracting HIV and other sexually transmitted infections, as well as unwanted pregnancies. This study reinforces a large body of work arguing that higher-risk sexual practices hinge on a complex of factors, including the intersection of normative gender roles and gender power relations with poverty, age and other forms of social difference and inequality (cf. Clowes et al., 2009; Shefer et al., 2012). Yet, while these findings reflect and substantiate other findings emerging from research on the topic of youths, HIV and sexuality, some of the specifics emerging from this study and others on university campuses reveal a range of subcultural practices particular to student life. These include peer pressure to be sexual, the drinking culture on campuses, and insecurities among many students who live away from home, which may all exacerbate the gender normative behaviours that facilitate higherrisk sexual practices. It is also evident that racialised and classed discourses on HIV and AIDS facilitate a sense of immunity, a tendency for ‘othering’ discourses, and risk denial among young people. A denial of HIV risk links to these discourses, but also relates to a denial of familiarity with people living with HIV. Given the high number of people living with HIV (indeed, many students at this university belong to communities with some of the highest HIV-prevalence levels in South Africa and globally), it is surprising that some students claimed to not know anyone living with HIV nor notice anyone ill with HIV. This finding may also link with HIV stigma and the fact that acknowledgement of AIDS as a cause of death is typically repressed from public discourse. Significantly, popular efforts to impact on sexual practices still seem to fail in contrast to the desired impact of interventions; inadvertently, these interventions and HIV-prevention messages may be having a negative effect on young people through the creation of what is called AIDS fatigue. Thus, a sense of information overload, saturation and personal impatience with this barrage of information becomes evident. University students’ tiredness with hearing HIV-prevention messages
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may be fuelling HIV-risk denial and dulling their consciousness of the importance of safer sexual behaviour. The findings here point primarily to a need to find innovative ways to impart HIV-prevention and safer-sex messages at higher education institutions, especially since young people are possibly more in denial of their risk than in the earlier phase of the epidemic in South Africa, as argued elsewhere (e.g. Mitchell & Smith, 2001a and 2001b; Baelden, Van Audenhove & Vergnani, 2012). Feminist researchers have long argued the importance of challenging normative gender roles and relations as part of the larger HIV/AIDS educational framework, and it may be that messages that speak to gender and human-rights norms in relationships, as well as gendered and sexual identities and multiple forms of power, may be more helpful than current upfront, directive and didactic messages that address basic HIV/AIDS knowledge and foreground HIV risk. Given young people’s fatigue and resistance in relation to HIV-prevention and safer-sex messages, it is arguably imperative to continue developing interventions that are more subtle or not explicitly linked to HIV, as well as more creative and inspiring for young people. Furthermore, since cultural and racialised discourses emerged as central to the way in which traditional heterosexual practices are legitimised, and the way in which HIV risk is ‘othered,’ it seems imperative to focus on deconstructing culture and notions of cultural difference, as well as on ways to engage in antiracist education on campuses. Such interventions could be part of broader initiatives to transform the institutional culture at South African universities. As importantly, the links between culture, traditional norms, and heterosexual practices in the light of HIV should be debated on university campuses. Acknowledgements — We acknowledge the students who shared their stories; we thank Elron Fouten, Melani-Ann Cook, Tania Vergnani and Lindsay Clowes for research support; the HIV and AIDS Programme at UWC for initiating and recruiting funding for the research and the anonymous reviewers for their l guidance. The authors — Tamara Shefer is a professor of women’s and gender studies and the deputy dean of teaching and learning in the Faculty of Arts at the University of the Western Cape. Her interdisciplinary research and publications have been mainly in the areas of heterosexuality, HIV, gendered and raced subjectivities, authorship and knowledge production. Anna Strebel is extraordinary professor of women’s and gender studies with the Faculty of Arts at the University of the Western Cape. She was one of the first to research the topic of women and AIDS in South Africa, and continues to publish widely on gender, sexuality, mental health and HIV. Joachim Jacobs is a programme manager in the HIV and AIDS Programme at the University of the Western Cape. He has extensive experience in the development and evaluation of HIV-prevention programmes and has led two major HIV/ AIDS collaborations involving universities in four countries of sub-Saharan Africa.
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Journal of Social Science 18(1), pp. 1–12. Perkel, A. (1992) The Mindscape of AIDS: Dynamics of Transmission. Cape Town, South Africa, Percept Publishers. Seloilwe, E.S. (2005) Factors that influence the spread of HIV/ AIDS among students of the University of Botswana. Journal of the Association of Nurses in AIDS Care 16(3), pp. 3–10. Shefer, T. (2009a) A Qualitative Study of UWC Students’ Perceptions of the Current Context of (Hetero)Sexual Practices on UWC Campus. Cape Town, South Africa, University of the Western Cape (UWC), HIV/AIDS Unit. Shefer, T. (2009b) Intersections of Gender and HIV: Overview and Critical Reflection on New Directions. UWC HIV and AIDS Research Centre, ‘HIV in Context’ Working Paper No. 2, University of the Western Cape (UWC), School of Public Health, Cape Town, South Africa. Shefer, T., Clowes, L. & Vergnani, T. (2012) Narratives of transactional sex on a university campus. Culture, Health and Sexuality 14(4), pp. 435–447. Shefer, T. & Foster, D. (2009) Heterosex among young South Africans: research reflections. In: Steyn, M. & Van Zyl, M. (eds.) The Price/The Prize: Shaping Sexualities in the New South Africa. Cape Town, South Africa, HSRC Press. Shisana, O., Rehle, T., Simbayi, L.C., Parker, W., Zuma, K., Bhana, A., Connolly, C., Jooste, S., Pillay, V. et al. (2005) South African National HIV Prevalence, HIV Incidence, Behaviour and Communication Survey, 2005. Cape Town, South Africa, HSRC Press. Shisana, O., Rehle, T., Simbayi, L.C., Zuma, K., Jooste, S., Pillay-Van Wyk, V., Mbelle, N., Van Zyl, J., Parker, W., Zungu, N.P., Pezi, S. & The SABSSM III Implementation Team (2009) South African National HIV Prevalence, Incidence, Behaviour and Communication Survey, 2008: A Turning Tide among Teenagers? Cape Town, South Africa, HSRC Press. Shisana, O. & Simbayi, L. (2002) Nelson Mandela/HSRC Study of HIV/AIDS: South African National HIV Prevalence, Behavioural Risks and Mass Media Household Survey, 2002. Cape Town, South Africa, HSRC Press. Staras, S., Tobler, A., Malonado-Molina, M. & Cook, R. (2011) Riskier sexual partners contribute to the increased rate of sexually transmitted diseases among youth with substance-use disorders. Sexually Transmitted Diseases 38(5), pp. 413–418. Strebel, A. (1995) Focus groups in AIDS research. Journal of Community and Health Sciences 2(2), pp. 59–69. Strebel, A. & Perkel, A. (1991) ‘Not our Problem’: AIDS Knowledge, Attitudes, Practices and Psychological Factors at UWC. Psychology Resource Centre Occasional Papers Series No. 4, University of the Western Cape (UWC), Cape Town, South Africa. Terry, P., Mhloyi, M., Masvaure, T. & Adlis, S. (2006) An examination of knowledge, attitudes and practices related to HIV/AIDS prevention in Zimbabwean university students: comparing intervention program participants and non-participants. International Journal of Infectious Diseases 10(1), pp. 38–46. The POLICY Project (2002) Siyam’kela: Measuring HIV/ AIDS-Related Stigma: Literature Review. Cape Town, South Africa, The POLICY Project, Centre for the Study of AIDS/ University of Pretoria, United States Agency for International Development (USAID), and Chief Directorate: HIV/AIDS and TB/ Department of Health. Available at: . The POLICY Project (2003) Siyam’kela: Examining HIV/AIDS Stigma in Selected South African Media: January–March 2003: A Summary. Cape Town, South Africa, The POLICY Project, Centre for the Study of AIDS/University of Pretoria, United States Agency for International Development (USAID), and
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AIDS fatigue and university students’ talk about HIV risk a
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Tamara Shefer , Anna Strebel & Joachim Jacobs
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HIV/AIDS Programme , University of the Western Cape , Private Bag X17, Cape Town , 7535 , South Africa Published online: 22 Jun 2012.
To cite this article: Tamara Shefer , Anna Strebel & Joachim Jacobs (2012) AIDS fatigue and university students’ talk about HIV risk, African Journal of AIDS Research, 11:2, 113-121, DOI: 10.2989/16085906.2012.698078 To link to this article: http://dx.doi.org/10.2989/16085906.2012.698078
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AIDS fatigue and university students’ talk about HIV risk Tamara Shefer1*, Anna Strebel1 and Joachim Jacobs2 University of the Western Cape, Women’s and Gender Studies, Private Bag X17, Cape Town 7535, South Africa University of the Western Cape, HIV/AIDS Programme, Private Bag X17, Cape Town 7535, South Africa *Corresponding author, e-mail: [email protected]
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Drawing on a qualitative study that included 20 focus group discussions with male and female students at an urban-based university in South Africa, this article reports on perceptions, attitudes and reported behaviour with respect to HIV and AIDS and safer sex in the campus setting, with an aim to better understand how young people are responding to the challenges of HIV and AIDS in contemporary South Africa. The findings demonstrate the gap between reported HIV-prevention knowledge and safer-sex practices among a group of young and educated South Africans. Although the participants reported that students were knowledgeable about HIV and had easy access to condoms on campus, a range of factors mediated their capacity to apply this knowledge to safer-sex practices. Besides the usual set of complex social-cultural dynamics, including normative gender roles and power inequalities between men and women, socioeconomic challenges, and differences in age and status between sexual partners, the findings reveal substantial denial, stigma and HIV/AIDS ‘fatigue.’ The findings point to the importance of seeking creative ways to impart HIV-prevention and safer-sex messages that are not explicitly referent to HIV but link rather with broader issues concerning relationships, lifestyle and identity, and hence are responsive to the particular cultural context of university campuses. Keywords: attitudes, condom use, gender issues, HIV prevention, risk perceptions, sexual behaviour, stigma
Introduction The results of social science research and HIV/AIDS interventions in South Africa over the last 15 to 20 years have proven the complex dynamics of the country’s HIV epidemic as it powerfully intersects with social inequalities concerning age, poverty and gender (Harrison, Xaba, Kunene & Ntuli, 2001; Harrison, 2008; Abdool Karim, 2011; UNICEF, 2011). Accordingly, young people’s degree of HIV risk may be viewed as ‘raced,’ classed and gendered. The latest survey by the Human Sciences Research Council (Shisana, Rehle, Simbayi, Zuma, Jooste, Pillay-Van Wyk et al., 2009) shows that black females between the ages of 20 and 34 years are the most at-risk population, with 32.7% HIV prevalence in this group. HIV prevalence particularly among women in this age group has remained high, at around 33%, as estimated in all three national HSRC surveys to date (see Shisana & Simbayi, 2002; Shisana, Rehle, Simbayi, Parker, Zuma, Bhana et al., 2005; Shinana et al., 2009). The link between poverty and HIV risk and prevalence has also been well illustrated; Hunter (2007) points out that estimated HIV prevalence in the informal settlements of South Africa is almost twice as high as estimated levels of prevalence in rural and urban areas. It has become increasingly clear that changing the behavioural practices contributing to the high rate of HIV infections cannot be achieved without addressing the larger issues of power and material inequalities that shape young people’s normative sexual practices. Young people, from school-going adolescents to young adults, are a target group for researchers and
practitioners in terms of HIV-prevention interventions (see National Progressive Primary Health Care Network, 1995; Department of Basic Education, 2010; Harrison, 2010; UNICEF, 2011). While few local studies have specifically examined university settings and campus life, numerous international and local studies have highlighted the salience of considering sexuality and casual sexual practices on university campuses (e.g. Page, Hammermeister & Scanlan, 2000; Ergene, Çok, Tümer & Ünal, 2005; Seloilwe, 2005; Adam & Mutungi, 2007; Clowes, Shefer, Fouten, Vergnani & Jacobs, 2009; Shefer, 2009a). Research by the South African Higher Education HIV and AIDS Programme (HEAIDS) (2010) has shown that sexual activity on university campuses increases in a linear fashion with students’ academic year of study. South African studies by Oxlund (2009) and Shefer (2009a) show how campuses are sexualised spaces where peer pressure to be sexually active is evident and reportedly exacerbated by alcohol and other substance use. It is notable that a review of literature on the topic of trends in alcohol use (Peltzer & Ramlagan, 2009) showed that alcohol trends among university students indicate higher levels of drinking than that shown in national surveys of the general population. Moreover, research has foregrounded the link between substance use and higherrisk sexual practices (Wechsberg, Jones, Zule, Myers, Browne, Kaufman et al., 2010; Staras, Tobler, MalonadoMolina & Cook, 2011). Other research in southern Africa has examined the occurrence of unequal, coercive and transactional sexual practices on university campuses (Oxlund, 2009; Masvawure, 2010; Shefer, Clowes & Vergnani,
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2012). All of these subcultural contextual dynamics clearly play a role in facilitating unsafe sexual practices. Yet the HEAIDS (2010) study estimated 3.4% HIV prevalence among students at South African universities, based on a sample size of 15 291 students from 21 universities; even the highest prevalence of 6.4% at an Eastern Cape site was substantially lower than expected in comparison with the figures given in the national surveys by Shisana et al. (2009) and the Department of Health (2008). Nonetheless, these are significant proportions in a grouping of young people who are expected to contribute significantly to civil society once they have graduated. In light of the considerable amount of research and concerted efforts by the state and civil society to impact on high HIV incidence among young people (cf. Holmes, 2005), levels of HIV incidence and prevalence in South Africa remain among the highest in the world. Moreover, the extent to which young people are responding to national HIV-prevention campaigns (such as a high volume of public HIV/AIDS educational material, and the increasing accessibility of condoms) has not been widely investigated. Some authors have discussed how the prolific public discourse on HIV and AIDS may be facilitating a sense of ‘AIDS fatigue’ among young people (Mitchell & Smith, 2001a and 2001b; Holmes, 2005). Mitchell & Smith (2001a, p. 60) argue that “an internalized AIDS fatigue on the part of those most affected (at least potentially) by the epidemic” also links to a sense of fatality that, given the high rate of new infections, one will contract the virus at some point. They suggest that “both of these ‘dead-end’ attitudes may be a function of information overload, something that might be described as an ‘AIDS fatigue barrier’” (Mitchell & Smith, 2001a, p. 60). This article draws on a qualitative study with a group of university students at an urban South African campus which documented reported behaviour and perceptions of sexual practices on campus. We present the findings with respect to attitudes about HIV and AIDS and reported practices of higher-risk or safer sex, to achieve a better understanding of how young people are responding to the challenges of the HIV epidemic in contemporary South Africa. Methods Qualitative methods, including focus group discussions, were utilised. Purposive sampling at the selected university targeted both male and female students who were recruited across all academic levels (from first-year to postgraduate) to represent the diversity of students across the faculties, nationalities, races, socioeconomic classes and cultures represented at the university. These are suggested as salient features by the literature, and had also emerged in the educational work of HIV programmes at this university. The university where the study was conducted is located in an urban area. In 2009 the student population was 48% coloured, 39% black, 7% Asian and 4% white. Considered a ‘disadvantaged’ institution prior to 1994, many students at the university remain disadvantaged both materially and educationally (Bozalek, 2012). A study examining the throughput of graduates in higher education institutions
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in South Africa (Letseka, Cosser, Breier & Visser, 2010) reported that this university had a high proportion of graduates in the lowest socioeconomic category (approximately three-quarters), compared to an average of 56% across the seven institutions studied. Twenty focus group discussions guided by a semi-structured interview guide were conducted. Only students who were over 18 years of age were included in the study. Each focus group included six to 10 participants, and the groups were variously mixed-gender, women’sonly or men’s-only. Participants were identified in advance through convenient forums, such as tutorial groups and lecture classes. A skilled facilitator regarded as acceptable and appropriate with respect to age, gender and cultural/ language background facilitated each group. The discussions were largely conducted in English, lasted 1–1.5 hours, and were audio-recorded with the participants’ permission. A demographic questionnaire was administered at the start of the discussions to collect information on the participants’ gender, age, programme/degree of study, years on campus, urban or rural background, and residence on or off campus. The larger study looked at reported sexual behaviour and the dynamics of sexual negotiation on campus, including students’ responses to the imperative of safer sex in light of HIV risk. The research was undertaken to gather rich qualitative data that would give those engaged in HIV prevention and education a better understanding of the particular and current context in which sexual practices and relationships take place on campus. Thus, the semi-structured interview guide asked questions about the nature and dynamics of sexual relationships on campus, with a focus on challenges to safe sex and equitable sexual practices. The participants were not asked to elaborate on their personal experiences but asked about what generally happens on campus. We specifically employed this thirdperson interviewing technique because prior experience (and other research on sexuality and other potentially sensitive topics: Strebel, 1995) suggested that it is more comfortable for participants to ‘distance’ themselves from the stories they tell. Speaking in the third-person, even if the experience is one’s own, arguably facilitates sharing, more than if directly asked about one’s own behaviour and experience. All standard ethical procedures were maintained, with particular sensitivity to issues of confidentiality and anonymity, given the focus on sexual behaviour and the link with HIV (which is still highly stigmatised in South Africa). Ethical clearance was obtained through the university’s research and ethics committees. A qualitative thematic analysis was conducted on the transcripts, which were transcribed verbatim from the audio recordings. The analytical software package ATLAS.ti was used to process and analyse the data. Qualitative research, which is “concerned with making sense of human experience from within the context and perspective of human experience” (Kelly, 2006, p. 346), has been widely applied in the pursuit of rich data within socially engaged research for the purpose of generating a deeper understanding of the particular social problem being researched. Drawing
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on the work of Braun & Clarke (2006, p. 81), our analysis involved identifying patterns or themes across the dataset “within a social constructionist epistemology (i.e. where patterns are identified as socially produced)….” Since the study was specifically commissioned to serve the purpose of informing HIV-prevention and educational interventions on the campus, we were concerned with the multiplicity of meanings in students’ perceptions and reported behaviour in relation to HIV and safer sex rather than attempting to ascertain the extent and ‘truth’ about actual practices. Notably, the study did serve to inform such interventions and led to the formulation of a range of novel and alternative messages for behaviour-change communication material on this campus.
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Findings The larger study generated a wide range of themes relating to sexual practices on the campus. Here, we draw out key themes concerning the extent to which the participants reported safer-sex practices among students, and constructions of students’ perceptions of HIV risk in light of their HIV knowledge and the extensive HIV-prevention messages in South Africa. The findings are presented in three sections: the participants’ reflections on students’ general knowledge about HIV and how this relates to safer-sex practices (particularly condom use); identification of challenges to practising safer sex, especially given university students’ knowledge of HIV and higher-risk behaviour; and perceptions about the risk of contracting HIV, including denial of the risk and AIDS ‘fatigue.’ HIV knowledge and condom use There was a strong sentiment that students were well-informed about HIV and safer sexual practices and that condoms were readily available on campus: ‘I think, in general, we are quite educated as to AIDS’ (mixed-gender group). ‘They’re aware of HIV and AIDS. They know everything…because I know there’s a lot of educational programmes, condoms everywhere you go; there’s posters everywhere, everybody knows about it’ (mixed-gender group). It is not surprising that students should report being knowledgeable about HIV and AIDS and well-versed in safer-sex practices, given the proliferation of interventions and the public promotion of HIV-prevention messages. Such findings are reflected in other studies in southern African university contexts (i.e. Harding, Anadu, Gray & Champeau, 1999; Peltzer, 2005; Ntata, Muula, Siziya & Kayambazinthu, 2008). For example, Ntata et al. (2008) found that almost 70% of students at a Malawian university felt they knew enough about HIV and AIDS, 67% knew where to find condoms on the campus, and over 80% knew where to access HIV testing on campus. However, despite university students’ HIV awareness, the participants reported that higher-risk sexual practices are common, and their narratives, elaborated in the next theme, highlight the complexity of factors that impact on young people’s heterosexual relationships and sexual negotiation:
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‘By the way they behave, I don’t think [students are practising safer sex]. Because all the information is there, it’s on TV, there’s condoms in every toilet, it’s on radio everywhere, but everyone’s pulling a blind eye, they just act like they don’t hear it, like they don’t know of it’ (mixed-gender group). ‘They [condoms] are all over but they are not being used. ’Cuz you can see in our toilets they are being used to close the taps. So they are using them but not for the right thing’ (women’s group). ‘People meet in the [student bar], they drink together, one is speculating, or one of them or both of them are thinking of having sex afterwards. All of a sudden they’re drunk and they find themselves having sex. So how is it possible, two of you, once you are in the room, you are excited, you want to have sex, I don’t think people will think about using condoms and HIV and AIDS. People have knowledge of HIV, people do know HIV is a deadly disease and everything, but how sex happens most of the time, it’s not something that is really planned’ (men’s group). ‘Ja, but I think the more they do it, the more extreme they become, you know. Sometimes it’s once without a condom and then they do it the whole time without a [condom], you know, it gets more extreme the more you do it. You don’t learn from it, you become, you actually do worse stuff than you did before’ (mixed-gender group). Similarly, Nigerian students reported good HIV knowledge, yet engaged in higher-risk sex (Harding et al., 1999); and only about half of Malawian first-year students reported using a condom at last sexual intercourse (Ntata et al., 2008). Notwithstanding the reported high prevalence of unsafe sex among students, there were also constructive and responsive narratives that revealed shifts in students’ behaviour and increased sexual responsibility. Alongside the reported practices of unsafe sex were perceptions that condoms are more widely used than in the past, and that safer sex with condoms is viewed positively and even responded to in congratulatory terms: ‘I don’t know for other people, but for me both times I was drunk and both times we did use condoms; I had the condoms [clapping]’ (mixed-gender group). ‘With me, that will be, it will show somebody who knows what they want, somebody who is serious about their life. They don’t want to get pregnant, AIDS or anything. They know what they want; they focus on what they want. Even if you are in a serious relationship, they still insist on using protection’ (women’s group). The participants talked about taking responsibility for one’s own behaviour, revealing an incorporation of messages about safer-sex practices and the importance of agency, and they made suggestions about how to improve communication about HIV risk and safer-sex messages to students: ‘I used to have unprotected sex with my partner and someone asked me — What about safe sex,
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aren’t you afraid of AIDS? And I was like — But I am faithful. But now the thing is, how can you be sure if he is faithful? And I am responsible for myself. I can’t just blame him. I must take responsibility for myself. I don’t want to know if he’s faithful or not, but let me just look out for myself. Let me use protection just in case’ (women’s group). ‘Maybe teach people how to talk about sex and how to negotiate sex, not in terms of condom use or whatever, but just the actual sex and [how to] say — I want to have sex with you — so that somebody can prepare, because I’m actually going to have sex and agree on that…and if it has maybe been spoken about, and if we can start teaching people that it is important to start talking to people about sex before we have sex, then somehow it might help to actually think about using condoms’ (men’s group). Reported challenges to safer-sex practices The participants suggested various reasons why they felt condoms are not used and why safer sex is not practised frequently despite reportedly widespread knowledge of HIV. They regarded higher-risk behaviour among students, especially difficulties in negotiating condom use, as a reflection of gendered power relations, as has been extensively reported in local and international studies exploring the dynamics of sexual negotiation (e.g. Varga & Makhubalo, 1996; Terry, Mhloyi, Masvawure & Adlis, 2006; Shefer & Foster, 2009): ‘Girls are really pressurised into not using condoms — actually easily pressurised’ (women’s group). ‘My point of view is, the point remains that both parties, the male and the female, need that pleasure, but now it’s as if the female part is denied the strategies. The ground is not levelled for both parties. Here is a man given all the potential to negotiate sex — he has access to a male condom, the opposite party doesn’t have — and here there are two people who need that transaction, that act. In other words, both of you are being pushed to get into that activity, but one has got more negotiating power, more facilities than the other’ (men’s group). ‘Most girls will keep quiet because they do not want their man to run away. If they raise such issues such as HIV testing, let’s do this, let’s do that, yes. Um, the males are more dominating in relationships, and most girls lack self-esteem’ (mixed-gender group). ‘Uhm, they [women] don’t have that strength or that power to initiate condom use and negotiate condoms. They just, they just, ja, too soft and, you know, I think they are the ones who are much at risk. Because a girl who goes [there], they know what’s going around in parties and the [student bar], and whatever; they know that guys sleep around, so I protect myself’ (women’s group). Similar to the findings of other local studies on condom usage (MacPhail & Campbell, 2001; Eaton, Flischer & Aaro,
2003), the participants highlighted the complex social and interpersonal contexts that impact on the dynamics of sexual behaviour and influence decisions about condom use. In this study, substance abuse and notions of uncontrollability ‘in the heat of the moment’ (as referred to above) were seen to lower students’ inhibitions and militate against the use of condoms, for example: ‘I have a friend, like when we’re at the [student bar] she leaves with guys, like every week it’s different guys. Because she drinks, she’s out of it, she doesn’t remember a thing, she’s out of control. I speak to her when she is sober and say — Listen do you use protection? She doesn’t care, because she’s on contraceptives. They’re just too drunk and they lose control, they don’t really care’ (mixedgender group). ‘I was at the point that in [your residence], yes, you might have the condoms on you, then you use it, but there’s also in the heat of the moment. This and that happens and you just don’t have it on you, and then you have that guilt you didn’t use a condom’ (mixed-gender group). Other issues relating to normative practices in heterosexual relationships, particularly men’s resistance to using condoms, also emerged frequently, including reports of men’s preference for ‘skin-on-skin’ sex, peer pressure, the coercion of women to not use condoms, and men’s threats to leave women who insist on condom use: ‘A lot of boys, they do that pull-out technique, to have sex skin on skin’ (women’s group). ‘And sometimes I actually wonder if it’s maybe, if it’s a little thing too with peer pressure. Maybe, what their friends are doing, they want to be, this or go on like that, but it’s like — Come on, get a life, let’s go. And, or sometimes you just want to fit in, maybe’ (women’s group). ‘Guys, most of them, if you are in a relationship with them they want to control you. Even if they want to come to your place and you are studying you can’t say you are studying, they want to come ’cuz they are like almighty. If you don’t want them to come, they’ll find somebody else to go to, and they’ll tell you — Is it how you want it to be? Then I’ll find somebody else. And you’ll feel guilty, like, ooh, he’s gonna find somebody else now’ (women’s group). As constructed by both men and women, the idea of condom use as inappropriate in long-term relationships where faithfulness is assumed also emerged (Shefer, 2009b). Perceptions of a need for condoms only with one-night stands and not with regular partners, and condom use as evidence of non-trust between partners, were reported by the participants as barriers to condom use: ‘Like the HIV issue, we know that it’s there, but I mean the girl would say — No, but I love him. I don’t want him to go to another girl because he insists that we don’t use condoms, because if we do condoms then he’ll go, that means I don’t trust him, so he will go to the person that I’m suspecting that he is having an affair with, and stuff like that’ (mixedgender group).
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‘But I’m just saying, with sex partners I’m sure they do use condoms, because they do have their own girlfriends and boyfriends, so they need [condoms] just for that one time’ (women’s group). ‘[It’s] linked to trust, too. You’re maybe in a relationship, maybe for one or two months, then you think, ok, now we trust each other, we can leave the condoms. I only have sex with you, so it’s fine. They develop that trust and that’s very dangerous’ (mixedgender group). Embarrassment at procuring condoms (even though readily available on campus) was also viewed as a barrier to condom use, especially for women. This points to the normative construction of female sexuality as passive and focused on having a relationship rather than enjoying sex, and therefore denotes the continued repression of positive discourses on female sexual desires, as identified in the international and South African literature (Holland, Ramazanoglu, Scott, Thompson & Sharpe, 1990; Lesch, 2000; Harrison, 2008; Kahn, 2008; Shefer & Foster, 2009). For example, one participant commented: ‘But you mentioned the condoms dispenser — no one wants to be seen go fetching a condom. Even if you have sex, you don’t want people knowing or seeing you with a condom. Like, I don’t want people knowing I’m having sex’ (mixed-gender group). While women were often seen as responsible for HIV infections and prevention methods, there was a perception that women are reluctant to use or carry condoms. Moreover, there seemed to be greater concern for unplanned pregnancy, so that if a woman was taking oral contraception this seemed to remove the need for using condoms as well: ‘And we are assuming that HIV and AIDS is the woman’s responsibility, and actually we are putting responsibility on the women more than the men; and yet it involves two people, you know what I mean?’ (men’s group) ‘It needs to become okay for a nice girl to carry a condom around…because I’ve heard it a million times, where girls don’t want to carry condoms around with them because people will see it and think that they are slutty’ (mixed-gender group). ‘It then makes me wonder, when a person is on contraceptives, right, then they are more, like, worried about them not getting pregnant. My question would then come, when they are on contraceptives, this tells me, then this tells me, that they will forego the condom, which means that they put them on high risk’ (women’s group). ‘Because I think that reputation of having a baby is much bigger than [HIV] status, because, I mean, [HIV] status is not something you can see, but obviously pregnancy is something people can see. So if you’re judged for something that people can see through, what would you really stop? Your pregnancy, probably’ (mixed-gender group). Denial and AIDS fatigue Discussion in the focus groups revealed a perception that many students are in denial of personal risk of infection, and
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the sense that HIV and AIDS was still largely unreal and invisible to most students: ‘I think that they do know the risks, but they tend to ignore them, since they think — Fine, I’m still young, and there are girls here and guys here that also study — Where could they possibly get the virus? They, like, tend to distance the virus from themselves and people surrounding them. So they totally ignore them, ignore the risks’ (mixed-gender group). ‘I don’t think they believe they are at risk. Most of the time they are thinking — Oh, it can’t happen to me. Some students you hear them saying they had sex with somebody, like at a party, and you say, like — Aren’t you scared of AIDS? — and they [say] like — No, it’s just AIDS, it won’t happen to me — and they are not like worried. Somebody once said to me — It’s like once you have AIDS, it’s like you’re a celebrity!’ (mixed-gender group). These comments are similar to the responses of students in other studies: for example, an early study among South African university students (Perkel, 1992) found that 63% thought it was ‘not likely at all’ that they were at risk of HIV infection; more recently, Ntata et al. (2008) found that among first-year Malawian students as many as 68% felt they were not at risk of acquiring HIV; and, Peltzer (2005) found that over 80% of both female and male students at a South African university indicated they had never worried about the risk of HIV infection. The participants also conveyed that talk about AIDS is widespread, although the thought of the HIV epidemic remained abstract to them; this possibly serves as a way of legitimising HIV-risk denial. Also evident was a sense of information overload: ‘For me, I think AIDS has become like this abstract thing. You hear about it. You see it on TV, and blah, blah, blah. But you don’t see it. You don’t see people suffering from it. Because there is no one near you who has [the disease] and you don’t see the effect it has on their families and stuff like that’ (women’s group). ‘I’ve never seen a real person with AIDS’ (mixedgender group). The argument among some participants that they had ‘never seen a real person with AIDS’ is somewhat unexpected in the South African context, where over 5.5 million people are living with HIV (UNAIDS, 2010), yet it may be serving to legitimate a denial of risk through a denial of the public presence of those who are ill. Interestingly, in a study of youths in an urban South African environment, Motsemme (2007, p. 75) found that young women avoided naming HIV and AIDS directly; they “put it at the back of their minds and chose to forget” that it could affect them, while at the same time experiencing “fatigue at the constancy of deaths taking place around them.” The negative stigmatisation of AIDS and those who are living with HIV, which has been of much concern in South Africa (cf. Bollinger, 2002; The POLICY Project, 2002 and 2003; Shisana et al., 2005; Shisana et al., 2009), was likewise reflected in the students’ comments:
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‘Ja, almost like, they portray the virus as like…an evil, a evil being; and in that way they, it’s easier to stigmatise people with HIV/AIDS. So they contribute to the stigma, stigmatising HIV/AIDS, people who have AIDS — they contribute’ (men’s group). ‘Uhm, well, you know people will still say that it could be sort of a stigma attached going for an HIV test’ (mixed-gender group). The student’s denial of HIV risk also drew on ‘othering’ discourses in racial terms, whereby mostly certain communities were viewed as at-risk (cf. Mitchell & Smith, 2001b; Deacon, Stephney & Prosalendis, 2005; Airhihenbuwa, Okoror, Shefer, Brown, Iwelunmor, Smith et al., 2009): ‘That’s the main thing, everyone’s like — Ag, man, it only happens to like, black people, it happens to poor coloured people — or something like that’ (mixed-gender group). ‘I’ve met one coloured person who…came to speak at our school. So, it was one coloured person that we know who has AIDS.… But he also said that he slept around and he was a womaniser, and all that stuff’ (mixed-gender group). ‘And it’s, it’s normally when they show people that have AIDS, it’s Africans. They don’t show coloured people. They don’t show whites. I don’t know why. But it’s what I’ve seen’ (women’s group). ‘You know I noticed that as much [as] we are being taught that HIV/AIDS is there, but every year we hear that the rates of HIV/AIDS are increasing. It’s not like that people don’t know that HIV/AIDS is there, it’s just that people are like —No, it won’t happen to me, no, it will happen to, you know, to black people, or you know these other people that are there’ (mixed-gender group). Closely associated was a sentiment that young people are experiencing AIDS fatigue, a situation similarly described by Holmes (2005). Moreover, some participants stated a perception of HIV fatalism and commented that the availability of antiretroviral (ARV) drugs had possibly reduced individuals’ fear of becoming HIV-infected: ‘We have become too comfortable with AIDS’ (women’s group). ‘But the prospect of getting another assignment on HIV and AIDS, I think that’s the thing. It’s another assignment…there’s no shock value to HIV and AIDS anymore’ (women’s group). ‘They brush it off now, because they’ve heard so much about it in school, and whatever, that now they think — Oh, it’s just another one of those posters again’ (mixed-gender group). ‘I don’t think students are even aware of what happens, ’cuz the thing is this other friend once told me we are all going to die someday, you’re just gonna die sooner [laughter], so what’s the big fuss about it? You get sick, they will provide for you, you will get ARVs. We’re not gonna be here forever, so you just gonna die sooner’ (women’s group). One participant’s suggestion of what is needed regarding HIV education highlights the information-saturation that
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reportedly has facilitated emotional exhaustion leading to apathy about practicing safer sex: ‘I think, like, people have heard enough of AIDS. Like what she said, they all know that. I think now we should just focus on teaching them self-esteem, like how to say — No. Support groups on motivation, not on HIV, HIV, HIV — because it’s tiring’ (mixed-gender group). Conclusions The findings highlight the continuing gap between knowledge and behaviour with respect to safer sex and HIV prevention among young and educated South Africans. In the time since early research conducted on university students’ attitudes and knowledge relating to HIV (see Strebel & Perkel, 1991; Perkel, 1992), young people have become largely familiar with HIV and the need for safer-sex practices, and they have easy access to condoms. In spite of this changed context, with increased access to information and resources as well as exposure to constant HIV-prevention messages, young people evidently remain at risk for contracting HIV and other sexually transmitted infections, as well as unwanted pregnancies. This study reinforces a large body of work arguing that higher-risk sexual practices hinge on a complex of factors, including the intersection of normative gender roles and gender power relations with poverty, age and other forms of social difference and inequality (cf. Clowes et al., 2009; Shefer et al., 2012). Yet, while these findings reflect and substantiate other findings emerging from research on the topic of youths, HIV and sexuality, some of the specifics emerging from this study and others on university campuses reveal a range of subcultural practices particular to student life. These include peer pressure to be sexual, the drinking culture on campuses, and insecurities among many students who live away from home, which may all exacerbate the gender normative behaviours that facilitate higherrisk sexual practices. It is also evident that racialised and classed discourses on HIV and AIDS facilitate a sense of immunity, a tendency for ‘othering’ discourses, and risk denial among young people. A denial of HIV risk links to these discourses, but also relates to a denial of familiarity with people living with HIV. Given the high number of people living with HIV (indeed, many students at this university belong to communities with some of the highest HIV-prevalence levels in South Africa and globally), it is surprising that some students claimed to not know anyone living with HIV nor notice anyone ill with HIV. This finding may also link with HIV stigma and the fact that acknowledgement of AIDS as a cause of death is typically repressed from public discourse. Significantly, popular efforts to impact on sexual practices still seem to fail in contrast to the desired impact of interventions; inadvertently, these interventions and HIV-prevention messages may be having a negative effect on young people through the creation of what is called AIDS fatigue. Thus, a sense of information overload, saturation and personal impatience with this barrage of information becomes evident. University students’ tiredness with hearing HIV-prevention messages
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may be fuelling HIV-risk denial and dulling their consciousness of the importance of safer sexual behaviour. The findings here point primarily to a need to find innovative ways to impart HIV-prevention and safer-sex messages at higher education institutions, especially since young people are possibly more in denial of their risk than in the earlier phase of the epidemic in South Africa, as argued elsewhere (e.g. Mitchell & Smith, 2001a and 2001b; Baelden, Van Audenhove & Vergnani, 2012). Feminist researchers have long argued the importance of challenging normative gender roles and relations as part of the larger HIV/AIDS educational framework, and it may be that messages that speak to gender and human-rights norms in relationships, as well as gendered and sexual identities and multiple forms of power, may be more helpful than current upfront, directive and didactic messages that address basic HIV/AIDS knowledge and foreground HIV risk. Given young people’s fatigue and resistance in relation to HIV-prevention and safer-sex messages, it is arguably imperative to continue developing interventions that are more subtle or not explicitly linked to HIV, as well as more creative and inspiring for young people. Furthermore, since cultural and racialised discourses emerged as central to the way in which traditional heterosexual practices are legitimised, and the way in which HIV risk is ‘othered,’ it seems imperative to focus on deconstructing culture and notions of cultural difference, as well as on ways to engage in antiracist education on campuses. Such interventions could be part of broader initiatives to transform the institutional culture at South African universities. As importantly, the links between culture, traditional norms, and heterosexual practices in the light of HIV should be debated on university campuses. Acknowledgements — We acknowledge the students who shared their stories; we thank Elron Fouten, Melani-Ann Cook, Tania Vergnani and Lindsay Clowes for research support; the HIV and AIDS Programme at UWC for initiating and recruiting funding for the research and the anonymous reviewers for their l guidance. The authors — Tamara Shefer is a professor of women’s and gender studies and the deputy dean of teaching and learning in the Faculty of Arts at the University of the Western Cape. Her interdisciplinary research and publications have been mainly in the areas of heterosexuality, HIV, gendered and raced subjectivities, authorship and knowledge production. Anna Strebel is extraordinary professor of women’s and gender studies with the Faculty of Arts at the University of the Western Cape. She was one of the first to research the topic of women and AIDS in South Africa, and continues to publish widely on gender, sexuality, mental health and HIV. Joachim Jacobs is a programme manager in the HIV and AIDS Programme at the University of the Western Cape. He has extensive experience in the development and evaluation of HIV-prevention programmes and has led two major HIV/ AIDS collaborations involving universities in four countries of sub-Saharan Africa.
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