In this dissertation, public health relevance is defined as a state whereby a condition or a situation, be it of social, political, economic or a cultural nature has either a positive or a negative implication for the health of a population or segment thereof. Health is significant as it is not only a goal to which all institutions of society should strive and a logical outcome of
38 social and economic development but also a necessary condition for the realization of that development (World Health Organization, 2009b).
The public health relevance of this study stems from the fact that it aims to identify the meanings that PLHIV attach to their conditions in terms of the circumstances within which they are diagnosed as HIV positive, the effects of HIV in their lives, and the coping strategies they adopt. This information is important as it can inform a review of intervention strategies targeting PLHIV and the general community. The results may also provide a basis for wider community mobilization and contribute to the creation of a conducive environment for adaptive coping. Improved quality of life arising from a supportive social environment can only be realized when opportunity is availed for PLHIV to articulate issues of concern to them and in ways that makes sense to them. In this sense, the method adopted for this study, a phenomenological approach, provided a chance for the people most affected, PLHIV, to tell their story as they experienced it.
The process of how people make sense of, live with and respond to HIV, including how they cope and adapt, and the challenges they face are matters of socio-medical or public health concern. This is because the meanings of illness are shared by a culture or group and are derived from the beliefs, values, and world views of that particular group. As such, meanings have a much wider reach and coverage and transcend the individuals experiencing the illness.
Moreover, being ill impacts not only the individual affected but his/her family, friends, network of relatives and the community at large in one way or another. Additionally, HIV may have far-reaching implications for other aspects of social life. Given that illness is experienced in the body, is something real, and is also closely related to the social life, it is consequently a social phenomenon and hence public health relevance of living with HIV (Roth and Conrad, 1987).
HIV/AIDS has a profound impact that has consequences for the entire social system. At the individual level, HIV is progressive and in conditions where medication and other forms of care and support are missing, it may lead to loss of physical strength and capacity to perform basic mundane functions thus hampering their engagement in productive activities—such as employment or in agricultural production. Infection with HIV may consequently lead to loss of household income and livelihood—in the sense of one losing a job or not being able to engage in income generating activities. Due to this loss, HIV increases the likelihood of dependency, poverty and loss of livelihood assets as these are sold to help pay for medical costs and other family needs such as school fees and other household expenses. When these
39 assets are exhausted, relatives and community members are often forced to come in to assist hence intensifying levels of dependency (McCracken and Phillips, 2012; Skolnik, 2008).
HIV also negatively affects families and communities. For instance, HIV/AIDS has led to a rise in the number of orphans at levels never before contemplated. As children lose one or both parents to AIDS, they are exposed to an uncertain present and future and are often at the mercy of a sometimes very cruel society. Moreover, due to the high numbers of these orphaned children, many are unable to find foster homes where they can be taken care of and consequently often end up as street children or engage in risky sexual behaviours—either due to sexual exploitation and abuse by others or out of a need to survive when no other options are available (McCracken and Phillips, 2012; Merson et al., 2012; Skolnik, 2008).
At the societal level, HIV has an adverse impact on the economic system, the workforce, the health care system, the public sector as well as the security sector. Similarly, HIV has damaging impacts on the education, political and the agricultural sectors. In some African countries, for instance, it is reported that HIV/AIDS-related diseases are decimating the workforce—especially the teaching fraternity and medical cadres—at faster rates than can be trained. The burden of HIV is further argued to be leading to socio-economic decay of several countries—especially those in SSA. Due to the impact of HIV on rural labour force, there are areas where agricultural production has been heavily impacted for there is no human power for preparing farms, planting and tending crops and collecting the harvest (Baylies, 2002;
Hosegood, 2009; Pennap et al., 2011; Skolnik, 2008; Zhao et al., 2011).
HIV/AIDS represents not only a public health challenge for individual nations but also to all of mankind as it does not discriminate based on any category including international boundaries. Due to the possibilities provided by international travel, migration and other events that bring people from several nations together—including sports and games—diseases including HIV have increasingly taken on a global dimension. The epidemiology of HIV/AIDS is such an epidemic whose reach is truly global. HIV is therefore an issue of international or global health concern. In this sense, in so far as health is concerned, the global community is bound by a common destiny and responses similarly have to take a global orientation (Skolnik, 2008).
HIV disease as well as its social sequelae is also a human rights concern as it is mostly associated with the poorest regions of the world—especially SSA—and with the powerless and defenseless, mostly the young in age and the female in gender. Examples are children infected vertically by their mothers during birth or breastfeeding, and those adults infected
40 horizontally by their partners or spouses. All these are largely unintentional occurrences. In terms of gender, more women than men are infected and among these women, younger women are at a greater risk. HIV and AIDS also disproportionately affect groups such as commercial sex workers, injecting drug users, long-distance truck drivers and other population segments who are exposed to infection due to their working conditions or lifestyle.
It can be argued that issues of power are at play as these groups do not have adequate access to powerful social statuses and adequate resources to influence the course of their lives (UNAIDS, 2006).
Since the onset of the epidemic to the present time, stigma and discrimination have been consistently identified as key barriers to an effective response to the devastating effects of HIV/AIDS. Additionally, stigma is reckoned as a universal phenomenon operating both at the global and local levels. Stigma and discrimination are manifested at all levels of society and permeates through all its institutions. Since stigma is a key barrier to HIV related interventions it is an important focus for public health (Groh et al., 2011; Makoae et al., 2008;
Melchior et al., 2007; Nyamathi et al., 2011; UNAIDS, 2007).
Additionally, HIV/AIDS contributes to the global burden of disease and is one of the leading causes of death. It is estimated that communicable diseases are responsible for about 44% of all deaths and for approximately 40% of the burden of disease 1(BD) as measured by disability-adjusted life years (DALYs)2 in countries classified as low- and middle-income (Skolnik, 2008). HIV/AIDS, malaria and tuberculosis rank among the communicable diseases with the most remarkable impact in developing countries (McCracken and Phillips, 2012;
Skolnik, 2008). Whereas data for 2002 showed that HIV/AIDS was the third leading cause of disease burden among women and men globally, it was listed as the leading cause of disease burden in WHO Africa Region (Pomerleau and McKee, 2005; World Health Organization, 2009a).
HIV was ranked as the sixth (6th) most significant cause of death in 2012 by the World Health Organization (WHO) (World Health Organization, 2014). HIV/AIDS accounted for about 1.5 million deaths in 2012 worldwide which represented 3% of all deaths. The other
1 "A measure of disease combining years of life lost due to premature mortality and years of life lost due to time
lived in states of less than full health.(McCracken, Phillips 2012)
2 Disability-adjusted life years: “The years of life lost to premature mortality and years lived within a disability,
adjusted for the severity of the disability. One DALY is one lost year of healthy life. The DALY thus gives a wider picture of health problems (disease burden) than by just mortality statistics, through incorporating the non-fatal consequences of ill-health and injuries" (McCracken, Phillips 2012)
41 important causes were Ischaemic heart disease (7.4 million), stroke and other cardiovascular diseases (6.7 million) and lower respiratory infections (3.1 million) (World Health Organization, 2014). The greatest contribution of HIV/AIDS as a cause of mortality was evidenced in low-income countries where according to WHO, it featured at the third position among the top ten causes of mortality. It accounted for 0.72 million of deaths or 8% of the total. The only other diseases that outranked HIV/AIDS were lower respiratory infections ranked first and responsible for 1.05 million deaths or 11% of all deaths. At the second position was diarrhoeal diseases accounting for 0.76 million (equivalent to 8%) of the total deaths. (World Health Organization, 2014). Figure 1-2 provides a comparison of causes of death across income categories globally.
(Source: World Health Organization, 2014)
Figure 1-2. Leading causes of death globally (2012)
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