Why have socioeconomic explanations been favoured over cultural ones in explaining the extensive spread of HIV in South Africa?

Abstract

Sexually transmitted infections (STIs) are transmitted via sexual networks, and differences in the structure of these networks constitute the key population-level parameter that determines differences in HIV prevalence. 1 The differences in HIV prevalence between South Africa's racial/ethnic groups (19.9%, 3.2% and 0.5% for 15 -49-year-old blacks, coloureds and whites respectively 2 are as big as those between the highest-and lowest-prevalence countries in the world. These large racial/ethnic differences are not related to individual level risk factors such as lifetime number of sexual partners, but are more likely determined by different sexual network structures.3 In African networks, sexual partnerships are more likely to be arranged concurrently, and this increases the interconnectedness of the sexual network in a non-linear fashion. Evidence from numerous sources and disciplines shows that these high concurrency rates are a key factor in driving high HIV transmission rates in southern and eastern Africa. Two main categories of factors have been advanced as being important in the promotion of these high concurrency rates: cultural and socio-economic factors. Socio-economic factors are unlikely to be the predominant determinants since neither HIV nor concurrency are contoured along the lines of poverty, at the level of countries or individuals. One of the few quantitative studies looking at the determinants of concurrency in South Africa found no relationship between income quintile and concurrency, but concurrency was more commonly practiced and accepted in black communities than among whites and coloureds. 5A literature review of the explanations for the striking differences in HIV spread by race in South Africa concluded that there was a strong bias favouring socio-economic explanations. 6 As an example, one of the premier textbooks on the epidemiology of HIV/AIDS in South Africa argues that the reason why HIV prevalence rates differ between races is that 'marginalisation and discrimination on the basis of race and/or ethnicity are key factors influencing vulnerability to HIV infection.' 7 No evidence however was provided to back up this assertion. What is the explication for this bias? We argue that the playing down of cultural factors in the South African HIV aetiological literature is the result of an intersection of three factors. EXPLAINING THE UNDER-APPRECIATION OF CULTURAL FACTORS HIV'S EmERGENCE IN A TImE OF THE RESONANCE AND CONSTRUCTION OF NON-RACIALISmThe first factor relates to the post-apartheid context of the emergence of HIV. Notions of white racial and cultural superiority were central pillars of the apartheid ideology. An uncritical use of race as an analytical variable and on occasion frankly racist views would characterise much South African medical and public health enquiry during the apartheid period. HIV then emerged into prominence during the difficult period while South Africa was attempting to build a new dispensation based on non-racialism. Given this backdrop and the fact that HI...