**3.2.1 Poverty is an over-riding risk factor in HIV/AIDS and GBV**

Rural incomes are low and provide only marginal resources for health care or for maintaining health. However, the bureaucracy required to supplement rural incomes reflects an interaction between affordability and availability issues:

*I think more funds need to be allocated for them so they'll be able to buy enough formula for the babies and immune boosters for the HIV patients. There needs to be enough funds for them, food like porridge, beans…foods that have protein….We have just one social worker, and it's hard for our HIV patients to access disability grants, and the orphans too, you know getting these grants take a long time.* 

Volunteers in the community who participate in essential home care activities find that the costs are too high:

*When this thing started home based carers used to love their job but now they do not get paid and they no longer like it, these people used to help the pensioners a lot but now do not because there is no pay.* 

#### **3.3 Issues of acceptability**

#### **3.3.1 Complex health care concepts and rural people**

In environments of socially mediated disease, there is often a tension between public health protocols and community knowledge and priorities. In this study area, clinical criteria for HIV/AIDS treatment occasionally conflict with community understandings of the disease and with their readiness to act:

*Why it is necessary for a person to have an ID for a CD4 count, meaning without an ID you cannot check CD4? Since people need to start treatment when their CD4 count is less than 200, you get people that come in very sick but they can't attend the sessions.* 

Similarly, ART compliance is more complicated for rural patients living at home:

*Maybe if they were like other pills and were being taken in the morning, midday, and night without specific times, it would make life easier especially those who are not educated. It would be so much better if the government could change the policy on taking ARVs, and not have a specific time.* 

Rural persons are among the last to learn about treatment complexities, or contradictions between earlier medical advice and current practice. For example, breastfeeding had been strongly promoted in rural areas in the past. Then it was not recommended for HIV positive mothers. Similarly, modern methods of birth control can lead to increased risks of HIV infection:

*The rate of HIV would go down if the prevention methods used (Depo-provera), were to be reduced, because you find that people don't want to use condoms.* 

Communication of complex health care concepts to rural people can be hindered by the mandate for training new professionals, illustrating the link between acceptability and availability of professional care:

*That's partially medicine. It's got a history of using funny abbreviations that nobody understands but it doesn't improve communication with people… But within the hospital, if you can't have clear communication between all the different health professions and patients, how can we expect the patients to disclose to their partners or families?* 

At the same time, language differences between Zulu, Xhosa and English-speaking staff and patients limit effectiveness:

*We are all from different cultures, backgrounds and communication is via translators and it can be difficult. You notice a huge shift in thought and a shift in the doctor/patient relationship as a result of that.* 

#### **3.3.2 Appropriate social care**

96 Social and Psychological Aspects of HIV/AIDS and Their Ramifications

Rural incomes are low and provide only marginal resources for health care or for maintaining health. However, the bureaucracy required to supplement rural incomes

*I think more funds need to be allocated for them so they'll be able to buy enough formula for the babies and immune boosters for the HIV patients. There needs to be enough funds for them, food like porridge, beans…foods that have protein….We have just one social worker, and it's hard for our HIV patients to access disability grants, and the orphans too, you know getting these grants take a long* 

Volunteers in the community who participate in essential home care activities find that the

*When this thing started home based carers used to love their job but now they do not get paid and they no longer like it, these people used to help the pensioners a lot but now do not because there is no pay.* 

In environments of socially mediated disease, there is often a tension between public health protocols and community knowledge and priorities. In this study area, clinical criteria for HIV/AIDS treatment occasionally conflict with community understandings of the disease

*Why it is necessary for a person to have an ID for a CD4 count, meaning without an ID you cannot check CD4? Since people need to start treatment when their CD4 count is less than 200, you get* 

*Maybe if they were like other pills and were being taken in the morning, midday, and night without specific times, it would make life easier especially those who are not educated. It would be so much better if the government could change the policy on taking ARVs, and not have a specific time.*  Rural persons are among the last to learn about treatment complexities, or contradictions between earlier medical advice and current practice. For example, breastfeeding had been strongly promoted in rural areas in the past. Then it was not recommended for HIV positive mothers. Similarly, modern methods of birth control can lead to increased risks of HIV

*The rate of HIV would go down if the prevention methods used (Depo-provera), were to be reduced,* 

Communication of complex health care concepts to rural people can be hindered by the mandate for training new professionals, illustrating the link between acceptability and

*That's partially medicine. It's got a history of using funny abbreviations that nobody understands but it doesn't improve communication with people… But within the hospital, if you can't have clear communication between all the different health professions and patients, how can we expect the* 

At the same time, language differences between Zulu, Xhosa and English-speaking staff and

*We are all from different cultures, backgrounds and communication is via translators and it can be difficult. You notice a huge shift in thought and a shift in the doctor/patient relationship as a result of* 

Similarly, ART compliance is more complicated for rural patients living at home:

**3.2.1 Poverty is an over-riding risk factor in HIV/AIDS and GBV** 

reflects an interaction between affordability and availability issues:

**3.3.1 Complex health care concepts and rural people** 

*people that come in very sick but they can't attend the sessions.* 

*because you find that people don't want to use condoms.* 

*patients to disclose to their partners or families?* 

**3.2 Issues of affordability** 

*time.* 

infection:

*that.* 

costs are too high:

**3.3 Issues of acceptability** 

and with their readiness to act:

availability of professional care:

patients limit effectiveness:

Counseling is considered to be a lynch pin in HIV/AIDS and GBV social care. It is an evolving practice that originated in the West and is a common response to post-traumatic stress disorder. In rural South Africa, confidential counseling is increasingly intended to minimize the risks of HIV transmission, to prepare people for medical and social consequences of the disease and to increase treatment compliance. However, counseling may not be viewed in the same way by rural people themselves:

*Our people do not understand the idea behind the concept of counseling. Even when you explain it to them they don't see the benefit of going there. People do not see how their problems can be solved by just talking.* 

Community based volunteers for public education, support or home care are often an essential adjunct in integrated HIV/AIDS care. It is rare for adult men or younger women to volunteer, however, as they are usually pre-occupied with wage labor and subsistence activities. In the rural area, the HIV/AIDS volunteers are often older women or unemployed youth, that is, groups having lower community status. Such secondary status and varying concepts of privacy can affect the effectiveness of these volunteers and their acceptance by the community, as noted by one volunteer:

*The problem is that we wouldn't be able to tell the community members what to do…they will say we think we are better. People who do counseling are those that you are close to, you come from the same neighbourhood, so it becomes hard to open up to them; especially if the families are not on good speaking terms. You go and share your story and the counselor will share it with everyone she knows, those are the reasons we fear going for counseling. People who do counseling are not well trained.* 

#### **3.3.3 Acceptability of health care in the context of violence**

Rural communities, in turn, may not be supportive of women who experience violence. Fear of stigma and rejection by partners, family and community members inhibit women from disclosing rape to others and seeking out health care. Lack of knowledge of the risk of contracting HIV and other sexually transmitted infections (STIs) through rape means women do not necessarily consider health care an urgent priority following sexual assault:

*She will not go to the police station because she might be afraid that her neighbours will laugh at her…. I think that she wouldn't go. Before a woman can go for medical help she has to tell certain people. If she does not want her rape ordeal to be known in the area, she can just let it slip. It is difficult for women to go to hospital without telling their mothers first. Moreover, if the raped woman lives with her partner and has not told him about the rape, it would be impossible to seek help. Also, not all women know the dangers inherent in rape. Some forget that the long term effects of rape can be catastrophic (i.e., contracting HIV/AIDS).* 

Even violence towards young children elicits contradictory responses. On the one hand, there is a feeling that child rape should be hidden to maintain a girl's reputation for future marriage. At the same time, children are considered to be especially vulnerable to the psychological consequences of rape, particularly stranger rape, and are in need of counseling. Women's susceptibility to GBV and HIV/AIDS due to poverty is clear:

*Look, you know, I'm unemployed. I'm the one without a job and my boyfriend is paying for me too, for my drugs and I must' absorb' a lot.* 

Even with a broad understanding of GBV-HIV links and their effects on communities, rural community women often have more immediate priorities than HIV testing and care:

*So hunger is first, violence and a fear of violence is second, generalized poverty is third, ("How am I even going to get to the clinic to get care? I don't have bus fare.") and then fourthly HIV. So* 

An Institutional Analysis of Access to

Organization, 2004].

deprivation.

GBV/HIV Services in Rural KwaZulu-Natal, South Africa 99

While the access framework used in this paper is useful for categorization of different dimensions of access, there is also a need for exposure of underlying mechanisms that contribute to these barriers. Three major mechanisms affecting access to HIV/AIDS and GBV services in the KwaZulu-Natal rural health care system may be posed from this study. First, due to many years of isolation during the apartheid era, the health professions maintained many traditional features. They were less influenced by broader paradigmatic and practice shifts occurring in health systems in other parts of the world. There continues to be considerable role differentiation and a clear medical hierarchy in South Africa. At best, the health professions are just emerging from a model of health that minimizes a social or community perspective on causes or solutions for health problems. Such medical elitism leads to hierarchies of treatment modalities, for example, an overdependence on postinfection testing and pharmaceutical treatments over the prevention and promotion of healthy social environments. Second and third tier health workers (nurses and VCT counselors) expect full health services (e.g., PEP) for themselves, yet there is not an effective system in place to similarly protect or treat community members. Individual social work professionals are viewed as primarily responsible for managing the consequences of gender based violence, but are restricted to working in clinical settings and are rarely exposed to community conditions that underlie such violence. Overall, traditional power differentials continue to separate health professionals from each other and from the communities they serve. Those who work in areas that carry elements of cultural stigma or shame (GBV or HIV), and more generally, in counseling, prevention or palliative roles (as opposed to curative), experience lower status and professional devaluation. These power dynamics, combined with overwork and lack of resources, is leading to ever-increasing burn-out among those providing GBV and HIV/AIDS related care. This situation is not unique to South Africa and has been recognized by the World Health Organization in its Integrated Management of Adult and Adolescent Illness model that promotes task shifting from doctors to nurses and from nurses to community health workers [World Health

Second, there is considerable stereotyping of rural and poorly educated populations. Gender based violence victims may be viewed by health staff as being in primitive social relationships that condone male violence as normative. The female victim is often seen as sharing responsibility since she has stayed in an abusive relationship. Alternately, women are viewed as being victims of an accepted rural tradition of rape. There is little understanding of a middle dynamic that is neither collusive nor coercive, but relational. Generally misunderstood is the victim's deeply ingrained role in 'absorbing' her male partner's anger, frustrations, and violent reactions to persistent social and economic

Third, rural South African society presents differing perspectives on appropriate hierarchies for action related to HIV/AIDS and gender based violence. The health care worker considers the proper order of priority to be actions within their scope of practice and experience, that is, HIV/AIDS testing, treatment and prevention education. Poverty alleviation and addressing the social causes of violence are given much lower priority by health workers as these are more distal in the causal chain. Community members, however, consider hunger relief and safety from violence as their most immediate priorities, without which, longer term poverty relief and HIV/AIDS treatment implementation become meaningless. From both perspectives, within a limited resource environment, only the

*sometimes people behave in a risky way because they have to deal with the first and second need and the third need. ("HIV will kill me six years from now, but hunger will kill me in a short while from now.")* 

Ironically, in the context of a conservative rural health care environment, gender violence may be viewed as a legitimating pre-condition for a woman to get prompt sexual health care. Exposure to HIV as a result of violence is more accepted in a clinical setting than is exposure due to consensual unsafe sex, which is often considered by health care staff to be preventable.
