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HIV Prevention and Education: The general context

		We operate – and try to educate – in a world that increasingly resists the message we put out. In short, the consensus within the AIDS arena is that prevention doesn't work. For a while it did – particularly for Gay men in the States – but long-term it has failed. Quite what has failed is debatable: the message, as always, about condoms and safer sex, has changed little. Maybe that's part of the problem. Maybe men and women think they know it all. After all, apart from the odd bit of unsubstantiated paranoia about oral sex, little has changed in terms of the information we give out since the late 1980's. But what seems to have failed us, all of us, most of all is the WAY we tell people about these things.

	The days of mass media and the publicity fear are well over – even our Minister of Health has spent our budget. What seems to be the way to go is the route that some projects in the US have had some success with – and that is to talk with, not to, to talk about, not at.

This means targeting and talking at length with small groups of people with a common cause. For us that means men and women and the common cause – I sincerely hope – is the prevention of the spread of HIV. The problem is that even that common cause is being challenged by the so-called return of unsafe sex – or slippage" as it is sometimes called. My feeling is that it has been there all along – it's just that people didn't talk about it. And now, slowly, it might just be becoming possible to do so – to admit that actually safer sex is bloody hard work and that it DOESN'T come naturally (if you'll excuse the pun).

THIS is what our health education initiatives need to be based on – reality, not some well-meaning belief that just because condoms are relatively accessible to an increasing number of people, that people are actually USING them. There are far too many reasons why they may well NOT be using them and it is talking about those reasons that matters. And we need to talk about them at a level that makes connections with the reality of those people's sex lives – and, for that matter, their lives as a whole – so that somewhere along the line meaningful connections are made and the beginnings of potential behaviour change can be made possible.




HIV Testing: The confessional of the 90's

confession = counseling and admitting to an indiscretion

repentance = guilt felt towards partner/wife , fear of placing regular partner at risk, expecting condemnation for the activity, fear of having contracted HIV

atonement/penance = waiting for the results

forgiveness = negative results

The increase in awareness and education around the issue of HIV transmission and infection has led to more people being aware of the risks they take when indulging in unprotected sexual activities. We have become aware of a group of clients who present for HIV testing following an incident of extramarital sex, contact with a sex worker or homosexual contact in a man who presents to the world as being heterosexual.

Anonymity vs confidentiality - often clients won't go to their own doctor because they feel the doctor knows the rest of his family and the information will not be confidential. The SAIMDC describes a doctor's duty to keep information confidential: "(no practitioner may) divulge verbally or in writing any information which ought not to be divulged regarding the ailments of a patient except with the express consent of the patient or in the case of a minor, with the express consent of the guardian, or in the case of a deceased patient, with the consent of the next of kin or the executor of his estate. [ Rule 16 of SAIMDC's Rules of Practise]. Despite the guarantee of confidentiality that this clause offers, it is cases such as the McGeary case (where the patient's HIV status was disclosed by his doctor to a dentist on the golf course) that cause patients to doubt the reality of this confidentiality.

We offer anonymous testing and are therefore perceived by clients as being a "safe place" to confess their transgressions.The counseling involves a frank discussion of the activities participated in and the risks inherent in those activities. This confession is often accompanied by embarrassment and the expression of guilty feelings. The level of anxiety related to the fear of contracting HIV is quite often out of proportion to the reality of the level of risk involved. An example of this would be the man who refused to accept assurances that masturbating in the presence of a sex worker was not a high risk activity. The fear of HIV appears to be linked to the degree of guilt felt towards the activity.

For men in a stable relationship there is not only the fear of having contracted HIV himself but also the fear that he may pass it on to his partner. While waiting to confirm his HIV status he may try to avoid sexual contact with his partner who is of course unable to understand his behaviour. This denial of his sexual desire is sometimes also seen as a sacrifice that indicates his repentance.

Since the availability of PCR testing , with the window period of 14 days, the client now has a much shorting waiting period as opposed to antibody testing with a window period of 42 days to 3 months. PCR testing is very expensive and restricted to certain centres. The public is generally not aware of the availability of this test and so the waiting period is extended unnecessarily.

For many men the anxiety levels peak in the period between the testing and the results becoming available. Inability to concentrate, sleep disturbance and constant preoccupation with a possible positive result are some common issues mentioned by clients. Often the client will describe symptoms of full blown AIDS e.g. Night sweats, persistent dry cough, weight loss, diarrhoea, fatigue, swollen glands. As these symptoms are so vague and can describe a multitude of illnesses, it can be hard for the client to believe that he is not HIV positive.

The results, in the majority of cases, do not indicate any cause for concern and the relief experienced is considerable. The negative HIV test result is almost an absolution and frees the man to put the incident behind him and get on with his life.

The following are very typical scenarios presented at our clinic:

Case 1: The bachelor's party:

Joe is getting married in a weeks time and his friends have arranged a party and also arranged for a stripper. As most of these parties go hand in hand with a lot of alcohol consumption, Joe has a reputation to live up to and a lot of pressure is also applied by his friends. When Joe wakes up the following morning he isn't very sure of the previous nights activities, but as people are starting to tell him what happened he is now starting to worry whether he actually did or did not have sex with the stripper.

Case 2: The white collar migrant worker.

John travels extensively in his job. He spends weeks away from home and lives in hotels all over the world. Though it sounds glamorous he gets lonely. On a business trip to the East his Japanese clients arrange a Geisha girl for him, how do you turn down the offer without offending the client.

Case 3: The Rugby world cup.

The opening match was in Cape Town and the Springbok's won. The men where far away from home and the "hookers" off the field looked like a good match for the rugby supporters.

The world cup series lasted 6 weeks and South African men where in a frenzy. Our clinic saw 2000 men over that period and not one tested HIV positive , but they all had very similar stories about guilt, and fear of infecting their partner.

Case 4: The secret homosexual

The married man in his fifties with three children who describes his wife as his best friend. This man frequents areas where he can have anonymous homosexual sex usually railway station toilets, shopping mall toilets etc. He visits the clinic because of fear of HIV but discussed his feelings of guilt towards his family and society.

Are people less promiscuous in the 90's? HIV has certainly dampened the "one night stand" , though it hasn't stopped it. It appears to us that the public in South Africa are certainly well informed about the dangers of HIV, but it seems that there is a definite lack of knowledge in how it is spread. Clients talk about using double condoms and washing repeatedly after sex (guilt?) , but are reluctant to believe that correct condom usage is 100% safe.

Hepatitis B and other STD's doesn't seem to be a thought for concern, as all these are seen as "curable". Except Herpes off course!!!!!

Interesting for me is that a very large group of our clients see oral sex as "safe". Even though felatio will be a higher risk activity for the recipient than culliningis. Syphilis (because of snail tract ulcers on the tongue) and Gonnorhea (in the back of the pharinxs) also make oral sex high risk activities. Hepatitis B will always be your biggest risk activity here.

As the disease is reaching out of proportion figures in our country we are still confronted with the same perception that it is a disease of "blacks and gays" ...........

KIM & ELNA McINTOSH

About the authors.

Kim Mc INTOSH is a social worker, with a Honours degree in Social work from UCT. ELNA McINTOSH is a clinical Sexologist, currently doing her Ph.D in Human Sexuality .