Social Issues

President Jacob Zuma will take almost half his cabinet to Limpopo this week to monitor and evaluate the provincial government’s progress in delivering health services.

National health spokeswoman Zanele Mngadi yesterday confirmed that Zuma would visit Siloam Hospital in Thohoyandou and Lebowakgomo Hospital in Lebowakgomo outside Polokwane on Thursday.

“The president and his delegation are expected to interact with key roleplayers in the health sector, including patients, medical and traditional practitioners, and senior management, to see how the province has strengthened health system effectiveness,” Mngadi said.

Mngadi said Zuma would be accompanied by performance monitoring and evaluation minister Collins Chabane and his deputy, Dina Pule.

Other delegates include finance minister Pravin Gordhan, health minister Aaron Motsoaledi and his deputy Gwen Ramokgopa, Public works minister Gwen Mahlangu-Nkabinde and social development minister Bathabile Dlamini.

“Among others, they are expected to look at maternal and child mortality rates, combating HIV/Aids and decreasing the burden of diseases like tuberculosis,” said Mngadi.

She said this visit was in line with national efforts to revamp the public health system through the implementation of the re-engineered Primary Health Care model.

Mngadi said six other hospitals and clinics in the province would also be evaluated. – AENS

HEALTH Minister Aaron Motsoaledi yesterday revealed a proposal to introduce three levels of healthcare in SA, with a focus on underserved areas such as rural regions and schools.

The proposal came at the Board of Healthcare Funders’ annual conference, where Dr Motsoaledi called for the regulation of healthcare fees .

He said manufacturers of antiretrovirals (ARVs) originally told the government it was not possible to reduce the cost of the life-saving HIV/AIDS medication because it was expensive. "We said: ‘ Give us the costs .’ And when the costs were given, we found that ... it was not as expensive as that," Dr Motsoaledi said. "And you remember we reduced ARV ( prices ) by 50%, didn’t we?"

Dr Motsoaledi elicited a swift response from the private healthcare industry last week after he broke down the cost of a circumcision in a private hospital.

According to a presentation by Dr Motsoaledi , hospital fees alone ranged between R4184 and R13900, excluding urologist and anaesthetist fees. These hospital fees did not include an overnight stay. In contrast, one of the urologists could do the procedure for R1500 in his rooms, and general practitioners in townships charged R600-R1200.

After a similar presentation last week, private healthcare providers said state hospitals charged less as they were subsided by taxpayers.

Whether medical schemes have to pay in full the minimum prescribed benefits or not to their clients is the subject of a court appeal.

During his presentation yesterday, Dr Mostoaledi hit out at the "deadly divide" in SA’s healthcare system . He announced a plan to introduce three streams of care, which would have an increased effect in rural areas.

The first is the provision of specialists in each of the rural district municipalities. These positions would be announced by the end of this month, and if the posts were not filled, the minister had received an undertaking from all the medical schools in the country to fill the posts from among their own staff on a year-long rotational basis.

The second part of the plan was the establishment of a school health programme. "We have 12-million learners and no one taking care of their eyesight and hearing. Drugs and teen pregnancies are running rampant, while we wait for them at the hospital. I want to see nurses in every school, and we will call on the help of retired nurses if necessary."

The third facet of the proposal was the provision of primary healthcare workers in every municipality. The success of a pilot project in KwaZulu- Natal has led to plans to roll out the system in every municipality in the country. With Sapa

HARARE, 4 July 2011 (PlusNews) - Zimbabwe has set a goal of circumcising 1.2 million men by 2015 - a bold target for a country that has been slow to get its circumcision programme off the ground but is now rapidly making up for lost time.

When the national circumcision policy was launched two years ago there was widespread scepticism as to whether the country had the capacity to provide mass male circumcision, in view of a health system that had been starved of resources, drugs and equipment for years.

Tinashe Damba, 29, is one of almost 30,000 men who have taken advantage of the free circumcision scheme offered by the ministry of health in conjunction with Population Services International (PSI), an NGO, and other partners.

"I thought the circumcision procedure was going to be very painful but I did not feel a thing," said a relieved Damba after leaving the operating room at a clinic in the capital, Harare. The only pain he felt was when his penis was injected with the anaesthetic that made it numb during the procedure.

"I heard that if you get circumcised you have a better chance of not contracting the deadly HIV. It's not 100 percent prevention, but you reduce the chances of contracting that disease."

A large study in Kenya, South Africa and Uganda in 2006 found that the procedure could reduce a man's risk of contracting HIV through vaginal intercourse by as much as 60 percent.

Before Zimbabwe launched its campaign, male circumcision had only been available at private health institutions and mostly for reasons other than as an HIV intervention measure.

"Blessing in disguise"

Zimbabwe is not the only country that has been slow to introduce free male circumcision in state facilities. In neighbouring Malawi, the government has yet to implement mass male circumcision, while South Africa has been criticized for moving too slowly in developing a national circumcision strategy.

"I do not think we were too far behind other countries," said Minister of Health and Child Welfare Dr Henry Madzorera, "but then we were going through a rough patch politically and economically, and the public health system was close to collapse."

A health worker strike that began in November 2008 shut down public health services for several months. The loss of qualified nurses and doctors who left to work in other countries made it even more difficult to deliver the service.

The delay was, according to PSI circumcision programme manager Roy Dhlamini, a blessing in disguise. "Only very small pockets of the Zimbabwean population practice circumcision [as a cultural rite]. People needed to be educated on the benefits, so a nationwide campaign to sell male circumcision was launched."

The findings of research in Zimbabwe’s rural areas, published in the May issue of the Tropical Medicine & International Health journal, show that 52 percent of the men surveyed were prepared to undergo the procedure.

Dhlamini said Zimbabwe was also benefiting from the success and challenges of those who had started earlier, resulting in the lowest rate of "complications" - less than 1 percent - compared to a regional average of more than 3 percent.

Two years ago, the programme had the capacity to circumcise only eight people per day at its flagship facility, the Spilhaus Family Planning Centre in Harare. From the time a client walked into the centre included up to two hours of mandatory counselling and an HIV test, with another half hour for the procedure, to when he walked out without his foreskin.

Staff shortages were another major problem. "We only had eight doctors and 18 nurses, now we have 40 doctors and 160 nurses and training is ongoing," Dhlamini said. The ideal is to have at least a doctor and eight nurses at a health centre in each of Zimbabwe's 62 districts.

The programme currently has five stationary and two mobile centres. "People have been travelling from as far as 500 kilometres to the few centres available. We want to make it more accessible for them by establishing the district centres and taking the service to them, using the mobile centres."

The process also had to be speeded up. "We devised the Model of Optimising Volumes and Efficiency (MOVE), whereby doctors now work in teams of three - one anaesthetizes, the other carries out the procedure, and the third one bandages the penis," Dhlamini said.

This has reduced the operation to fifteen minutes and counselling now takes one and a half hours.

The campaign was largely financed by external donors but the cash-strapped government has also contributed. "This programme is part of the health delivery system. It is carried out primarily in already established government health facilities, and we provide the staff," Health Minister Madzorera said. The government will also pay allowances to those involved in field work.

Earlier in 2011, PSI and the ministry of education targeted adolescents older than 13 during school holidays, resulting in a 200 percent jump in the number of circumcisions. "We plan to repeat the exercise in the next school holidays," PSI’s Dhlamini said.

Nevertheless, some are still sceptical about whether circumcision will bring down the incidence of HIV. Mary Sandasi, Executive Director of the Women's AIDS Support Network (WASN), feels that male circumcision does not protect women and may lead some men, especially younger ones, to believe it is the silver bullet against HIV.

"Thirty years after the first AIDS case was identified we are still getting infections, even in countries where men are circumcised as infants, so this may not be the answer," she said, adding that the only solution for sexually active people is the correct and consistent use of condoms. "They need to remind men after the operation."

Health minister Madzorera said Sandasi's concerns would be valid in the absence of pre-circumcision counselling, which makes it clear that the procedure has to be used with other HIV prevention interventions.

"The message is repeated during the obligatory visits to a medical centre after the procedure. After these visits we keep on reminding those circumcised through multi-media campaigns, so there is no let-up."

Madzorera is confident the target can be reached. "The success to date of this programme is due to the fact that Zimbabweans are quick to adapt to new ideas. We have rural chiefs encouraging their people to get circumcised - that is a good sign."

Private healthcare prices in South Africa have to be regulated, Health Minister Aaron Motsoaledi said.

Speaking at the Board of Healthcare Funders conference at Sun City, Motsoaledi called for a pricing negotiation forum, saying healthcare in South Africa was "predatory".

He said the health structure was worse now than during apartheid.

"There is a tendency to believe that a long and healthy life is the right of those that can afford it and that is totally wrong," he said.

"The reality is that our people are dying in large numbers. We are running a healthcare system in this country that is not working."

The solution lay in re-engineering the primary healthcare system.

Motsoaledi announced a plan to introduce three streams of care, which would have a particular impact in rural areas.

Board spokesman Heidi Kruger welcomed Motsoaledi's comments, saying: "I think it's brilliant. The sooner it comes through the better. We can't have a situation where there is no containment on costs."

Kruger said private healthcare providers charged whatever they wanted, "pushing up" medical aid premiums.

The current system was an "open-ended liability for funders" so medical schemes could not budget properly.

Regulating healthcare costs would be "very constructive" and "provide certainty", Kruger said.

Motsoaledi is hoping to begin setting up the pricing forum by the end of the year.

However, he told delegates at the conference that hospitals were creating a stumbling block in the process because that sector did not want to have its prices regulated.

Motsoaledi accused the public and private health sectors of "engaging in destructive, unsustainable practices". He was particularly outspoken about the high cost of private hospital treatment and called for a stronger emphasis on primary care, rather than the present curative system with its "rapidly escalating" costs.

"The public health system is in a crisis of quality and I am going to deal with it head on, but it is not an excuse for profiteering," he said.

"Our country is going in the wrong direction . all of us, public and private," he said. "We have a predatory healthcare system where the sick and the vulnerable are the ones who get attacked."

FIVE female scientists, from Stellenbosch University and UCT, are among a group of 10 “inspiring women scientists” who have been honoured with 2011 L’Oréal-Unesco Regional Fellowships For Women in Science.

The ceremony took place in Joburg last night.

The L’Oréal Corporate Foundation created the For Women in Science partnership with Unesco in 1998, and since then more than 1 000 women scientists across the world have received awards or support in pursuing their careers, through various fellowship programmes.

Each of last night’s winners receive R180 000 towards the completion of their PhDs in the fields of microbiology, environmental science, medical virology, chemistry and agriculture.

The local recipients are:

lDalene de Swardt, 31, is doing her PhD in medical virology at Stellenbosch University.

She said her research, in the field of HIV/Aids, focused on a specific immune cell, the dendritic cell.

Swardt explained that the cells contributed towards the activation of the immune system, and that she was investigating what happened to these cells in people with HIV.

She was developing a natural agent that she hoped would block HIV from entering healthy cells, while also curbing the activation status of the HIV virus “so that it (the agent) can attack and clear out the infection”.

l Jeanne de Waal, 27, who is doing her PhD in agricultural sciences, also at Stellenbosch.

De Waal said she grew up in Pretoria and had to swop her high heels for gumboots when she began her studies, “but it is quite fun being a girl in the field of agriculture”.

Receiving the award was a great honour, she said, adding that it was a wonderful reward for her hard work and long hours spent working on her PhD.

De Waal is looking at environmentally friendly pest management practices, and is developing a biological pest control agent (a worm) to effectively control pests on apples and pears.

She said that biological control agents were already commercialised in parts of Europe and the US, but not in South Africa.

“We want to develop agents that are endemic to South Africa because insects are building up resistance to antibiotics and pest control.”

De Waal added that the demand for organic and sustainably produced food had also helped drive the process towards more environmentally friendly pest control management.

l Kim Trollope, 34, is focusing on yeast microbiology for her PhD. Her research focuses on producing an enzyme used for the production of sweeteners from cane sugar (sucrose).

The sweeteners are lower in calories and safe for use by diabetics. Trollope explained that her PhD would supplement existing work being done in this regard, by potentially providing an understanding of how the enzyme functioned, and by producing a novel enzyme with improved properties.

All three said they would use the money to attend international conferences which were important for networking with others in their field.

l The other two fellowship recipients, Olutayo K Boyinbode, 37, from Nigeria, and Rachel Muigai, from Kenya, both live in Cape Town and are studying at UCT.

Boyinbode is completing her PhD in computer science.

Muigai’s PhD is focusing on the sustainability of concrete structures.

UNITED NATIONS, Jun 30, 2011 (IPS) - When the United Nations inaugurated a landmark special agency for women last January, Secretary-General Ban Ki-moon set an initial target of 500 million dollars as the proposed annual budget for the new gender-empowered body.

But nearly six months later, the voluntary funding for U.N. Women (UNW) from the 192 member states has remained painfully slow.

Ambassador Hardeep Singh Puri, India's Permanent Representative to the United Nations, expressed disappointment over the funding shortfall.

Nearly six months after its operationalisation, the actual contributions and pledges received are modest and only around 80 million dollars, he said.

"This is not commensurate with the aspiration and ambition assigned to U.N. Women," he complained.

Addressing the first regular meeting of the 41-member executive board of UNW early this week, he said: "We must not be oblivious of the fact that activities enumerated in the Strategic Plan need resources."

The Strategic Plan envisages financial requirement of nearly 1.2 billion dollars in 2011-13.

"If we have to ensure that U.N. Women stands for action, the donor community has to make generous contributions to U.N. Women," said Ambassador Puri.

Stephen Lewis, a former deputy executive director of the U.N. children's agency UNICEF and co-founder of the international advocacy organisation AIDS-Free World, has been one of the strongest advocates of UNW since long before its creation.

In an interview with IPS, Lewis said total funding raised so far - anywhere between 80 million and 126 million dollars - is "hopelessly, pathetically below what's needed and was expected".

"I gather that UN Women has now lowered its sights to a target of 250 million dollars. That's a travesty ... barely more than the cumulative total of the four small entities that were rolled into UN Women at its formation," he said.

The four women's entities that were folded into UNW were: the U.N. Development Fund for Women (UNIFEM); the Office of the Special Adviser on Gender Issues; the U.N. Division for the Advancement of Women; and the International Research and Training Institute for the Advancement of Women (INSTRAW).

The extended title of the new UNW is: 'the United Nations Entity for Gender Equality and the Empowerment of Women', and it is headed by the former president of Chile Michelle Bachelet.

Lewis said the secretary-general's target was 500 million dollars, which he described as "ridiculously low".

The target set by non-governmental organisations (NGOs) was one billion dollars ("barely enough").

"At the moment, UN Women is being strangled at birth by a coalition of the wealthy," said Lewis, a former Canadian ambassador to the United Nations.

"All the misogynist countries, from Pakistan to Sudan, must surely be laughing behind the scenes. They never wanted UN Women and now the Western donors are doing the dirty work for them," he said.

"It's an ugly business and shows, yet again, that when it comes to women, the U.N. can never get its act together," declared Lewis.

"As always, we and others will give Michelle Bachelet the benefit of the doubt. She's quite superb as an under-secretary-general (USG, the rank she holds in the U.N. totem pole)," he added. "But even Michelle Bachelet cannot change the world for women without the resources to do so."

Antonia Kirkland, legal advisor at the New York-based Equality Now, told IPS that without a significant increase in funding by member states, UN Women risks being as sidelined as the previous four entities it replaced that focused on women's empowerment.

"We must ensure that governments fulfill their legal obligations to protect women's rights".

Kirkland said the UN Women's Executive Board must concretely implement commitments made by its members and must devote adequate resources and projected funds to this entity, whose creation was a result of tireless efforts and advocacy by the international women's movement, and in particular the GEAR campaign.

A coalition of over 300 international non-governmental organisations (NGOs) led a global campaign for Gender Equality Architecture Reform (GEAR) in the U.N. system resulting in the creation of UNW.

The coalition included Women's Environment and Development Organisation (WEDO), Center for Women's Global Leadership, International Planned Parenthood Association, Asia Pacific Women's Watch, African Women's Development and Communication Network and Development Alternatives with Women for a New Era, among others.

Kirkland said member states have already invested precious time and money to establish UN Women. It is now time to urgently implement programmes that will benefit women and girls around the world, and give them the promised opportunity to achieve equality and enjoy their full human rights.

Meanwhile, Ambassador Puri told the executive board that to ensure that UN Women stands for action, "We would support all efforts to ensure that scarce resources are not diverted from programme activities in the field to administrative expenditure at U.N. Headquarters."

He said UN Women will be measured by what and how it delivers in the field, not just by what it symbolises.

The first challenge of resource mobilisation to fulfill its ambitious agenda is critical and would demonstrate the trust the international community bestows on UN Women. This needs a sound plan and a committed senior management, he said.

"I am happy to see that the revisions which have been made in the support budget late last week are the right steps in the right direction," Puri noted.

The Indian envoy described the initial target of 500 million dollars as reasonable as well as modest.

"Although I do want to point out here that the Secretary General last year had actually proposed that UN Women should be created with the initial corpus of one billion dollars," he said.

This was also the demand of the developing countries and civil society.

"This might sound ambitious, but the lower target of 500 million dollars should not make us complacent and limit ourselves," he said.

Instead, "We should be prepared to revisit this target later this year, and consider upward revision, in a realistic and practical manner."

"I would like to inform you that the Government of India is seized of the need to make appropriate contribution to UN Women," he added.

Cape Town - A call has been made for explicit and, ideally, government-backed policies to support countless people providing care to people living with HIV and AIDS amid reports that many care givers are neither officially known nor rewarded for their work in Southern Africa.

'Very often when people talk about care workers in the SADC region they talk about nurses, doctors and other people employed at health facilities.

'They do not talk about people providing care in the shadows: home-based caregivers like mothers, wives, sisters, grandmothers, grand children and others looking after people living with HIV,' Ms Loga Virahsawmy, GEMSA regional chairperson, said in a recent interview.

With approximately two in five of all people infected with HIV globally in the past few years, Southern Africa is now regarded the epicenter of the global HIV pandemic.

Experts say HIV and AIDS disproportionately affects women and girls, who also form the overwhelming majority of people providing care and support to people infected and affected by the pandemic.

Loosely defined, care workers are people who help the sick or infirm.

The majority of care workers in Southern Africa provide home-based care for people living with HIV, often without being paid.

Virahsawmy explained that caregivers may be close family members such as children, wives or sisters socially or culturally expected to nurse the sick, or may be associated with organizations (such as NGOs) or linked to government-run health facilities.

She said recently the Gender and Media Southern Africa (GEMSA) Network audited care work policies in 12 countries that are members of the Southern African Development Community to establish the extent to which care work was recognized in those countries.

She was optimistic that the study would deepen and broaden the understanding of the challenges and needs of care givers all over the region.

The Southern Times has obtained a copy of the audit, which shows a serious dearth of laws and policies with respect to care work in six of the audited countries.

The audit was conducted in Botswana, the Democratic Republic of Congo, Lesotho, Malawi, Mauritius, Mozambique, Namibia, South Africa, Swaziland, Tanzania, Zambia and Zimbabwe.

The audit says Namibia has an 'excellent community home-based care policy'.

'The new CHBC policy calls for a monthly incentive of N$250 – N$500 (roughly US$31-62). Under the new policy, all caregivers will require an identity card; T-shirt; shoes; umbrella; a home-based care kit; some form of transport; communication funds; and a monthly monetary incentive…the government will re-train all care givers using a standardized manual.

'Government will accredit those who pass the training through the Namibian Qualifications Authority,' says the audit of Namibia.

It adds that the new policy would address the psychological needs of care givers and encourage men to get involved in care work.

In Botswana, no clear policy on care work exists and the government is not keen on paying caregivers, arguing that incentivizing care work would compromise the spirit of volunteerism.

That being the case, only donor organizations provide financial incentives while the government provides volunteers with transportation allowances of P151 (about US$22) per month and clinical supplies.

At the time of the audit there was no stipulated minimum training for volunteer caregivers.

Training provided to them by nurses lasted about a week followed by refresher courses should new issues have arisen.

In Tanzania care work was not recognized as a profession and there was no policy with respect to payment of caregivers.

Gender equality also appears not to be a prime issue in the sector.

The Zimbabwe audit found that the government also had no policy on gender policy and payment of caregivers.

However, new guidelines recommended incentives that included uniforms, bicycles, food packs, monetary allowances, free medical treatment, support for income generating projects, part-time jobs in hospitals and funeral assistance.

The guidelines also espouse training on basic care.

Mr. Mike Podmore, who is based at the Voluntary Services Overseas headquarters in London where he works as an HIV policy and advocacy advisor said women and girls remained the unsung heroines in the response to HIV.

'Home-based care is one of the great, invisible and forgotten responses to the HIV and AIDS pandemic across the world but especially so in Southern Africa where the pandemic is generalized.

'The region is the epicenter of the HIV pandemic. Home-based care is the care and support mostly provided by women and girls in the community; either by family or loved ones or within community-based organizations by community volunteers,' Podmore said.

He said most caregivers – whether in the home or working for community organizations – worked each and every day of the week, looking after between 10 to 20 people each.

'They walk long distances between their clients. They provide care for them in their homes, often with little or no training and with very little equipment.

'For example, only a few of the home-based carers have access to home-based kits or equipment like gloves or simple things like soap.

'If they want those things they have to pay for them out of their pockets. An awful lot of carers are doing this. Most carers are made poorer by what they do.'

He said research on home-based care is still very limited and stressed the need for a deeper and broader l understanding of the lives of volunteers and the level to which they receive remuneration for what they do or what it costs them to deliver.

However, Podmore said there are some studies that are beginning to give a better understanding of home-based care.

One of them was done by Voluntary Services Overseas-RAISA and the World Health Organization's Africa office.
That research was conducted across six Southern African countries and included interviews with the caregivers and other key stakeholders.

The study came up with several recommendations targeted at governments and civil society.

'The idea is to make home-based care visible, properly supported and resourced. The second study was conducted by the Huwai Commission with funding from the United Nations Development Programme.

'This is a network of women's organizations globally. They interviewed nearly 2 000 carers across six southern and eastern Africa in 2009.'

On the key findings of that research, Podmore said: ' They asked the care givers if they had received any training.

'Only two-thirds had received any training at all and half of those had received once-off training. Only seven percent of all those interviewed were receiving any form of stipend or monetary recompense for the work they did.

'The interviews covered a whole range of issues including access to training, equipment and it gave us a good insight into what the issues were.'

Podmore said policies need to be improved so that more resources are made available to community and home-based programmes; both funding the formal health sector and providing the resources and support to people who have been providing home-based care on their own for such a long time.

'There is need to re-look at human resources for health; ensure that men are getting involved in care work and challenging gender norms in that respect; creating a link between nurses and doctors as well as community and home-based carers on the ground so that support is given to those carers.

'Nurses and doctors can hopefully pass on less complex duties to the care givers.'

Indications are that the involvement of men in care work has been very minimal, with some reports suggesting the few that get involved prefer clerical or administrative roles.

While conceding that bringing more men on board is not easy, Pomore was optimistic that it could be done.

'There are short-term and long-term approaches. Short-term approaches entail engaging men very specifically; perhaps by identifying tasks related to home-based care that they might feel comfortable doing given the traditional roles for men and women.'

He suggested this might involve some lifting, fetching or cutting of firewood and opined that giving men some sort of stipend might draw them into the sector.

A long term approach would entail redefining or understanding what it means to be a man or a woman.

'It involves talking to men and young boys about their conception of being male while showing them that it is important for them to get involved in care work.'

Podmore said schools and other agents of socialization would have to be roped in. 'This is challenging gender norms. It has to begin at school. By the age of 19 or 20 men have already formed a lot of their understanding of who they are, what they should or should not be like.

'This is not to suggest that men at that age are unreachable. I am just saying at that age there is a lot of dismantling to be done before one can rebuild new attitudes. Schools are the best place to start.'

Virahsawmy and Podmore spoke as 20 parliamentarians from Angola, Malawi, Mozambique, Botswana, Namibia, South Africa, Swaziland and Zimbabwe, as well as representatives from seven NGOs met in Cape Town to discuss the burden of care work on women and girls.The SADC Parliamentary Forum organized the one-day workshop in collaboration with VSO-RAISA. The workshop called for more research into the contribution and plight of caregivers and for policies and laws to support care work and care givers.

JOHANNESBURG, 27 June 2011 (PlusNews) -  In theory, it should go something like this: pregnant woman tests HIV-positive as part of prevention of mother-to-child HIV transmission (PMTCT) services at her antenatal clinic, and tells dad-to-be; dad tests for HIV and they support each other, start treatment if need be, and prevent HIV transmission to baby or dad.

It seldom turns out that way. In a small, qualitative study of about 60 women in two clinics in the Durban area, Tamaryn Crankshaw, a PMTCT programme manager at McCord hospital in Durban, South Africa found that while two-thirds of the women did tell their partners they were HIV positive, only half of them reported that their partner had been tested for HIV as a result.

"There were some positive outcomes but mostly there was a lot of blame, recrimination, and silences,"Crankshaw told IRIN/PlusNews. "HIV was never raised again within the context of the relationship, and in a lot of cases it was actively discouraged."

As in previous studies, the women also reported being physically, verbally and emotionally abused after disclosing their HIV-positive status.

Surprisingly, the women's disclosure sometimes prompted men to disclose that they were also HIV-positive, or to consider their partner’s HIV-positive diagnosis as a proxy for their own HIV status.

In two cases, women reported that their disclosure had prompted unprotected sex as their partners, who purported to be HIV-negative, intentionally exposed themselves to HIV infection to show their commitment to the relationship and to starting a family, said Crankshaw, who presented her findings at the recent 1st International HIV Social Sciences and Humanities Conference in Durban.

"In South Africa, HIV disclosure is a very prominent component of HIV prevention and treatment because it’s assumed to mediate sexual risk behaviour, and is widely regarded as important to... supporting [adherence to] antiretrovirals," she told IRIN/PlusNews.

"In the PMTCT setting, HIV disclosure receives particular emphasis because of [HIV] prevention aims however... very little attention has been paid to the success of these strategies, and whether they do reduce risks or change behaviour."

What's love got to do with it?

About 30 percent of women choose to keep silent about their HIV-positive diagnosis. New research shows how a lack of trust between partners in some communities may be interfering with the expected HIV prevention benefits of HIV disclosure. This may merit a new take on HIV counselling and testing for couples.

For most women, multiple concurrent partnerships are a relationship reality. There is also mutual suspicion, a very low expectation of permanency, and their own emotional baggage, like being unwilling to trust. This may affect a partner’s willingness to disclose his HIV status, Crankshaw said.

"The thing is, we also have our ups and downs," said one 29-year-old mum. "I am not sure about our future... so I don't see the need to tell him something so confidential [like my HIV-positive status]."

Multiple concurrent partnerships, in which men and women have more than one sexual partner at the same time, are thought to be one of the main drivers of HIV in southern Africa.

Data from a larger sample of 656 men and women in rural KwaZulu-Natal, analysed by researcher Deborah Mindry of the University of California, Los Angeles, reinforced many of Crankshaw's observations about relationships.
 

Mindry found that awareness of the HIV risks associated with multiple concurrent partnerships and fear of contracting HIV led many men to monitor their partner's behaviour in order to assess their own HIV risk. This included, for example, asking a girlfriend's family to confirm her whereabouts over a weekend, or sending male friends to ask their girlfriends out as a test of the woman's fidelity.

"Sometimes men… end up controlling a person... this is what I feel when it comes to using condoms," said one HIV-positive new mum, who spoke to Crankshaw about the guilt she felt after not being able to negotiate safe sex with her partner. "I felt I was not in control of the situation but… I was counselled here and I knew everything."

Crankshaw said the reality that disclosure by HIV-positive mums did not always spark partner testing or risk reduction should lead to a rethink of PMTCT programme design:

"We forget to look at the fact that what drove prior risky behaviour will continue to drive future risky behaviour. Disclosure is not going to change that," she told IRIN/PlusNews. "We have to stop accessing only the pregnant woman because she's the easy one to access, because she's already in care."

What's best for baby

Crankshaw suggested that couples counselling might help share the burden of behaviour change between new mums and dads. Couples counselling has gained popularity in recent years, but it is still not easy to get couples, especially with complicated relationship dynamics, to test together in large numbers.

Mindry found that many couples were grappling with major issues and were reluctant to address HIV, but many were better able to talk about HIV and risky behaviours within discussions about existing or future children.

Crankshaw said Mindry's findings are part of a growing body of research showing that voluntary HIV testing and counselling - and subsequent behaviour change - may be more palatable to couples when presented in the context of reproductive services. As a result, McCord Hospital will begin offering reproductive services to people living with HIV.

"People have very serious issues in their relationships already, and HIV just adds another dimension," she told IRIN/PlusNews. "We have to start addressing these lived realities, and see how we might address broader issues in their lives and... how this can help us address HIV."