Viljoen, Lario

Thesis (PhD)--Stellenbosch University, 2021.ENGLISH ABSTRACT: Since the 1990s, HIV prevention efforts have evolved from a primary focus on sexual behavioural change to an increasing focus on treatment-based prevention modalities as scientific evidence about the preventive benefits of antiretroviral treatment (ART) has accumulated. As these new prevention technologies have been tested and implemented worldwide, new knowledge gaps have emerged about how the availability of HIV treatment as prevention (TasP) would fit into sexual experiences and shape relationship dynamics in high HIV burden contexts.
In this thesis I aim to understand how women in South Africa experience sex, intimacy, and health in the context of a changing HIV prevention landscape. As women are disproportionately affected by the disease, the study of their sexual experiences and relationship dynamics in the context of treatment-based prevention is especially urgent. Furthermore, the dynamics of intimacy, care, and emotional connections in relation to sex in Africa remain underexplored. Historically, research on sex in Africa has positioned women as either fetishised or diseased, and the rise of the HIV epidemic did little to redirect this problematic narrative. I challenge these narratives and explore women’s conceptualisations of sex, focusing on how intimacy and emotional connections are prioritised.
The study is nested in the HPTN 071 (PopART) HIV prevention trial, a community-randomised trial conducted in South Africa and Zambia from 2012-2018 that aimed to test the effectiveness of TasP at population-level through a strategy called universal test and treat (UTT). We conducted a qualitative cohort study with 89 households (n = ⁓300 participants, including 180 women) over 18-24 months to describe individual and community experiences of the trial. I analysed data from the cohort to explore women’s narratives of their sexual experiences. Working across theoretical constructs (scripting theory, performance theory, responsibilisation) and empirical findings, the central emerging theme relates to the ongoing tensions between idealised or expected conceptions of women’s sexual lives and their experienced realities. This is evident in the discord between women’s perception of HIV risk (assigned to ‘transgressive’ others) and how their own intimate relationships are described (trust, fidelity, respect, risk-free). Through focusing on idealised notions of romantic sex, HIV risk is dismissed, and idealised relationship values upheld, even when partners fail to live up to these expectations. An HIV diagnosis, or the possibility of HIV risk, is positioned as challenging to women’s conceptualisations of intimate relationships (safe, trustworthy) and to their conceptualisations of self (as morally ‘good’ women).
As an early study of the effects of UTT on women’s sexual lives, the findings show that readily available HIV testing and treatment has not yet shaped the sexual narratives of women in South Africa. Despite fears related to behavioural disinhibition (where people engage in more risky sex), I did not find demonstrable differences in women’s narratives around their sexual experiences in places where treatment-based prevention strategies were implemented. These findings suggest that public health programmes must be responsive to women’s changing experiences and perceptions of their own HIV risk and consider presenting TasP as a partnered solution.AFRIKAANSE OPSOMMING: Sedert die 1990s, soos wetenskaplike bewyse vir die voordele van antiretrovirale behandeling (ART) na vore gekom het, het MIV-voorkomingspogings ontwikkel vanaf ŉ hooffokus op seksuele gedragsverandering na ŉ fokus op behandelingsgebaseerde voorkomingstegnieke. Soos hierdie nuwe voorkomingstegnieke wereldwyd getoets en geimplementeer is, het kennisgapings ontstaan oor hoe die beskikbaarheid van behandeling-as-voorkoming (TasP) in seksuele ervarings sou inpas en die dinamika van verhoudings sou vorm in areas met ŉ hoe MIV las.
In hierdie tesis onderneem ek om te verstaan hoe vroue in Suid-Afrika seks, intimiteit, en gesondheid ervaar in die konteks van ŉ veranderende MIV-voorkomingslandskap. Aangesien vroue disproporsioneel geaffekteer word deur die siektetoestand, is die bestudering van hul seksuele ondervindinge en dinamika van hul verhoudings in die konteks van die beskikbaarheid van behandelingsgebaseerde voorkoming veral dringend. Die dinamika van intimiteit, sorg, en emosionele konneksies in verband met seks in Afrika is steeds onbekend. Vroeere navorsing rakende seks in Afrika het vroue oorwegend as ‘gefetisjeerd’ of ‘besmet’ voorgestel. Die toename van die MIV-epidemie het nie hierdie problematiese narratief help verander nie. Ek bevraagteken hierdie voorstellings en ondersoek vroue se konseptualiserings van seks met ŉ fokus op hoe intimiteit en emosionele konneksies geprioritiseer kan word.
Hierdie ondersoek is deel van die HPTN 071 (PopART) MIV-voorkomingsstudie – ŉ ewekansige gemeenskaps-studie wat in Suid Afrika en Zambie geimplementeer is vanaf 2012-2018. Die studie het die effektiwiteit van TasP op populasievlak getoets deur middel van ŉ universele toetsing en behandeling (UTT) strategie. As deel van hierdie studie het ons ŉ kwalitatiewe kohortstudie met 89 huishoudings (n = ⁓300 deelnemers, insluitend 180 vroue) oor ŉ tydperk van 18-24 maande uitgevoer om die ervarings van individue en gemeenskapslede te dokumenteer. Data is ontleed om vroue se narratiewe oor hul seksuele ondervindings te ondersoek. Deur die gebruik van teoretiese konstruksies (‘scripting’ teorie, ‘performance’ teorie, normalisering en verantwoordeliking) en empiriese bevindinge, is ŉ sentrale tema geidentifiseer – die spanning tussen geidealiseerde of verwagte konseptualisering van vroue se seksuele lewe en die realiteit. Die tema is duidelik in die onenigheid tussen vroue se persepsies van MIV risiko (toegeken aan morele ‘oortreders’) en hoe hul eie intieme verhoudings beskryf word (vertroue, getrouheid, respek, risiko-vry). Deur te fokus op geidealiseerde beskrywings van romantiese seks word MIV risiko verwerp en die geidealiseerde verhoudingswaardes onderhou, selfs wanneer seksuele maats nie aan verwagtinge voldoen nie. ŉ MIV-diagnose, of die moontlikheid van MIV risiko, word posisioneer as uitdagend teenoor intieme verhoudings en vroue se konseptualisering van ‘self’ (as morele ‘goeie’ vroue).
Hierdie vroee studie rakende die effek van UTT op vroue se seksuele lewens wys dat die beskikbaarheid van MIV-toetsing en -behandeling nog nie die seksuele narratiewe van vroue in Suid-Afrika beinvloed nie. Nieteenstaande vrese rakende gedrags-disinhibering (deelname aan riskante seks), is geen bewys gevind van verskille tussen vroue se narratiewe van seksuele ondervindinge in plekke waar behandelingsgebaseerde voorkomingsstrategiee geimplementeer is nie. Hierdie bevindinge stel voor dat publieke gesondheidsprogramme moet reageer op vroue se veranderende omstandighede en persepsies van MIV risiko en dat TasP moontlik as ŉ seksuele vennootskapsoplossing aangebied moet word.Doctora

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Linking love and health: Social narratives of sex, intimacy, and love in the context of universal testing and treatment of HIV

https://scholar.sun.ac.za:443/bitstream/10019.1/110314/1/viljoen_linking_2021.pdf

Linking love and health: Social narratives of sex, intimacy, and love in the context of universal testing and treatment of HIV

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