Equity in access to HIV/AIDS services in Zambia : the role of social cohesion in HIV prevention and care

Zambia has for many years experienced a generalised HIV epidemic. Large-scale antiretroviral programmes have been successfully introduced (Egger et al. 2005; Stringer et al. 2006). Despite progress in controlling both new infections and access to treatment, the scale and impact of the epidemic remain major concerns. Persistent social inequalities and discrimination continues to create significant barriers to access HIV/AIDS services. It has been argued that social cohesion, understood as collective networks of solidarity and trust in a society, could reduce susceptibility and vulnerability to HIV (Meyer-Weitz, 2005; Loewenson, 2007) and generate social action (Kawachi et al., 1997). This thesis aimed to investigate the influence of social cohesion along the continuum of HIV care in Zambia (uptake of testing; uptake of ART; adherence to ART and retention in care). To do so, a community-based cross-sectional survey methodology was implemented in four sites in the Southern and Central provinces of Zambia: two rural (Namwala and Monze district), one commercial centre (Mazabuka) and one urban area (Lusaka). The study population consisted of adults, women and men, over the age of 18, who were residents of one of the four sites.
The main conclusions of this thesis are based on the results of four studies conducted to explore the effect of social cohesion along the HIV care continuum. The results are presented in four scientific papers that have been included as chapters in this thesis (Chapter 6 to Chapter 9)
The box below presents an overview of what this thesis adds to the existing evidence.
What is already known?
Social cohesion plays a positive role in both reducing susceptibility to HIV and dealing with vulnerability to AIDS.
Gender-based violence and gender inequalities increase vulnerability to HIV infection and deter uptake of HIV testing in women.
HIV/AIDS-related stigma is a major barrier to HIV prevention efforts hampering uptake of HIV testing, adherence to ART and delaying general health seeking among people with HIV.
The existing quantitative studies on the link between poverty and HIV/AIDS present conflicting evidence.
What does this thesis add?
In Zambia, social cohesion - measured by networks of action, trust and reciprocity either at the level of the couple, the family and the community - plays a significant role in access to HIV/AIDS services even when factors such as stigma, socio-economic status, gender and other individual factors are taken into account.
Not all levels of social cohesion (couple, family and community) exert their effect in the same way along the continuum of HIV care.
Not only enacted violence but tolerance to gender-based violence within households hampers the uptake of HIV testing. This is often a reflection of prevailing social norms with respect to gender and power relations in a community. High levels of tolerance to gender-based violence are more common in discohesive environments.
HIV/AIDS-related stigma strongly hinders uptake of testing and retention in care. High levels of stigma are more common in discohesive environments.
Livelihoods insecurity deters uptake of treatment and adherence especially in women. However, increasing social ties can help balance this negative effect.
Promoting social cohesion among men, especially through increasing men’s participation in community activities, could have harmful effects unless underlying gender norms of masculinity are mainstreamed in the design of the intervention.
What do these findings lead to?
Social discohesion and disempowering conditions (discriminatory gender norms, high levels of stigma and livelihoods insecurity) are the recurrent obstacles of access along the HIV continuum of care in Zambia. The strategy to scale up access to HIV/AIDS services in Zambia needs to prioritize interventions aimed at promoting social cohesion and reducing disempowering conditions which are especially present in discohesive environments.
Social cohesion primarily deals with creating environments that enable couples, families and/or communities to overcome (inevitable) social tensions and conflicts. These enabling environments can be achieved through facility-, community- and policy/institutional- level interventions promoting non-violence and gender-equitable norms as well as mobilizing communities to enforce laws preventing discrimination based on gender and/or HIV status.
In conclusion, promoting greater social cohesion in local communities in Zambia has the potential to reduce social inequalities that deters access to HIV/AIDS services. It may also facilitate collective action, for reducing tolerance to violence, reducing stigma and discrimination and compensating economic burden. However, the mobilisation of social cohesion in local communities requires an awareness of the risk of rising inequality, especially for men unless “masculine” gender norms are changed.