Women, HIV Prevention, and Behavioral Versus Holistic Approaches: The United States and South Africa

Date01 December 2017
AuthorSuzan M. Walters,Karen L. Baird
Published date01 December 2017
DOIhttp://doi.org/10.1002/wmh3.245
Women, HIV Prevention, and Behavioral Versus Holistic
Approaches: The United States and South Africa
Karen L. Baird and Suzan M. Walters
This paper focuses on the dominant approaches to HIV prevention for women in the United States
and South Africa. Examining the Diffusion of Evidence-Based Interventions (DEBI) program in the
United States and loveLife in South Africa, we f‌ind that the United States focuses on women’s
individual behavioral change, whereas South Africa takes a broader and more holistic approach,
targeting social determinants of health. The variation in approaches is found to be determined by the
differing history of the epidemic, origins of HIV prevention programs, ideologies, and funding for
HIV prevention in each country, with important implications for women’s health and portrayal in
the public sphere.
KEY WORDS: HIV/AIDS, women, policy
Introduction
In this article, the social determinants of women’s risk for HIV and country-
level HIV prevention policies are examined, and a comparison of the United
States and South Africa’s approaches is offered. Even though the environmental
factors shaping women’s vulnerability to HIV—poverty, economic inequality, and
violence, to name a few—are similar in both countries, the HIV prevention efforts
of each country greatly differ. Comparing the prevention efforts of South Africa
and the United States highlights how countries approach HIV prevention in
dissimilar manners, and how and why countries engage in such diverse efforts.
In the United States, HIV prevention policies for “high risk” women primarily
focus on individualized risk-reduction strategies or behavioral modif‌ication—for
example, convincing women to use condoms and to reduce their number of partners.
The Centers for Disease Control (CDC) is charged with developing and implement-
ing HIV prevention programs and the CDC’s DEBI program (“Diffusion of
Evidence-Based Interventions”) was the major HIV prevention program from the
late-1990s to 2010.
1
In South Africa, the loveLife program was created in 1999. It
takes a broader and more holistic approach—an approach that goes beyond safe sex
messaging. Individual behavioral change was and is targeted, but socioeconomic
World Medical & Health Policy, Vol. 9, No. 4, 2017
466
doi: 10.1002/wmh3.245
#2017 Policy Studies Organization
factors that structure vulnerability or “risk” for women receive much greater
attention. loveLife addresses “the social determinants of HIV: poverty, unemploy-
ment, lack of access to healthcare and education, low social solidarity, lack of self-
worth, belonging and identity” (loveLife, 2016).
The DEBI and loveLife programs represent the dominant approaches to HIV
prevention adopted by each country, and we focus herein on the particular
implications for women. In the f‌irst section, the HIV/AIDS epidemic and its
implications for women in the United States are discussed. Next, the United
States’s DEBI program is described and analyzed. The following section discusses
the epidemic in South Africa and its loveLife HIV prevention program. Though
South Africa had other HIV prevention programs that utilized similar tactics as
loveLife (e.g., Khomanani), loveLife was the largest (Collinge, 2005). An analysis
as to why different approaches to HIV prevention were developed and
implemented, and the consequences of the different foci, is offered in the last
section of the paper. Though some analysts compare various governments’
responses to HIV/AIDS (Gauri & Liebermann, 2006; Lieberman, 2007, 2009;
Nattrass, 2006; Patterson, 2006), such works usually focus on funding and/or
access to treatment; few compare national HIV prevention programs. Our analysis
highlights factors that impede or promote governments’ ability to address social/
structural determinants of HIV infection for women.
United States
HIV/AIDS and Women
Although the majority of HIV/AIDS cases continue to occur among men, the
proportion of AIDS cases found in women increased from 8 percent in 1985 to 27
percent in 2000; as of 2014, 23 percent of those living with HIV/AIDS are women
(CDC, 2016b). Women of color are disproportionately affected: African Ameri-
can/Black women compose 61 percent of women living with HIV, and Latinas 17
percent (CDC, 2016b). Hence, not all women are equally at risk. This disparity is
not limited to women, as these differences ref‌lect the racial/ethnic disparity in
the epidemic as a whole. All African–Americans/Blacks are at a heightened risk
for HIV/AIDS, but particular groups, such as Black men who have sex with men
(MSMs) and lower income, heterosexual Black women are at an even greater risk
(CDC, 2016b).
African–Americans/Blacks have always been affected by HIV/AIDS in the
United States, but in the mid-1990s, the epidemic clearly became one of color:
more Blacks than Whites were diagnosed with AIDS and more Blacks than
Whites died from AIDS (Black AIDS Institute [BAI], 2007; CDC, 2006). These
trends have continued to the present and the racial gap has only increased. In
2014, of the people newly infected, 44 percent were Black and 31 percent were
White (CDC, 2016a).
Transmission of HIV infection in women primarily occurs through heterosex-
ual sex. This surpassed injection drug use (IDU) for women in the mid-1990s.
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Baird/Walters: Women and HIV Prevention 467

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