Aspirations and sex: Coming of age in the eye of the HIV storm

July 2, 2014, Institute of Tropical Medicine Antwerp

How do you shape your hopes, ambitions and expectations when growing up in an environment devastated by HIV/AIDS? For her doctoral thesis, Ellen Blommaert looked for answers in Winam, a rural area of western Kenya where HIV/AIDS wreaked havoc among the population. She found that young people between 16 and 25 take a pragmatic approach to sexual risks because sexuality plays an important role in their quest for a better future. According to Blommaert, who defends her thesis tomorrow (Wednesday 2 July) at the University of Amsterdam, anthropologists have an important role to play in prevention projects that take expectations of youngsters better into account.

Ellen Blommaert investigated the way youngsters between 16 and 25 years engaged in , how (if at all) they avoided health risks associated with sex, and how they interpreted the relationship between sex, love and money. When Ellen began her fieldwork in 2005, antiretroviral drugs (ARVs) in Winam were only available at very high cost. Nyanza province, of which Winam is part, was hit harder by the HIV/AIDS epidemic compared to any other Kenyan region. The disease was able to spread quickly and extensively because of chronic poverty and high mobility. Many, often very young people, lost their life.

"Young people hope to move out of rural areas to urban areas not only for education or jobs, but also to expand their social and . Due to the instability of their social networks, some of the youngsters increase their sexual networks, including, sometimes, sexual liaisons with multiple, concurrent partners," says Ellen Blommaert.

While trying to enjoy "playing sex", these youngsters behave pragmatically to avoid the linked to sex. But instead of reducing their number of sexual partners or changing their sexual behavior as advocated in government and NGO health campaigns, they have developed a tactic, which is embedded in locally meaningful modes of reasoning. Within their social network, they try to reconstruct the sexual and medical history of their potential sexual partners through informal conversations. They hope thus to minimize their risk of exposure to HIV. However, the many small groups of sexually active people are in turn combined to several larger groups. The result is that the sexually active youngsters in Winam were, one way or the other, all sexually connected to each other, even though they had no direct sexual contact. " Individuals could escape infection by chance, but in the end, all were structurally highly likely to get HIV.," says Blommaert.

In Winam young women under 20 are HIV-positive more often than their male counterparts (6% vs 0.5%). According to Blommaert, this development is directly related to "structural violence", created by the prolonged socio-economic crisis in Winam and the fragmentation of social networks. It is important to see the decisions young people face in this context of enduring uncertainty in which youngsters, despite their inventiveness, struggle to realize their plans. In her study, she tried also to broaden the concept of 'transactional sex' and untangle stereotypical ideas about female subordination, male dominance and transactional sex in sexual relationships.

The study in Kenya confirms that biomedical prevention messages, promoting the use of condoms and Voluntary Counseling and Testing (VCT), are incomplete and do not reflect the realities of young people's lives. In her thesis, Ellen describes and analyses an existing HIV prevention project for young people in Winam and whether this type of projects makes a difference at all in the everyday lives of these youngsters. And while these projects do certainly have an impact, it is not necessarily the one anticipated by the designers, the implementers or the participants. According to Blommaert, these activities often start with objectives which respond to the priorities of funding agencies but are not necessarily connected to the needs of young people. At the time when ARVs were only available at a very high cost, young people had few future perspectives when they were informed about their HIV status. "Therefore, many youngsters in Winam preferred to live in uncertainty instead of knowing the biomedical truth. Prevention projects should take this into account,"
said Blommaert.

Prevention: a closer collaboration between epidemiologists and anthropologists

"Combination HIV prevention" (a package of interventions taking into account both the individual and the socio-economic context) remains a must in the fight against AIDS, even at a time where the disease has become chronic rather than fatal. Blommaert remarks that young people in particular will welcome projects that arise from their aspirations and expectations. She believes that anthropologists have an important role to play, together with epidemiologists. The latter still have a major influence in the set up and implementation of current projects. Blommaert claims that "anthropologists have an important role in the fight against AIDS. An integral collaboration between anthropologists and epidemiologists should today be the rule rather than the exception. "

At the time of the study, Ellen Blommaert was a member of the Unit of Epidemiology and Control of HIV/STD at the Institute of Tropical Medicine (ITM) in Antwerp and the research group of the Amsterdam Institute of Social Science Research (AISSR).

Her study was part of a collaboration between ITM, the U.S. Centers for Disease Control and Prevention (CDC) and the Kenyan Medical Research Institute (KEMRI) aimed at developing and testing prevention interventions for . Blommaert conducted participant observation for 20 months. This was supplemented by informal and formal in-depth interviews (including family history), life histories, focus group discussions and a diary kept over a long period by one of the youngsters.

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