Associations of poverty, substance use, and HIV transmission risk behaviors in three South African communities☆
Introduction
It has long been known that poverty is associated with poor health and health compromising behaviors. Malnutrition, lack of access to health care, poor sanitation, limited resources for meeting basic needs, conflict, and violence are among the conditions of poverty that impede health and well-being (Adler & Ostrove, 1999; Lantz, House, Lepkowski, Williams, Mero, & Chen, 1998; Baum, Singer, & Baum, 1981; Ewart & Suchday, 2002). HIV infection is linked to poverty because of poor health care infrastructure, greater social density, social isolation leading to closed sexual networks, alcohol and drug abuse, and engaging in sex in exchange for survival resources. For example, Shisana and Simbayi (2002), in the South African national household HIV prevalence study showed that HIV infections are most prevalent in urban townships and urban informal settlements characterized by poor economic infrastructures and greater social density. HIV/AIDS is clearly not the direct result of hunger and impoverished living conditions (Le R Booysen, 2004), but it is likely that poverty creates a social and environmental context that promotes the spread of HIV infection.
Among the factors that connect poverty to HIV/AIDS, research has investigated the role of psychological stress. Experiences of poverty and community stress are associated with greater risks for HIV infection in US inner cities (Kalichman, Adair, Somlai, & Weir, 1995; Kalichman, Hunter, & Kelly, 1992). Latkin, Williams, Wang, and Curry (2005) showed that indicators of neighborhood social disorder such as exposure to violence, crime, loitering, litter, vacant buildings, and vandalism were associated with psychological distress which in turn was associated with greater frequency of injecting drugs and needle sharing practices, indicating a direct connection among perceptions of community stressors, psychological distress, and behavioral risks for HIV transmission.
The current study extends previous research on community stressors in relation to AIDS (Kalichman & Simbayi, 2003; Kalichman, Simbayi, & Jooste, 2005). We examined stressors experienced in three economically and racially different Cape Town communities, and their associations with substance use history and HIV transmission risks. We hypothesized that community stressors would differ for the three communities, and would be associated with greater substance use and HIV risks.
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Participants, communities, and procedures
Participants were men and women living in three communities in Cape Town, South Africa, a city with a population of over 3 million people. Table 1 presents the demographic characteristics and economic conditions of the three participating communities as reported in the 2001 South African census. Two of the communities were designated townships and each had surrounding informal settlements. One of the townships is home to indigenous Africans of Xhosa heritage (). This community was used in
Measures
Measures were administered in English, Xhosa, and Afrikaans. All measures were translated using back translation procedures. Participants completed the measures on their own with assistance as needed. Less than 10% of participants required reading assistance. For these participants, the field worker and the participant went through the survey together, with the participant responding on his or her own survey form while the field worker read the items aloud. This occurred in as private a place
Data analyses
One set of descriptive analyses compared the three communities on demographic characteristics and HIV risk factors using contingency table chi-square (χ2) tests for categorical variables and one-way analyses of variance (ANOVA) for continuous variables. Significant χ2 tests were followed by pair-wise planned comparisons between cells again using χ2 tests and significant ANOVAs were followed by planned comparisons using least-significant differences tests.
A second set of analyses on the
Results
Comparisons of the three communities on participant demographic characteristics are shown in Table 2. In addition to the known racial composition differences between communities, results indicated that participants from the urban residential community were significantly more likely to be female and married, had more years of education and scored higher on the AIDS knowledge test than the two township communities. Results also showed that respondents in the two townships were significantly more
Discussion
On a community level, HIV risk was related to socio-cultural characteristics across the three communities in Cape Town, South Africa. For example, communities with the highest levels of poverty also demonstrated the greatest degree of HIV risk. Participants in the townships were also more likely to have known someone with HIV/AIDS but were only slightly more likely to have been tested for HIV than persons in the better resourced urban neighborhoods. In some respects, the three communities that
Acknowledgments
National Institute of Alcohol Abuse and Alcoholism Grant R21 AA014820 and National Institute of Mental Health Grant R01 MH071160 supported this research.
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National Institute of Alcohol Abuse and Alcoholism Grant R21 AA014820 and National Institute of Mental Health Grant R01 MH071160 supported this research.