STD/AIDS prevention in Portuguese-speaking Africa: a review of the recent literature in the social sciences and health Prevenção das DST/AIDS nos países africanos de língua ofi cial portuguesa: revisão da literatura

The article reviews academic literature in the social sciences and health on the problems and challenges of STD/AIDS prevention in Portuguese-speaking African countries. Based on a bibliographic survey of the SciELO, PubMed, and Sociological Abstracts databases between 1997 and 2007, the research under review was organized into two groups, according to content. The first group of studies sought to understand STD/AIDS vulnerability among social groups by examining local cultural and socioeconomic factors as related to gender dynamics, sexuality, color/race, religion and health care. The second group encompassed critical assessments of shortcomings in the STD/AIDS educational messages delivered by governments and international agencies. Attention is called to the way in which the presence of traditional medicine systems and the occurrence of civil wars in the post-colonial period impact the STD/AIDS epidemic in the African countries under study. Acquired Immunodeficiency Syndrome; Sexually Transmitted Diseases; Prevention; Gender; Africa This exploratory study reviews the literature in the field of the social sciences and health on the problems and challenges of STD/AIDS prevention in sub-Saharan Africa, with a focus on research in Portuguese-speaking African countries (known by the acronym PALOP, for Países Africanos de Língua Oficial Portuguesa): Mozambique, Angola, Cape Verde, Guinea-Bissau, Equatorial Guinea, and São Tomé and Príncipe. The survey encompassed scientific production from 1997 to 2007 available in the SciELO, PubMed, and Sociological Abstracts databases. Methodologically, the search cross-referenced descriptors related to AIDS, African countries and prevention, and socio-cultural dimensions like gender and sexuality, among others. The studies were divided into two groups. The first examined vulnerability to STD/AIDS among social groups, based on analyses of the cultural and socio-economic factors linked to gender roles, sexuality, emotional and sexual interactions, religious affiliation, social networks, educational level, and access to social goods and healthcare services. The second group offered critical evaluations of shortcomings in the educational STD/AIDS messages of governments and international agencies. Attention is called to the specific features of African countries, including a marked reliance on traditional medicine and recent civil wars. Although the factors examined in both groups constitute specific dimensions, in the complexity of the real world they are all interFÓRUM FORUM 680 Cad. Saúde Pública, Rio de Janeiro, 25(3):680-686, mar, 2009 twined, with relations of mutual determination and association, and they should be interpreted in conjunction. Cultural and socio-economic dimensions of the HIV/AIDS epidemic The concept of gender – that is, cultural attributes associated with the female or male sex – has made its growing influence felt in the world literature on the HIV/AIDS epidemic. Interpretations of rising HIV transmission through heterosexual relations and among women, especially in contexts of socio-economic inequality and social marginality, have taken into account the implications of hierarchical relations, which are characterized by the hegemony of male power and concomitant greater female subjugation, partly grounded in the control of sexuality. These features are found in various contexts in sub-Saharan Africa. Reflecting this tendency, the literature under review explores how local gender dynamics matter to our understanding of STD/AIDS vulnerability and how these dynamics are interdependent on the socio-economic conditions of the contexts in question. The present text discusses these factors based on the surveyed studies on Portuguesespeaking African countries, except for Equatorial Guinea and São Tomé and Príncipe, where no research was identified. Studies conducted in Mozambique, and in rural regions in particular, draw a connection between vulnerability both to the AIDS epidemic and social practices by which men control female sexuality and to childbearing and reproduction of the family, which constitutes an important cultural value. These factors clash with prevention messages centered on the negotiated use of condoms. Within this universe, widows are especially vulnerable, as they have no ownership rights to their husband’s estate and are subject to rape and sexual exploitation by male family members 1. Approaching from the factors of gender, socioeconomic conditions, educational level, and religious affiliation, other analyses have contributed to a deeper understanding of local logic systems and their implications when it comes to constructing ideas about health and risk. In this regard, one set of research 2,3,4,5 addresses the way in which religious beliefs in subSaharan Africa shape social and gender norms and influence the interpretation of prevention messages. One illustration of this approach is a study 2 conducted in rural Mozambique and in urban areas of the capital among members of two types of denominations: “mainline” (Catholic and Presbyterian) and “curative” (Assembly of God, Zionist, and Apostolic). The study found gender asymmetry in messages about STD/AIDS prevention and in members’ views and practices within both types of denominations. Centered around family values and moral standards, the prevention messages aimed at men emphasized the risks of extramarital sex. Among women, protective recommendations focused on a commitment to housework and to the husband’s sexual satisfaction. Differences were observed between the social profiles of members of each group and between doctrinal messages. With most of their members coming from lower, rural classes, curative denominations display a more homogenous profile and lesser doctrinal flexibility. Mainline denominations, however, display greater social diversity, openness, and political connections, which means their members enjoy greater exposure to other messages and are more flexible about sexual morality. In other words, despite similarities between the messages of both religious types, the meaning assigned to each message depends upon members’ educational level and social environment. Likewise, research into the new meanings attributed to control over sexuality in the more well-to-do urban regions of Mozambique suggests that sexual mores may be growing more flexible. Some authors have observed that young, urban, educated middle-class females are more likely to challenge traditionally defined gender roles, putting them in a more advantageous position in sexual negotiations and leaving them less vulnerable 6,7. Karlyn 8 analyzes one sexual practice among young people in the capital of Mozambique, known as saca cena, where casual sexual contact does not follow traditional gender rules. During these practices, young females play an active role in sexual conquest and negotiation, indicating increased assimilation of prevention messages. According to research, signs of new perceptions and new meanings within specific regions and groups are still rather insignificant. Studies focusing on national surveys show that for males and females aged 15 to 24, their perception of the risk of acquiring HIV is unrealistic. Gender asymmetries are visible in the fact that men receive more education. Women tend to marry earlier and have relations only with their husbands, while men marry later and have a greater number of partners 9,10. Other studies have shown that involvement in a stable, monogamist relationship presents a major barrier to the use of condoms by young people, as the participants tend to place trust in their partner based on their established ties. Prevention campaigns reinforce this notion when they center on sexual abstinence, being STD/AIDS PREVENTION IN PORTUGUESE-SPEAKING AFRICA 681 Cad. Saúde Pública, Rio de Janeiro, 25(3):680-686, mar, 2009