Characteristics of study Participants
Study participants included young women (aged 15-30), old women (over 30 years), Men and the youth particularly the unmarried. Most of the community study participants had attained primary education, 1/3 had no education at all and most mentioned subsistence farming as a livelihood. Key informants were mainly district officials, NGO and health facility staff as well as community leaders at village and parish levels.
HIV and AIDS overshadowed by basic community needs
Throughout the four study sub-counties, community members recognised HIV and AIDS as a community problem. However, in terms of ranking, issues of; water, food, treatment and sanitation (mainly lack of excreta facilities) came before HIV and AIDS. When FGD participants and key informants were asked how HIV and AIDS compared to other community problems and how significant it was in their daily lives, anxiety about satisfying immediate needs of food, shelter, water, medical care and housing were repeatedly evident. Generally, HIV and AIDS were perceived as something for the future since it does not kill immediately compared to hunger. It therefore appeared that the unmet basic needs had over shadowed the fear for HIV and AIDS.
Findings revealed that women were more concerned about meeting the basic needs especially food as illustrated by the voice below.
Yes we know AIDS exists, but we are much more worried about the conditions of our daily lives than HIV. We do not even find enough food to satisfy our stomachs, and what we worry about is what we will eat today (FGD Young women Koyo, Pajule sub-county)
Men were on the other hand more concerned about the wider community needs like water, sanitation facilities and the fear of re-occurrence of insecurity.
HIV is a problem but for now we need water. In the camps where we moved from we had water flowing but in this village people walk long distances to look for water through the bush. Even if you brought a seminar on HIV now people will insist on water as their main problem (Community Leader, Acholi-Bur)
The main reason why some people have not yet come to the village is lack of water, latrines and fear that insecurity may re-occur but not HIV and AIDS. Those still in camps are better off than us here. Concern is trying to drill a bore hole which will help us a lot when completed (FGD Men Winya, Pader Kilak).
These findings show that whereas community members were aware that HIV and AIDS were serious problems, concern to meet the urgent basic needs constituted a greater priority for them. It is quite natural that people cannot think about strategic issues before meeting their practical needs.
Community and district leaders emphasised that more interventions geared towards livelihood improvement were required and once such took place then HIV issues could be mainstreamed there as one of the leaders noted;
What we need to do is to work on community needs like provide water in returnee villages, give people seeds....but when for example a water project is being commissioned then people can be told about HIV and they will listen; or even when they are being given agricultural inputs like seeds (District leader)
What is evident from the above voice is that whereas communities were pre-occupied with pressing basic needs, interventions geared at addressing these needs could also adopt integrated messages and other activities that address HIV as a cross-cutting issue.
Perceived trends of HIV transmission
Community members and informants believed that HIV and AIDS were on the increase in their communities. This perception was deeply rooted within the complexities and vulnerabilities created by war and the long standing social cultural practices as presented in the subsequent sections of this paper.
Insecurity and HIV and AIDS
Most study participants were of the view that insecurity had exacerbated the spread of HIV in Pader District. Throughout the discussions the major themes linking HIV to insecurity emerged and these were; congestion in camps associated with moral decadence, rape and defilement, sex for money and other material gains, increasing poverty, and the general breakdown in the health care system including shortage of HIV counselling and testing services.
Congestion in camps associated with moral decadence
Both FGD participants and key informants reiterated that the war had displaced many people from their villages and pushed them in congested camps where they lived for a long time and feared that their children had been exposed to sexual immorality. To this, one district official noted;
The war has pushed many people into camps; even children have been born and grown up without proper guidance. You can see the camp environment which exposes children to immorality at an early age due to lack of privacy and some are lured into sex using small gifts (District Official).
The linkage between insecurity, social dislocation and sexual immorality was also emphasised by men who observed that;
Before the war, we used to live in families with our own rules and it was easy to discipline children. It was not easy to have many people mix up like today in camps so the family has lost its value in protecting its members and this has exposed us to HIV (FGD Men).
The above findings show that insecurity and displacement in Pader district have greatly weakened the family institutional structure with regard to enforcing discipline among family members especially children thus creating impetus for the risky practices that were perceived to increase the spread of HIV.
Discussions with the youth confirmed the decay of the family structure due to insecurity and its linkage with risky behaviours which exposed the youth to HIV. As one FGD member retorted;
You know there are many youth who did not go to school or dropped out of school due to the war. They are idle and they can do any thing. Parents no longer have much control over them (FGD male youth).
Poverty, vulnerability and risk of HIV infection
As a result of the war and displacement, most people had lost their property and livelihood bases. This situation forced some people to adopt risky coping strategies in attempts to meet the basic necessities of life. Such strategies included; sex for money and other material gifts, marrying off young girls and marital breakdown in favour of those who had money.
Desperate men with money hungry for sex in the district engage the services of women and girls who are equally desperate for cash and survival; depending on how much money is available. All these are results of the war and increase the risk of HIV infection (District official).
The search for the means to meet the survival needs emerged again and again in discussions with community leaders as a factor that pushed some women into risky sexual practices that increased their vulnerability to HIV infection.
With war people are desperate for survival, so they are struggling for every thing like food and shelter; regardless of the consequences of this exchange which may include HIV (Community Leader, Acholi-Bur)
Men and women in focus group discussions pointed out that poverty which had increased because of the war had resulted into family breakdown and increased promiscuity with potential to increase risk to HIV infection as male and female community members explained.
You know before the war people had their gardens and would cultivate their own food. But we lost all these things. So as women struggle to meet the needs of their families like food, some have been lured into sex by men who have money and it becomes a habit. Such acts increase chances of getting HIV (FGD Men) Some women, who do not have a strong heart, gave themselves in to the men who had money or those that were in charge of welfare in camps so that they could get some money to buy food for their children. It was not easy; we can blame them but on the other hand they had no choice. If children are crying and they are hungry you can find when you have done what you would not do-if circumstances were different including having sex with men for money (FGD Women)
What emerges from the above voices is that destruction of family livelihoods resulting from conflict had served to push women into a situation characterised by difficult and risky choices which exposed them to risks of HIV infection.
For some men displacement and insecurity meant loss of power and ability to provide for their families. Indeed some men testified that they knew colleagues whose wives had been taken by men who had money and were in influential positions as noted below.
War is bad. You cannot be a man if you cannot provide for your family. Some men will have to start all over again. Like our friend who had two wives but when we came to the camps he could not provide for them so both wives were taken by other men who had money (FGD Men).
There are also women who do not go away. But they have men aside who give them money. The cause of this is one; the war which made men lose their assets and sources of income. Husbands for such women may not know but they can bring for them HIV (FGD men).
War and sexual abuse-double troubles for women
Study findings also revealed that women and girls were victims of sexual abuse due to war than men. Through focus group discussions and interviews, women and girls were sighted as victims of rape and defilement by rebels and soldiers alike thus increasing the risk of HIV infection. One community leader in Awere observed:
During the war many women were forced into sex either through rape or in exchange of money and materials.
Vulnerability to HIV infection was closely knit in role expectations of men, women and children at household level. In order to meet these role expectations different family members adopted varied coping strategies some of which increased the risk of HIV infection. For instance, in order to meet the needs of their families, some women went in for extra marital sex in exchange of food, money, blankets and other household requirements. In this context, failure to meet basic needs resulting from war, poverty and displacement increased vulnerability to HIV infection the level of awareness not withstanding. Men recounted how soldiers, aid workers and business men had preyed on their wives since they had material and financial resources.
There is a man in this village that had 3 wives when we were in the bigger camp but all of them were taken by soldiers because they had money (FGD Men Coo rom)
Some parents were also said to encourage their adolescent daughters to 'be self reliant'; which also included engaging in sex for money as a survival strategy. This was also linked to limited livelihood options in the war torn district.
There are many young girls in this district who have sex with old men because they want money and other material things for survival (Community leader Pajule).
Discussions with the youth also confirmed that family pressures and inability to provide for the needs of the youth was a major push factor into risky sexual relationships.
You can tell your parents you need Vaseline and they tell you that you should find how to buy it yourself since you are a big girl now. What does that mean? So some girls have been pushed into finding men to help them and some men may give them HIV in exchange (FGD female youth)
If you have some money it is not difficult for one to get a girl. You just need to have some little money to buy for her lunch or a dress and she is yours. So the boys and men who have money have many girl friends (FGD male youth)
Role expectations coupled with an insecure environment aggravated exposure to HIV infection particularly for women and girls. For instance, women and adolescent girls had to go and till the fields, collect firewood and water that were inevitable even when they knew that going out to these places was risky, some times involving rape and defilement. Findings from FGDs and key informants confirmed this vulnerability embedded in the struggles by women and girls to meet their family role expectations as noted by one community leader:
We have heard very bad experiences because of the war; you hear a girl or woman was raped on the way to the well to fetch water. Some of those women may end up getting HIV (Community Leader)
Social-cultural context and HIV and AIDS
When asked as to whether there are any social cultural practices that increased the spread of HIV in Pader district, most of the study participants responded in the affirmative. The main themes that emerged linking HIV spread to the social cultural context include; polygamy, widow inheritance, alcoholism, traditional ceremonies, silence about sex, submissive place of women and resistance to condom use.
Discussions with community members and key informants re-affirmed that widow inheritance, polygamy and early marriages were fuelling the spread of HIV and AIDS in the district. One respondent retorted; 'If I die my brother will represent me'. Literally meaning that when he dies his brother will inherit his wife. In relation to polygamy one local leader who disclosed having 5 wives defended the practice as 'a gift from God!'
"Men in this area have many wives and other women a side. A man generally with one woman is seen as if he is not a man enough. HIV is going to finish us" (FGD Women Bolo)
Other risky cultural practices identified were; using un-sterilized instruments by traditional healers and alcoholism which was seen as a norm for most men. The congested camp environment characterised by poverty was again mentioned as a threat to fostering morals in children with regard to sexuality. Abstinence was seen as very hard or even impossible to enforce.
Having many sexual partners, over use of alcohol and early marriages in our setting are major challenges in the fight against HIV and AIDS (District official)
Furthermore, the spread of HIV was linked to silence related to sexuality and HIV status.
HIV has challenged us, it is not easy to talk about sex in our culture, those are bedroom matters... many adults find it difficult to advise the young ones on HIV prevention (District official).
Even when people test, they prefer their HIV status to remain secret partly because of the secrecy related to sex and the fear of stigma (FGDs men).
I would not reveal that I am HIV positive to others, for fear of embarrassment, isolation and discrimination (FGD Female Youth Pajule)
In view of stigma, a person living with HIV observed;
"Once people know that you are sick, they will soon refuse to associate with you thinking that you are dying any time. By the time you die you will be alone like a stranger and very miserable because we don't have the modern drugs that I hear make people better and can even 'cure' the disease'.
Cultural functions like marriage, naming of children and rituals related to the birth of twins were also linked to increasing the risk of HIV transmission. Respondents argued that such functions brought many people together and increased avenues for alcohol consumption and casual sex. A common belief that healthy looking persons are likely to be free from HIV re-enforced the risk. It was common to find a woman or man widowed living with HIV getting married over and over again as long as he/she looked healthy. Some traditional healers and herbalists were said to lure their clients particularly women into sexual relationships, a practice with potential to increase the spread of HIV.
It was also strange to note that some people believed that ARVs cure AIDS. To this one elderly man noted that 'AIDS no longer kills the very rich, they buy modern drugs and recover and begin their lives all over again! It is the poor that are in trouble!'
On the contrary this notion was dismissed in focus group discussions for the youth and by key informants.
'HIV and AIDS has no cure; people have no spare parts-you have to test blood, use condoms, be faithful, abstain and be safe! Once you have HIV it will never leave your body until you die (FGD Youth Awere Sub-county).