The Ubuntu concept, sexual behaviours and stigmatisation of persons living with HIV in Africa: A review article

Abstract

Stigma and discrimination and risky sexual behaviours have been major stumbling blocks to the efforts by implementers to mitigate the effects of HIV amongst communities in Africa. A key cultural resource, based on evolving South African cultural traditions, is the notion of Ubuntu, which is grounded in respect, ethics, humanity and the interconnectedness of beings. This concept can be a useful resource in upholding confidentiality, a central requirement in research ethics and the deliverance of health promotion interventions regarding HIV/AIDS. This article explored the applicability of the Ubuntu concept in enhancing safe sexual practices and positive attitudes towards persons living with HIV, with the view of achieving Zero new infections, Zero discrimination against persons living with HIV (PLHIV), and Zero AIDS-related deaths. A review of literature was undertaken. Electronic databases, academic journals and books from various sources were accessed. Several key search terms relating to the tenets of Ubuntu, stigma and discrimination towards PLHIV, and sexual behaviours were used. Only references deemed useful from relevant texts and journal articles were included. Going therefore by the Ubuntu tradition of basic respect and compassion for others, one will expect positive attitudes towards PLHIV. This review therefore advocates positive attitudes towards PLHIV. Also, according to the Ubuntu tradition that prescribes a rule of conduct and social ethics, one would expect the sexual behaviours of youths in Africa to be good. This review article also advocates safe sexual behaviours of adolescents in Africa. With this in mind, from a critical Ubuntu-centric philosophical perspective, this article breaks new ground by advocating the use of the Ubuntu concepts in enhancing safe sexual practices and positive attitudes towards PLHIV in Africa. This could in turn bring about safe sexual practices among youths, and curb the discrimination and stigmatization against PLHIV in Africa.

Introduction

To date sub-Saharan Africa (SSA), remains the epicentre of the HIV epidemic, accounting for 68% of all people living with HIV, which is about two-third of the global total. This implies that for every three people who are living with HIV in the whole world, two reside in SSA.¹

The fact that HIV is primarily transmitted through sexual intercourse,² has caused the disease and people living with HIV (PLHIV) to be severely stigmatized; it has become an emotive and highly controversial subject. The involvement of all stakeholders in the communities is critical for the attainment of the broad goal of achieving Zero New Infections, Zero Discrimination and Zero AIDS-related deaths.¹

Risky sexual behaviors, stigma and discrimination have been a major stumbling block to the efforts by implementers to mitigate the effects of HIV amongst communities. ^1,3 HIV/AIDS is a disease of behaviour and the behaviours associated with it include commercial sex work, injection drug use and being gay, which already carry some forms of stigmatization in many parts of the world. This stigmatization is then perpetuated on those infected and sometimes even on their families as they get ashamed of it. What has led to the pervasive stigmatization of PLHIV across SSA is fundamentally poor comprehensive knowledge of the correlates of transmission and prevention methods.⁴

Because of the way HIV/AIDS is perceived by large sections of the population in SSA, people infected are usually blamed for being responsible for their woes and sometimes those infected blame themselves for their situation. Poor and inaccurate knowledge of routes of infection of HIV among youth seem universal and are critical sources of stigma and discrimination against PLHIV. For example, Fagan and McDonell (2010) assessed HIV/AIDS knowledge, attitudes, and behaviour among Aboriginal and Torres Strait Islander youth aged 18-22 and found that 64%, 55% and 68% of the participants believed coughs and sneezes, hugging, and mosquito bites respectively could transmit HIV.⁵ Again, 80% believed taking family planning pills could protect against HIV infection.⁵A similar study among 2000 young adults in Guyana, reported 95.6% HIV/AIDS awareness but only 29.5% comprehensive knowledge of transmission routes and prevention methods.⁶

In the 2008 Ghana demographic and health survey (GDHS) over 95% of participants aged 15 through 49 had heard of and were aware of HIV/AIDS but only 28% of females and 32% males demonstrated comprehensive knowledge of HIV/AIDS.⁷ Besides, followers of many religious organizations consider HIV/AIDS as a curse from God for engaging in despicable moral conducts such as commercial sex work.³ In comparing church HIV/AIDS mobilization in Ghana and Zambia, it was found that there was a loss of long-term interest in HIV/AIDS activism in Ghana than Zambia due to continuous stigma and discrimination against PLHIV.⁸ Again, the methodologies used in HIV/AIDS prevention interventions, educational materials, and even in the media may help perpetuate stigma and discrimination.

In examining the drivers of stigma and discrimination against PLHIV among young people in Ghana, it was reported that the displaying and portraying of fear, horror, and secrecy about HIV/AIDS creates a desire for retribution among PLHIV in addition to consolidating stigmatization and discrimination. ⁹ Therefore, poor knowledge of transmission routes and views of the origin of HIV/AIDS are critical factors influencing the stigmatization and discrimination of PLHIV.

Sadly, for PLHIV and their caregivers, healthcare settings and healthcare professionals that could be the warmest places and kindest people respectively, to help alleviate their pain and suffering, also turn to perpetuate stigma and discrimination. This is a significant hurdle to providing appropriate care for PLHIV and healthcare accessibility by PLHIV themselves.³ However, the same issues that bring about stigma and discrimination in the general population such as low comprehensive knowledge of HIV/AIDS transmission routes and prevention methods may be the cause of stigma and discrimination in healthcare settings. In addition to the above, the high sense of fear of getting infected through contact with HIV-positive individuals could further drive HIV/AIDS stigma and discrimination in healthcare settings. Besides, healthcare professionals like nurses live in the same communities as the general public and are witnesses to the rejection of and discrimination against PLHIV. Thus, their fear of getting infected is not the only cause of their disposition to perpetuate stigma, but they also fear of being rejected and discriminated against by society if they are infected. In a study to examine HIV/AIDS stigma among nurses in Thailand, high levels of stigma and discrimination were reported. The nurses were asked between living with HIV/AIDS positive person and leukemia patients and none of them chose to live with HIV/AIDS positive person, among reasons given by the nurses were fear of being infected and fear of being rejected even by family members. ¹⁰

The manifestation of stigmatization and discrimination of PLHIV takes many forms. Some of these include rejection by community members and family members, refusal to eat with, share bed, shake hands, or even get closer to them.^3,10 Other forms of stigma and discrimination against PLHIV include blaming and ostracism by individuals and community members; and yet many PLHIV hold strong negative concepts about themselves. ¹¹ These then affect the health seeking behaviour of PLHIV, and even those who do not know their HIV status are pushed away from voluntary counseling and testing. HIV positive people may therefore not seek HIV services early for fear of being labeled, mocked, abused and ostracised. Those on antiretroviral treatment (ART) may miss their treatment especially when they are at community gatherings like funerals because they do not want the person next to them to know that they are on treatment.

Combating HIV/AIDS stigma and discrimination and improving positive selfesteem for PLHIV requires concerted and collective effort that has multidisciplinary and leadership approach. Improvement in comprehensive knowledge of routes of transmission and prevention methods as well as dealing with wrong perceptions and myths are critical. However, since the drivers of stigma and discrimination against HIV/AIDS and PLHIV are community factors, ¹² it is fundamental that community involvement through engagement of community leaders is required to fight stigma and discrimination against PLHIV. Community leaders need to play a major role in the fight against stigma and discrimination and protect the rights of the infected and affected and other vulnerable population groups in their respective areas.¹³

Community leaders are highly respected and influential in their communities. People, including PLHIV, turn to them for guidance and solutions to different challenges they face. This article will motivate, encourage and assist our communities to effectively tackle HIV and AIDS.

Ubuntu (a Zulu word) serves as a spiritual foundation for African societies. It is a unifying vision or world-view enshrined in the Zulu maxim Umuntu ngumuntu ngabuntu, meaning: a person is a person through other persons.¹⁴

Essentially, this traditional African aphorism articulates a basic respect and compassion for others. It can be interpreted as both a factual description and a rule of conduct or social ethic. It both describes human beings as being-with-others and prescribes what being-with-others should all be about. As such, Ubuntu adds a distinctly African flavour and momentum to a decolonised assessment of the religious others. While Western humanism tends to underestimate or even deny the importance of religious beliefs, Ubuntu or African Humanism is resiliently religious.¹⁵ Therefore Ubuntu could be used as a framework in the fight against discrimination and stigmatisation aimed at PLHIV.

This article explores the applicability of the Ubuntu concept in enhancing safe sexual practices and positive attitudes towards persons living with HIV, with the view of achieving Zero new infections, Zero discrimination against PLHIV, and Zero AIDSrelated deaths.

Methods of research

A systemic review of the literature was undertaken. Electronic databases, academic journals, and books from various sources were accessed. Several key search terms relating to the tenets of Ubuntu, stigma, and discrimination towards persons living with HIV, and sexual behaviours were used. Only references deemed useful from relevant texts and journal articles focusing on Africa were included.

Current status of knowledge

Values of Ubuntu

Ubuntu as an ancient philosophy or world-view has its roots deeply anchored in traditional African life. It is therefore defined as the art of being human being.¹⁶

According to Broodryk (2002), a more comprehensive definition of Ubuntu is: Ubuntu is an ancient African world-view based on the following primary values: i) intense humanness; ii) caring; iii) sharing; iv) respect; v) compassion and associated values.

Thereby ensuring a happy and quality human community life in the spirit of family. These primary values of Ubuntu are not abstract, but form the foundations of Ubuntu life coping skills. These values will thus manifest in their practical applications during the exposition of Ubuntu personality.¹⁷

Virtues of an ideal man according to Ubuntu

The Ubuntu personality is thus a reference to the ideal human being as it is manifested in the living of the ancient Ubuntu values.¹⁸ The ideal man, according to the Ubuntu world-view, possesses all the following virtues: i) a kind person; ii) living in harmony; iii) friendly; iv) modest; v) helpful; vi) humble; vii) happy.

Ubuntu values, sexual behaviours and discrimination against persons living with HIV/AIDS

The values of Ubuntu are directly linked to the basic beliefs of the ideal Ubuntu person. These Ubuntu values should correlate positively with the HIV/AIDS-related knowledge, attitudes towards persons living with HIV, accurate perceptions regarding HIV/AIDS and sexual behaviours of youths. Interestingly, the majority of people in Africa are not aware of the word Ubuntu. This review article in this respect establishes this awareness.

For the western person, the maxim A person is a person through other persons, has no obvious religious connotation. One will probably interpret it as nothing but a general appeal to treat others with respect and decency, especially persons living with HIV, and female adolescents, who often experience sexual violence and rape.

However, in African tradition, this maxim has a deep religious meaning. The person is to become through another person, ultimately, an ancestor; ancestors are extended family. Dying is an ultimate homecoming. Not only the living must, therefore, share with and care for each other, but the living and the dead depend on each other.^19,20

Louw (1988) points out that societal perception about the identity and morality as well as the negative labeling of PLHIV, have an enormous impact on people who live with the epidemic. The person living with HIV is seen by others as a failure and as one who has brought misfortune on him/herself by leading a sinful or immoral life. In many cases, such perceptions result in a severely damaged self-image and an inferiority complex.²¹

In the African context in which Ubuntu is central, the harm done to one’s identity as a result of such destructive perceptions becomes exaggerated. In that context, others and their opinions are quite important in forming and maintaining one’s identity and self-image. If other people become judgmental, they destroy one’s identity. In this way, the person living with HIV loses a sense of her/his own identity. It is therefore not surprising that PLHIV sometimes experiences society, especially church people, as alienating hypocrites.

People living with HIV could become more confused and depressed, and feel helpless and weak. Loneliness and negative thoughts determine the thought processes and perceptions of patients. People living with HIV are in need of a cure but are informed that no cure has yet been found. They have no certainty about who their friends are. They are not sure whether they are about to be shunned because of HIV/AIDS.

Going therefore by the Ubuntu tradition of basic respect and compassion for others, one will expect positive attitudes towards PLHIV. This review, therefore, advocates a positive attitude towards PLHIV.

Also, going by the virtues of an ideal man of the Ubuntu tradition that prescribes a rule of conduct and social ethics,18 one would expect the sexual behaviours of youths in Africa to be good. This review article also advocates safe sexual behaviours among youths in Africa.

Ubuntu inspires people to expose themselves to others, to encounter the difference of the humanness so as to inform and enrich their own.²² Thus understood, Ubuntu translates as To be human to affirm one’s humanity by recognising the humanity of others in its infinite variety of content and form.²³ This translation of Ubuntu attests to a respect for particularity, individuality, and historicality without which decolonisation cannot be. The Ubuntu tradition can impact a high-risk perception of HIV/AIDS among adolescents, and a consequent positive perception of the protection that condoms offer against HIV infection.

The traditional African practice of gender inequality; female genital mutilation; and sexual risk behaviours (coerced sex, multiple sexual partners, early sexual debut and non-use of condoms), do not reflect the Ubuntu tradition.

It is important to note that the Ubuntu concept of dignity and respect for all humans have been used in various interventions to fight HIV/AIDS.²⁴ These tenets of Ubuntu as described above can be found in different programs across many countries in SSA and in HIV/AIDS control programmes but have not been coordinated in the form Ubuntu prescribe. A classic example is a collaboration and multi-sectorial approach adopted in Uganda since the early 1990s. Uganda was one of the countries devastated by HIV/AIDS but collective effort demonstrated in political leadership, religious leadership involvement, and community coalitions, greatly fostered efforts to fight the epidemic. These concerted efforts made Uganda AIDS Action, a singular HIV/AIDS action in Africa that has achieved commendation and recommendation around the world. The Ugandan ministry of health (2015) attested to this, stating with strong political leadership, a vibrant civil society, and an open and multi-sectorial approach, Uganda sustained an impressive response to the epidemic. This was built into the Love Life, Stop AIDS AIDS control program.²⁵ In Zambia, community leaders such as the clergy strongly advocated for reduced stigma and discrimination against PLHIV which helped sustained the fight against HIV/AIDS.⁸ The importance of community leadership’s involvement in eliminating stigma and discrimination against PLHIV is, therefore, overdue.

Conclusions

The Ubuntu concept can be used in HIV/AIDS programmes that focus on HIV/AIDS prevention through reducing discrimination against PLHIV. The focus should be on all stakeholders, including community and cultural leaders, religious authorities and traditional leader to address discrimination and stigmatisation towards PLHIV, and socio-cultural aspects of HIV/AIDS. Traditional and cultural leaders have a comparative advantage in dealing with socio-cultural norms and values that underlie sexual and related behaviours. If significant behaviour change is needed, the active support of traditional and cultural leaders will be important to address parallel changes in norms and values.

The Ubuntu concept should be used in addressing the following issues:^24,26,27 i) addressing the vulnerability of young women and girls to HIV/AIDS; ii) promoting the role of men in HIV/AIDS prevention; iii) promoting sexual reproductive health (SRH) education; iv) discouraging multiple concurrent partnerships (MCP); v) reducing gender-based violence; vi) addressing intergenerational and transactional sex; vii) promoting life-skills education, self-efficacy and negotiation skills; viii) fighting stigma and denial of HIV/AIDS.

A cultural and values-based approach, focusing on the Ubuntu concept, should be used to address HIV/AIDS prevention in Africa. Working with a broad range of cultural and traditional leadership structures could drive behaviour change at three different levels: i) community - social norms and contexts; ii) individual - knowledge, behaviours and attitudes; iii) structural factors - leadership, policy, infrastructure.