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CHAPTER 5 KNOWLEDGE LEVELS OF INMATES AND STAFF AS REGARDS HIV/AIDS
INTRODUCTION
HIV/AIDS as an epidemic has occupied the centre stage in public health and many political discourses. It has also presented several challenges to the correctional community. AIDS has been reported as the leading cause of mortality in correctional institutions (Long, 1998:28). As a result, there are vigorous debates on the utility of the harm reduction components with regards to curbing the spread of HIV in the correctional environment. The vulnerability to being HIV infected during the incarceration largely depends on the person‟s knowledge of HIV/AIDS and the prevalent risk taking behaviours (Akhtar, Luby, Rahbar & Azam, 2001:351).
Education is perceived as the primary form of HIV prevention, as argued below. Given the absence of a cure, education plays a pivotal role in fighting the AIDS epidemic. Without concerted efforts regarding education in this respect, the epidemic will continue to increase to unprecedented levels (Long, 1998:2; Katjavivi & Otaala, 2003:1). Currently, education is widely used to disseminate information with regards to HIV/AIDS both in the public and correctional settings. The education of inmates in this respect, HIV/AIDS enhances their knowledge, exposes them to possible behavioural modifications, and reduces fear of being infected, thus contributing towards curbing the prevalent risk taking behaviours associated with HIV/AIDS in correctional institutions (Hogan,1994:221; Martin, Long &West, 1995:6; Collica, 2002:103; Kourelakis, Power, Gnardellis & Agrafiotis, 2003:105; Oyewale, 2008:16; Katjavivi & Otaala, 2003:5).
This chapter provides an outline of HIV/AIDS related knowledge levels of inmates and staff. The specific knowledge domains covered herein include; the meaning of HIV/AIDS, general awareness of this syndrome, modes of HIV transmission, HIV prevention methods, sources of HIV/AIDS knowledge and attitudes towards the pandemic. The knowledge assessment section of the questionnaire is modelled on the AIDS Knowledge and Attitudes Questionnaire (AKQA) previously used by Long (1998) on inmate populations in the Pennsylvania correctional system. The knowledge scale in this study consists of a total of 26 items; with 23 items measuring HIV/AIDS covering the above mentioned knowledge domains and three items gauging the attitudes towards HIV/AIDS.
A total of 22 items offer choices between two responses, „true‟ or „false‟. The correct responses are calculated to produce a knowledge score while incorrect responses are indicative of a „knowledge gap‟ score. A single item deals with sources of HIV/AIDS and offers a choice of six subsets from which respondents have to select any applicable response. The three items dealing with attitude towards HIV/AIDS vwere based on the Likert scale with the four response categories being „strongly agree‟, „agree‟, „strongly disagree‟, and „disagree‟. For the analysis, the „agree‟ and „strongly agree‟ responses are collapsed into affirmative answers whereas the „disagree‟ and „strongly disagree‟ responses collectively represent negative answers.
The concept „knowledge‟ is defined in various ways. According to Hornby (2000:658) knowledge may be defined as “understanding and skills acquired through education and experience”. Furthermore, Houaiss and Salles (2001:802) as cited in Ernesto (2007:19) define knowledge as “the theoretical and practical mastery of a subject”. In addition, Oyewale (2008:37) states that there are two forms of knowledge namely; conceptual and procedural.
The conceptual knowledge refers to a “connected web of knowledge (a network) in which linking relationships of the discrete bits of information about a phenomenon are made”. Procedural knowledge is defined as “the knowledge exercised in the performance of some task” (Oyewale, 2008:38). In sum, knowledge can be referred to as the acquisition of factual information regarding a subject by means of education with the ability to apply it intelligently to make a difference. In this study, knowledge refers to a general understanding of HIV/AIDS and the ability to use such information for specific purposes: the prevention and management of HIV/AIDS. It is critical for persons to possess a basic understanding of HIV/AIDS in order to survive the scourge.
HIV/AIDS is a very formidable major public health problem ravaging all populations on a global scale. Approximately 25 million people worldwide have died as a result of HIV related diseases since 1981, with about 66% stemming from Sub-Saharan Africa. As a result, this region is alluded to as the epicentre of the HIV pandemic (Ntombela, Stillwell & Leach, 2008:73; Dijkstra, Kangawaza, Martens, Boer & Rasker, 2007:636). According to the prevalence studies in the Sub-Saharan countries, South Africa houses the highest number of HIV infected people. (Katjavivi & Otaala, 2003:2; Condon & Sinha, 2008:37).
AIDS first became apparent in South Africa around 1983. To date, it is estimated that one in 8 to 10 adults is HIV positive ( City Press , 2008: 14; Moosa, 2009:16). It is further estimated that approximately 5.7 million South Africans were HIV positive as at the end of 2007, and of these approximately 18.1% were 15 to 49 year old individuals. This is the cohort which forms the core of the inmate population. This is a devastating situation that requires urgent attention (Mwamburi, Dladla, Qwana & Lurie, 2005:518; Delva, Pretorius, Temmerman, 2009:639; Matjila, Hoosen, Stolz & Cameron, 2009:91; Buys, 2009:143; Grundlingh, 2009:239).
It is worth noting that there is significant under-reporting, owing to a number of reasons, inter alia, stigmatization and fear of victimization. On the African continent, being HIV positive carries a stigma; hence the prevalent fear of being victimized (Okonkwo, Reich, Alabi, Umeike & Nachman, 2007:252); consequently the level of HIV/AIDS might be greater than the above mentioned statistics. South Africa contains a population of 47.9 million with the number of incarcerated inmates and awaiting trial detainees estimated at 162095 as at the end of October 2009 (Ncana, 2009:13). The site of this study is in the Gauteng province, which is the most densely populated province with an estimated population of 9.6 million. There are 26 correctional centres in Gauteng with a capacity of 26709 and an inmate population of 44 833 as at 2004 (Luyt, 2008:5).
Generally, it is estimated that the rate of infection amongst inmates is six times higher than in the general community (Keeton & Swanson, 1998:119; West, 2001:20). However, in the South African correctional centres the precise extent of the HIV prevalence is illusive. This is owing to the lack of mandatory testing, and scanty records on HIV cases. Earlier attempts to quantify HIV/AIDS rates amongst inmates have been met with resistance from the Department of Correctional Services (Luyt, 2008:148). Despite the resistance, there have been attempts to do so. Lanier (2009:63) estimated that approximately 41% of the inmates are living with HIV.
The HIV/AIDS knowledge levels of South Africans have been found to be varied. The Human Sciences Research Council (HSRC) noted the HIV/AIDS knowledge gaps amongst the less educated people. In some instances, the awareness of HIV/AIDS was high yet respondents exhibited inadequate knowledge regarding prevention methods and whether AIDS is curable. In another study, high school learners knew the basics of HIV/AIDS but lacked knowledge of the modes of transmission and preventive strategies (Grundlingh, 2009:244).
AIDS has no cure; hence HIV is the most difficult retrovirus to deal with. It appears in one‟s immune system in various forms. Also, the virus constantly mutates and multiplies itself; as a result it is impossible to treat the syndrome with a single drug or a vaccine (Hammet, 1988:17). Since there is no cure for AIDS, education has been alluded to as one of the most important harm reduction strategies that can be employed to address this epidemic (Nyamathi, Bennet, Leake, Lewis & Flaskerud, 1993:65; Collica, 2002: 103; Koulierakis et al., 2003:103). Feucht, Stephens & Gibbs (1991:10) submit that “in any health crisis, the reduction of risk depends greatly upon the level of knowledge among those at risk‟.
However, Martin et al. (1995:26) cautions that providing HIV information per se cannot be expected to bring change. They suggest that inmates should be taught risk reduction skills, provided with the opportunity to practice such skills, and lastly, be accorded access to risk reduction resources, in order for the acquired knowledge to make a significant difference. Therefore, individuals need in-depth knowledge of HIV with accompanying practical and access to harm reduction components in order to effectively deal with the prevention and management of HIV/AIDS (Reader, Carter & Crawford, 1988:125; Al-Owaish, Moussa, Anwar, Al-Shoumer & Sharma, 1999:172).
In sum, adequate HIV/AIDS knowledge is critical as it enhances better management of the disease and care for the infected. The amelioration of risk taking behaviours and the curbing of consequent HIV affliction to a greater extent depends on the knowledge acquired by those at risk as well as their application thereof. The following discussion provides a description of these knowledge content areas: the meaning of HIV/AIDS, basic knowledge about it, HIV transmission routes, and HIV prevention methods. Lastly, the chapter delineates sources of information and the attitudes of inmates and staff towards HIV/AIDS. It is important to score the AIDS knowledge questions according to content areas in order to identify issues that require intensive efforts to improve knowledge (Keeton & Swanson, 1998:121).
THE MEANING OF HIV/AIDS
It is essential for persons to know the meaning of the acronyms as this serves as a foundation of HIV/AIDS knowledge. A brief explanation is as follows:
a. HIV: It is a virus (V) that attacks the immune (I) system of a human (H) being and makes it weak, that is, Human Immunodeficiency Virus.
b. AIDS: It is an acquired (A) virus that makes the immune (I) system deficient (D) and presents itself as a syndrome (S). The virus renders the body incapable of fighting a set of opportunistic infections (Whiteside & Sunter, 2000:1).
Tables 18 and 19 consist of two items to check whether the respondents have a basic understanding of the acronyms. The questions require affirmative responses to indicate sound knowledge levels in this respect. Negative responses are the indicator of a knowledge deficit.
From Tables 18 and 19, all the respondents show a basic understanding of the meaning of both acronyms, although minimal knowledge deficits are still evident. The incorrect responses with regards to the meaning of both abbreviations range between 10.39% (inmates) and 14.10% (staff). The two items were mostly answered correctly. The level of correct understanding of the concept HIV/AIDS ranges from 85.90% to 89.61% for all the respondents. The correctional staff should be purveyors of correct information and represent a major source of knowledge; therefore the deficits noted therefore call for intensive efforts to bring all correctional staff to the desired level of knowledge.
It is generally expected that some inmates would indicate a knowledge deficit in this regard owing to their social background. Inmates largely stem from groups of out-of-school youths who have missed out on HIV programmes that are part of the structured learning environment in the community. Inmates drop out of school for various reasons, including poverty, loss of interest, and failure to meet academic requirements (Haigler, Harlow, O‟Connor, & Campbell, 2004:41; Francis & Rimmansberger, 2009:604). In this study, findings on the education levels of the inmate respondents reveal that 64.43% have studied up to grade 10. It is highly likely that they mostly started studying after their incarceration.
BASIC KNOWLEDGE OF HIV/AIDS
It is widely reported that HIV causes AIDS. HIV is a viral agent that attacks the white blood cells (T4 cells), weakens the immune system, and progresses into full blown AIDS over a number of years (Hammet, 1988:3). Adequate knowledge on HIV/AIDS enables one to invoke preventive strategies and manage the condition effectively if infected. The nine items in Tables 20 and 21 measure basic HIV/AIDS knowledge of inmates and staff at the Leeuwkop Correctional Centre, respectively. The range of responses requires either affirmative or negative responses depending on the content. Items (ii), (iv),(vi),(vii), and (viii) require „false‟ as an answer to be considered correct whereas items (i), (iii), (v) and (ix) require „true‟ as a response to indicate an acceptable level of knowledge.
Overall, the majority of all the respondents answered all the items correctly. The scores of all the respondents show that they are knowledgeable regarding the aetiological agent of AIDS. As indicated in Tables 20 and 21, most of the respondents (91.30%-inmates to 92.41%-staff) know that AIDS is caused by the HIV virus. Only 7.59% (staff) to 8.70% (inmates) responded incorrectly to the statement regarding whether AIDS is caused by HIV. Generally, this knowledge deficit may be attributed to the misinformation that was transmitted by government agencies after the onset of AIDS. For example, the initial government response to the HIV/AIDS epidemic in the country perpetuated flawed and dangerous myths.
It has been widely reported that the former State President, Honourable Thabo Mbeki publicly denounced the link between AIDS and HIV at the World Conference on AIDS in 1999 (Condon & Sinha, 2008:35; Lanier, 2009:61). Therefore, this statement may have caused a ripple effect with regards to the general misunderstanding of HIV/AIDS. Equally in other African states, the response to the HIV pandemic in the early 1980s was that of denial which exerted an adverse effect on the level of HIV knowledge. For example, as a consequence of the denial the HIV knowledge level of the correctional staff in Nigeria was found wanting. They were found to display the same knowledge deficit as the inmates (Ikuteyijo & Agunbiade, 2008:287).
Another knowledge deficit concerning the aetiology of HIV was also noted in a study conducted on AIDS and prostitution at a city jail for women, where 83% of 23 respondents knew that AIDS is caused by a virus (Beatty, 2005:73). Sweat and Levin (1995:357) investigated knowledge about AIDS in detail among the US population. They found that although most respondents (62.9%) knew that AIDS was caused by the HIV, about 11% still did not know this. Ikuteyijo and Agunbiade (2008:282) conducted a study on HIV institutional policies, HIV knowledge levels, and risk taking behaviours in two Nigerian correctional institutions. They established that 67.6% (n=341) revealed a deficit of knowledge regarding basic AIDS issues.
No one is born with AIDS: it is an acquired virus. There has to be an exchange of bodily fluids for one to contract HIV. For example, there has to be contact with infected blood, semen, vaginal secretion, and breast milk (Whiteside & Sunter, 2000:3). The responses to the question regarding whether „AIDS is a medical condition you were born with‟ as reflected in Tables 20 and 21 above indicate that the majority of the respondents exhibit a high level of knowledge that AIDS is an acquired disease. A total of 91.71% of the inmates and 93.42% of staff refuted that AIDS is a congenital condition.
In addition, there is a distinct difference between having AIDS and being HIV positive. HIV positive individuals do not necessarily develop AIDS, which is entirely dependent on one‟s immune system. HIV can be dormant in one‟s system for a period of approximately 10 years before there is progression to full blown AIDS status. The process of HIV infection is that the virus enters one‟s body and attaches itself to the CD T-cells which are normally 1200 per micro litre of blood and at this stage the person becomes HIV positive. It is only after the virus has depleted the cells to approximately 200 per micro litre when it is said that one has AIDS (Whiteside & Sunter, 2008:8).
It is at this stage, the infection has to be closely monitored through repeated medical checkups, as failure to do so may result into morbidity and mortality. The responses in Tables 20 and 21 show that there are recognizable knowledge gaps amongst inmates and staff in terms of the question that „all people who have HIV are sick with AIDS‟. The inmates (64.71%) indicated a slightly lower percentage of correct responses than that of the staff (77.92%). It is of concern that more than 20% of the staff reflects a knowledge deficit relating to the difference between HIV and AIDS.
In contrast, a study conducted on HIV knowledge amongst Scottish inmates indicated that the majority 82.5% (n=559) revealed a clear understanding that „having AIDS and being HIV infected are not the same‟, as compared to 64.71% (n=209) in this study (Power et al., 1993:15). In addition, it is reported that some inmates regarded HIV and AIDS as being synonymous, a testimony that they do not know the difference (Gunter, Snach-Alridge & Moss, 1993:14). It is therefore vital to improve knowledge of both local inmates and staff regarding the stages of HIV and the inherent differences between HIV and AIDS.
There is no cure or vaccine for HIV and its sequellae (Martin et al., 1995:6; AlOwaish et al., 1999:163; Grundlingh, 2009:239). In this study some respondents believe that AIDS is curable. The affirmative responses to the question „AIDS can be cured and people recover from it‟ were 16.67 % (staff) to 21.67% (inmates). These responses are incorrect and given the inherent fatality attributed to AIDS,
the knowledge deficit requires urgent intervention. Similarly, in a comprehensive study on HIV knowledge, attitudes, beliefs and practices in Kuwait, 11.5% (n=2219) reported that there was a vaccine for AIDS.
The responses of all the respondents to the question of whether „AIDS can be cured by having sex with a virgin‟ show that the majority are knowledgeable in this regard. Nevertheless, a knowledge deficit is still evident in that 7.59% (staff) and 12.20% (inmates) responded affirmatively, which may result from the myth prevalent among African men that having sexual contact with a virgin cures AIDS. This myth is largely blamed for the reported infant sexual abuse perpetrated by adults in South Africa.
It is widely reported that the first cases of AIDS were found among gay people; the virus was acquired through male-to-male sexual transmission. Those who had been infected developed rare types of pneumonia (pneumocyctis carini) and cancer (Kaposi‟s sarcoma). Later, information became available that heterosexuals had also been infected. Notwithstanding this additional information, myths that AIDS only affects gay people prevailed (Hammet, 1988:3; Tewksbury, Vito, & Cummings, 2006:230). In this study, a larger percentage both inmates (95.42%) and staff (97.47%) exhibited accurate knowledge regarding the statement that „All gay people have AIDS‟; that is, they responded negatively to the statement. This clearly indicates that myths previously held about gay people and AIDS have been successfully dispelled.
Furthermore, it is common knowledge that HIV is transmitted through sexual contact (Whiteside & Sunter, 2000:10; Williamson & Martin, 2005:115) since the semen also carries the virus. The responses to the statement on whether „HIV is carried in men‟s semen‟ indicate that there is a serious knowledge deficit in this respect among both the inmates and the staff. As compared to the staff
(61.84%) who responded correctly to this statement, only 45.45% of the inmates did so, which suggests that more education on this aspect is required for both the inmates and the staff. Such knowledge is important in order to employ preventive measures such as consistent use of condoms.
Finally, it is imperative for persons to know that once infected, medical attention is required. As stated earlier, HIV weakens the immune system hence the need for prompt medical intervention. Most of the responses to the statement as to whether „AIDS is a medical condition that cannot be fought off by one‟s body‟ were correct. The responses, 75.13% (inmates) and 80.77% (staff), indicate that most of them would seek medical attention once infected. Such knowledge would, amongst others, enable them to invoke measures that prevent the transmission of HIV.
KNOWLEDGE OF HIV TRANSMISSION MODES
HIV is transmitted through the exchange of bodily fluids of seropositive individuals. The virus has to enter the body through a mucous membrane into the blood of another person (Long, 1998:10; Whiteside & Sunter, 2000:10). The likely routes of HIV transmission include unprotected sexual intercourse, perinatal (intrauterine and peripartum) functions, and blood inoculation. Unprotected sex is the key mode of transmission as the virus is carried in the semen. It has been widely reported that HIV transmission though unprotected sex is rampant amongst inmates (Jolofani & DeGabriele, 1999:7; Krebs & Simmons, 2002:60). The probability of being infected sexually is even higher in the presence of sexually transmitted diseases (STDs) which causes inflammation of the genital tract (Coetzee & Johnson, 2005:193).
Perinatal HIV transmission takes place from a pregnant HIV positive mother to baby towards the second trimester. It is estimated that the rate of transmission during pregnancy ranges from 5% to 10%. Also, after birth the transmission may occur from the infected mother to a baby through breastfeeding. It is therefore prudent for an HIV infected mother to resort to formula feeding (Martin et al., 1995:29; Coovadia, 2005:185).
Blood transfusion introduces the virus directly into the blood stream of another person. Although there are measures in place to reduce the risk of infection, there is still a minimal chance of being infected even when the blood has been screened. According to the World Health Organization (WHO) approxiamtely 80,000 to 160,000 cases of HIV occur through blood products (Whiteside & Sunter, 2000:13). The risk of contracting HIV through the routes alluded to ranges from high to low. For example, the risk of transmission through open wounds and cuts is lower than via blood transfusion and the sharing contaminated equipment.
There is ample evidence that HIV cannot be transmitted through casual contact, be it hugging, kissing, handshaking, sharing personal belongings or using same toilet seat (Hammet, 1988:8-15; Long, 1998:10). Despite this, there are prevailing misconceptions regarding casual contagion. In a study on HIV transmission among Iranian inmates at the Rajaei-Shahr correctional institution, the respondents exhibited a high knowledge of HIV yet 95% (n=100) identified kissing and shaking hands as modes of transmission (Eshrati, Asi, Dell, Afshar, Millson, Ismali, & Wilkes, 2008:4).
TABLE OF CONTENTS
DECLARATION
ACKNOWLEDGEMENTS
ABSTRACT
CHAPTER 1: OVERVIEW OF THE STUDY
1.1. Introduction
1.2. Background
1.3. Statement of the Problem
1.4. Aims of the Study
1.5. Rationale of the Study
1.6. Research Questions
1.7. Definition of Terms
1.8. Research Design
1.9. Limitations of the Study
1.10. Summary
References
CHAPTER 2: HARM REDUCTION: HISTORY, PHILOSOPHY, AND THEORIES
2.1. Introduction
2.2. History of Harm Reduction
2.3. Philosophy
2.4. Theories
2.5. Summary
References
CHAPTER 3: INTERNATIONAL AND SOUTH AFRICAN OVERVIEW OF HARM AND RISK REDUCTION COMPONENTS
3.1. Introduction
3.2. Dublin Declaration on HIV/AIDS in Prisons
3.3. International Harm Reduction Components
3.4. South African Overview
3.5. Advantages and Disadvantages of Harm Reduction Models
3.6. Summary
References
CHAPTER 4: RISK TAKING BEHAVIOURS IN CORRECTIONAL CENTRES
4.1. Introduction
4.2. Sexual Activities
4.3. Drug Use
4.4. Tattooing
4.5. Summary
References
CHAPTER 5: KNOWLEDGE LEVELS OF HIV/AIDS OF INMATES AND STAFF AT LEEUWKOP CORRECTIONAL CENTRE
5.1. Introduction
5.2. Meaning of HIV/AIDS
5.3. Basic Knowledge Levels on HIV/AIDS
5.4. Knowledge of HIV/AIDS Transmission Modes
5.5. Knowledge of HIV/AIDS Prevention Methods
5.6. Sources of Information
5.7. Attitudes towards HIV/AIDS
5.8. Summary
References
CHAPTER 6: FINDINGS, RECOMMENDATIONS AND CONCLUSION
6.1. Introduction
6.2. Findings
6.3. Recommendations
6.4. Other Recommendation
Conclusion
References
GET THE COMPLETE PROJECT
HARM REDUCTION IN STATE PRISONS
