No abstract

While international guidelines are currently being drawn up about HIV and infant feeding practices, and national and regional guidelines are under discussion in South Africa, there have been remarkably few studies that have sought to elicit HIV-positive mothers' experiences of breastfeeding and of paediatric infection. There is an urgent need to document this 'grass roots' knowledge in different sites, and for this data to be used to inform policy development, and for advocacy and counselling purposes. This qualitative investigation reports on the experiences and decisions taken around breastfeeding by a peer support group of 13 HIV-positive mothers meeting at King Edward VIII Hospital, Durban. In this study, the particular focus of information-giving and decision-making as to breast or formula feed is concerned with the impact on individual HIV-positive women and their babies. The most significant finding is that at no stage during their pregnancy were any of these mothers given information about the risks of HIV transmission through breastmilk. The study data were elicited in an in-depth group discussion, and individual women were invited to re-enact their stories in a follow-up discussion for clarification purposes. The women also discussed how they dealt with problems surrounding confidentiality in cases where few have been able to disclose their status to the extended family. There have been renewed calls for further investment in counsellors, with an enhanced role for community activists as peer educators. While there are severe resource constraints and low morale among many overworked nurses, one of the general problems in hospital settings remains the vertical health paradigm. This does not accommodate women's experiences, preferences, social networks and lay knowledge, and inhibits many women from becoming full participants in decisions affecting their own and their family's health.

In this presentation, which reports on work in progress, I discuss the different discourses and changing representations of the Ugandan official AIDS Control Programme (ACP) and those of the churches. There would appear to be two phases. In the first phase, the differing verbal strategies used by the ACP and the churches and the tensions between them are encapsulated in their respective slogans: Love Carefully of the ACP and Love Faithfully of the churches. Arguably these rehearse different political agendas and contend for hegemony. In the second phase, illustrated principally from posters designed for World AIDS Day organized on 1 December 1988 in Kampala, I show how the ACP would appear to have adapted its verbal strategies in order to reach some accommodation with the medicomoral discourse of the churches, supported by the President. I argue that AIDS discourse needs to be seen as part of a complex development and political issue, with a clear gender dimension necessitating close, qualitative ethnographic studies; that a study of AIDS discourse is not purely an abstract concern with the symbolic and a `first-world' luxury—but that it has clear implications for social policy, social action and the quality of life for those with AIDS and their carers.

AIDS in Africa is a gender, development and rights issue involving power and differential access to resources. The risk situations for women in stressed development contexts of war, destabilisation and displacement, and the many contexts of transactional sex, are poorly understood by policy makers and the medical community. The dominant epidemiological paradigm has focused on female 'prostitutes' in a number of African cities. The limitations of this approach are discussed, as are the different contextualised meanings of sexual exchange. The importance of women's experience of sexually transmitted diseases and HIV and their perceptions of risk are stressed, as is the need for non-judgmental services linked to primary and comprehensive health care, and for sensitive, qualitative research. It is argued that all women who engage in unprotected penetrative sex are at risk. Most health promotion messages, however, construct an image of women as prostitutes ('Avoid prostitutes') or seek to mobilise women as carers and educators of families and communities.