To the Editor:
Over 20% of South Africans aged 15-49 years are infected with HIV, with substantially higher prevalences in black African settlements than in other areas.1-3 According to media reports and commentaries, misinformation about the epidemic has arisen among black Africans, including genocidal conspiracy beliefs about the role of government and whites in causing the epidemic (eg, that HIV is manufactured by whites to reduce or control the black African population).4-7 Historically, such beliefs may have some basis in reality. During apartheid, the government attempted to develop biological weapons from existing viruses and bacteria, including HIV, to control or eradicate the black African population.8 Moreover, several key government leaders, including the Health Ministry, have contributed to misinformation about the causes and treatment of HIV, including the belief that AIDS is not caused by HIV.9-11
Regardless of their origin, genocidal beliefs may be barriers to HIV prevention efforts. In the United States, HIV conspiracies are associated with decreased condom use among African American men.12,13 In South Africa, relationships between such beliefs and HIV prevention behaviors have not been tested quantitatively. One critical prevention behavior that may be influenced by genocidal beliefs is HIV testing. National probability survey estimates suggest that less than a fifth of South Africans older than 14 years have been tested and are aware of their serostatus.1 Mistrust of the government, as exhibited by such beliefs, may extend to mistrust of government establishments (eg, public health departments) that conduct testing. Although several patient-related psychosocial barriers to testing have been identified,14-17 no research has examined the extent to which genocidal HIV beliefs may be contributing to low testing rates.
We examined the association of endorsement of genocidal HIV beliefs to HIV testing behavior among 503 men and 438 women recruited from sexually transmitted infection clinical units in 3 clinics in Cape Town (73%), Johannesburg (14%), and Queenstown (13%) that provided comprehensive health services, including HIV testing. Measures were available in English and were translated/back translated to local languages. Participants were compensated the equivalent of US $10. The institutional review boards of University of Connecticut and the Human Sciences Research Council of South Africa approved this study.
Using audio-computer-assisted self-interviews, participants reported their sex, race, age, education, employment, and marital status, whether they had ever known someone diagnosed with HIV/AIDS and if they had ever been tested for HIV. Those tested were asked their most recent results. HIV risk and prevention knowledge was assessed with an 11-item test adapted from prior research18 (alpha = 0.71) that was scored for number of correct responses. Eleven AIDS-related stigma items were developed for use in South Africa (alpha = 0.72).19 Items were responded to from 1, “Agree,” to 4, “Disagree;” higher mean scores represented stronger stigmas. Participants rated 6 AIDS-related beliefs from 1, “Strongly Agree,” to 4, “Strongly Disagree:” (AIDS is a serious problem in my community; medicines for AIDS do more harm than good; only prostitutes and drug users get AIDS; the government is doing all it can to fight AIDS; and the government is telling the truth about AIDS) with one embedded genocidal HIV belief (AIDS was introduced by white people as a way to control black Africans).
Descriptive statistics indicated that over two thirds of participants (N = 644, 68%) had been tested for HIV of which 158 (24%) were HIV positive. All analyses were restricted to the 471 men and 312 women who tested negative. The mean age of the subsample was 28.92 years (SD = 7.62); nearly all (94%) were black Africans; 48% were unemployed; and the median education level was 10 years. In univariate analyses, participants who had not been tested for HIV had lower HIV knowledge, held more stigmatizing views about people with HIV, were less likely to be married, and were younger than those who had been tested (Ps < 0.05). Among the 6 AIDS-related beliefs, only the genocidal belief that “AIDS was introduced by White people as a way to control black Africans” was significant. In a multivariate logistic regression that included all demographic characteristics, HIV knowledge, and stigma, only participant age and the genocidal belief remained significant predictors of having been tested for HIV (Table 1).
Despite the emergence of strong conspiracies about HIV since the start of the epidemic,4 until now, no empirical quantitative studies have demonstrated a link between endorsement of such beliefs and HIV prevention in South Africa. Our results suggest that genocidal HIV beliefs undermine public support for government-sponsored HIV-related programs and individuals' participation in such programs. The association between genocidal beliefs and lack of HIV testing was robust even after controlling for HIV knowledge and AIDS stigmas, which suggests that lack of knowledge about HIV is not the root cause of belief in conspiracies. Thus, interventions that focus on disseminating information about HIV risk may not be effective in increasing testing.
Given historical oppression under apartheid and current South African policymakers' inconsistent prevention messages, belief in genocidal conspiracies may be difficult to change. Such beliefs may tap into a deep mistrust of the government around HIV issues. Policymakers need to present a consistent and strong prevention platform about the importance of testing, which, combined with recent increases in testing services, will be essential in restoring confidence of South Africans in their government's response to HIV.
Laura M. Bogart, PhD*
Seth C. Kalichman, PhD†
Leikness C. Simbayi, PhD‡
*Health Program, RAND Corporation, Santa Monica, CA
†Department of Psychology, University of Connecticut, Storrs, CT
‡Human Sciences Research Council, Cape Town, South Africa
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