HIV/AIDS is one of the challenges to human life and dignity. It affects all levels of society and has a massive impact on global economic and social development, (Rowden, 2009). Studies have been conducted on its impact on human life and how it could be controlled. This review was conducted by exploring literature from a variety of sources for published articles on HIV/AIDS and its stigma. Literature from research covering a period of 8 years from 2002-2010 was extracted from Assia, PubMed, Sage, British Medical Journal, Cochrane and Absco-host, and reviewed for the study, objectives, methodology and key findings. Relevant books, journals, documents and reports from organisations such as UNAIDS, and the World Bank were also reviewed. Both qualitative and quantitative data was used to present the information.
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Despite facing a lot of criticism on its top-down approach, the biomedical model remains the dominant concept in health and illness. Its credibility lies on its scientific methods and expert knowledge used to diagnose or understand illness and treatment. This model views the body as a machine composed of different parts working together for it to function. If one part is not functioning properly, the aim is to find what is wrong with it through diagnosis and fix it by prescribing medicine, (Taylor &Hawley 2010:12). Focus is therefore restricted to the physical illness of an individual’s body and the scientific understanding of disease, making the approach heavily based on pharmacology. While pharmacology is beneficial in the treatment and prevention of HIV/AIDS, it is criticised for promoting the privilege of the biomedical model, further enhancing undermining of alternative approaches to health and healing. The biomedical approach may be inappropriate to some communities and create feelings of helplessness and vulnerability therefore affecting the success of the intervention. (Global Health Watch, 2008, Farmer, 1999).
Lay concepts of health and illness are diverse and complex than those of the medical model. They focus on people’s experiences of health and illness in relation to their overall life experiences and are embedded within local social and cultural structures. Unlike in the biomedical approach, indigenous approaches seek to heal the whole person by linking the illness with the person’s social and economic background, (Taylor, 2003). However critics of this model argue that lay concepts are difficult to evidence and research hence they remain marginalised and scarcely recognised as legitimate knowledge, (Taylor &Hawley, 2010:13). On the contrary, Taylor, (2003) argues that lay perspective is crucial knowledge for public health as it identifies roots of illnesses for possible long term prevention and treatment for the larger population as compare to individually focused interventions.
Influence of power systems such as the dominance of the medical model hinder progress on preventions and treatment of diseases such as HIV/AIDS and stigma as they govern relationships between health structures and lay people. Goffman, (1990), and Parker and Aggleton, (2003),’s theories of stigma in helping us to understand how stigma is constructed and its influence in peoples’ lives view stigma and discrimination as functional systems which maintain boundaries between those in power and those without. Through such power, social inequalities are developed leading to creation of social norms. These formulate stigma by governing interactions between people and reinforce power structures that serve to maintain control of the powerless, (Farmer, 2005). Both theories have been widely used in HIV related stigma to highlight how prejudice, negative attitudes, abuse and maltreatment directed towards PLWHA have hindered the progress of prevention and treatment.
Research highlights that stigma and discrimination in health care settings deriving from social power imbalances contribute a great deal in keeping people away from accessing HIV/AIDS treatment and care. Patients felt greatly affected by health workers feeling uncomfortable with them and treating them in an inferior manner. In Tanzania, some discriminatory and stigmatised practices such as gossiping about patients’ HIV’s status, neglect, verbal abuse, testing and disclosing HIV’s status without consent were noted, (D.C Synergy, 2005). Similarly in India, health workers were disclosing patients’ HIV status to their families without patients’ consent, (Mahedra et, al, 2007). Harassment, avoiding and isolation of HIV-positive patients and testing without counselling are common features of stigmatisation in most studies. Some health workers wore protective clothing even if there was no physical contact during interactions. Fear of being identified as infected with HIV also influenced people to prolong testing for HIV and only accessed services when their illness was at an advanced stage, (Bond and Aggleton, 2002; Kinsler et al, 2007; Varga et al 2006; Kalichman and Simbayi, 2003). In Zambia, HIV-positive health workers were hiding their HIV status from their colleagues in fear of being stigmatised, (Dieleman et al, 2007).
While most of the literature on HIV/AIDS and access to health services is negative, there is evidence of the value of supportive and de-stigmatising HIV services in some parts of the globe. Brazil has been hailed as a model by PLWHA. They reported supportive inclusive structural systems that create healthy environments that promote active participation of different groups in society and the government, (Caltado, 2008). In South Africa where most people believe in traditional healing, Aids Activism has made a positive significance in HIV/AIDS prevention and treatment by translating and mediating the biomedical approach within local ideological frameworks which are easily understood and acted on by the locals, (Colvin, Robins, 2010).
Literature reveals that collaboration between lay perspectives and biomedical approach is essential for successful control of HIV/AIDS and stigma. There is no cure for AIDS but Anti-retrovirals (ARVs) can prolong life by lowering levels of HIV in the body therefore delaying the process between HIV and AIDS, (Robin, 2009). Although ARVs are now readily available in most countries, numbers of newly infected people are rising. According to the World Bank, 60 million people are living with HIV/AIDS worldwide. Access to treatment has increased dramatically but for every 100 people on treatment, 250 become newly infected, (World Bank, 2010). As such, pressure is now rising on the effectiveness of only relying on the biomedical approach for treatment and care of HIV/AIDS.
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While lay perspectives are considered effective, this cannot be confirmed as true with HIV/AIDS care. In South Africa, despite people heavily relying on traditional healing approaches, HIV prevalence continued to rise. Significance towards effective control of the epidemic has been noted with the increase in accessibility of ARV’s, (Colvin, 2009). In the UNAIDS Report On The Global AIDS Epidemic 2010, in 7 countries, five of them in Eastern Europe and Central Asia, HIV incidences increased by more than 25% between 2001 and 2009. Sub Saharan Africa, although still remaining the most highly affected by the epidemic, figures either stabilised or showed signs of decline owing to positive behaviour due to increased services that are embedded in local culture. The report affirms that stigma and discrimination, lack of access to services and bad laws can make the epidemic worse, (UNAIDS, 2010).
Due to the challenges presented by HIV/AIDS to global public health, Baum. (2008:241) calls for collective participation of all sectors in the fight against this deadly disease. She asserts that community level mobilisation where there is partnership between lay people and structures is the effective way of combating HIV/AIDS and stigma. This is further supported by Farmer, (1999:90), who does not condone the dominance of the biomedical perspective in health and healing. He believes that lay people have a significant role in the process of health improvements and emphasises on the importance understanding lay people’s experiences as essential knowledge for successful interventions. He holds that health care services should be accessible to PLWHA without fear of being stigmatised. Educating health care professionals about the impact of stigma on patients and policies that encourage inclusion of PLWHA in decisions that affect their lives are some of the key factors of effectively tackling the epidemic. Parker and Aggleton, (2003) also claim collective participation between lay people and health structures as key to successful anti-stigma services.
Relationships between health structures and PLWHA could also be improved by engaging lay people through advocacy. The Greater Involvement of PLWHA, (GIPA) principle emphasises the need for involvement of PLWHA at all levels in combating HIV/AIDS because they understand their situation better. Therefore their voices could be heard well if their needs were presented by people in the same situation, (UNAIDS, 2007). In the Zambia study, professionals living with HIV/AIDS are in a better position to advocate for people accessing services. Baum, (2008:550) affirms that advocacy involving public health practitioners is an effective way of influencing structural barriers in public health.
Literature has highlighted the contested nature of concepts of health and healing underpinning access to services providing treatment and prevention of HIV/AIDS and its stigma. The biomedical approach conceptualises health and illness through science and expertise with focus on the individual. Lay concepts view health and healing as embedded within local social and cultural structures and therefore seek to address public health for a wider population. Literature suggests that neither approach in isolation is effective in prevention and care for HIV/AIDS. Arguments have centred on the importance of collaboration of the models. Therefore there is need for intervention programmes to develop holistic approaches that are underpinned by the two models but it is also important to understanding each of the concepts in its own right.
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