Prevention of HIV in Lesotho’s apparel industry: A social work perspective

Introduction

This article explores factors associable with the spread of HIV in Lesotho’s apparel industry with the view of proposing prevention strategies. Data from the country revealed that HIV prevalence was 23.6 percent in 2009 or the third highest in the world (National AIDS Commission (NAC) and Ministry of Health and Social Welfare (MHSW), 2012: 25). Prevalence between women and men varied: 26 percent women compared to 18 percent men were HIV-positive (NAC and MHSW, 2012: 27). The incidence of HIV per age group increased exponentially from 15 to 34 years for both sexes (NAC and MHSW, 2012). Approximately 5 and 40 percent of women in the age groups 15–19 and 30–34 years, respectively, were HIV-positive compared to roughly 3 and 40 percent of men in the corresponding age ranges.

A possible factor for the astronomic rate of HIV in the country is labour migration. The apparel industry in the country was understood to employ a total of 40,000 employees in 2012 (Apparel Lesotho Alliance to Fight AIDS (ALAFA), 2013; Central News Agency (CNN), 2011), the majority of whom were believed to originate from outside industrial towns (ALAFA, 2013). A giant entity by global standards, Lesotho Highlands Water Project reportedly employed more than 16,000 employees, understood to be predominantly labour migrants from both Lesotho and the Republic of South Africa (RSA), in the approximately 10 years it took to implement Phases 1A and 1B (Lesotho Highlands Water Project (LHWP, 2013). Furthermore, up to 44,000 Lesotho migrants were thought to be working in the mines of RSA in 2013 (Business Day Live, 2013), while reports continue to claim that a considerable number of illegal miners in RSA originate from Lesotho (IRIN, 2014; SABCNews.com, 2014). Other notable employers of labour migrants from Lesotho include four diamond mines in the country as well as the countrywide civil service. Additionally, a significant proportion of domestic servants in Maseru, the capital of Lesotho, are believed to originate from outside the district.

Labour migration is understood to amplify the risk of HIV among both migrating and non-migrating sexual partners (Agadjanian et al., 2011; Brummer, 2002; Corno and de Walque, 2007, 2012; Decosas, 1998; NAC and Health Economics and HIV/AIDS Research Division (HEARD), 2009; United Nations Development Programme (UNDP), 2005). Not surprisingly therefore, the prevalence of the virus in Lesotho’s apparel industry is possibly double the national prevalence. Out of a sample of 1195 industry workers found using unspecified sampling methods, 42.7 percent were found to be HIV-positive, with figures peaking within the age range 30–34 years, wherein 51 percent women and 43.9 percent men were found to be HIV-positive (ALAFA, 2012). Almost half of all study participants (47%) reported experiencing a genital ulcer and/or circumspect discharge from the same area in the month preceding the study (ALAFA, 2012). Sixty-three percent of the workforce in Lesotho’s apparel industry is reportedly women. Women’s disproportionate risk of HIV infection is well documented. Lesotho’s apparel industry is hence an important research site for investigating HIV risk factors.

Objective of the study

The objective of the study was to investigate factors which promote the spread of HIV in Lesotho’s apparel industry and to propose ways to address them.

HIV risk factors among labour migrants in Lesotho’s apparel industry

Several factors could amplify Lesotho apparel workers’ risk of HIV infection. First, most of the workers are understood not to have acquired tertiary education (ALAFA, 2012). Research in some contexts suggests a negative relationship between education and HIV (Asiedu et al., 2012; Coburn et al., 2013), although no relationship between these variables was found in Lesotho (Asiedu et al., 2012; MHSW and ICF Macro, 2010). Second, anecdote suggests prevalence of transactional sex among the migrants, while sex work is reportedly a concern in the country as a whole (Corno and de Walque, 2007; Federation of Women Lawyers (FIDA) and Lesotho Council for Non-governmental Organisations (LCN), 2012; NAC and HEARD, 2009; Stoebenau et al., 2011). Finally, there is a relatively high rate of sexual concurrency in the country generally (rate of 25% in Lesotho compared to 10% average in the Southern African Development Community (SADC); World Bank et al., 2009).

Stigma further magnifies migrants’ risk as it can act as a barrier to HIV testing and treatment (Corno and de Walque, 2013; Kimane and Ntimo-Makara, 1997; Murray, 1981). It can further have the effect of discouraging migrant labourers from disclosing positive HIV status to spouses due to risk of spousal and community ostracisation (Dano, 2006; Kamya, 2006).

Disjuncture between health services in urban versus rural areas is a potential obstacle to access to health services for migrant workers. UNDP (2005) asserts that it could be challenging for migrants to shift from traditional to modern medicine. The challenge is compoundable by cost of accessing services in terms of time away from work and user fees. Moreover, apparent aloofness of health service personnel in migrants’ host towns was cited as a major stumbling block to access to health services by some migrant workers (UNDP, 2005). Furthermore, health service personnel were found to be opposed to migrants’ traditional beliefs (UNDP, 2005), possibly further compromising a functional relationship between the two.

Social isolation is also a concern regarding the risk of HIV infection for migrants. According to UNDP (2005), social isolation of labour migrants is characterised by poor social integration, distrust and even contempt of migrants by host communities, increasing chances of casual sex. In the context of women migrants in Lesotho, it is compoundable by the poor status traditionally afforded to women, which can preclude open discussion about sex while potentially putting them in a position where they have to provide sex to men for favours (Corno and de Walque, 2007, 2012).

The findings of UNDP (2005) were corroborated by a comparative study of migrants and non-migrants in Angola. A study by Sen et al. (2010a, 2010b), based on social capital theory, investigated propensity for risky sexual behaviour among migrant and non-migrant males in two settlements of Luanda. With social capital measured by the strength of migrants’ social relationships in host towns, migrants in the study were found to command comparatively less social capital. This appeared to predict risky sexual behaviour such as multiple concurrent sexual relationships, non-use of condoms and ignorance to HIV status. The study concluded that meaningful social integration with host societies can act as a buffer for risky sexual behaviour among migrant populations (Sen et al., 2010a, 2010b).

Services for addressing HIV in Lesotho’s apparel industry

HIV counselling and testing, treatment and care services for HIV are provided mainly by ALAFA (2013) to apparel industry workers. It is noteworthy, however, that ALAFA (2013) does not mention providing any services to families of apparel industry workers, lobbying or advocacy for social investment in the form of housing or schools for the benefit of apparel workers.

Research methodology

This article presents part of a study conducted for the purpose of graduate study. The MHSW in Lesotho and the University of KwaZulu-Natal in RSA separately granted ethical clearance for the study. Permission to enter the community and consult the index person was provided by a local headman. Snowballing (Sarantakos, 2005) was found to be the most appropriate sampling strategy: the migrant population is settled among non-migrants, and migrants were considered the best people to identify others. However, the sampling strategy’s main weakness (propensity to yield participants from index persons’ social circle) is duly acknowledged as one of the limitations of this study (Leedy and Ormrod, 2001). The sampling yielded more than 40 women, 30 of whom fit the criteria for inclusion (i.e. migrants for a minimum of 2 years) and agreed to participate. Women were strategically chosen due to their structural disadvantage in the context of Lesotho combined with disproportionate risk of HIV infection.

Data were collected by the author and a research assistant with the use of interview guides to ensure data quality (Strydom and Delport, 2002). The guide covered a range of topics with respect to both interviewees and their nuclear families such as demographic information and sexual and social behaviour since migrating to Maseru. Interviews took 60–90 minutes. Data were voice-recorded and subsequently transcribed. Data collection took approximately 6 weeks between June and July 2008 among migrant workers in their homes in an informal residential area around Ha-Thetsane, an industrial site in Maseru.

Content analysis, selected to emphasise contextual subjectivity and for its capacity to reinforce trustworthiness (Babbie and Mouton, 2006; Fouché and Delport, 2002; Leedy and Ormrod, 2001; Terre Blanche et al., 2006), is employed to present the study’s findings. As suggested by Terre Blanche et al. (2006), familiarisation, data immersion and checking were performed. In checking, the two researchers exchanged samples of recordings and compared them to transcripts to confirm transcription quality and coding consistency.

Several themes emerged during transcription, and these were coded accordingly in a process of open coding as explicated by Babbie and Mouton (2006). Sentences or paragraphs were coded under one theme depending on their content to retain participants’ voices. The following themes are presented in this article in line with its objective: sexual behaviour, social isolation and health services.

Lincoln and Guba’s (1985) guidelines for ensuring trustworthiness of research findings were used as reference. For instance, researchers adhered to the principle of prolonged engagement with participants within prevalent research constraints. Research methods as applied are outlined, while the sample is described at length (Lincoln and Guba, 1985).

Findings

Study sample

The sample of the study was made up of 30 women, 25 of whom were married, 3 still married but deserted and 2 never married. Out of the 25 married women, 7 had migrated to Maseru with their legal spouses. Five said they were in ‘long-term’ sexual relationships with men other than their legal spouses. One deserted woman and one never married (aged 29 and 23 years, respectively) were not in sexual relationships at all at the time of the study and were averse to relationships with men in Maseru. For married women, marriage duration range was 2–19 years (mean = 4.8 years). Participants’ ages ranged from 22 to 36 years (mean = 27.3 years). Participants had been migrants in Maseru for a minimum of 2 years and a maximum of 12 years. The bar chart in Figure 1 depicts the number of participants by age. As the chart illustrates, 90 percent (n = 27) of the women were aged between 22 and 29 years, while those in the age group of 30–36 years made up the smallest percentage.

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Figure 1.

Number of participants by age.

Participant’s education levels ranged from 4 to 12 years of schooling as follows: 7, or 23.3 percent, of the women had 4 years of schooling; 8 or 26.7 percent had gone beyond 6 years but below 10 years; and the majority, or 50 percent (n = 15), had attended 12 years of school which is the minimum years required for admission to university in Lesotho.

Discussion

A non-probability sampling technique yielded 90 percent of participants between the ages of 22 and 29 years, suggesting that women in the apparel industry are generally young and by implication sexually active and still likely to change sexual partners a number of times. Nationally, HIV prevalence in this age group is up to 35 percent ascending to approximately 40 percent in the subsequent age grouping (NAC and MHSW, 2012). The large presence of this group presents a programming opportunity for a high-significance population in spreading HIV in the apparel industry and the country as a whole, as stated by Brummer (2002), NAC and HEARD (2009), ALAFA (2012), as well as Stoebenau et al. (2011).

Participants appear to have normalised both HIV and sexual concurrency, an apparently common trend throughout Lesotho where the rate of sexual concurrency is more than twice the average rate in the SADC as found by the World Bank et al. (2009). In the last demographic and health survey, up to 45 percent male and 25.9 percent female Basotho respondents reported recently being in concurrent relationships, 50 percent of whom said they used condoms (MHSW and ICF Macro, 2010). The so-called hyper-endemic nature of HIV in Lesotho could result in generalised HIV apathy. Moreover, the success of the national antiretroviral therapy (ART) programme which saw a marked decline in both HIV-related morbidity and mortality could cause people to be insensitive to the threat of HIV. ART is freely available in Lesotho. Third, as Sen et al. (2010a, 2010b) observed with reference to migrants elsewhere, HIV prevention may not be a priority when people lack social capital. Considering the implications of HIV infection, blindness to the virus is perturbing and warrants social work attention underpinned by policy.

Alternatively, devolution of sexual determination to partners could be reflective of prevalent social exchange patterns in migrants’ places of origin (UNDP, 2005). Basotho women are traditionally expected to be sexually naive which could account for their reticence in assuming responsibility for protection during sex or even broaching the subject with both extramarital and marital partners. Salient, though, is that workers’ real or feigned sexual diffidence could predispose them to HIV infection and promote the spread thereof.

Furthermore, this could imply that preservation of social relationships, particularly marriages, through conformity to socially prescribed gender norms takes precedence over protection from life-threatening illnesses such as AIDS for Basotho women. The arguments are particularly relevant to apparel industry workers who are believed not to have tertiary education and, by implication, at a comparative disadvantage economically. Finally, they are founded on the understanding that Basotho women are generally aware of HIV and its modes of transmission (World Bank et al., 2009).

Furthermore, girls are typically taught domestic skills, sometimes at the expense of commercial skills, in addition to being castigated for ‘talking too much’. Boys, on the other hand, are rarely taught domestic skills and are encouraged to be enterprising, articulate and assertive. Moreover, sexual forwardness is socially reproachable for women although it is encouraged among males (World Bank et al., 2009). This mode of socialisation in conjunction with attitudes towards sexual conduct could lead to unequal gender relations and compromise any sense of security in intimate relationships. The result of unequal and insecure relationships is that women try too hard to please their partners – even at their peril – and are amenable to more than one intimate companion. The foregoing repertoire of social dynamics can manifest in a high rate of multiple concurrent sexual relationships – as found by authors such as World Bank et al. (2009) and corroborated by thisstudy – in the apparel industry of Lesotho.

Noteworthy, migrating with spouses did not seem to affect attitudes towards multiple concurrent sexual relationships. Respondents who lived with their spouses in the host town also insinuated proclivity towards concurrency, with one indicating that she is in a relationship with a married man whose wife works in the same industry. Thus, concurrency among migrant labourers could also be interpreted as a way of life. A critical point raised by participants was distance between themselves and legal spouses as a factor which promoted concurrency. Nonetheless, an in-depth understanding of factors underlying multiple concurrent sexual relationships in Lesotho is indicated.

Social isolation emerged as a tremendous risk for almost all participants, consistent with findings of the UNDP (2005) and Sen et al. (2010a, 2010b). To extrapolate findings of the UNDP (2005) and Sen et al. (2010a, 2010b), migrant isolation, a manifestation of suspicion and contempt of migrants, increases the likelihood of casual sex. A further risk of being socially isolated is that migrants can engage in alcohol use, elevating the possibility of risky sex (Sen et al., 2010a, 2010b). Even without alcohol consumption, the risk of resorting to risky sexual activity in pursuit of companionship and/or recreation is high for socially isolated populations, as underscored by this study (Sen et al., 2010a, 2010b).

Women were aware of their economic disadvantage relative to the sexual partners they met in town. Studies have empirically found such disadvantage to have deleterious implications for women’s capacity to assert their sexual rights and to negotiate safe sex. The possibility of women’s inferiority is concerning in the context of Lesotho, which is battling with extreme incidence of HIV. Lesotho passed the Sexual Offences Act (Parliament of Lesotho, 2003), the Capacity of Married Person’s Act (Parliament of Lesotho, 2006) and the Land Act (Parliament of Lesotho, 2010). According to the Sexual Offences Act, married women have legal recourse against husbands if exposed to life-threatening illnesses by the latter (Parliament of Lesotho, 2003). The Legal Capacity of Married Persons Act and the Land Act protect women’s property rights specifically in the event of marriage dissolution (Parliament of Lesotho, 2006, 2010). Basotho women’s apparent dependence on men even at the risk of life is thus perplexing and calls for empirical examination.

Not surprisingly, the study found no relationship between women’s education and their responses pertaining to risky sexual behaviour. The sample’s schooling ranged from 4 to 12 years. However, increase in years at school did not seem to affect attitude towards risky sexual behaviour and/or sexual determination. This is consistent with Asiedu et al.’s (2012) and Coburn et al.’s (2013) discovery that education in Lesotho, in contrast to other countries in the region, is unrelated to probability of HIV infection. This study, however, cannot claim to offer a conclusive explanation for this trend, although it has revealed a rather disquieting level of reckless sexual behaviour among participants regardless of education level.

Obstacles to use of health services as reported by participants are disconcerting and could partly account for the high rate of genital ulcers and/or discharge reported by ALAFA (2012) and cited herein among this group. The outcome of ALAFA’s (2012) study regarding possibly untreated sexually transmitted infections (STIs) further corroborates the possibility that many apparel workers do not fully utilise free workplace-based health services. Equally perturbing is participants’ expressed inability to apply learnt information for protecting themselves from HIV, suggesting a missed opportunity as well as cost inefficiency in programming as alluded to by the World Bank et al. (2009). ALAFA’s (2012) commendable efforts in providing workplace-based health services as discussed thus become ineffective if perceptions and attitudes of target populations and those of health personnel are not harmonised.

Recreation ‘provides opportunities for people to interact socially, fulfilling the human need to feel connected … and provides … the opportunity to develop relationships and find meaningful connections outside of the workplace … which is … vital to life satisfaction’ (Roberg, 2006: i). Additionally, recreation enhances self-esteem and meaningfully occupies and stimulates the mind outside of work. Low self-esteem arguably leads women to multiple concurrent sexual relationships. Participants’ expressed lack of recreational involvement therefore raises concern.

A single positive factor for participants was found to be church affiliation, although very few participants attended. Church can broaden people’s social circle and keep them productively engaged. Nonetheless, religious organisations globally have not been seen to leverage their influence in the fight against HIV. Hence, while church attendance can be valuable on one level in reducing migrants’ HIV risk, it requires reinforcement by other social agents or services.

Finally, in addition to the sampling strategy, other limitations of the study are gender exclusivity and use of vernacular for data collection. The sample is also relatively small. Accordingly, results of the study cannot be generalised to the population of migrants in Maseru. It is further conceded that some meaning might have been lost in translation of the interviews despite meticulous quality control measures.

Recommendations

To address identified challenges, social work intervention, revision and extension of coverage of ALAFA services, as well as a bigger survey are propounded.

The findings indicate a need for robust social action by social workers. Arrangements which facilitate healthy sexual relations between migrants and their usual partners – preferably on exclusive terms – should be sought and brokered by social workers. For instance, apparel industry merchants should be pressured into providing free weekly transportation to migrants’ places of origin.

Second, social workers could play a role in organising workers to engage in productive recreation rather than remaining idle outside working hours. An example of a cost-effective recreational activity cited by many women in this study is traditional dances. Lesotho traditional dance entails vigorous body movement and is hence valuable exercise. During dance, women sing, and singing is an effective stress reliever. The benefits of exercise to body and mind need no explication. Similarly, benefits of recreation to preventing risky sex are self-explanatory. In addition, social activities such as the one described have the capacity to build inter- and intra-group social networks which can translate to social capital for migrants.

Similarly, the need for employment of counselling social workers in the apparel industry emerges. Such professionals would coach migrants in interrelationship communication, particularly relating to negotiation of safe sex. They would further mitigate the risk of social isolation and sexually unwise decisions by migrants through cognitive behavioural approaches.

Social workers should also assume a leading role in scaling up social marketing of condoms in the industries. This would help to dispel the notion that condoms should be used only with ‘loose’ women as it emerged in this study. Condom use can instead be associated with a wealthy, healthy and happy future – the motivation behind women’s migration to Maseru in the first place. Hence, condom use should be marketed as one of the strategies by which women can retain and display wealth as well as maintain health and happiness for themselves and their families by avoiding HIV. Appealing to women’s weak points – their purported maternal instinct – could also prove worthwhile. To this end, the importance of living healthy long lives to protect their children could be invoked to incite them to make sound decisions regarding sex.

ALAFA remains the main health service provider in Lesotho’s apparel industry. The organisation’s services should therefore be improved upon in several dimensions, starting with evaluating and modifying the attitudes of health personnel in order to improve their capacity to work with apparel industry workers whose social circumstances, attitudes and beliefs could be inhibitive to the use of modern health services.

This study has further highlighted the need for a large-scale knowledge, attitude, and practice survey among migrant workers themselves. The article refers to a study by ALAFA, whose sample was small in relative terms and by implication not representative of the migrant worker population. The researcher is unaware of any study of bigger proportions among migrant workers in Lesotho. It is believed that such a study could be highly informative and could act as a baseline for scaling up programmes for controlling the scourge of HIV among migrants with the possibility of a ripple effect to the larger population.

Conclusion

Almost a quarter of all Basotho and almost half of all apparel industry workers, the majority of whom are women, are HIV-positive. The study has established a common tendency for multiple concurrent sexual relationships among female apparel industry workers and paradoxical failure to take responsibility for protection during sex. Social isolation and incompatibility between health services and migrants’ needs, also discovered, could account for both the trend of risky sexual behaviour and the high incidence of HIV and other STIs among migrants. For the modest economy whose social and economic progress is threatened by HIV, prevention has the potential for higher efficacy. Social workers are therefore called upon to escalate prevailing prevention efforts in Lesotho.