HIV/AIDS and ‘othering’ in South Africa: The blame goes
GEORGE PETROS1, COLLINS O. AIRHIHENBUWA2,
LEICKNESS SIMBAYI1, SHANDIR RAMLAGAN1& BRANDON BROWN3
1Human Sciences Research Council, Cape Town, South Africa,2Penn State University, PA, USA,
and3University of California at Irvine, CA, USA
In order to explore the relevance of social concepts such as stigma and denial to the transmission of
HIV, this qualitative study sought to examine cultural and racial contexts of behaviour relevant to the
risk of HIV infection among South Africans. A cultural model was used to analyse transcripts from 39
focus group discussions and 28 key informant interviews. Results reveal how cultural and racial
positionings mediate perceptions of the groups considered to be responsible and thus vulnerable to
HIV infection and AIDS. An othering of blame for HIV and AIDS is central to these positionings,
with blame being refracted through the multiple prisms of race, culture, homophobia and
xenophobia. The study’s findings raise important questions concerning social life in South Africa
and the limitation of approaches that do not take into account critical contextual factors in the
prevention of HIV and care for persons living with AIDS.
Re ´sume ´
Afin d’explorer la pertinence des concepts sociaux tels que le stigmate et le de ´ni sur la transmission du
VIH, cette e ´tude qualitative a cherche ´ a ` examiner les contextes culturels et raciaux des
comportements a ` risques pour le VIH chez les Sud Africains. Un mode `le culturel a e ´te ´ utilise ´ pour
analyser les transcriptions provenant de 39 groupes focus et de 28 entretiens avec des informateurs
cle ´. Les re ´sultats re ´ve `lent comment les positionnements d’ordre culturel et racial influencent les
perceptions vis a ` vis de groupes conside ´re ´s comme responsables, et par conse ´quent vulne ´rables a `
l’infection a ` VIH et au sida. Faire porter la responsabilite ´ « sur l’autre » pour le VIH et le sida est au
cœur de ces positionnements, l’accusation se re ´fractant a ` travers des prismes multiples de race, de
culture, d’homophobie et de xe ´nophobie. Les re ´sultats de l’e ´tude soule `vent des questions importantes
concernant la vie sociale en Afrique du Sud et les limites des approches qui ne prennent pas en
compte les facteurs contextuels qui sont cruciaux pour la pre ´vention du VIH et les soins des
personnes vivant avec le VIH.
En este estudio cualitativo queremos analizar los contextos culturales y raciales de conductas con
respecto al riesgo de infeccio ´n del VIH entre la poblacio ´n sudafricana con el objetivo de estudiar la
importancia de conceptos sociales, tales como el estigma asociado a la transmisio ´n del VIH y la
negacio ´n de poder contagiar el virus. Mediante un modelo cultural, analizamos las transcripciones de
Correspondence: George Petros, Human Science Research Council, Private Bag X 9182, 69-83 Plein Park Blgm, Plein Street,
Cape Town, South Africa. Email: firstname.lastname@example.org
Culture, Health & Sexuality, January–February 2006; 8(1): 67–77
ISSN 1369-1058 print/ISSN 1464-5351 online # 2006 Taylor & Francis
39 grupos de discusio ´n y 28 entrevistas a informantes clave. Los resultados indican de que ´ modo las
posiciones culturales y raciales tienen una influencia en las percepciones de los grupos que se
consideran responsables y, por lo tanto, vulnerables a las infecciones del VIH y el sida. Para estas
posiciones es de vital importancia la construccio ´n de la otredad en cuanto a quie ´n culpabilizar por el
VIH y el sida, de modo que la culpa se refractarı ´a a trave ´s de muchos prismas de raza, cultura,
homofobia y xenofobia. Los resultados de este estudio plantean preguntas importantes con respecto a
la vida social en Suda ´frica y la limitacio ´n de enfoques que no tienen en cuenta los factores
contextuales de importancia para la prevencio ´n de VIH y el cuidado de personas que viven con el
Keywords: Othering, HIV/AIDS, stigma, discrimination, denial, South Africa
South Africa currently has the largest number of people living with HIV/AIDS (PLWHA)
in the world (UNAIDS 2004). A recent national household survey of HIV prevalence in the
country found an 11.4% prevalence amongst persons age 2 years and older (Shisana and
Simbayi, 2002). Factors contributing to the epidemic include stigma, denial and an active
‘othering’ of People Living with HIV/AIDS (PLWHA). Stigma has been cited as the
greatest obstacle the world over in combating the epidemic (WHO/UNAIDS 2000). The
resulting discrimination experienced by PLWHA or people who are suspected to be
infected leads to silence over their positive HIV status (Johnston 2001).
Stigmatization is seen by some as a product of prejudicial thoughts and behaviour that
results from actions of governments, communities, employers, health care providers, co-
workers, friends, and families (Cameron 1993, Jayaraman 1998, Zierler et al. 2000). Others
have defined HIV-related stigma as a process intimately linked to the reproduction of
power structures in society (Link 2001, Parker, 2001, Parker and Aggleton 2003). Achmat
(2001), among others, has argued that in South Africa HIV-related stigma may be more
strongly expressed against women than against men. There have also been cases of children
infected by HIV not being admitted to school (Sapa 2002), and children orphaned by
AIDS face discrimination at school or in their communities (Streak 2001).
In the absence of a cure, fear of being infected increases the stigmatization of people
living with HIV (Paterson 1996) and hence the tendency to engage in denial. In their
analysis of the reasons why people want and do not want to disclose their HIV status,
Qwana et al. (2001) found that denial causes people who are infected to hide their
condition. Both silence and denial about HIV and AIDS are dangerous because they
prevent people from accurately assessing their own personal risk of infection (Siegel and
Gibson 1988). They also reinforce the view that HIV and AIDS are conditions that affect
not the self, but others.
At a contextual level, Caneles (2000) has advanced the concept of othering as a process
that can potentially be negative, positive or potentially both, depending on the situation and
the person assigning the concept. Negative othering involves the exploitation of power
imbalances in relationships such that one gains at the expense of others. Importantly,
negative othering can also create an illusion of control by the attribution of risk-enhancing
behaviour to the other and by blaming outgroups for being at risk (Nelkin and Gilman
In the broader post-colonial literature, scholars have critiqued forms of societal othering
inscribed in Orientalism (Said 1978) and African identities (Chinweizu and Jemie 1987,
Ngugi 1986), often represented in differences between the ‘West and the rest’. Othering
G. Petros et al.
can also occur through more opaque instances of exclusion, particularly through actions
that do not make the news and are taken for granted as part of the routine of daily life
(Sibley 1995). These include institutional and structural arrangements whereby boundaries
are constructed between different groups in society, some of whom believe themselves to be
superior to others.
Otherness can therefore be used to stigmatize certain groups by race, sexuality, or
condition of mental/physical health (Dear et al. 1997) particularly when the disease is as
fatal as HIV, and fear of contagion or infection is a major concern. This fear is in most cases
irrational and can lead to what Cohen (1980) coined a ‘moral panic’ with the intention to
win public support by deploying certain moral directives into the universe of discourse.
This study sought to explore the concept and practice of othering as it operates in relation
to HIV and AIDS in modern-day South Africa.
Thirty-nine (39) focus group discussions comprising eight to ten participants each and 28
key informant interviews were conducted in all nine provinces in South Africa in 2002.
Two age categories were interviewed, namely, young people aged 18–24 years and adults
aged 25–49 years. Data were collected in rural, urban and farming settings. Participants
represented different gender, language, race and religious groups. Key informants included
local chiefs, traditional healers, religious leaders and initiation leaders. The facilitators and
key informant interviewers were drawn from all nine provinces and were trained in advance
for 3 days each.
Focus group discussions and key informants interviews addressed the following areas:
cultural interpretation of illness and response to HIV and AIDS, traditional healing
practices, death rites, marriage practices, rites of passage, HIV testing issues, mass media,
sexual practices, gender issues and alternative healing practices.
Interview tapes were transcribed, translated and analysed using Atlas.ti computer
software. Fifteen primary categories were identified, which were later reduced to eight.
These were further regrouped as a result of group consensus reached at a workshop
involving the research team and the focus group moderators to identify four broad thematic
areas, namely, (a) stigma, denial and discrimination; (b) belief systems and interpretation
of health and illness; (c) economic inequity; and (d) gender inequity. These four themes
were analysed using the PEN-3 Model. Although the present paper focuses on stigma,
denial, and discrimination as processes of othering, the data analysis shows the interplay of
the four major themes identified above. Ethical clearance for the study was sought and
granted by the Human Sciences Research Council Interim Ethics Committee.
The PEN-3 model
PEN-3 is a cultural model in which cultural codes and meanings are examined as part of
the development, implementation and evaluation of health promotion programmes
(Airhihenbuwa 1995, Airhihenbuwa and Webster 2004). The model identifies three
inter-related factors influencing health beliefs and behaviours: (i) relationships and
expectations (which are classified as perceptions, enablers or nurturers), (ii) cultural
empowerment (which are classified as positive, existential or negative) and (iii) cultural
identity (which is classified in relation person, extended family, neighbourhood). The
model has been used to examine the cultural bases of cancer prevention behaviour (Erwin
HIV/AIDS and ‘othering’ in South Africa
et al. 1996, Paskett et al. 1999); the prevention of cardiovascular risks (Walker 2000), and
HIV prevention, care and support (Airhihenbuwa et al. 2003).
Essentially, the cultural empowerment and relationships and expectations domains act as
assessment/appraisal domains in cultural assessment. The three categories implicit in each
of these two assessment domains are used to create a 363 table containing nine categories.
Table1 details each of the nine PEN-3 assessment domains. The cultural identity domain
is later used by researchers and/or public health practitioners to work with the community
in prioritizing areas for intervention. In this paper, we focus only on the assessment
domains to report on how those interviewed othered HIV and AIDS.
The key question to be explored in this paper is how people living with HIV and AIDS
are othered in five specific (but potentially inter-related) ways: by race, religion, gender,
homophobia and xenophobia. Data are presented for each of these dimensions to
show whether participants’ views could be considered positive, existential and/or negative.
The intent was to move beyond the individual analytic level to begin to examine the
social processes that condition such perspectives within systems of group affiliation and
Othering by race
Before and under Apartheid, the division of society into racial groups, the marginalization
of Black South Africans, and the undermining of family cohesion through the migratory
system and race laws, resulted in family breakdown. Men often lived in single men’s hostels
far away from their families in urban areas (Lurie 2000, Jochelson 2001, Fassin 2002),
which created a fertile environment for men to have multiple sex partners, and for the
transmission of sexually transmitted infections such as syphilis (Jochelson 2001, Simbayi
2002). To some extent, this situation and the generally poor accessibility to health services
Table 1. Nine PEN-3 categories for HIV and AIDS-related stigma.
1.Positive perception: refers to knowledge, attitudes and/or beliefs that positively influence support for
Existential perception: refers to knowledge, attitudes and/or beliefs that influence decisions about
behaviour toward a PLWHA in a manner that could be described as unique to that culture.
Negative perception: refers to knowledge, attitudes and/or beliefs that contribute negatively to HIV and
Positive enablers: refers to availability, accessibility, acceptability, and affordability of resources that are
supportive of PLWHA.
Existential enablers: refers to availability, accessibility, acceptability, and affordability of resources that are
traditionally available in the community or society and are supportive of PLWHA.
Negative enablers: refers to the lack of available, accessible, acceptable, and affordable resources, and
which contributes to HIV and AIDS stigma.
Positive nurturers: refers to influence of significant others and community contexts that are supportive of
Existential nurturers: refers to influences of significant others and community contexts in making decisions
and choices that are based on traditional values that are non-stigmatizing.
Negative nurturers: refers to influences of significant others and community contexts that negatively
respond to HIV and AIDS-related stigma and which prevent support to PLWHA.
G. Petros et al.
partly explains the high prevalence of HIV amongst Black Africans relative to other racial
groups (Colvin 2000, Simbayi 2002). Claims that HIV originated in Africa and the racist
link between sexual promiscuity and African-ness have also served to reinforce the othering
of Black Africans in relation to the epidemic (Ratele and Shefer 2002, Farmer 1998,
South Africans from different racial backgrounds blame each other as either being the
source of HIV or being responsible for spreading the disease. Whites accuse Blacks, and
Blacks accuse Whites, of having brought AIDS into South Africa. This finger pointing
creates a false sense of security through denial of one’s own racial group’s exposure and
vulnerability to HIV. While there is some evidence to suggest that Black South Africans
are more likely to be infected than their White counterparts (12.9% compared to
6.2%, Shisana and Simbayi 2002), when prevalence rates are analysed by locality,
it becomes clear that it is socio-economic status rather than race that creates
vulnerability. For example, in the same study by Shisana and Simbayi (2002), HIV
prevalence was found to be 28.4% in urban informal settlements compared to 15.8% in
urban formal settlements.
In the course of this study, racial blaming was evident in the following negative
perceptions displayed by two adult urban White Jewish Western Cape women:
I think about it actually. When playing with Black babies, when I walk up to Black babies. And I
don’t think about it with White babies, only if it’s a Black baby, I will play with and I’m thinking,
‘Oh! Like there’s nothing wrong’.
But I think that is the perspective of a lot of people. Actually, I think a lot of people see it as a Black
disease. They don’t see it as a White disease … ‘Well I’m White. Why are you speaking to me? The
Blacks get HIV/AIDS! … it’s a Black disease. It doesn’t happen in our cultures’. White people see
it as a Black disease.
A reverse position was observed in the negative perceptions expressed by a rural Black
African man from the Eastern Cape
women with whom we live [are infected], because many of them sleep with these Europeans.
Racial othering in the context of the history of cheap labour, poor education and the
resulting role of servitude for disadvantaged Black South Africans compounds fear with
ignorance of HIV transmission. Resentment of the other thereby becomes mixed with
blame for the disease, as exemplified in the following negative and existential perception
and nurturer displayed by a young urban White Free State male:
I had a case where people that I know had a servant who went for a[n] [insurance] policy and
then she [found she] had the disease … But the reaction is, she makes food, what about the
food? She touches children, she touches the clothes, the beds … it’s frightening. Now … I
can’t imagine associating with such a person. Doesn’t matter what they say. Even if you
touch him or her you’re not going to get it. For me it’s a … no one really knows how this disease
This participant’s othered behaviour was clearly nurtured within the family as is evident in
his reaction to the person living with HIV/AIDS as a potential vector for infection. The fear
of not knowing how the disease is transmitted here conflicts with the certainty of the Black
African body as a vector for its spread.
HIV/AIDS and ‘othering’ in South Africa
Othering by religion
In South Africa, religion plays a major role in the lives of most communities. As a result,
religion has become a perceived safe zone from which to deny and distance AIDS as
a problem that affects those outside one’s religious space. However, upon a closer
examination, religion is sometimes also used to mask forms of racial othering. For example,
a Hindu is almost always a person of Indian origin, a Muslim is almost always someone of
Asian origin, and a Jew is usually of White or European origin.
The following views were expressed by an urban Islamic Sheikh from the Western Cape,
an urban White protestant priest from Free State, and a male urban Hindu from KwaZulu-
Natal, respectively. Anchored in a religious ethos, they here serve as negative nurturers and
negative enablers of othering:
Because there was an attitude … that this doesn’t affect us. It does not affect [the] Muslim
community. It’s other people.
I would not encourage my parishioners to go for AIDS test because I think the risk factor at this
stage in our parish, a White parish in Free State, with professional people, is very low. There are
extremely low numbers who fall in this category.
The majority okay, amongst the Indians basically and majority of them feel they won’t get AIDS …
compared to other race groups.
Othering by gender
Throughout South Africa, women continue to bear the burden of the disease and the blame
associated with it (Shisana and Simbayi 2002). This is to some extent due to historically
discriminatory employment practices, which caused Black African women to experience
either low pay or high levels of unemployment (Smith 2000). On average, Black African
women have a lower social status than men, have less access to safe housing, and are often
dependent on their male partners as breadwinners for support. This may render some
vulnerable to sexual abuse (Flood et al. 1997).
HIV infection rates for men and women vary, sometimes widely, and in many situations
where men outnumber women, women tend to be infected at younger ages than men
(Williams et al. 2000). This high rate of infection amongst women contributes in some
cases to an othering of women as sexually promiscuous, as loose, as prostitutes, and as dirty
and immoral. Through such processes, their male counterparts are culturally absolved of
blame for the high incidence of HIV infection that can be found in most Sub-Saharan
African countries (Simbayi 2002).
The low socio-economic status of most women and their dependency on men for
economic support places them in a vulnerable position for HIV infection and may cause
them to carry the blame for AIDS in South Africa (Leclerc-Madlala 2002). Deaths due to
AIDS have exacerbated scapegoating and the re-stigmatizing of women, who may be
blamed both for their husbands’ HIV-related deaths (Nabaitu et al. 1994) and for spreading
HIV (Leclerc-Madlala 2001). As a consequence of these social constructions, many
believe that women are to blame for transmitting HIV as the following negative perceptions
and enablers expressed by a rural SePedi-speaking woman from the Limpopo Province
I think it’s women who are most at risk for contracting HIV/AIDS … are more at risk
because of running around having multiple partners. You find women in the streets
G. Petros et al.
undressed saying they are looking for men, selling their bodies, what is that? Do you know that
those are the ones carrying diseases? … they are the ones that spread this disease. That’s how I see
However, a Shangaan speaking female from rural Mpumalanga saw the problem as
inevitable given the poor economic condition of women. She described matters using the
following existential and negative enablers:
Women get involved in multiple sexual relations because of poverty and need for money.
Men were also blamed by some women, as witnessed in the following existential perception
expressed by a girl during a mixed female and male youth group discussion held in urban
I think the men are the main culprits to bring AIDS home, ‘cause they are the ones who go out and
go for those long business vacations or whatever, and when they come back with AIDS … So then
we easily get HIV because one man sleeps with five women.
Such a view of the complicity of men in the spread of HIV was supported by an urban
Jewish Rabbi from Western Cape in this negative perception, although with an additional
…men are the problem because they are fornicators, both men and women are at risk of HIV, but
in African communities males are at risk.
Elswhere, Stadler (2003) has noted that an undue focus on young women’s
vulnerability can obscure the significant HIV risks that men face due to the relative
affluence, power, mobility and masculine sexuality they possess. Therefore, gender
inequity and inequality affecting both women and men are critical factors affecting
HIV transmission in South Africa. They have important consequences too for how
people are cared for when they are sick, what happens when they die and who inherits
Homophobia has been defined as the ‘combination of fear and self-righteousness in which
homosexuals are perceived as contemptable threats to the moral universe’ (Goleman 1990:
1). Homophobia can be either internal or external. Internal homophobia represents learned
biases that some individuals internalize as parts of their belief systems. While external
homophobia is overtly observed or experienced, it is often expressed as verbal abuse,
physical battery, religious discrimination or in the targeting of homosexuals for
discrimination. This exclusion or separation increases the stigma load borne by those
groups seen as responsible (Crewe 1991).
Among some South Africans, homosexuality continues to be viewed as the source of
AIDS as expressed in the following negative perceptions displayed by an urban male
Afrikaans speaking youth from Free State:
…I mean I have one or two friends who are homosexuals, and as far as I know they are not
[HIV] positive, but still, just that increased risk means that I don’t really visit them unnecessarily
often. [laughter] It’s an unfounded fear, still causes that feeling in me, I don’t know about the
HIV/AIDS and ‘othering’ in South Africa
The following comments from an adult urban White man from Gauteng located gay men
firmly within the historical trajectory of the epidemic, but with a moral condemnation of
It took root in the Gay community, then they brought it under control. Then it spread to drug
users and others. Now it seems like the Gays have started to become even more promiscuous than
they were. I don’t know if it is just their behaviour or if the rates of it is because the rates of
[infection] have dropped.
Baptist minister from an urban area, and by an adult Jewish male from an urban area.
This is not a new phenomenon. Such things characterized Sodom and Gomorrah. God has since
derived a plan to get rid of them [homosexuals]. We have them in South Africa and the church
must play a role to deal with them.
It’s more than fear ... It’s an aberration as well. Do you think the distinction would be made
between a Jewish doctor say who contracts AIDS from a little prick and somebody who was …
homosexual … There will be a major difference in the acceptance … you know if you are late for
dinner because of work, you hold a moral high ground, both will be looked after, but one with open
arms, the ‘other’ [homosexual] with closed arms.
Xenophobia consists of attitudes, prejudices and behaviours that exclude and vilify
others because they are considered to be outsiders or foreigners to the community,
society or national identity (ILO, OHCHR and IOM 2001). Internationally and
throughout the course of the epidemic, a large number of countries have sought to place
the blame for HIV and AIDS on foreigners. For example, the USA, Cuba and India are
countries that have policies that prescribe selective testing for people that come from
countries that are considered high risk for HIV infection. A xenophobic mindset is also to
be found within the South African context. Some interview participants in the present
study felt that ‘outsiders’ were to blame for bringing HIV into South Africa, even though
South Africa has more reported cases of HIV and AIDS cases than the countries being
blamed. The following negative perceptions shared by a rural San Chief from Northern
Cape illustrate this point.
What I’ve noticed … the people on the border [army] … Zimbabwe … Mozambique … Botswana
border … lots of things are picked up there. And these people brought it home [rural areas] with
The distancing of this disease by attribution to foreigners can lead to complacency
and denial creating a setting for the silent spread of HIV. A false sense of security is
represented in the positive and existential enablers captured in the following comments,
made by a rural traditional leader and male rural youth initiation leader from the Eastern
In the past, we did not have it in our community. It has been brought by foreigners and use the way
I said earlier … that he hires a room here he will infect all the women here. I say it came with
foreigners because in Sotho all diseases have names but this one we do not have it.
We had people from Zimbabwe who have AIDS and we got it from those people.
G. Petros et al.
Much of the current blame and othering of HIV/AIDS in South Africa can be traced to its
complex history in racism, patriarchy and homophobia. In South Africa, Apartheid
ideology compounded pre-existing inequalities in health provision along race and class
lines. Concurrently, low social status and economic dependence on men affected women’s
capacity to determine their sexual lives and to confront gender coercion and violence
(Strebel 1995, WHO/UNAIDS 2000). The early identification of HIV/AIDS among White
gay men and the tendency to blame ‘outsiders’ for the arrival of HIV infection in the
country have fuelled the homophobia and xenophobia implicit in many community
Against this backcloth, this paper has attempted to chart the implications of these
processes for the everyday subjectivities and responses of diverse groups of South Africans
today. Responses vary from care, compassion and understanding to stigmatization,
discrimination and denial. Importantly, processes of othering on grounds of race, gender,
sexuality and xenophobia not only take place at a personal level. Instead, they enable some
groups to live with a false sense of security and to feel that they can continue to ignore
AIDS as something out there in ‘other’ communities, and not their own Reducing stigma is
likely to require group focused intervention to sensitize all South Africans to the problem of
othering and its complex social dynamics. The message should be that everyone is at risk of
HIV infection irrespective of their perceived safe social space.
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