"We Smoke the Same Pipe": Religion and Community Home-Based Care for PLWH in Rural Swaziland.

We draw on a study of a church-run community home-based care organization in Swaziland to explore how individuals living with HIV perceived caregivers' impact on well-being. Our primary concern was to examine how religion, as a heuristic practice of Christian-based caregiving, was felt to be consequential in a direly underserved region. Part of a larger medical anthropological project, we conducted semi-structured interviews with 79 community home-based care clients, of whom half (53%) said they would have died, some from suicide, without its services. We utilized a critical phenomenological approach to interpret semantic and latent themes, and explicated these themes within a 'healthworld' framework. Participants were resolute that caregivers be Christian, less for ideological positioning than for perceived ontological sameness and ascribed traits: "telling the truth" about treatment, confidentiality, and an ethos of unconditional love that restored clients' desire to live and adhere to treatment. Findings are intended to help theorize phenomenological meanings of care, morality, health, and sickness, and to interrogate authoritative biomedically based rationalities that underwrite most HIV-related global health policy.

Reckoning HIV/AIDS care: A longitudinal study of community home-based caregivers and clients in Swaziland.

The article is a descriptive case study of a community home-based care (CHBC) organisation in Swaziland that depicts the convergence of CHBC expansion with substantially improved health outcomes. Comprised of 993 care supporters who tend to 3 839 clients in 37 communities across southern Swaziland, Shiselweni Home-based Care (SHBC) is illustrative of many resource-limited communities throughout Africa that have mobilised, at varying degrees of formality, to address the individual and household suffering associated with HIV/AIDS. To better understand the potential significance of global and national health policy/programming reliance on community health workers (task shifting), we analysed longitudinal data on both care supporter and client cohorts from 2008 to 2013. Most CHBC studies report data from only one cohort. Foremost, our analysis demonstrated a dramatic decline (71.4%) among SHBC clients in overall mortality from 32.2% to 9.2% between 2008 and 2013. Although the study was not designed to establish statistical significance or causality between SHBC expansion and health impact, our findings detail a compelling convergence among CHBC, improved HIV health practices, and declines in client mortality. Our analysis indicated (1) the potential contributions of community health workers to individual and community wellbeing, (2) the challenges of task-shifting agendas, above all comprehensive support of community health workers/care supporters, and (3) the importance of data collection to monitor and strengthen the critical health services assigned to CHBC. Detailed study of CHBC operations and practices is helpful also for advancing government and donor HIV/AIDS strategies, especially with respect to health services decentralisation, in Swaziland and similarly profiled settings.

Reckoning HIV/AIDS care: A longitudinal study of community home-based caregivers and clients in Swaziland

The article is a descriptive case study of a community home-based care (CHBC) organisation in Swaziland that depicts the convergence of CHBC expansion with substantially improved health outcomes. Comprised of 993 care supporters who tend to 3 839 clients in 37 communities across southern Swaziland; Shiselweni Home-based Care (SHBC) is illustrative of many resource-limited communities throughout Africa that have mobilised; at varying degrees of formality; to address the individual and household suffering associated with HIV/AIDS. To better understand the potential significance of global and national health policy/programming reliance on community health workers (task shifting); we analysed longitudinal data on both care supporter and client cohorts from 2008 to 2013. Most CHBC studies report data from only one cohort. Foremost; our analysis demonstrated a dramatic decline (71.4%) among SHBC clients in overall mortality from 32.2% to 9.2% between 2008 and 2013. Although the study was not designed to establish statistical significance or causality between SHBC expansion and health impact; our findings detail a compelling convergence among CHBC; improved HIV health practices; and declines in client mortality. Our analysis indicated (1) the potential contributions of community health workers to individual and community wellbeing; (2) the challenges of task-shifting agendas; above all comprehensive support of community health workers/care supporters; and (3) the importance of data collection to monitor and strengthen the critical health services assigned to CHBC. Detailed study of CHBC operations and practices is helpful also for advancing government and donor HIV/AIDS strategies; especially with respect to health services decentralisation; in Swaziland and similarly profiled settings

A qualitative study of community home-based care and antiretroviral adherence in Swaziland.

INTRODUCTION: Antiretroviral therapy (ART) has rendered HIV and AIDS a chronic condition for individuals in many parts of the world. Adherence, however, is integral to achieving chronicity. Studies have shown both relatively high ART adherence rates in sub-Saharan Africa and the importance of community home-based care (CHBC) to facilitating this process. In light of diminished HIV and AIDS funding globally and increased reliance on CHBC throughout Africa, a better understanding of how CHBC may strengthen ART adherence is essential to improving patients' quality of life, tending to the needs of care supporters and achieving healthier populations. METHODS: This article reports findings from a qualitative study of a CHBC organiztion serving an estimated 2500 clients in rural Swaziland. Semi-structured questionnaires with 79 HIV-positive clients [people living with HIV and AIDS (PLWHA)] yielded data on diverse aspects of being HIV positive, including insights on whether and how PLWHA perceived care supporters to facilitate ART adherence in a high stigma and structurally impoverished setting. RESULTS: Ninety-two percent of participants said their health had improved since care supporters came into their lives. A major finding was that an estimated 53% of participants said they would have died, a few from suicide had the care supporter never intervened. More than one in four participants (27.9%) sought HIV testing after a care supporter began visiting them. Nearly a third (31%) commenced ART after and largely as a consequence of care supporter intervention. Approximately one in four (23%) reported that their care supporter had helped them to disclose their HIV-positive status to family members. Twenty-seven percent said they had felt discouraged or had been discouraged from taking ART by members of their family or community. DISCUSSION: General inductive analysis of participant reports suggested two social mechanisms of CHBC impact on ART adherence: (i) cultivating client-care supporter "talk" to enhance treatment uptake and literacy, reduce felt stigma and challenge social pressures to desist from ART and (ii) real-time interactions between clients and care supporters whereby the care "relationship" was itself the "intervention," providing lay counsel, material and financial assistance, and encouragement when clients suffered stigma, side effects and other obstacles to adherence. These social dynamics of adherence generally fall outside the purview of conventional clinical and public health research. CONCLUSIONS: PLWHA reports of care supporter practices that enabled ART adherence demonstrated the pivotal role that CHBC plays in many PLWHA lives, especially in hard to reach areas. Relative to clinic personnel, care supporters are often intensely engaged in clients' experiences of sickness, stigma and poverty, rendering them influential in individuals' decision-making. This influence must be matched with on-going training and support of care supporters, as well as a clear articulation with the formal and informal health sectors, to ensure that PLWHA are correctly counselled and care supporters themselves supported. Overall, findings showed that PLWHA experiences of CHBC should be captured and incorporated into any programme aimed at successfully implementing the Joint United Nations Programme on HIV and AIDS (UNAIDS) Treatment 2.0 agenda Pillar 4 (increasing HIV testing uptake and care linkages) and Pillar 5 (strengthening community mobilization).

Free love: a case study of church-run home-based caregivers in a high vulnerability setting.

The purpose of this study is to explore the concept of religious health assets (RHA) and its relevance to HIV/AIDS. This manuscript describes the experiences of caregivers with a church-run home-based care organisation in Swaziland, site of the world's highest HIV prevalence (42%). In light of reduced antiretroviral treatment rollout in some areas of Africa, strengthening mechanisms of treatment support with HIV prevention has never been more critical. One modality may be community home-based care (CHBC), a core feature of the World Bank's Multi-Country HIV/AIDS Program for Africa. Yet, these entities, and the frontline activities of local congregations, remain underexplored. Part of a larger anthropological study of religion and HIV/AIDS in Swaziland, this manuscript draws on 20 semi-structured caregiver interviews to discern patterns in motivations; perceived client needs; care practices; and meanings of religiosity. Thirteen participants were care coordinators who oversaw approximately 455 caregivers across nearly half of the 22 communities served. Grounded theory analysis suggested that caregivers facilitated vital decisions around HIV testing, HIV disclosure, treatment uptake/adherence, as well as reduced HIV stigma. Also salient was the importance of a Christian ethos, in the form of 'talk' and 'love', as critical culturally situated care practices. Having expanded to an estimated 600 caregivers and 2500 home-based clients between 2006 and 2009, Participants' reports intimated their roles as agents of broader social transformation. This article contributes to the expanding study of RHA and challenges authoritative global public health strategies that have largely marginalised local religious aspects of HIV/AIDS. Future applied research examining how 'home' and 'church' may be vital public health settings outside of, but integral to, formal health services and HIV programming is warranted.

Hazarding health: experiences of body, work, and risk among factory women in Malaysia.

In the 1970s, Malaysia launched an export-oriented development strategy as a means of financing the nation's modernization. The success of the strategy hinged significantly on intensive recruitment of women for factory employment. I draw on descriptive qualitative research, including interviews (51), surveys (106), and ethnography in Malaysia to investigate factory women's experiences of work and work-related health risks. Discourse analysis surfaced a latent consciousness of bodily changes in relation to work. A grounded theory analysis showed a compromised access to occupational risk knowledge that may bear negatively on women's well-being and the role women's new labor identities played in mediating the meanings of work and risks. Given the predominance of women workers in low-end manufacturing globally, I aimed to contribute to theoretical and applied understandings of gender, globalization, and health.

Religious participation and HIV-disclosure rationales among people living with HIV/AIDS in rural Swaziland.

Despite the cultural salience of Christianity in many parts of Africa and the expansion of antiretroviral treatment, few studies have examined experiences of religious participation among HIV-positive individuals. Correspondingly, most studies of HIV self-disclosure in sub-Saharan Africa focus primarily on disclosure to sexual partners. Addressing both concerns, the central concern of this article is HIV self-disclosure in church settings, where disclosure rationales functioned as a key heuristic to explore experience of HIV-positivity, religiosity, and church participation. Given 39.2% antenatal HIV prevalence in Swaziland-the highest in the world-and an estimated 6 500 local congregations, this article draws on a medical anthropological project in Swaziland to investigate experiences of church participation among HIV-positive individuals. The data were derived from semi-structured interviews with 28 HIV-positive individuals across three domains: 1) pre- and post-diagnosis religiosity; 2) HIV stigma and support in church settings; and 3) decisions around HIV disclosure. Field research and open-ended interviews with individuals close to people living with HIV, health personnel, and pastors provided important contextual data. A grounded theory analysis showed that HIV disclosure in church settings is a highly reflexive process, mediated by subjective religiosity, the social dynamics of church networks, and broader structural vulnerabilities. Church participation often entailed significant stigma, which negatively affected self-disclosure and help-seeking practices; however, a rhetoric of 'courage' emerged to describe individuals who voluntarily disclosed their HIV-positive status. Pastors and pastors' wives were key protagonists in disclosure strategies. A church-based defense of the meaning of personhood for people living with HIV was among the most important findings. Given that congregations in much of Africa are predominantly female, and because women comprised the majority of the sample, the study productively problematised church settings as sites of analysis where gender, poverty, and religion intersect disease epidemiology in ways that may have untapped programmatic implications.

"Controlling ourselves, by ourselves": risk assemblages on Malaysia's assembly lines.

Since the early 1990s, the Malaysian government has identified factories as high risk for HIV and AIDS. Signaling epidemiological concerns over the rising rates of HIV among factory workers, a significant proportion of whom are women, the label also appeared to reconstitute stereotypes of factory women as dangerously sexual and of factories as immoral spaces. Drawing on ethnographic research in the export processing zones of Penang, Malaysia in the mid-1990s, I examine the meanings and experiences of HIV risk among factory women themselves. Data were analyzed using discourse and grounded theory methods, the former to identify women's multiple modes of rationalizing HIV risks, and the latter to theorize the sources and significance of women's HIV risk assemblages. The heuristic of assemblages as localized knowledge spaces helped to show that biomedical and socioreligious risk lexica operated not as fixed epistemological categories but as situational resources in women's risk scripts. Overall, women desired multiple risk knowledges to help them "control themselves by themselves," a project of reflexive self-shaping mediated by the diverse and discordant discourses of gender, ethnicity, and modernity in Malaysia that shaped how HIV risks were engendered and experienced.

"Mixing" as an ethnoetiology of HIV/AIDS in Malaysia's multinational factories.

Minah Karan, the stigmatizing label appended to Malay factory women in the 1980s, signaled a dangerous female sexuality that risked spreading beyond the factory gates and infecting Malaysia's idea(l)s of its traditional kampung culture. This article narrates how Minah Karan, as the former antihero of development, was reconstituted in the 1990s, with the government's labeling of factories as "high-risk settings" for HIV/AIDS. This is an ethnoetiology based not on any evidential epidemiological data but on the racial and gendered "mixing" that transpires behind factory walls: a fear that the "mixing of the sexes" means ipso facto "sexual mixing" among the races. The article demonstrates how importation of the high-risk label articulates at the local level the new and contested linkages, economic, religious, and scientific, constitutive of globalization. The pragmatic nature and imperatives of this high-risk process are discerned in factory women's accounts of how they negotiate the interactional imperatives of factory work, because transnational structures of productivity violate the social boundaries that have long connoted political stability, moral integrity, ethnic community, and individual safety. The article concludes by questioning whether ethnoetiologies, especially when they concern sexual networks, become social etiologies, because this would locate ethnoetiologies as central to conventional public health praxis rather than as ethnographic exotica in the margins.