Building contexts that support effective community responses to HIV/AIDS: a South African case study

In this paper we discuss our conceptualisation of a 'health-enabling social environment', and some of the strategies we are currently using to build social contexts most likely to support effective HIV/AIDS management in southern Africa. In developing these ideas, we draw on our on-going collaboration with residents of Entabeni, a remote rural community in South Africa where 43% of pregnant women are HIV positive. The aim of this collaboration is to facilitate contextual changes that will enable more effective community-led HIV/AIDS management in an isolated area where people have little or no access to formal health or welfare support, and where HIV/AIDS is heavily stigmatised. We give an account of the three phases of collaboration to date. These include research; the dissemination of findings and community consultation about the way forward; preliminary project activities (skills training for volunteer health workers; partnership building and a youth rally) as a way of illustrating what we believe are six key strategies for facilitating the development of 'AIDS-competent' communities: building knowledge and basic skills; creating social spaces for dialogue and critical thinking; promoting a sense of local ownership of the problem and incentives for action; emphasising community strengths and resources; mobilising existing formal and informal local networks; and building partnerships between marginalized communities and more powerful outside actors and agencies, locally, nationally and internationally. We discuss some of the triumphs and trials of this work, concluding with a discussion of the need to set realistic goals when working at the community level in highly conservative patriarchal communities to tackle problems which may be shaped by economic and political processes over which local people have little control.