The sexuality of young people living with HIV in Senegal, between social norms and family secrets

In Africa, deficiencies in programs to prevent mother-to-child transmission of HIV during pregnancy still lead to a fairly high number of births of HIV-positive children. Along with the generalization of antiretroviral (ARV) treatment programs and early medical treatment of children born with HIV, the number of young people living with HIV is gradually increasing. In Senegal, 13-19 year olds represent about 36% of the 6,700 under 20 living with HIV (estimate, Spectrum 2018).

During adolescence, the question arises for them – and their families – about entering into sexuality: What restrictions are there for young people and their families? What support or accompaniment can they take advantage of to cope with this delicate period in their lives?

An anthropological study aimed at describing and analyzing the socio-cultural and organizational dimensions of the medical and social care of children and young people living with rural HIV was conducted in Senegal in 2020-2021.

Studies were conducted at 14 regional hospitals and health centers in 11 regions of Senegal. Interviews and observations involved 85 HIV + children / adolescents, 92 parents / guardians and 47 health professionals. The entry of young people into sexuality has been the subject of a specific analysis.

Amys story

(All first names are fictitious and the story is anonymized.)

Amy is 22 years old, she lives in a city very far from the capital (Dakar). Her mother died when she was three years old and she was raised by Fatou, her aunt, even the mother of three children. A strongly affective relationship binds Amy and her guardian, who was very attached to her mother.

Amy has been on ARV since a young age without knowing her HIV status. As a 17-year-old, she had periods of rebellion and refusal of treatment and wanted to know what her illness was. Her aunt feared the shock of the announcement and the revelation of the disease, which she had always carefully hidden from those around her. Only she and her husband were informed. After consulting with the social worker at the health center where Amy is being followed, Fatou revealed her HIV status to her.

His adherence to ARV treatment was improved after these discussions. In the following year, the girl became more flirtatious and often went out with her friends. Fatou was worried about her niece’s future and the thought that she might have sex. She confided in the social worker. This one offered to receive when the time came, Amy’s fiancé, when it would be a matter of marriage, to discuss with him.

A year later, Fatou discovers that Amy is pregnant. This pregnancy triggers a family scandal that forces Amy to leave home and seek refuge with a cousin in a remote village. Fatou was blamed for her lack of supervision and the shame that fell on the family. Far from the health center where she was usually followed, Amy did not say she was HIV-positive and stopped taking her treatment. She gave birth at a clinic near her new home. Three months after giving birth – when she returned to her aunt – a test showed her baby was HIV-positive. »

Amy’s story reveals a set of limitations that determine the ability of young people and their family environment to control the entrance to sexuality.

Social constraints

In Senegal, the dominant social norm values ​​virginity before marriage and establishes abstinence from young people as a cardinal moral value. Out-of-wedlock sexuality is condemned, and girls’ virginity by marriage is promoted as an ideal; the restriction is less for the boys to whom a simple moderation is recommended.

The use of contraception is socially reserved for married couples. Dramas associated with covert abortions or infanticide regularly make headlines in the context of criminalizing the voluntary termination of pregnancy. Abortion and infanticide are the primary cause of the imprisonment of women in Senegal.

Parents’ attitudes towards young people vary according to gender. For girls, pregnancies out of wedlock are ill-conceived or condemned: they bring stigma to the girl and her family. The head of the family attributes the responsibility to the mothers or guardians who are found guilty of not being able to “keep their daughter”.

These pregnancies are often the cause of violent family tensions, as the fear of them explains abortion attempts. In rural areas, the early marriage of girls is often considered to be the best solution to prevent accidental pregnancy. For boys, the appeal to religious morality or discretion is the only instruction.

Trial of young single women in Senegal, BBC Afrique, 4 September 2020.

The sexual health of young people in Senegal is a major social and public health problem: the 2017 Demography and Health Survey revealed that 19% of women had their first birth before the age of 18. 8% of women aged 17 had started their reproductive lives (DHS 2017). For several years, various “reproductive health” programs have been developed for young people across the country.

Supported by the Ministry of Health and the Ministry of Family or NGOs, they broadcast information in the form of TV series (f. Positive ; That’s life), smartphone apps (Hi Teen, Bibl CLV), with the aim of combating early pregnancies – the main causes of early school dropout among young girls -, early marriages, female genital mutilation and sexually transmitted infections.

“Teen Clubs” have been set up in the capital and secondary cities. These programs are regularly the subject of fierce criticism from social actors, most often religious, who consider their content to be contrary to traditions and moral values. Access to these programs is often restricted to rural teens whose standard of living does not allow them to own a smartphone.

HIV-related restrictions

Reducing social representations regarding HIV / AIDS gives rise to yet another register of restrictions affecting access to sexuality. In families, the care of children and young people living with HIV is most often characterized by various forms of silence about the disease. The primary concern of parents or guardians is to maintain absolute silence about the child’s illness as it is a sign of its biological parents.

When the child is orphaned by parents who may have died of HIV, the guardian’s silence about these events is appropriate. For the remarried mother of an HIV-positive child, the risk of revealing the child’s status is perceived as a threat that is likely to destroy this new association. The nature of the disease is revealed to the child as late as possible so that it does not reveal this information arbitrarily in the entourage and the neighborhood. Parents want to protect themselves – and the child – from the risks of stigma and discrimination.

Read more: Tensions and dilemmas surrounding the announcement of the disease for young adults living with HIV in Senegal

Different strategies have been put in place to maintain the confidentiality of members of the same household or within the family (medicines or their consumption are hidden; pretexts exist to justify frequent visits to the health center, etc.). The arrival of a teenager living with HIV at the marital age and the possibility of his entry into sexuality reactivates the fear of his parents or guardians. They are torn between the desire that their child can have a normal life while respecting social benefits through marriage, and the fear that the existence of the disease in the family on this occasion will be revealed publicly.

Responses from healthcare professionals and HIV nurses

In response to government demands, many health professionals across the country are required to participate in the implementation of various reproductive health programs that are in principle open to young people. Our study shows that many professionals reject strategies that facilitate access to contraception for young people.

For personal moral reasons or for fear of being accused of promoting sex outside of marriage, many are resistant to the idea of ​​offering contraception to young people. The criminalization of abortions causes some to report suspected abortion to the gendarmerie in order not to be prosecuted for complicity.

When questions about sexuality concern young people living with HIV, they are most often directed at the social service of the health structure: social counselors and mediators in collaboration with PLHIV associations. These actors play a key role in supporting children and young people living with HIV; it is often those who know best the medical history of children and adolescents who advise them and try to strengthen their adherence to medical follow-up.

To reinforce the motivation to take ARV treatment, which is still just as restrictive, they often remind us “that with ARVs you can live normally, get married and have children […] ; you do not have to say you are ill ”. If they treat the issue of sexuality in a cruel way, it is rare that they develop this topic. For them, too, sexuality is considered only within the framework of marriage: they promote abstinence before marriage – which they recommend as late as possible – and suggest that parents and young people return “when the time is right”.

This attitude, which consists in postponing the response, reflects the difficulties of health professionals in proposing solutions in accordance with both their moral values ​​and the needs of the younger generations. As the possibility of a marriage becomes clearer, some brokers offer different strategies to inform the future spouse: to perform an HIV test for the two suitors, and then announce their seropositivity with warning of legal threats in case of detection of the diagnosis.

In some associations of PLHIV, mediators play the role of matchmaker by facilitating the identification of a spouse among HIV + members of the association, thus promoting a kind of serological endogamy that will guarantee the preservation of secrecy surrounding the disease. .

Outside the major urban centers, young people have very limited, if any, access to information on sexuality and contraception. The high number of teenage pregnancies is the result of difficulties in taking into account the needs of this age group.

Young people living with HIV are faced with the silence imposed on the disease and the denial of their sexuality. An individualized approach, centered on their needs, should be promoted, in particular through confidential access to contraception. This approach could be supported by associations of PLHIV, whose competence development would make it possible to support young people at this crucial stage of their lives.

This article is from the study “Therapeutic failure in children and adolescents living with HIV in a decentralized context in Senegal, anthropological approach” (ETEA-VIH, ANRS 12421) conducted by the research team: Aljoner Diagne, Halimatou Diallo, Maimouna Diop, Seynabou Diop , Fatoumata Hane, Ndeye Ngone Have, Oumou Kantom Fall, Ndeye Bineta Ndiaye Coulibaly, Gabriele Laborde-Balen, Khoudia Sow, Bernard Taverne.

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