Elsevier

Social Science & Medicine

Volume 67, Issue 12, December 2008, Pages 2126-2134
Social Science & Medicine

Antiretroviral therapy in Zambia: Colours, ‘spoiling’, ‘talk’ and the meaning of antiretrovirals

https://doi.org/10.1016/j.socscimed.2008.09.006Get rights and content

Abstract

We examine responses to the roll-out of antiretroviral drugs (ARVs) in Zambia in 2004, focusing on material features of the drugs (colour, shape, size, origin), ‘spoiling’ (concern about toxicity, side effects of the drugs) and rumours (‘talk’ about the drugs). Data consists of interviews with 10 people living with HIV and 21 healthcare practitioners. We found that the colour symbolism of ‘traditional medicine’ has some influence on ideas about ARVs, suggesting possible ‘meaning responses’ that could affect treatment outcomes. Respondents also become concerned when colours, shapes and side effects differ from expectations. ‘Talk’ about ARVs concerns risks of medication, sustainability of treatment programmes and people's feelings of vulnerability within larger socio-economic contexts in which countries like Zambia are disadvantaged. Understanding the associations that pharmaceuticals evoke can improve treatment programmes by elucidating public and patient concerns and sensitising healthcare professionals to the historical and political circumstances that condition the ‘meaning’ of ARVs.

Introduction

This article describes a study conducted in Zambia in 2004 during the roll-out of antiretroviral (ARV) therapy for HIV/AIDS. We examined patients' and practitioners' attitudes to the material characteristics of pharmaceuticals, ‘spoiling’ (concern about treatment strength, sometimes manifested in the experience of side effects) and rumours (‘talk’). We hypothesised that earlier biomedical interventions, colour symbolism and everyday experiences of the political and economic factors that hinder people's search for effective treatment could influence perception and use of ARVs.

We asked people living with HIV (PLWH) and practitioners (biomedical and traditional) to describe their reactions to the recent provision of ARVs and their ‘perceptible qualities’ (Etkin, Ross, & Muazzamu, 1990, 922). We also asked about dosage and life-long medication and explored informants' knowledge of alternative therapies and their experience and management of side effects. Informants were asked to compare the appearance and side effects of ARVs with those of other pharmaceuticals used for common infectious or chronic diseases (namely medication for malaria, tuberculosis, diabetes, epilepsy, herpes zoster and other STIs). We also asked about ‘talk’ they may have heard about ARVs.

Many studies discuss the clinical, delivery, access and educational dimensions of ARVs in Zambia (Dhaliwal et al., 2002, Dieleman et al., 2007, Stringer et al., 2006, Whyte et al., 2004). Others discuss ARVs in resource-poor settings (Farmer et al., 2001, Rabkin et al., 2002, Whyte et al., 2002). None, however, use Zambians' previous experiences with biomedical interventions to understand responses to today's roll-out or explore the significance of material characteristics, experiences of side effects and risks or the effects of the political economy of healthcare on concerns about ARVs. Our approach builds on studies of the introduction and interpretation of pharmaceuticals and their ‘social lives’ (Whyte et al., 2002) and studies of ‘meaning responses’ that can influence treatment outcomes (Moerman & Jonas, 2002). We also examine how the ARV roll-out in Zambia reflects wider contexts, situating medical experiences within the realm of social, political and economic relations and global inequities (Comaroff and Comaroff, 1999, Fairhead et al., 2006, White, 2000).

Section snippets

Background

Zambia carries one of the highest burdens of HIV/AIDS in the world. At the time of the study, the national prevalence for adults was 16%, rising to 23% in urban areas (UNAIDS/WHO, 2004). After nearly two decades in which most Zambians saw a diagnosis of HIV as a death sentence, the government is now rapidly introducing ARVs, assisted by US funding – the President's Emergency Plan for AIDS Relief in Africa (PEPFAR). This has given hope to PLWH, transforming HIV into a more manageable disease.

Methodology

We conducted the study at four sites in Lusaka (UTH, Chelstone clinic, Kamanga compound, Msisi compound) and in two rural districts (Choma in southern Zambia and Samfya in northern Zambia). We chose health facilities representing rural and urban contexts where PLWH and healthworkers had different levels of access to and knowledge of ARVs – UTH was the first government hospital piloting ARVs, Chelstone one of the four pilots for the ARV roll-out and Choma District Hospital one of the pilot

Materiality of medicines

Material characteristics have received some attention in studies of pharmaceutical use in the developing world (Bledsoe and Goubaud, 1985, Etkin et al., 1990, van der Geest and Whyte, 1991, Nichter and Vuckovic, 1994, Whyte et al., 2002, 5). Previous historical work has noted that colour can be important to African evaluations of a medicine's efficacy (Vaughan, 1991), though few have pursued this insight (for exceptions, see Bledsoe and Goubaud, 1985, Etkin et al., 1990). In contrast,

‘Spoiling’

The ‘spoiling’ and side effects questions used in the study revealed a number of key perceptions about toxicity or efficacy.3 The two dressers felt that ARVS were very strong and that this strength was appropriate – equivalent to the strength of the disease. Concerns about potential toxicity,

‘Talk’

The healers in the study observed that having faith in the medicine was important for curing the disease. Lack of faith in medicine – especially novel pharmaceuticals – and suspicion of the purposes of treatment also emerged from the interviews. One informant, an elderly healer in rural Samfya, engaged in a common (though not universal) African analysis of the HIV/AIDS epidemic – that it and its remedies were designed by whites to kill Africans.

‘Medicine that comes from out[side] of the

Conclusion

Our data reveal a small but salient use of colour symbolism when informants evaluate pharmaceuticals, indicating the need for further research into potential meaning responses that can influence treatment outcomes. Informants also clearly drew on previous encounters with pharmaceuticals when responding to ARVs, making strong parallels with TB drugs and their side effects and implying deeper connections to previously introduced pharmaceuticals and their side effects. Other factors such as

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    The Wellcome Trust funded the research on which this article is based – University Award Grant No. 056339, ‘Mining and medicine in Zambia’; International Collaborative Research Grant No. 073963, ‘The necessity of history: contextualising the introduction of antiretroviral treatment in Zambia’. We are grateful to the staff of ZAMBART and, especially to the medical researchers, Joseph Banda and Helen Ayles, for their help in Zambia during fieldwork in 2004. The research could not have been accomplished without the translation and insights of the following research assistants: Phales Mitimingi, Timothy Mgala, Florence Moyo and Titus Kafuma. Thanks also to Elizabeth Colson, Sandra Wallman and the anonymous reviewers from Social Science & Medicine for their helpful comments.

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