They protect us, but are they using protection? The potential impact of HIV on the South African Police Service

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Published on April 23, 2014

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The drivers of HIV and AIDS in the South African Police Service (SAPS) and impact of the disease on this workforce are neglected areas of research. Existing evidence suggests that while the occupational risk for contracting HIV is low, there are factors associated with the profession that, if left unmanaged, place police officers at risk of contracting HIV. This study’s two aims are to identify the potential pathways of HIV infection within policing services and determine the probable impact of HIV and AIDS on SAPS.

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They protect us, but are they using protection? The potential impact of HIV on the South African Police Service Gavin George and Jeff Gow The drivers of HIV/AIDS in the South African Police Service (SAPS) and impact of the disease on this workforce are neglected areas of research. Existing evidence suggests that while the occupational risk for contracting HIV is low, there are factors associated with the profession that, if left unmanaged, place police officers at risk of contracting HIV. This study’s two aims are to identify the potential pathways of HIV infection within policing services and determine the probable impact of HIV/AIDS on SAPS. Through a systematic literature review on HIV/AIDS within police services, and by analysing selected SAPS human resource data, the causal pathways and impact of HIV/AIDS on police services are explored. The study finds that police officers (particularly male officers) are likely to be highly susceptible to HIV infection as a result of risky sexual behaviours born out of occupational characteristics such as high levels of stress, difficult working conditions, living away from home and interactions with sex workers. The problem is exacerbated by the ‘macho’ culture that often prevails among police officers. HIV/AIDS interventions within SAPS must focus on sustained behaviour change. Further, HIV programmes must equip officers with the knowledge and awareness to avoid engaging in high-risk sexual practices that may compromise their health and the effectiveness of the policing service. Keywords HIV/AIDS, South African Police Service, impact, drivers Introduction South Africa is notorious for alarmingly high crime rates which vindicate the need for a well- capacitated and effective police workforce.1 At the same time, the country is also experiencing high HIV/AIDS prevalence rates. With an estimated 6.4 million people infected with HIV in ISSN: Print 1024-6029/Online 2154-0128 # 2014 Institute for Security Studies African Security Review, 2014 Gavin George is a Senior Researcher at the Health Economics and HIV and AIDS Research Division of the University of KwaZulu Natal, South Africa ( za) Jeff Gow is a Professor of Economics at the University of Southern Queensland, Toowoomba, Australia ( Downloadedby[UNIVERSITYOFKWAZULU-NATAL]at03:1823April2014

2012, South Africa’s epidemic remains the largest in the world.2 Evidence suggests that HIV/ AIDS has compromised the ability of the South African Police Services (SAPS) to effectively execute its responsibilities.3 HIV/AIDS is affecting SAPS primarily through the morbidity and mortality of senior and experienced police officers.4 Hence, SAPS is experiencing the loss of highly specialised and technically trained employees that cannot easily be replaced. This generates institutional fragility, compromising the overall capacity of SAPS to effectively deal with crime and respond to societal demands. Evidence also suggests that police officers, as a result of certain occupational-related factors, stand a greater risk of contracting HIV/AIDS than many other sub-populations.5 Literature on the impact of HIV in the private sector is well documented and reveals that as a result of absenteeism, ill-health retirements and death, the primary impacts are reduced productivity and higher operating costs.6 SAPS serves the public, and its vulnerability is therefore shared not only internally, but by the constituency it serves and protects. Conceptual framework Military and paramilitary organisations, like the armed forces and police services respectively, are usually characterised by male-dominated workforces. The nature of the work undertaken, and the enforcement of national and international laws and rules, ultimately requires the use of force against transgressors or non-compliant opponents. This enforcement of authority is usually accompanied by aggression and physical restraint or punishment of transgressors. In itself, these activities allow for the rule of law to be maintained for the betterment of society. The downside is that a culture of authority and physical toughness is built up in organisations and reinforced. These characteristics are also commonly found in many male groupings in society generally. R. W. Connell coined the term hegemonic masculinity to refer to this dominant or main form of masculinity within the gender hierarchy of a society.7 Hegemonic masculinity results in power residing with the dominant male group. Many (probably almost all) military and paramilitary organisations like SAPS have the characteristics of hegemonic masculinity with their emphasis on and association with heterosexuality, marriage, authority and physical toughness. The concept has gained traction in organisational studies as the influence on gender in workplaces and how they function has become increasingly recognised.8 In the military and police forces specifically, patterns of hegemonic masculinity have been increasingly identified with a wide range of entrenched negative behaviours with deleterious effects on both the guards and the captured.9 These characteristics of violence and aggression have been found to be necessary for guards to survive, and if advancement is desired, to thrive.10 The culture of many police services, SAPS included, can be described as ‘macho’. This is evidenced by the characteristics of a highly masculine, high risk, high stress and militarised organisation. The change of leadership assignations in SAPS in 2010 to mimic that of the military is further evidence of this macho culture. The link between hegemonic masculinity, southern African military and paramilitary organisations and a high risk of HIV transmission has been clearly established in the literature.11 Shefer and Mankayi interviewed a group of South African National Defence Force men on their masculinity, sexuality, sexual relationships and HIV/AIDS.12 The discussions point to a 2 African Security Review Institute for Security Studies Downloadedby[UNIVERSITYOFKWAZULU-NATAL]at03:1823April2014

dominant construction of male sexualities in the military and the complex intersection of hegemonic masculinities and military masculinities, which facilitate a particular vulnerability to unsafe sexual practices. Mankayi found in her interviews with 14 South African male soldiers that whilst there is increasing condom use, generally resistance to condom use is still high.13 The paper focused on the factors inhibiting condom use and explored issues of responsibility for safe sex practices to prevent HIV infection among this group, which is particularly vulnerable to HIV because of its working conditions; for example, working far from home and being among communities where its members possess greater economic and political power, as well as in relation to their identities and sexualities as men, and how this is exaggerated by the institutional framework of the military. Findings of this study show that most participants used the socially desirable discourse that safe sex practices (specifically condom use) should be everybody’s responsibility. However, there was also the discourse of the ‘other’ responsible person, which was linked to gender, race, ethnicity, education and rank. The paper concludes with a recommendation that tackling HIV in the military needs to involve the rigorous examination of social factors such as gender, race and ethnicity. Mankayi and Naidoo claim that the military’s organisational culture tends to condone or encourage risk-taking behaviour.14 Willingness to accept and engage in risk-taking behaviour is central to good soldiering and is strongly associated with readiness for combat. This core attribute of military culture might predispose soldiers to engage in other higher-risk behaviours, such as unprotected sex. Soldiers’ working and living conditions, such as the high level of work-related stress in combat and deployment situations, and being away from home and particularly from partners for long periods, are reported as contributing to high levels of HIV in military groups. This research explored the underlying value system in the military context as a strong enabler of higher-risk sexual practices among male soldiers. This not only obstructs gender equality in the military but also impacts on the prevalence of HIV. The findings highlight that when soldiers are on deployment or attending military courses they are often tempted to engage in higher-risk sexual behaviours. Underlying this narrative are patriarchal notions that men ‘need’ sex and cannot endure being without it, and that they have the right therefore to demand it from their partner or to seek it from multiple partners. Male soldiers’ sexual practices appear to be rationalised predominantly on the basis of the ‘male sexual drive’ discourse. The research found an association between work in the military and higher-risk sexual activity. Tran et al described condom use behaviours and examined correlates of use in the Botswana Defence Force (BDF). Analyses were based on 211 male BDF personnel, aged 18 to 30, who completed a cross-sectional survey that collected baseline data. Results showed that 51 per cent of participants reported always using condoms, 35 per cent used condoms most times, and 14 per cent used condoms occasionally or never. Condom use varied by partner type and was typically higher with casual partners in comparison to regular partners. However, use among soldiers is lower than ideal and below that of the rest of society.15 Despite what is known about HIV/AIDS within military settings, there remains a shortage of literature and empirical work on the prevalence and determinants of HIV/AIDS within SAPS, as well as on the impact of the epidemic on policing services, particularly in a high prevalence country such as South Africa. To this end, this study has two research aims; first, to understand the potential pathways of HIV infection within policing services and, second, to determine the probable impacts of HIV/AIDS on SAPS. Features 3 Downloadedby[UNIVERSITYOFKWAZULU-NATAL]at03:1823April2014

Methodology To answer the first research aim, a systematic literature review was undertaken. EBSCO Host was used to search the following databases: Academic Search Complete, Africa-Wide Information, ERIC, Health Source (Nursing/Academic edition) and PsycINFO. In addition to this, a search on the ProQuest database was performed. The date range was limited to publications from 1990 to June 2013, and only peer reviewed and full text documents were requested. The literature search was conducted using the keywords HIV [or] AIDS [and] police [and] military in each search. The second research aim is answered using publically accessible SAPS human resource (HR) data. Due to the limited empirical evidence for the impact of HIV/AIDS on SAPS, an analysis of selected SAPS HR data for the period 2002 to 2012 was undertaken, and provides proxy indicators for impact. Trends on specific indicators, such as absenteeism, death as a result of ill health, and other demographic variables were analysed. As a result of the lack of empirical work on HIV/AIDS within the police force, and to draw appropriate comparisons, reference is also made to findings from workplace HIV/AIDS studies and general South African mortality rates. Results and analysis A total of 140 publications were produced from the search and, from these, 14 documents were selected during the filter process. The filter process involved reading the title and abstract of the publication to determine its relevance to the review. These were then separated into review-related publications (4) and empirical publications (10). The review-related publica- tions were used to form the basis of establishing what is currently known about HIV within police forces (both worldwide and in South Africa), while the empirical publications were sorted into themes. Three key themes emerged from the analysis of the literature and selected HR data, which were: occupational risks for contracting HIV, behavioural risk factors associated with the occupation, and impacts on policing. These themes are listed below. Occupational risks for contracting HIV While there is a general perception that police officers are at ‘high risk’ of contracting HIV, there is no empirical evidence to support this view. The only occupational risk for contracting HIV revolves around contact with infected blood, which might occur at a crime or accident scene. There are, however, established protocols for handling blood in routine police work, such as the use of gloves. Evidence suggests that even when police work involves contact with blood, the risk of infection is low.16 A study in the United States (US) which investigated 42 cases of reported exposure to blood in the line of police work found no evidence to establish a link between exposure to blood and HIV infection.17 The exposure to blood in these instances occurred in circumstances where there was little or no time for the officer to put on protective gear, such as gloves (for example, stabbing with a sharp object or needle or during a fight). The study found that 9,5 per cent of police officials tested positive for HIV, but failed to conclusively link the blood exposure to the mode of transmission, suggesting that these officers could have been infected through an alternative mode of transmission. Caution should 4 African Security Review Institute for Security Studies Downloadedby[UNIVERSITYOFKWAZULU-NATAL]at03:1823April2014

be exercised in extrapolating this finding. A study in Amsterdam analysed 112 exposures of police officers to blood and concluded that the risk of HIV infection amongst police officers, whilst low, was still higher when compared to the general public.18 There are no studies in South Africa that have attempted to establish a link between blood exposure and HIV infection among police officials. More research is needed to determine the risk associated with blood exposure in areas that have high HIV prevalence rates, since the chances of contact with infected blood are higher in these regions than in the developed world. In his review of literature of HIV and SAPS, Themba Masuku concluded that due to the relatively low risk for occupational exposure to HIV infection, interventions that do not deal with lifestyle issues, stress and problems of misconduct will fail to effectively address the problem of HIV/AIDS in the police.19 Factors relating to these issues identified through the literature search will now be discussed. Behavioural risk factors associated with the occupation Police work can involve working away from home, which disrupts social and family life. This lifestyle of police officers can place abnormal stresses on families and spouses.20 Job commitments and pressures sometimes promote breakdowns in communication between spouses.21 Faced with these stresses, feelings of isolation and frustration can result in risky sexual behaviour.22 Police officers are also forced to experience traumatic situations, and exposure to such situations could make an individual vulnerable to post-traumatic stress disorder (PTSD).23 Though stress and PTSD can be treated using clinical psychological interventions, police officers are fearful of seeking psychological help.24 Psychological stresses can influence police officers to resort to high-risk activities as a way of dealing with these issues.25 Research has further noted that multiple and concurrent sexual partnerships are perceived as common behaviour, and while the majority of police officers are aware of the risks, the practice continues unabated.26 It is further suggested that sexual liaisons with multiple partners serve to increase the size and diversity of the police officers’ sexual and social network, and therefore increases their social capital but at increased risk of HIV infection.27 These risky sexual behaviours are often instigated by officers due to their considerable power and influence within the communities in which they work.28 Ted Leggett expands on this point by noting that police officers have considerably higher salaries than other civil servants and are often better paid than other men in the communities in which they work.29 This economic power is what attracts younger (economically vulnerable) women to them.30 It is these social relationships of inequality that help to fuel the HIV epidemic, as these often put sexual partners in unequal relationships.31 High-risk sexual behaviour is often worsened by economic inequality between males and females.32 For women, their lack of economic resources intersects with the social relationship of gender inequality, undermining their ability to negotiate condom use with male partners. When girls and young women are dependent on men for their economic security, they are less able or willing to negotiate safe sex, fearing they will be abandoned or fearing violence. Their relationships are formed with older men who are more likely to have more resources as well as more sexual partners, increasing both dependency and risk. Girls have cited the need for money or the desire for material goods as a motivation for having sex or forming relationships.33 In India, Jindal and Arora studied the sexual practices and HIV status of a sample of 280 police officers (99 per cent male).34 A total of 94 per cent were married and 93 per cent Features 5 Downloadedby[UNIVERSITYOFKWAZULU-NATAL]at03:1823April2014

reported having multiple concurrent sex partners, including the use of sex workers. Details of the frequency of multiple sexual partners, the number of sexual partners and the frequency of use of sex workers were not provided, highlighting the need for more empirical work in this area. In a Cambodian study, researchers found that of the 332 male police and military personnel that participated in the study, 56 per cent acknowledged having sex with a sex worker in the past month and 88,5 per cent in the past year.35 Only 38 per cent reported consistent condom use with sex workers.36 In Nigeria, Amos Aremu investigated the sexual practices of 996 police officers (609 married and 387 not married).37 More than 45 per cent of the respondents indicated that they engaged in sexual relations with more than one partner, with some (26,5 per cent) having between 4 to 7 sexual partners.38 In addition to this, only 11 per cent of the sample indicated that they use condoms, and the frequency of condom use is unclear.39 An earlier Nigerian study among 358 police officers found a high prevalence of multiple sexual and extramarital sexual partners, as well as the use of sex workers.40 The author concluded that this cohort is highly susceptible to contracting HIV and other STDs. The literature review revealed that there were no published (quantitative) empirical studies that specifically examined the sexual practices of South African police officers, and their relative risk for contracting HIV. Some believe that urban-based officers are at increased risk for contracting HIV due to their contact with sex workers, a high HIV-risk population.41 South African law criminalises the selling of sex and all associated activities, and this has resulted in frequent contact between the police and sex workers. Research reveals that sex workers are forced to have unprotected sex with police officers to evade arrest and have little power to negotiate safe sex.42 Nicolé Fick further argues that, while on duty, police officers are perceived as guardians of the public and command respect due to their position within the community.43 This ‘hero’ image can be hard to tone down when dealing with vulnerable groups such as sex workers, and this could result in abuse.44 However, more research is needed to determine the extent to which police officers utilise the services of sex workers and/ or request sexual favours in order to avoid arrest. Moreover, this research should identify which regions are particular hot spots for the abuse of sex workers by the police. Finally, research suggests that HIV risk amongst police officers is associated with alcohol and drug use.45 These studies contend that it is the social rather than the physical conditions that place police officers at greater risk of HIV infection.46 Among other factors, research has attributed the gravitation toward these social ills to occupational stress.47 Impact on policing Very little empirical work has examined the impact of HIV/AIDS on the ability of SAPS to execute their work effectively. However, evidence from a survey of 305 police officers in the Johannesburg region of South Africa suggests the virus is impacting on workload.48 Respondents were asked how often they found themselves doing the work of other staff because those people were unable to work. About half the participants (49 per cent) responded ‘very often’, and 18 per cent responded ‘somewhat often’.49 Evidence suggests that HIV/AIDS is eroding the capacity of the South African armed forces to function optimally.50 Martin Schönteich argues that HIV/AIDS may impact on crime and SAPS’ response to crime in two ways.51 Firstly, he argues that the high number of adult deaths and orphaning will result in an increase in the proportion of adolescents and young adults relative to the general population,52 and that this larger youthful population could result in more delinquent behaviour, predatory 6 African Security Review Institute for Security Studies Downloadedby[UNIVERSITYOFKWAZULU-NATAL]at03:1823April2014

crime and inter-group conflict. It is possible that less resilient orphans who experience social exclusion will be at greater risk of becoming antisocial individuals and even violent offenders.53 Secondly, Schönteich argues that SAPS’ capacity to deal with possible changes in crime patterns will be compromised because the organisation itself has lost (and is losing) trained personnel as a result of HIV/AIDS.54 Ongoing research is needed to monitor this dynamic so that policy and practice may be more actively informed. Employee trends The analysis of the HR data reveals significant increases between 2002 and 2012 in personnel numbers amongst black female and male cohorts, who are in the highest risk pool for HIV transmission.55 HIV prevalence studies in workplaces spanning 10 years from 1997 illustrated that prevalence was higher among men (11,3 per cent) than women (9,8 per cent) and higher among black Africans (16,6 per cent) than other race groups (2,7 per cent).56 This research argued that race remains the variable most strongly associated with HIV prevalence in South Africa. Within SAPS, whilst most other race groups have either levelled off or are declining in number, black Africans have increased considerably.57 For instance, the number of black male personnel increased by 63 per cent from 63 283 during 2002 to 100 486 in 2012.58 The number of black female personnel increased over 200 per cent from 16 581 during 2002 to 48 688 during 2012.59 Evidence, therefore, suggests that SAPS are drawing recruits from the most-at-risk population. Death and ill health retirements Research suggests that mortality statistics are an indirect indicator for the prevalence of HIV.60 The research shows that if the aggregate data on mortality have the following three characteristics then an approximate HIV profile can be created: (1) a distinct increase in mortality should correlate with the heightened phase of the epidemic; (2) mortality should increase significantly among the demographic cohorts of the population that have highest prevalence; and (3) there are no other known explanations for the abnormal mortality profile.61 Data from SAPS indicates that mortality rates increased from 2002 to 2005 and reduced from 2006 onwards. Figure 1 shows the number of deaths and ill-health retirements within SAPS. The data reveals that the mortality rate per 100 000 officers was 0,62 in 2002 and reduced to 0,30 by 2009.62 The number of deaths decreased significantly from 2005, when it was recorded at just less below 1 200, whilst dropping to 310 in 2006. This data closely matches the decline seen in South Africa’s mortality trends since the widespread availability of antiretroviral (ARV) treatment through the public health system from 2004.63 It therefore appears that the initial increase in the observed mortality and discharge rates is attributed to the maturing of the HIV/ AIDS epidemic, whilst the subsequent reduction could be influenced by the availability of ARV treatment in the public health system from 2004. It is noted with interest that mortality trends are increasing from 2007 onwards and this could be the result of non-adherence to ARV treatment or simply that a larger number of SAPS employees are unaware of their status and are not accessing treatment before succumbing to the virus. These data need to be monitored and further research is required to ascertain the true cause of these worrying trends. For comparative purposes, Figure 2 is used to demonstrate the differences in mortality rates per 100 000 employees between SAPS and the general South African population. In 2002, Features 7 Downloadedby[UNIVERSITYOFKWAZULU-NATAL]at03:1823April2014

the mortality rate was 0,62 for police officers.64 In 2003, the mortality rate for police officers increased to 0,78.65 Mortality rates for police officers peaked during 2004, reaching 0,85.66 After this point, SAPS mortality rates declined rapidly to between 0,1–0,2 during the period 2006–2009.67 It should be noted that the trends in these data closely resemble those witnessed in the general South African population within a similar age group. Figure 1 Deaths87 and discharge for ill health – SAPS officers 0 200 400 600 800 1 000 1 200 1 400 02/03 03/04 04/05 05/06 06/07 07/08 08/09 09/10 10/11 11/12 Number of deaths Number discharged for ill health Source SAPS Annual Reports 2002/2003–2011/2012 Figure 2 Mortality rates – comparison of SAPS officers and the South African general population 0.36 0.38 0.40 0.42 0.44 0.46 0.48 0.50 0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 00/01 01/02 02/03 03/04 04/05 05/06 06/07 07/08 08/09 09/10 10/11 11/12 MortalityRate PercentageofWorkforce SAPS Death Rates SA AIDS Mortality (15-49) Source SAPS Annual Reports 2002/2003–2011/2012; Actuarial Society of South Africa (ASSA), 2011.88 8 African Security Review Institute for Security Studies Downloadedby[UNIVERSITYOFKWAZULU-NATAL]at03:1823April2014

Discussion The systematic review of the literature on HIV and the police revealed that this is an under- researched area. There is nevertheless evidence which demonstrates that police officers have the propensity to engage in risky sexual practices, a phenomenon that was prevalent in all the countries included in our review. Based on these findings, we have hypothesised potential pathways through which police officers may contract HIV. This is shown below in Figure 3. The figure suggests that the risk factors associated with the profession may expose an individual to risky behaviour which in turn exposes him to HIV infection. For instance, constant exposure to traumatic situations without adequate therapeutic assistance or without the self-efficacy to utilise the available assistance may result in undesirable consequences. While psychological stress of this nature is treatable, police officials may often be fearful of seeking psychological help from within the organisation.68 Some of this fear is due to a culture of masculinity and the perception that seeking help would be seen as weak or cowardly.69 Robyn Pharoah notes that, as a result, some police officers resort to high-risk activities such as alcohol and drug abuse and risky sexual behaviour to ‘let off steam’.70 It should be noted that the practice of unsafe sex by police officers is not always a response to stress, since it may sometimes be opportunistic in nature, as may sometimes be the case with the exploitation of sex workers. The results of this investigation demonstrate that although the number of deaths dropped sharply from 1 200 in 2005 to 310 in 2006, there was no such significant drop in the amount of sick leave days, which fluctuated between 7–10 days annually per employee during the period 2002–2012.71 This suggests that the introduction of ARV treatment could have contributed to a decline in employee deaths, but not employee sick leave. One possible reason for this is that HIV-positive employees may be presenting for treatment when already in a late stage of the disease (especially with a CD4 cell-count < 50), thus giving treatment little chance to assist in terms of sick leave and absenteeism.72 This research indicates that whilst ARV treatment was available in the private sector from the early 2000s, many employees failed to take advantage of the service.73 This was as a result of employees not knowing their status and therefore only presenting for treatment once they had entered the symptomatic stage of the disease. Figure 3 Potential pathways of HIV infection Risk factors associated with profession: Disruptive lifestyle Exposure to traumatic situations Stress Exposure to sex workers Macho culture Risky behaviour: Substance abuse Extramarital affairs Sex with sex workers Multiple sexual partners Unprotected sex HIV Infection Occupational risk: Exposure to infected blood Features 9 Downloadedby[UNIVERSITYOFKWAZULU-NATAL]at03:1823April2014

Based on data from the mining sector, whilst voluntary counselling and testing (VCT) rates are increasing, evidence suggests that the uptake of ARVs is slow.74 Given what is known about the uptake of VCT and ARV treatment in the private sector, it is not likely that uptake within SAPS would have been much higher, hence one possible explanation for the acute decrease in the number of deaths observed within SAPS is different or improved methods of HR data recording. This seriously highlights the need for more research into this area, and continued accurate data recording within SAPS. The non-reduction in sick leave impacts on productivity and results in higher workloads for others, which contributes to stress, and in some cases, increased vulnerability to HIV infection (see Figure 3). In mitigating the impact of HIV, SAPS must have the resources to support a workforce operating under difficult and highly stressful circumstances. In this regard, it is of concern that in 2003 there were only 167 counsellors out of 257 available posts in SAPS, with the average number of SAPS personnel per counsellor being 787. By 2012, the number of personnel per counsellor increased to 2 020. In addition, employment posts for counsellors have decreased from 257 in 2003 to 97 in 2012. Thus, the ratio of SAPS personnel to counsellor is dramatically increasing, making it difficult to provide the services required by SAPS personnel. Figure 4 provides an illustration of how the number of SAPS personnel per psychologist or counsellor has increased over the examined time period. As noted earlier, prevalence studies have demonstrated that workplace HIV in South Africa is significantly higher among black Africans (16,6 per cent) than among other race groups (2,7 per cent).75 Whilst most other race groups have either levelled off or are declining in number, black African personnel have increased considerably.76 Hence the evidence suggests that SAPS are drawing recruits from the most-at-risk population, and this has serious implications for the intensity and frequency of prevention and treatment efforts. For instance, while the number of deaths decreased between 2005 and 2007, there has been a marked rise in deaths since 2008, suggesting that current treatment and prevention initiatives may not be having the desired effect. Figure 4 Number of SAPS personnel per psychologist or counsellor 927 1 064 1 169 1 104 1 237 1 562 2 002 2 020 0 500 1 000 1 500 2 000 2 500 04/05 05/06 06/07 07/08 08/09 09/10 10/11 11/12 Number YEARS Source SAPS Annual Reports 2004/2005–2011/2012 10 African Security Review Institute for Security Studies Downloadedby[UNIVERSITYOFKWAZULU-NATAL]at03:1823April2014

Colvin et al. provide the caveat that there is no evidence that race per se increases the risk of HIV infection and suggests that further research is required to determine how and in relation to which factors race is a proxy measure.77 Research has furthermore provided conflicting evidence on HIV prevalence rates within different categories of workers. In the early 2000s, modelling of the HIV epidemic in South Africa suggested that HIV prevalence decreased significantly with workers’ skill levels.78 Workplace studies by Colvin and Evian affirmed this view.79 However, other surveys have suggested either the opposite or contradict the linearity of such correlations or that the differences are not significant.80 Adriaan Pienaar, for example, drew on data of insurance policy applicants and found that while HIV was more prevalent overall amongst unskilled workers, rates were higher amongst individuals with tertiary level qualifications than those with secondary school certificates.81 Without disaggregated data, it is impossible to determine which cadre of workers are most susceptible to HIV infection but one can confidently state that SAPS would be most impacted should their highly qualified and experienced personnel become infected and ultimately leave the force. It is these employees that cannot be replaced by individuals outside of SAPS and therefore need replacing by those within. This could result in inexperienced employees taking up more senior roles before they are adequately trained or have the requisite experience, and this in turn can result in the degradation of services offered by SAPS. Conclusion Given the need for effective health promotion interventions targeting HIV/AIDS in sub- Saharan Africa, there has been a proliferation of initiatives and internationally funded projects in this region.82 Despite these often expensive interventions, health promotion practitioners have enjoyed only limited success, and while the reasons for this failure may be innumerable, many would argue that poorly planned and evaluated interventions are contributing factors.83 To this end, a rigorous monitoring and evaluation plan for HIV-related interventions is strongly recommended so that SAPS may adjust aspects of its HIV/AIDS strategy that are not working, and have a clear indication of which aspects are effective. Improving the uptake of counselling will always be a challenging task, given the stigma that is often associated with counselling. SAPS should look to recruit psychologists and counsellors who could train their officers on life skills and equip them with coping mechanisms to deal with stressful working conditions that, evidence suggests, could otherwise lead to risky behaviour by police officers. Due to the various similarities that exist between military personnel and police officers, studies with men in the military are a useful source of information for this paper. An analysis of 14 qualitative interviews with men at the South African military academy suggests that hegemonic masculinity and its associated traditional male sexual practices are key areas of challenge for HIV/AIDS interventions, and more broadly in addressing issues of gender inequality.84 Recommendations from this study suggest a need to pay attention to creatively raising and assessing the complexities of gender and sexuality in the military.85 The findings from our systematic literature review on HIV and the police suggest that a similar form of masculinity prevails among many police officers, a notion that is supported by findings such as multiple partners and extramarital sex. Interventions of this nature may therefore assist in Features 11 Downloadedby[UNIVERSITYOFKWAZULU-NATAL]at03:1823April2014

reducing the frequency of risky sexual behaviour, and they may even assist in the uptake of counselling as men begin to view masculinity in a different way. As a result of the ongoing loss of personnel to the epidemic, proactive measures should be taken to ensure a fair degree of retention among police officials. HIV/AIDS interventions within SAPS must go beyond knowledge transference to a focus on sustained behaviour change. These initiatives should equip officers with the skills they require to avoid engaging in sexual practices that may compromise their health. Evidence suggests that interventions of this nature with adult men have the potential to produce positive changes in their sexual practices.86 The drivers of the HIV/AIDS epidemic in SAPS and the impact of the disease on the profession are neglected areas of research. Existing evidence suggests that while the occupational risks for contracting HIV are extremely low, there are risk factors associated with the profession, such as stress, exposure to traumatic situations, a macho culture, exposure to sex workers and a disruptive lifestyle, which may influence police officers to engage in risky sexual practices, thereby placing them at risk for contracting HIV. Interventions are required to ensure that in a country experiencing high levels of crime and HIV/AIDS, the impact of the epidemic on SAPS is mitigated. Acknowledgements The authors would like to acknowledge Shaneel Bachoo for his assistance on the paper. Notes 1 Gregory Breetzke, Understanding the magnitude and extent of crime in post-apartheid South Africa, Social Identities 18 (2012), 299–315. 2 Mia Malan, Household survey: HIV prevalence increases, Mail & Guardian, 20 June 2013, 2013-06-20-household-survey-hiv-prevalence-increases (accessed 7 August 2013). 3 Martin Schönteich, A bleak outlook: HIV/AIDS and the South African Police Service, South Africa Crime Quarterly 5 (September 2003), 1–6; Robyn Pharoah, Not business as usual: public sector responses to HIV/AIDS in South Africa, Pretoria: Institute for Security Studies, 2005. 4 Pharoah, Not business as usual. 5 Schönteich, A bleak outlook. 6 Gavin George, Jeff Gow and Alan Whiteside, HIV/AIDS in private sector companies: cost impacts and responses in Southern Africa, HIV Therapy 3 (2009), 293–300. 7 R W Connell, Masculinities, Sydney: Allen & Unwin, 1995. 8 R W Connell and James W Messerschmidt, Hegemonic masculinity: rethinking the concept, Gender and Society 19 (2005), 829–859. 9 James W Messerschmidt, Hegemonic masculinities and camouflaged politics: unmasking the Bush dynasty and its war against Iraq, London: Paradigm, 2010. 10 James W Messerschmidt, Managing to kill: masculinities and the space shuttle Challenger explosion, Masculinities, 3(4) (1995), 1–22. 11 Punyuzwa Titi, South African Police Service officers’ perceptions of HIV/AIDS from Umtata Central Police Station, Durban: University of Zululand, 2009; Tamara Shefer and Nyameka Mankayi, (Hetero)Sex: discourses on male (hetero) sexual practices among a group of the (hetero)sexualization of the military and the militarization of young men in the South African military, Sexualities 10 (2007), 189–207; Nyameka Mankayi, Military men and sexual practices: discourses of ‘othering’ in safer sex in the light of HIV/AIDS, Journal of Social Aspects of HIV/AIDS 6 (2009), 32–44; Bonnie Robin Tran, Anne Goldzier Thomas, Mooketsi Ditsela et al, Condom use behaviors and correlates of use in the Botswana Defence Force, International Journal of STD and AIDS 24 (2013), 883–892; Nyameka Mankayi and 12 African Security Review Institute for Security Studies Downloadedby[UNIVERSITYOFKWAZULU-NATAL]at03:1823April2014

Anthony Vernon Naidoo, Masculinity and sexual practices in the military: a South African study, African Journal of AIDS Research 10 (2011), 43–50; Lindy Heinecken, The potential impact of HIV/AIDS on the South African Armed Forces: some evidence from outside and within, African Security Review 18(2) (2009), 60–77; Audrey E Pettifor, Diana M Measham et al, Sexual power and HIV risk, South Africa, Emerging Infectious Diseases 10 (2004), 1996–2004. 12 Shefer and Mankayi, (Hetero)Sex. 13 Mankayi, Military men and sexual practices. 14 Mankayi and Naidoo, Masculinity and sexual practices in the military. 15 Tran et al, Condom use behaviors and correlates of use in the Botswana Defence Force. 16 J Chambers, Mandatory HIV and hepatitis testing: the flaws in the executive’s proposals, SCOLAG Journal 332 (2005), 116–119. 17 Richard E Hoffman, Nancy Henderson et al, Occupational exposure to human immunodeficiency virus (HIV) infected blood in Denver, Colorado, police officials, American Journal of Epidemiology 139 (1994), 910–917. 18 Gerard J B Sonder, Anneke van den Hoek, Rosa M Regez et al, Trends in HIV postexposure prophylaxis prescription and compliance after sexual exposure in Amsterdam, 2000–2004, Sexually Transmitted Diseases 34 (2007), 294–296. 19 Themba Masuku, An overview of the implementation of the SAPS policy and five year (2000–2005) strategic plan on HIV & AIDS: the case of Johannesburg policing area, Johannesburg: Centre for the Study of Violence and Reconciliation, 2007. 20 James Habyarimana, Bekezela Mbakile, and Cristian Pop-Eleches, The impact of HIV/AIDS and ARV treatment on worker absenteeism: implications for African firms, Journal of Human Resources 45 (2010), 809–839. 21 Titi, South African Police Service officers’ perceptions of HIV/AIDS. 22 Ibid. 23 American Psychiatric Association, DSM-IV, Washington: American Psychiatric Association, 1994. 24 Masuku, An overview of the implementation of the SAPS policy and five year strategic plan on HIV & AIDS. 25 Ibid. 26 Schönteich, A bleak outlook. 27 Ibid. 28 Masuku, An overview of the implementation of the SAPS policy and five year strategic plan on HIV & AIDS. 29 Ted Leggett, What do the police do? Performance measurement and the SAPS, Pretoria: Institute for Security Studies, 2005. 30 Ibid. 31 Tony Barnett, Social policy interventions to enhance the HIV/AIDS response in sub-Saharan Africa: alternative perspectives, in Bjorn Lomborg (ed), RethinkHIV: smarter ways to invest in ending HIV in sub-Saharan Africa, Cambridge: Cambridge University Press, 2012, 281–292. 32 Wendy Santis, Cheryl Vince Whitman, Sridhar Venkatapuram et al, HIV/AIDS and employment: protecting young people and involving them in work-related solutions, London: London School of Hygiene and Tropical Medicine, 2003. 33 Pettifor et al, Sexual power and HIV risk, South Africa. 34 Neeraj Jindal and Usha Arora, Trend of HIV infection in police personnel attending VCTC of a tertiary care hospital, Indian Journal of Community Medicine 32 (2007), 201–202. 35 Caroline A Ryan, Ouk Vong Vathiny, Pamina M Gorbach et al, Explosive spread of the HIV-1 and sexually transmitted diseases in Cambodia, Lancet 351 (1998), 1175–1180. 36 Ibid. 37 Amos Oyesoji Aremu, Influence of multiple partners and use of contraceptives on the sexual behaviour of Nigerian police: some counseling implications, International Journal of Police Science and Management 11 (2008), 160–169. 38 Ibid. 39 Ibid. 40 Ebenezer Olutope Akinnawo, Sexual networking, STDs, and HIV/AIDs transmission among Nigerian police officers, Health Transition Review 5(Supplement) (1995), 113–121. Features 13 Downloadedby[UNIVERSITYOFKWAZULU-NATAL]at03:1823April2014

41 Ibid. 42 Nicolé Fick, Sex workers speak out: policing and the sex industry, South African Crime Quarterly 15 (2006), 13–18; Q A Karim, S S Karim et al, Reducing the risk of HIV infection among South African sex workers: socioeconomic and gender barriers, American Journal of Public Health 85 (1995), 1521–1525. 43 Fick, Sex workers speak out. 44 Ibid. 45 Leggett, What do the police do?. 46 Alex de Waal, Jennifer F Klot, Manjari Mahajan et al, HIV/AIDS, security, and conflict: new realities, new responses (AIDS, Security and Conflict Initiative), Copenhagen: Netherlands Institute of International Relations, 2009; Seth C Kalichman, Leickness C Simbayi, Redwaan Vermaak et al, Randomised trial of a community-based alcohol- related HIV risk-reduction intervention for men and women in Cape Town, South Africa, Annals of Behavioural Medicine 36 (2008), 270–279. 47 Schönteich, A bleak outlook. 48 Masuku, An overview of the implementation of the SAPS policy and five year strategic plan on HIV & AIDS. 49 Ibid. 50 Sonder et al, Trends in HIV postexposure prophylaxis prescription and compliance. 51 Schönteich, A bleak outlook. 52 UNICEF, Africa’s orphaned and vulnerable generations: children affected by AIDS, New York, NY: UNICEF, 2006. 53 Martin Schönteich, The coming crime wave? AIDS, orphans and crime in South Africa, Southern African Journal of HIV Medicine 3 (2002), 30–34. 54 Schönteich, A bleak outlook. 55 Mark Colvin, Cathy Connolly, and Lorna Madurai, The epidemiology of HIV in South African workplaces, AIDS 21(Supplement 3) (2007), S13–S19. 56 Ibid. 57 South African Police Service (SAPS), Annual report 2002/2003, Pretoria: South African Police Service, 2003; SAPS, Annual report 2003/2004, Pretoria: South African Police Service, 2004; SAPS, Annual report 2004/2005, Pretoria: South African Police Service, 2005; SAPS, Annual report 2005/2006, Pretoria: South African Police Service, 2006; SAPS, Annual report 2006/2007, Pretoria: South African Police Service, 2007; SAPS, Annual report 2007/2008, Pretoria: South African Police Service, 2008; SAPS, Annual report 2008/2009, Pretoria: South African Police Service, 2009; SAPS, Annual report 2009/2010, Pretoria: South African Police Service, 2010; SAPS, Annual report 2010/2011, Pretoria: South African Police Service, 2011; SAPS, Annual report 2011/2012, Pretoria: South African Police Service, 2012. 58 Ibid. 59 Ibid. 60 Sonder et al, Trends in HIV postexposure prophylaxis prescription and compliance. 61 Ibid. 62 SAPS, Annual report 2002/2003 to Annual report 2009/2010. 63 Malan, Household survey. 64 SAPS, Annual report 2002/2003. 65 SAPS, Annual report 2003/2004. 66 SAPS, Annual report 2004/2005. 67 SAPS, Annual report 2006/2007 to Annual report 2009/2010. 68 John M Violanti and Fred Aron, Police stressors: variations in perceptions among police personnel, Journal of Criminal Justice 23 (1995), 287–294. 69 Sonder et al, Trends in HIV postexposure prophylaxis prescription and compliance. 70 Pharoah, Not business as usual. 71 SAPS, Annual report 2002/2003 to Annual report 2011/2012. 72 Gavin George, Workplace ART programmes: why do companies invest in them and are they working?, African Journal of AIDS Research 5 (2006), 179–188. 73 Ibid. 14 African Security Review Institute for Security Studies Downloadedby[UNIVERSITYOFKWAZULU-NATAL]at03:1823April2014

74 Anil Bhagwanjee, Inge Petersen et al, Bridging the gap: can provider initiated opt-out VCT close the gap between VCT and HIV treatment uptake? Perspectives of VCT/HIV treatment service users in a mining sector workplace setting in South Africa, African Journal of AIDS Research 7 (2008), 271–279. 75 Colvin et al, The epidemiology of HIV in South African workplaces. 76 SAPS, Annual report 2002/2003 to Annual report 2011/2012. 77 Colvin et al, The epidemiology of HIV in South African workplaces. 78 Rob E Dorrington, Estimating the extent of the HIV/AIDS epidemic: some questions and answers on the ASSA2000 model, Law, Democracy and Development Journal 5 (2001), 129–136. 79 Colvin et al, The epidemiology of HIV in South African workplaces; Clive Evian, Matthew Fox, William MacLeod et al, Prevalence of HIV in workforces in southern Africa, 2000–2001, South African Medical Journal 94 (2004), 125–130. 80 Adriaan Pienaar, HIV/AIDS weighs on profits, fin24,,6778,1518-27 (retrieved 7 August 2013); Carel van Aardt, The demographic impact of HIV/AIDS on provinces and Living Standards Measure (LSM) groups in South Africa, 1996 to 2011, Stellenbosch: Bureau of Market Research, 2011; James Thurlow, Jeff Gow, and Gavin George, HIV/AIDS, growth and poverty in KwaZulu-Natal and South Africa: an integrated survey, demographic and economywide analysis, Journal of the International AIDS Society (2009), 12:18. 81 Pienaar, HIV/AIDS weighs on profits. 82 David Sanders, Ruth Stern, Patricia Struthers et al, What is needed for health promotion in Africa: band aid, live aid or real change? Critical Public Health 18 (2008), 509–519. 83 Ibid. 84 Shefer and Mankayi, (Hetero)Sex. 85 Ibid. 86 Kalichman et al, Randomised trial of a community-based alcohol-related HIV risk-reduction intervention. 87 These death statistics exclude fatalities that occurred during official police work. 88 Actuarial Society of South Africa (ASSA), 2008 ASSA Model, Cape Town: ASSA, 2011, http://aids.actuarialsociety. (accessed 7 August 2013). Features 15 Downloadedby[UNIVERSITYOFKWAZULU-NATAL]at03:1823April2014

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