Arts, Faculty of
Political Science, Department of
DSpace
UBCV
Lo, Dustin
Master of Arts - MA
University of British Columbia
Background: Different Sub-Saharan States, such as Botswana, Kenya and Malawi, use different policy approaches to mitigate AIDS epidemic, which generate different public receptions towards the government and HIV-prone key populations, aside from trends in HIV prevalence. This research explores factors which can affect people’s subscription to governments’ “scientific”, “evidence-based” paradigms, beyond traditional culture and state’s capacities in service deliveries, and into states’ discourses in their policy articulations and programming. Method: Theoretically guided by Schmidt’s (2008) Discursive Institutionalism and Gauvin’s (2014) “3i model”, an interpretive critical discourse analysis is conducted between Botswana, Kenya and Malawi, in light of their policy documents derived from national HIV Strategies. It takes a “medley” approach to compare state’s problem definition on AIDS, framing on significant ideas, and qualities of policies, particularly in regards to HIV-related interactions: behavioural change interventions and counseling. Studies of the cases of Botswana and Kenya are extended to empowerment and stigma mitigation towards key populations, with references to the legacies of states’ policy discourses, their Key Population Survey, and conceptualizations in “human rights”. Results In early 2010s, the majority of people in Botswana show willingness to comply to state’s behavioural advices and services on HIV, and increasingly, to seek for government’s support in personal matters. The rates are lower in both Kenya and Malawi, despite former’s relatively high adequacy and level of HIV-knowledge than the latter. The state of Botswana “universalizes” dis-courses towards a public health regime, which Malawi attempts but fails; Kenya “privatizes” the matter of health instead. Despite policy efforts to empower key populations in human rights means, stigma against them remain in both Botswana and Kenya, primarily perpetuated by the society (Botswana) or authorities (Kenya). Conclusion Discourses stimulating interactionally equitable interactions in national AIDS’ policy programming, aided by resource adequacy, are necessary to foster “scientific” behavioural change from traditional influences in sexual health, to establish state’s hegemony in national the public health regime. However, legal rights alone, stemmed from state’s attitudinal and policy changes, carries little direct effect to compel against everyday societal stigma against the sexually discriminated people.
“Let’s talk sex scientifically!”: Examining Sub-Saharan States’ Communication Strategies in Sexual Health from AIDS Programming in Relation to Their Political Leverage and Stigmas Against HIV’s Key Populations by DUSTIN LO A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF ARTS in THE FACULTY OF GRADUATE AND POSTDOCTORAL STUDIES (Political Science) THE UNIVERSITY OF BRITISH COLUMBIA (Vancouver) December 2022 © Dustin Lo, 2022 ii The following individuals certify that they have read, and recommend to the Faculty of Graduate and Postdoctoral Studies for acceptance, the thesis entitled: “Let’s talk sex scientifically!”: Examining Sub-Saharan States’ Communication Strate-gies in Sexual Health from AIDS Programming in Relation to Their Political Leverage and Stigmas Against HIV’s Key Populations submitted by Dustin Lo in partial fulfilment of the requirements for the degree of Master of Arts in Political Science Examining Committee: Yves Tiberghien, Professor, Political Science, UBC Supervisor Lisa Sundstrom, Associate Professor, Political Science, UBC Supervisory Committee Member iii Abstract Background Different Sub-Saharan States, such as Botswana, Kenya and Malawi, use different policy ap-proaches to mitigate AIDS epidemic, which generate different public receptions towards the gov-ernment and HIV-prone key populations, aside from trends in HIV prevalence. This research ex-plores factors which can affect people’s subscription to governments’ “scientific”, “evidence-based” paradigms, beyond traditional culture and state’s capacities in service deliveries, and into states’ discourses in their policy articulations and programming. Method Theoretically guided by Schmidt’s (2008) Discursive Institutionalism and Gauvin’s (2014) “3i model”, an interpretive critical discourse analysis is conducted between Botswana, Kenya and Malawi, in light of their policy documents derived from national HIV Strategies. It takes a “med-ley” approach to compare state’s problem definition on AIDS, framing on significant ideas, and qualities of policies, particularly in regards to HIV-related interactions: behavioural change inter-ventions and counselling. Studies of the cases of Botswana and Kenya are extended to empower-ment and stigma mitigation towards key populations, with references to the legacies of states’ policy discourses, their Key Population Survey, and conceptualizations in “human rights”. Results In early 2010s, the majority of people in Botswana show willingness to comply to state’s behav-ioural advices and services on HIV, and increasingly, to seek for government’s support in per-sonal matters. The rates are lower in both Kenya and Malawi, despite former’s relatively high adequacy and level of HIV-knowledge than the latter. The state of Botswana “universalizes” dis-courses towards a public health regime, which Malawi attempts but fails; Kenya “privatizes” the matter of health instead. Despite policy efforts to empower key populations in human rights means, stigma against them remain in both Botswana and Kenya, primarily perpetuated by the society (Botswana) or authorities (Kenya). Conclusion Discourses stimulating interactionally equitable interactions in national AIDS’ policy program-ming, aided by resource adequacy, are necessary to foster “scientific” behavioural change from traditional influences in sexual health, to establish state’s hegemony in national the public health regime. However, legal rights alone, stemmed from state’s attitudinal and policy changes, carries little direct effect to compel against everyday societal stigma against the sexually discriminated people. iv Lay Summary AIDS create opportunities for states to increase their social influential power over alternative so-cial authorities when societies look for answers to mitigate HIV’s impacts. Although states offer social goods, resources and treatment services on this, people’s compliance and reliance to state’s solutions vary: some do, but others turn to traditional authorities instead. I would explore how the way states “talk through” their HIV/AIDS-related ideas from their na-tional policies on HIV can generate such difference, and the implications to social stigmas im-posed against vulnerable groups of the disease. States’ policymaking in HIV consists of agendas to raise knowledge levels, facilitate interactions on sexual health, and promote clinical services. I aim to discover and compare Botswana, Kenya and Malawi’s balancing between the three components, that would generate different levels of collectivity towards the state-initiated “scientific” direction, and treatments towards the socially disadvantaged. v Preface This thesis is original, unpublished, independent work by the author, D. Lo. vi Table of Contents Abstract ......................................................................................................................................... iii Lay Summary ............................................................................................................................... iv Preface ............................................................................................................................................ v Table of Contents ......................................................................................................................... vi List of Tables ................................................................................................................................. ix List of Figures ................................................................................................................................ x Chapter 1 – Introduction .............................................................................................................. 1 1.1 Spreading the “Correct” Messages on AIDS as State-building............................................ 1 1.2 How much stake does a state have compared to social actors to moderate sexual health discourses? .................................................................................................................................. 2 1.3 Core Research Theme, Agenda, Questions and Hypotheses ................................................ 5 Chapter 2 – Literature Review .................................................................................................... 8 2.1 Common Explanations in States’ (In)competence and (In)equity in Implementing HIV/AIDS Policies ...................................................................................................................... 8 2.1.1 Rational Choice Explanation: Does Investing in PLWHA’s Welfare and Equity “Worth the Resource Effort” in State’s Perspective ............................................................................. 8 2.1.2 Sociological Institutionalist Explanation: Reflection, or Failure of Deflection, of Moral Panic............................................................................................................................ 10 2.2 Shortcomings from Rational Choice and Sociological Explanations: Overly Static Assumptions in Agents and Ideas.............................................................................................. 12 Chapter 3 – Theory Section ....................................................................................................... 14 3.1 Discursive Institutionalism (DI): Acquiring Political Power via Communication of Ideas 14 3.2 Ideas, Interests and Institutions in Public Health: Complimenting DI with Gauvin’s “3i” Framework ................................................................................................................................ 18 Chapter 4 – Research Methodology .......................................................................................... 20 4.1 Discourse Analysis Plus Mini Comparative Case Study ................................................... 20 vii 4.2 Data and Timeframe Selection .......................................................................................... 21 4.3 Country-Case Selection ...................................................................................................... 22 Chapter 5 – Analyses .................................................................................................................. 23 5.1 The Communicative Policy Agendas in HIV: “Behavioural Change Interventions” and “Counseling” ............................................................................................................................. 23 5.2 Observations From State’s Proposals in Behavioural Change (Communication/Intervention/Education) Strategies ................................................................ 25 5.2.1 Contexts: Communicating the Grounds behind AIDS’ Policy Programmes ............... 25 5.2.2 Contents and Quality of IEC Agendas ........................................................................ 26 5.2.3 Formulation of BCI Policy Approaches ...................................................................... 28 5.2.4 Patterns from Governments’ Behaviroual Change Policy Agendas When Separating I, E & C ..................................................................................................................................... 29 5.3 Observations from State’s proposals in HIV-Counselling ................................................. 29 5.3.1 Types, Orientations and Derived Linkages & Networks of Counselling Agendas ...... 29 5.3.2 The Articulations on “Consent” ................................................................................... 30 5.4 Discussion .......................................................................................................................... 32 5.4.1 Power in Ideas: Conceptual Qualities put forth by the Governments to Alter the Problem Definition ................................................................................................................ 33 5.4.2 Power through Ideas: Appealing for Expanded Public Interests from State-Modified Problem Definitions to the Public ......................................................................................... 35 5.4.3 Power over Ideas: Assigning Responsibilities and Networking Strategies from State-Modified Problem Definitions ............................................................................................... 37 Chapter 6 – Implications: Legacies from Policy Discourses ................................................... 40 6.1 Implications to States’ HIV Human Rights Policy Agendas: Universality to Access Versus Universality in Access ............................................................................................................... 40 6.2 The Divergence: Botswana ................................................................................................ 41 6.3 The Divergence: Kenya ....................................................................................................... 42 viii Chapter 7 – Research’s Applicability and Limitations ............................................................ 45 7.1 Applicability of This Research’s Approach: Discursive State Development ..................... 45 7.2 Limitations: Contextual Incomprehensiveness and Imprecision ....................................... 46 Chapter 8 – Conclusion .............................................................................................................. 48 8.1 Comprehensive, Open Communicative Policy Programmes and Resource Capacity Needed to Pursue the New Social Goods .................................................................................. 48 8.2 New Scholarly Value to Existing Literature ....................................................................... 50 Bibliography ................................................................................................................................ 51 Appendices ................................................................................................................................... 74 Appendix A: List of Tables ....................................................................................................... 74 Appendix B: List of Figures ...................................................................................................... 96 ix List of Tables Table 1 Fairclough’s Tri-layered Model of Critical Discourse Analysis .................................... 74 Table 2 List of Documents Examined ......................................................................................... 75 Table 3 Country Profiles: Botswana, Kenya, and Malawi .......................................................... 76 Table 4 States’ Remarks on National Condom Policy Directives from Prevention/BCC Strategies ....................................................................................................................................... 77 Table 5 All Ideational-Type “Informative”, “Educating”, “Communicating”, Policies Regarding Behavioral Changes from States’ Prevention/BCC Documents and National Strategies ............. 78 Table 6 All Interactive-Type “Informative”, “Educating”, “Communicating”, Policies Regarding Behavioral Changes from States’ Prevention/BCC Documents and National Strategies ............. 80 Table 7 All Referral-Type “Informative”, “Educating”, “Communicating”, Policies Regarding Behavioral Changes from States’ Prevention/BCC Documents and National Strategies ............. 82 Table 8 Categorization of State Governments’ HIV Pre/post-test Counselling Strategy Agendas....................................................................................................................................................... 83 Table 9 Discourses on the Agenda of “Consent” in State Governments’ HIV Pre/post-test Counselling Strategies .................................................................................................................. 85 Table 10 Country Indicators on National Socio-Political Changes between Mid-late 2000s to Early-mid 2010s: Adequacy (Category 1) .................................................................................... 87 Table 11 Country Indicators on National Socio-Political Changes between Mid-late 2000s to Early-mid 2010s: Bottom-up Trust and Reliance (Category 2) .................................................... 89 Table 12 Country Indicators on National Socio-Political Changes between Mid-late 2000s to Early-mid 2010s: HIV Knowledge, Misconceptions and Stigma (Category 3) ........................... 91 Table 13 Country Indicators on National Socio-Political Changes between Mid-late 2000s to Early-mid 2010s: Behavioral Compliance (Category 4) .............................................................. 93 Table 14 Indicators on Tolerance and Acceptability Regarding Key Populations ....................... 94 x List of Figures Figure 1 The Logic Behind State's (Discursive) Power-making in the Lens of DI ..................... 96 Figure 2 Summative Figure on Theoretical Concepts Addressed in This Research .................... 97 Figure 3 Summative Diagram on The Relationship between the Quality of Policy Programming and Outcomes in Social Stigma .................................................................................................... 98 1 Chapter 1 – Introduction 1.1 Spreading the “Correct” Messages on AIDS as State-building The AIDS epidemic has devastated states in the Sub-Saharan Africa (SSA) since the 1980s. The “social impacts” of AIDS, hampering human and social development within states, can be understood in twofold. First, the epidemic impedes socio-economic growth and national development. Mortality, child orphanage, labour absenteeism, child education, skyrocketed public health expenditures, etc. are all concerns of societies and states’ governments on the surface. Deep down, the epidemic exposes problems in norms, practices, and traditions in sex and health embedded in traditional social cultures and beliefs (Ghana AIDS Commission, 2005, p.9), as well as states’ incapacity in political and institutional collaborations (National AIDS Co-ordinating Agency, Republic of Botswana [NACA Botswana], 2003, p.9). To states, despite convergence with non-state actors on seeing AIDS as an epidemic problem, contradictions with them may arise when they have different understandings and reasonings to the causes, and solutions to “solve” (i.e. mitigate) AIDS epidemic. Notably, African societies, as in Kenya, Uganda, or Ghana, commonly regard men seeking medical help as “feminine” (USAID, n.d.), partners using condoms as signal of “distrust” (Barker & Ricardo, 2005, p.40), and people having HIV as a result of “witchcraft”, “satanic acts”, or “sins” (Tenkorang, 2011, pp.1009–1010; Roura, et. Al., 2009). Existing social beliefs perceive that HIV “can be cured by sleeping with a virgin, eating fresh vegetables, and making ancestral sacrifices” (Sano et. Al., 2016, p.2). These contradict with states’ vision to mitigate the epidemic through awareness campaigns and education (NACA Botswana, 2003, p.9; Uganda AIDS Commission, 2011, p. i). States must be able to challenge the “common senses” present in societies, and impose their visions of 2 interventions, i.e., paradigm and discourses through communications, to turn things around in its ideals, and leverage its powers in state’s human development regime. Second, Social impacts of epidemics of diseases are not confined to losses in human lives or economics. Healthy people in societies may stigmatize: to devalue people living with or associated with disease(s) (Ministry of Health, Republic of Kenya [MoH Kenya], 2014, Stigma Index, p.x) around the “infected” status, to isolate patients further through increased psychological costs on the “avoidable” infection(s). Penetrative to people’s everyday cognitive senses, stigmas bar people associated with the disease to socialize normally. In SSA, stigmas towards people/patients who live with AIDS (PLWHA hereafter) and “key populations” (i.e. populations especially vulnerable to HIV, e.g. sex workers, homosexuals, prisoners, etc. KP hereafter) often intertwine with broader struggles, such as sexuality, poverty, and gender non-conformity (Danil, 2020, p.388). The Ghanian society associates men who take an HIV test as “one (men) who has sex with men” (MSMs hereafter), which discourages them to accept HIV services (Kushwaha et. Al., 2017, p.9); gay HIV-positive male prisoners are reportedly tortured in prisons (Asylos and Asylum Research Centre Foundation, 2021, p.43). These societal stigmas obstruct citizens’ exercise of human rights. To states, these are testimonies for them in ensuring citizen’s right to health, qualitative coverage on effective healthcare services, and their own authority in the national human development regime. 1.2 How much stake does a state have compared to social actors to moderate sexual health discourses? Before AIDS’ peak at around 2000 (National AIDS Control Council of Kenya [NACC Kenya], 2009, pp.6–7), SSA state governments such as Botswana and Uganda had started formulated national AIDS Policy Strategies/Frameworks to tackle the impacts of AIDS 3 addressed above. They vow to unite all sectors across private, civil and public spheres to “take actions” against HIV epidemic (National AIDS Commission, Republic of Malawi [NAC Malawi], 2009, p.8) in the publications, by deliberating collective actions codes with policy programmes. They unanimously institutionalized this approach through signing the United Nations Declaration of Commitment on HIV and AIDS in 2001 (UNAIDS, 2001). Generally, the documents outline strategies towards 2 (or more) major thematic components: 1. Treatment, care and support: to “improve the quality of life of people infected and affected by AIDS” (NACC Kenya, 2005, p.i) (e.g. HIV Testing & Counselling (HTC), Clinical Care, individuals’ Nutrition Intake) 2. prevention: “decreasing high-risk behaviours which make particular groups vulnerable to HIV infection” (NACC Kenya, 2005, p.20) (Behavioural Change Interventions/ Communications (BCI/BCC hereafter), condom strategies, key population strategies) Within the timeframe stated in the Framework/Strategies, state’s Ministry of Health would then follow-up with tributary documents (e.g., see Table 2 in Appendix 1) which propose guidelines and state-initiated programme ideas for actors to coordinate and collaborate with the state. Collectively, these documents aspire to operationalize governments’ HIV policy directions to people of different degrees of vulnerability, to better governments’ “allocation of resources” (MoH Kenya, 2009, vii), address “structural factors” that “increase vulnerability” (NAC Malawi, 2009, p.8), and “better people’s productivity of life with positivity” (Ministry of health, Republic of Botswana [MoH Botswana], 2009, p.1). Ideally, the conveyance of policies shall make PLWHAs or HIV’s key populations receive “best possible” guidance and services, with support from HIV-negative people and clinical authorities (MoH Botswana, 2013, p.33, Ministry of Health, Republic of Malawi [MoH Malawi], 2016, p.1). 4 States’ policies on AIDS re-shuffle not only resource distribution, but also, ideas, responsibilities, and advices in actions to the general public and social actors. These may modify societal “common senses” on HIV and AIDS should they accept the new way to understand HIV and comply with the policies. Therefore, states potentially hold significant discursive power in facilitating cognitive and normative changes in societies, to penetrate their own ontologies (i.e. constitutions of what “is”) of subjects (i.e. HIV/AIDS) in the public realm for their visions in social development (e.g. Botswana’s Vision 2016/2036; Uganda’s Vision 2040; Kenya’s Vision 2030). Researchers have suggested factors which can affect states’ leverage compared to other societal actors’ in HIV’s agenda and normative settings, or i.e., in replacing (mis)conceptions with an “evidence-based” paradigm, and stigmas with “zero stigma” (NAC Malawi, 2009, p.15; MoH Kenya, 2014, p.ix) attitudes. Factors range from their experience in institutionalization (Akenraye, 2010, pp.89–90), capacity to distribute educative resources (Tenkorang, 2013, p.306), to power of local socio-religious influences (Ntata, 2007, p.573). Human rights organizations (i.e. Human Rights Watch) however have criticized national AIDS policy directions of selected states, namely Zimbabwe or Uganda, as repressive to sexual minorities, in spite of their “weak” resource capacities. Their apparent success to lower HIV prevalence rate through resource distribution is marred by the policy approach to “criminalize” HIV transmission, executed through policies which violate patients’ privacy and potentials of arbitrary enforcement (e.g. the criminalization of “attempted transmission”) (Human Rights Watch, 2014). They show that states may have independent power to sway public courses of actions to people and normative outcomes related to the theme of epidemic, regardless of societal forces. This perhaps foreshadows the importance to study states’ communicative approaches to articulate, legitimize 5 and form coalitions to support (the stances of) their policy ideas: vital to society, PLWHA & KP’s well-being, yet understudied. Specifically, how do states attempt to “win” the authority to facilitate discourses and moderate communications related to HIV/AIDS from the society? What in their policymaking can determine their success in bolstering their influential power, particularly in enabling (long-lasting) behavioral and attitude changes beyond “awareness”? For the “capable” states, how can their deliberations in “human rights” policies and profiling towards the “key populations” in policy documents perpetuate or mitigate stigmas against key populations? Ultimately, considering the local context simultaneously, why would “capable” states hold different levels of will to eradicate the stigmas? 1.3 Core Research Theme, Agenda, Questions and Hypotheses Therefore, this research intends to explore the 3-way relationship between state governments’ institutionalizing approach to cultivate and reorient communications on HIV/AIDS, their influential power, and the perpetuation of social stigmas. It aims to provide a new understanding in how states leverage their power of authority through penetrating its normative influences with policy articulations. To explore the relationship, I will perform a two-part comparative discourse study in states’ (differences in) approaches in national HIV/AIDS policies, that aim to 1. reform national HIV-related communications, in light of HIV “treatment” and “prevention”, and 2. lay foundations to renew “human rights” regime under the context of HIV epidemic. In specific, it aims to, via analyzing the discourses related to HIV’s “behavioural change interventions” and “counselling”, and the associations of “key populations” portrayed within Botswana, Kenya, and Malawi’s national HIV/AIDS policy documents: 6 1. Dissect the state-cultivated policy contexts in the policy sets which address the need to reform HIV-related ideations; 2. Identify patterns and quality of states’ distributions of social responsibilities to reform sexual-health-related human interactions, and relate them to state’s discursive power; and 3. Briefly explore states’ approach to contextualize key populations (in light of HIV) to the quality in “human rights” policies drawn on them; add insights to its implications on social stigma. In this light, the 2-part main research question of the paper is: 1. How do SSA states enhance their discursive power (i.e. social-level ubiquity) through communicating AIDS policy programmes? Why do their powers vary? 2. Extendedly, How do the conceptualization and “empowerment/human rights” policy programming targeting Key Populations from states affect patterns of societal stigma against them? The 2-Part Statement of Argument, in response to the research question, is: 1. The discursive potentials (i.e. potentials in modifying socio-cultural norms and pratices) from a paradigm shift to associate “science” in sexual health, caused by national AIDS policy programming under AIDS epidemic, can upset the normative authority of non-state actors for state’s leverage. The programmes’ comprehensiveness to facilitate interpersonal-level changes in HIV/sex-related communications, accompanied by adqruate public health resources in 2000s, determine state’s influential power in society in 2010s. 7 2. State’s tendency to envision “equity” as “equity in treatment”, rather than “access”, can help mitigating stigma targeting KPs. The difference reflects a qualitative difference in HIV programming’s’ profiling effects, which may alter commitment to protect minority rights. This research will commence with a literature review that encapsulates rationalist and sociologist explanations in addressing states’ hardships to “care” for PLWHAs and the perpetuated societal discriminations towards KPs. The subsequent theory section will lay this research’s analytical foundations in state’s discursive power and effects to intervene societal HIV communications, by critically introducing Schmidt’s (2008) discursive institutionalism (DI) with references to Gauvin’s (2014) “3i” model in public health. The Methodology section which comes after will address indicators corresponding to the hypotheses, and the justifications of the research design and cases. The research will then reach the Core Analyses to respond to the research question with cases of Botswana, Kenya and Malawi (Part A only), before closing with implications in state’s future trajectories in policymaking regarding morality and minority rights. 8 Chapter 2 – Literature Review 2.1 Common Explanations in States’ (In)competence and (In)equity in Implementing HIV/AIDS Policies Scholars from various disciplines, ranging from political science, psychology, sociology, and public policy, have contributed, or demonstrated states’ constraints to commit to de facto universal AIDS healthcare, and reasons behind the persistence of HIV/AIDS-related stigmas towards KPs and PLWHA. Perceivably, their focuses can be incapsulated in two theoretical lenses, of 1. Rational Choice, or 2. Sociological Institutionalism. While stigma itself is a dire issue to KPs, it also reflects states’ incompetence in resource appropriations (rational choice) or deliberations in curating norms (sociological institutionalist), when putting forth their proposed policy agendas. Their lines of arguments and shortcomings will be unfolded in the paragraphs below. 2.1.1 Rational Choice Explanation: Does Investing in PLWHA’s Welfare and Equity “Worth the Resource Effort” in State’s Perspective Rational choice (RC hereafter) theory assumes states exist and function to appropriate utilities to maximize and accommodate (the equilibrium of) individual interests (Rakner, 1996, p.4). They are supposed to respond to external impacts that destabilize the societies (i.e. “uncertainties”) and the market, by appropriating (human) resources and facilitating coalitions for new collective actions. Their stabilizing interventions are institutionalized when states have enough authority to consolidate them into practices and turn them “sticky” through time. In the case of AIDS endemic, states elaborate on their proposals to mitigate its spread via Policy Frameworks, to react to derived socio-economic instabilities from the endemic. The policy initiatives elaborated in the tributary documents then carry promises to appropriate resources and 9 cliental support to reduce long-term public health resource burdens (treatment), reduce risk factors for future burdens (prevention), so as to maintain goodwill and functioning of societies. However, states may be too poor to implement policies beyond basic treatment and clinical care. In expanding beyond the basics of healthcare services (i.e. basic treatment), states put their “fiscal space”: “the budgetary space available to allocate public resources to a specific objective, without damaging other developmental objectives” into account (Remme, et. Al., 2016, p.67). As in Malawi (p.71), the expenditures to run facilities which deliver basic ART treatments or other significant epidemics may exhaust the already limited national resources and health infrastructure. For instance, having only 3 licensed psychiatrists in Malawi’s entire public health system (in 2010) (Kavita, 2020, p.16) poses obvious challenge for Malawi to expand counselling programmes that support PLWHA and families, let alone to commit to policies in changing sexual-behavioural norms. As the resource deficiency undermines peripheral support, drives up prices and scarcity (hence, opportunity cost) for basic care (e.g. Malawi, Ntata, 2007), it disincentivizes everyday people to commit to government programmes and causes inconvinence to PLWHA’s daily lives. This perpetuates stigma against PLWHAs, as their signs of “illnesses” (e.g. frequent travels to clinics, medicine, etc.) look apparent. On the other hand, states and societies may not see sufficient incentives (Schmidt, 2008, p.12) to advocate for social changes beyond disease mitigation itself, and may use policies to signal their lack of commitment. States may deprioritize well-being needs of the KPs to “give way” to allocating resources to tackle existential threats from HIV/AIDS and other epidemics. Regarding Botswana and Ghana, Gore (2021) and Laar and DeBruin (2017) share similar insights in how states’ act to recognize “key/vulnerable populations” can be a risk-adverse strategy to reduce pressing needs to allocate actual commitment (Gore, p.342) to the vulnerable 10 people. Looking into the case of Kenya, Johnson (2007) notions that education on HIV, allocation of services, etc. are all by de facto functional instruments to constrain non-hetero-monogamous sexual behaviours to save potential costs from treating new HIV cases (pp. 64–65), coincided with the “sexually-deviant” populations identified (p.48). Furthermore, as in Ghana, the low social demand in instruments towards behavioural change (e.g. condoms), driven by social sentiments such as them “taking away sexual pleasure” (Ananga, et. Al., 2017, p.6), may disincentivize states from supplying them (Reproductive Health Supplies Coalition, 2013). Not only it disrupts state’s plans to run its strategies, it also perpetuates traditional gendered (mis)conceptions and discrimination. 2.1.2 Sociological Institutionalist Explanation: Reflection, or Failure of Deflection, of Moral Panic Sociological institutionalism (SoI hereafter) posits states as facilitators and upholders of cultural norms, who appropriate and sustain (non)material interests (e.g. morality) and hence, the functioning of society (Schmidt, 2008, pp.12–13). Theoretically, states as social actors are expected to make use of its unique institutions to mediate individuals (back) to a normatively “acceptable” state, as in gender, family values, and economic productivity, to uphold social functioning (Schmidt, 2008, p.14). In light of AIDS epidemic, distinct policy areas derived from states’ Strategic Framework are drawn in response to different aspects of social morality, presumably threatened by the emergence, development and/or perpetuation of the disease. Societal “barriers” towards a stigma-free social environment and compliance to state-proposed behavioural changes may arise, when states' execution towards the proposed policies interacts with deep-seated socio-cultural values or moral panic. 11 Particularly, SSA states are inclined to conform to local normative moral expectations in sexual “acceptability” and “natural orders” in gender throughout the policymaking progress. The expectations are ubiquitously constructed by a powerful societal influence, which consists of legacies of pre-colonial traditions & religions, colonial sodomy laws, and (post-colonial) institutionalized Abrahamic religions (Atuguba, 2019, pp.113, 114; Asante, 2020, p.29). Indicated by Oti-Boadi and Dziwornu’s (2014) survey on the “acceptability of homosexuality” among Ghanaian university students, states are presented with strong norms in “motherhood” and “manhood” and dichotomies between “me/acceptable versus other/unacceptable” behavioural acts. These sway state(speople) to hold back from progressive policy initiatives with their presumed unpopularity. In the case of introducing condoms to reduce HIV/AIDS risk, Muula (2006) observes that Malawian policymakers condition themselves to sexual-religious norms in abstinence during parliamentary discussions on it (pp.23–24), which may explain the low supply and condom use rate in the country (Jimu et. Al., 2022, pp. 5–6). Kushwaha et. Al., (2017) also record that in Ghana, Healthcare providers who counsel PLWHAs cast prejudicial judgements on their “risky” behaviours prior to HIV (pp.8–9). Police’s harassments and forceful compulsion of sex workers to HIV testing in Ghana laterally reflect and fortify the “whore-phobic” sentiment that sex workers, and extendedly, sexually-marginalized PLWHAs, are “cursed, sexually dangerous, ‘immoral’, and helpless victims.” (Global Network of Sex Work Projects, 2015, p.2). In sum, the societal moral authority in sexual order meddles the operations and effectiveness of state’s policy agendas and may perpetuate stigmas under moral panic. 12 2.2 Shortcomings from Rational Choice and Sociological Explanations: Overly Static Assumptions in Agents and Ideas Both streams of thoughts assume states as rational, independent yet static “administrators” which include and exclude policy actors and interests (Skocpol, 1985, p.14), and institutions as given structures that constrain sequence of interactions and reduce uncertainties to everyday politics (North, 1990, p.3). Specifically, states serve as the end of the social system to satisfy and arbitrate resource (RC) and normative (SoI) needs from the society. All policy actors are presumed linearly “rational” who communicate social ‘interests’ and ‘(social)goodness’ based on (sets of) common-sensical “social facts” (Crossman, 2019), of which the “facts” drive policy practices and principles forward. Progressive policy changes can come from external shocks (e.g. international conventions, economic crises, etc.) which pressure and challenge the “facts”, while the inelasticity of the local social “facts” like poor economic capacity or society’s gendered values may hold states back. Discourses read from the policy documents “objectively” reflect pre-existing social interests in written form. However, both streams of thought take “social facts” as granted, and overlook the flexibility of discourses and the backstage process that form and consolidate them: communications. After all, “social facts” are selected and appropriated before becoming common sense through people’s cognitive acts, of symbolic use (i.e. textual/verbal communications) or practices (i.e. behavioural communications). Viewing via this lens, State governments as actor(s) do not only “arbitrate” social interests. Via the unique power to formulate and execute national policies, they are empowered to set new standards in what counts as “rational”, “correct” or “acceptable” reaction to a social concern like HIV/AIDS. Operationalizable discourses, as “the interactive processes of conveying ideas”, (Schmidt, 2008, p.1), implied in policy documents, 13 can leave implications for future trajectories in policy progression, and derived from it, how states aspire their social actors behave and align with state’s mindset. This lens helps fulfilling the gap to explain how policy progressions can happen endogenously without major external shocks to the subject. Neither RI nor SoI can help examining states’ self-determining power for its leverage as demonstrated, as RI treats governments’ policy discourses as instrumental, while SoI primarily investigates policy practices, agents and societal influences only. 14 Chapter 3 – Theory Section 3.1 Discursive Institutionalism (DI): Acquiring Political Power via Communication of Ideas Interpretivist scholars who study (political) communications, such as discursive institutionalists (DI hereafter) like Bacchi and Ronnblom (2014), Coulas (2021) and Schmidt (2008), instead perceive “institutions” as fluid human constructs that skew human interactions hence socio-political coalitions on a subject, rather than discreetly independent and reactive structures. Exchange of ideas is centered as basis of institutional development, when state and social actors deliberate thoughts on, interact with, and practice arrangements under a set local power dynamic. Coulas (2021) would further regard written policy themselves as constitutions of “state institutions”, as they represent state’s growing definitions towards a politicized subject and the gauging/meddling of political interests from it (p.5). Based on this premise, despite policy agendas on HIV/AIDS may look similar across states, they diverge not (just) in execution, but also on the subjective ideas which drive them behind and the subsequent path dependence/long-term policy implications. In the following paragraphs, I will elaborate more on how DI can provide a guiding path to explore the institutionalizing potentials of state-led HIV/AIDS policies from the ideas embedded in them. Systematized by Vivien Schmidt (2008), DI is designed to address how states as policy initiators leverage their power from politicized subjects through manipulating ideas, acts or practices of persuasion, and control over policy communications (or in Schmidt’s terms, power “in”, “through” and “over” ideas respectively). Particularly, states as policy actors can generate unique 1. Interpretations and ideas to policy subjects, and 2. Discourses: patterns of idea-related interactions and practices (Bacchi and Ronnblom, 2014, p.174). A state here is theoretically 15 recognized as a human construction that has an own unique “voice” towards politicized subjects, who interact with, rather than passively accept, the social reality and inputs which social actors relay through. In this lens, policy formulation is itself a power-making process, that empowers states with new channels to impose their versions of social ideas, reform coalitions, and penetrate their influences through and to everyday social practices. States do get power in the form of institutional authority, when their policy discourses condition people to align with state’s aspects of salience on a subject matter, agreeing with its standpoints or not. The indicator is that whether they become ingrained to talk and perform in accordance to so, as members of “discourse communities” (Wahlström and Sundberg, 2018, p.167). To DI, States’ “ideational interests” and power-making originate from imposing powerful impacts within (i.e. to permeate or penetrate), rather than to, the society (i.e. to make one-time signals or explicitly compel), via symbols and practices which signify its ideas. Mitchell’s (1991) “state effects” analogy runs close to explain states’ “interests” under DI. As they hold leverage from other socio-political actors with their exclusive agents (e.g. state apparatuses, state-owned enterprises, etc.) and constructs (e.g. laws, policies, borders, legal documents/services, etc.), states can permeate their influences and by embedding ideas in the exclusives (Mitchell, pp.93–94). Each policy or law formulated encodes a thought or action that produces the inescapable societal effects assigned to a given audience of concern, that they are mediated (not) to perform in certain ways. Cumulatively, they turn more abstract concepts generated from human interactions into practice in ways that help states to “superimpose” social behaviours in more aspects of lives (Mitchell, pp.92, 94). Ultimately, states’ conceptualizations would become stickier and more legitimate in future, as everyday communications and discourses on political subjects must pass through (social) goods which states offer (e.g. as for HIV epidemic, publicly- 16 distributed condoms, sex education, or HIV testing facilities/procedures etc.) to be made sense. Compared to rationalist theories, states’ (governments) role is much more animate and interventive. Phenomena or happenings in societies are not themselves “political”; they become thinkable in a political way via human communications. The political power-making mechanism begins with an authority’s construction of subjective ideations. The goal for the power-maker is to reorient actors’ cognitive focuses on the subject, and constructs common patterns on how actors exchange ideas (Wahlström and Sundberg, 2018, p.167) in line with it. Assuming the power-maker is the state and the subject is AIDS, discursive institutionalization would unfold and proceed as follows. First, constructing ideations: a state cognitively sensitizes what AIDS is, and the relationship between itself, the society and the disease, in a self-determined “rational” system of reasons for founding “strong” interests later (Schimidt, 2008, p.16). These constructions of meaning make “the epidemic of AIDS” thinkable in a political sense, and establish state’s “belief system” on it, or, the “power of ideation” (Caestensen and Schmidt, 2015, p.321). This, when combined with states’ inherent authority, can be made authoritative (or, power “in” ideas in Schmidt’s terminology) (Carstensen & Schmidt, p.323). A Policy Response would come across state’s mind by this point, which addresses its reasonings in the necessity of a national, state-led response. Second, Formulating (policy) ideas: After making sense of AIDS politically, the state creates “ideas”: “policies, programs, and philosophies—and types of content—cognitive and normative” (Schmidt, 2008, p.2), that convert and operationalize the ideations to proposals of 17 actions. Written policy agendas as in the official Strategies and the tributary documents lay out the deliberations of the ideas. Though ideas constitute power, “it does not stop here” (Schmidt, 2008, p.16). Having ideas alone cannot compel others to agree upon one’s own (subjective) ideations, owing to differences in “degree of goodness” in an idea (Schmidt, 2008, p.15) from actors’ positionalities and perceived “realities”. This is fundamentally different from RC and SoI that social beliefs are common-sensical and fixed before policymaking. Therefore, the power-making process continues, with: Third, articulating discourses: A state then attempts to integrate ideas into policy programmes. The bundling of ideas is to impose one’s principles to others as the agreeable “common sense” for a (new) cognitive order. Consistent practices of the integrative policies (e.g. counselling services, education campaigns, condom advocacies) would effectively (propose to) (re)form subtle systems of relations between objects, groups and so forth (Rasiński, 2011, pp.17, 18) surrounding the subject. These ideally would bolster states’ power “through” ideas: capacity to induce other actors to equip with the same “appropriate” cognition at its discretion (Carstensen & Schmidt, 2015, p.324), and pave way for institutionalization to happen. Fourth, permeating control in social-level communications: extended from above, the successful mediation of social members to perform the policies would systematize ideas to a system of “the common sense”. This “mainstreaming” effect would facilitate a renewed culture that involves societal attitude and interactional changes regarding HIV. With the agreement of state’s ideas solidified as the “common cognition”, state is now acquiring more paradigmatic power to unite social actors and members under its imposed normative influences to aspects of everyday lives related to HIV (e.g. sexual ethics, dynamics of clinical care, gender relations, etc.) 18 which are hard to resist (i.e. power “over” ideas, Carstensen & Schmidt, 2015, p.326). This completes the theoretical cycle of DI, which may restart when new ideas come along. Figure 1 in Appendix 2 demonstrates the above logical flow. 3.2 Ideas, Interests and Institutions in Public Health: Complimenting DI with Gauvin’s “3i” Framework State governments aspire cooperation from social actors who would not automatically be persuaded and aligned with states’ policy ideas in public health issues. To wield cooperation, points of convergence must be drawn to signal actors that state conducts the policymaking for the social good. Gauvin’s (2014) “3i” model presents a sound model in how state and social actors with distinct sets of ideational assumptions are motivated to engage in the policy development process in sync. He posits “problem definition” as the starting point to construct a policy (p.1), when social actors have come up with roughly a common agreement that an existing crisis shall warrant actions to be taken (McGill, n.d.). From that point, a 3-way influence serves as the main directional drive towards the policy formulation: values from conventions and norms (ideas), positionality, economic and political leverages perceived from different actors (interests), and patterns of networks/connections, relationships, or hierarchy between or within actors (institutions). With deliberate evaluations in costs and benefits under the influence, policy options would be developed from thoughts (i.e. problem definition), and eventually be narrowed down to affirmative policy decisions and actions. The “3i model” can complement a discursive-institutional analysis in state’s power leverages from establishing policy discourses over AIDS-related sexual health subjects, as it helps yielding insights in how state and actors get their interests converged. It is compatible with DI’s view that discursive changes form new equilibriums of interests, as “problem definitions” 19 involve articulations of perceptions. Also, “interests” in 3i need not to be static material pursuits; contextually-bounded points of constructs that “make (the most) sense” (e.g. sexual ethics under the prevalence of STDs) may also stand. State’s power is leveraged when it acquires authority to control the points, that social actors are compelled to interact on HIV with references to state’s. The 3”i”s then can signal the end points of what each type of ideational power achieves. Particularly, “interests” denotes the end point to power through ideas: state’s capability to foster agreements and mobilize collective actions from ideas. “Ideas” serves as the end point to power in ideas: state’s ability to manipulate and capitalize on social (normative) ideas to its advantage. “Institutions” signals the end point to power over ideas: state’s authority to keep its status quo as leader of the normative coalition on HIV mitigation. Moreover, the versatility of what constitutes as “ideas” and “interests” from this model implies the fluid and intersubjective nature of “problem definitions” (and hence policies themselves). The fact that Gauvin’s (2014) model does not fixate on a variable to explain potential prevalence of certain components of ideas and interests leaves researchers room to compare discursive variations and outcomes of policy coalitions (i.e. institution) between states. Therefore, complementing the DI theory with the “3i” model can yield good references on state’s political objectives from changing discourses, and to evaluate their successes on it. The exact theoretical relationship between 3is and DI’s powers is illustrated in Figure 2 in Appendix 2 (on p.97). 20 Chapter 4 – Research Methodology 4.1 Discourse Analysis Plus Mini Comparative Case Study This research will examine and compare the discursive practices from Botswana, Malawi and Kenyan state governments, regarding policy areas of 1. behavioural change interventions (BCI), 2. counselling (mostly from the “HIV Testing & Counselling model”) (Part A), and 3. human rights (Part B, Kenya and Botswana only), written in their national-level HIV-related policy documents. For each category, states’ perceived policy contexts will first be laid out and compared, followed by critically-interpretive descriptions to their policy approaches in accordance to the self-defined contexts, and lastly, same to the nature of their specific policy agendas. The subsequent analytical section will examine the comprehensive qualities and effectiveness of states’ cultivation of new “scientific” paradigms (Part A) and human rights regimes (Part B), factoring in states’ material support in addition. These are key to their relative power leverage against local actors (Part A) and stigmas which key populations suffer (Part B). Malawi is dropped from Part B as the government has not conducted a nationwide “Key Population Behavioral Survey”. Part A’s approach is a loose reference to Fairclough’s tri-layered model (applied in Tambunan et. Al., 2018, and Qiao and Ma, 2019’s works) of critical discourse analysis, to reveal how “states gauge policy texts in a certain way to use to assert power within a socio-political context” (Snowden & Karlsson, 2021, p.4). It may help capturing the mechanism behind the necessities for the success of a state-initiated paradigm shift: there is: a) a compelling mediating force to change cognitive thinking on a subject (sexual health) that b) appeals to social members, with c) realistic support to new practices in the (AIDS) situation, to change social conditions to its leverage. Perceivably, the critical-interpretive descriptions focus on the meso-level of matters, 21 while the analytical section connects with the macro level. Please refer to Table 1 for the full model. Part B will come in a form of mini case study, as partly an extension to some conceptualizations from Part A’s analytical section. Tables 10, 11, 12 and 13 lays out 4 categories of indicators which “states’ leverage” (dependent variable for Part A) will be incapsulated by: 1. state’s presence and its public appeal; 2. citizens’ trust and reliance to states; 3. HIV literacy and attitudes; 4. compliance to States’ HIV Paradigm. Table 14 lays out the indicators of stigmas: difficulty for key populations to interact with social members or agents and the healthcare system” (dependent variable for Part B). 4.2 Data and Timeframe Selection This discourse analysis will compare discourses from their communication-type policies: “counselling”, “behavioural change interventions (BCI)” for Part A, and “(key populations’) human rights” policies for part B. It will examine them from a series of Strategic Plans and their tributary, “applicational” documents between the 3 (part A) or 2 (part B) states. Part A will feature reads from Strategic Framework, HIV-Prevention/BCI Strategy, and HIV Testing & Counselling Guidelines (Pediatric Guidelines for Malawi, since an “adult version” published in late-2000s is not found), while Part B will focus on documents regarding Key Populations and Human Rights Policies (full list see Table 2). The timeframe of Part A’s documents will be 2003 to 2009, after SSA states’ consensus to regularly produce Strategic Frameworks in 2001, with the data indicating “states’ leverage” mostly extracted between 2010 to 2015. This time gap is deliberated because it takes time for the 22 policy effects to ferment, and for the paradigms to mature if they work. Yet, data beyond 2015 are not selected for Part A’s outcomes due to the necessity to accommodate Part B, as “human rights” is a tributary concern (relative to survival) which comes after a decline in prevalence. Hence, the documents’ timeframe for Part B centers around 2012 to 2014, with the effects noted in Table 14 extracted mostly in the late 2010s. 4.3 Country-Case Selection Botswana, Kenya, and Malawi are selected for the analyses, owing to their gross similarities in historical, religious, and cultural influences to sexual ethics, AIDS impacts, and public perception towards public health by mid-2000s. All once British colonies, they have carried the legacy of “sodomy law” from the colonial state. All states feature a majority Christian population (Pew Research Centre, 2016a), which would initially see condoms as alien to the sexual morality (Bartelink, 2021, pp.190–191; Motswapong, 2021, p.233). Polygyny is also a common phenomenon for all. By mid 2000s, all states still recorded an HIV prevalence rate of over 6% (UNAIDS, 2007, p.9), and experienced decreases in life expectancy in 1995 (see Table 3). Bratton’s (2007) survey suggests that people in the countries have similar levels of access to health services (~30%) and support towards governments’ AIDS-mitigating spending (~35-40%) (pp.11, 16). Other relevant comparative details are laid out in Table 3 in Appendix 1. Uganda and Zimbabwe, frequently cited as “successful” examples in mitigating AIDS (UNAIDS, 2011; Genuis and Genuis, 2005), and many other SSA anocracies/dictatorships, are opted out from this research for their authoritarian rulership, which may undermine DI’s theoretical analyses as DI assumes a flexible dual-way (government–society) interactive structure. Ghana was initially shortlisted as a case, but was opted out due to its low HIV prevalence rate. The Analytical Section will now begin. 23 Chapter 5 – Analyses 5.1 The Communicative Policy Agendas in HIV: “Behavioural Change Interventions” and “Counseling” The policy agendas of Counseling and BCI serve as states’ approaches to stimulate HIV-related interpersonal dialogues from top-down and between social members. Whereas BCI fea-tures “a range of communication programmes to change sexual behaviour” (National AIDS and STI Control Programme [NASCOP], 2014b, p.35), HIV counselling, often bundled with HIV testing, is defined as “a confidential dialogue between a client(s) or patient(s) and a service pro-vider aimed at enabling the client or patient to make informed decisions about HIV testing … and, make personal decisions related to HIV” (MoH Botswana, 2009, p.25). In governments’ vi-sion, they generally play complimentary roles to complete treatment services for HIV-testers/ PLWHAs (counselling) or prevention advices for everyday people (BCI), to raise awareness, lit-eracy and debunk misconceptions for an “enabling” social environment on HIV (NACA Bot-swana, 2006, pp.4–5). They help penetrating HIV-related scientific knowledge in different set-tings: clinical and healthcare for counselling, and school, media, and community for BCI. Sub-jects of counselling typically include “fact/evidence-based” (NACC Kenya, 2005, p.44) HIV knowledge, testing procedures, result disclosure; subjects of BCI commonly consist of life skills (oriented towards female youth), (interactions towards) safe sex, etc. All countries prioritize counselling towards (pregnant) women, caregivers and PLWHAs in their HIV Testing documents. From all the suggestions in states’ HIV-test counselling proce-dures, they all call for obtaining consent, promote benefits of HIV testing, and advocate for cli-ents’ referrals and risk-reduction plans (see Table 8). These facilitate governments’ cultivation of a “scientific language” on HIV, which introduces new scientific concepts and symbols (e.g. 24 drugs and biological reactions), codes for calculated actions, and all-weather support network(s). HIV-testing services, under the guidelines of Ministry of Health, provisionally serve as institu-tional “enablers” of superstition-free STI-free healthcare, to foster “scientific” conversations on and off healthcare facilities. All states would also introduce the “3C model”: confidentiality, con-sent, and counselling (NASCOP, 2008, p.v; MoH Botswana, 2009, p.12; MoH Malawi, 2007, pp.3–4), as a warranted qualitative step-up compared to the “traditional” old communication models. The two most prominent programmes common among states regarding BCI are the “in-formation, education, and communication” (IEC) and “behavioural change communication” (BCC) schemes. For IEC, they broadcast HIV knowledge and messages to raise literacy towards “HIV” as a proper, mitigatable disease. They discursively intervene in the existing sexual orders based off “social traditions/norms” by promoting the reduction of sex partners, advocating con-doms and HIV testing before sex (see Tables 5, 6 and 7), for a “safer” code of sexual ethics. Pub-licly available condoms and HIV testing services would serve as media to facilitate this code. For BCC, to foster new communication patterns to sustain the code, all countries’ BCI frameworks feature “empowering” life skills programmes (NACC Kenya, 2009, p.57) oriented to school girls’ independence and abstinence. These programmes, enacted by the institutions of public edu-cation and media, strive to empower women and mediate men to cognitively reform themselves from pre-existing societal notions, which are portrayed to contain many misconceptions, gender inequality, and taboos, through skillful deliberations and a “correct” understanding of HIV. These lay the foundation to cultivate a stigma-free social environment to communicate on AIDS-related subjects. 25 All states suggest to “mainstream” HIV messages and services, and create an “enabling” environment for an AIDS-mitigating sexual-health culture, with an “evidence-based” approach. Despite so, the potentials for them to reform societal sentiments on sexual ethics via policy artic-ulations vary. The qualitative differences in the scopes and visions, comprehensiveness, and ubiquity of the policy strategies affect their effectiveness to stamp discursive authority to medi-ate social members off pre-existing norms surrounding sex and health in local communities. Adopting discourse analysis, state’s efforts to a-moralize and mobilize upon their HIV-sexual discourses will be elaborated below. 5.2 Observations From State’s Proposals in Behavioural Change (Communication/Intervention/Education) Strategies 5.2.1 Contexts: Communicating the Grounds behind AIDS’ Policy Programmes While all three state governments all identify “cultural practices” as a hindrance to HIV mitigation, owing to unsafe sexual transactions (NAC Malawi, 2009, p.20; NACA Botswana, 2006, p.9; NACC Kenya, 2009, p.31), their pinpoint of it in relation to deeper social structures differ. For instance, in Factors facilitating HIV transmission in Malawi, NAC Malawi (2009) considers “harmful cultural practices” as an “other” determinant, alongside with “transactional sex” and “gender inequalities” (p.20). Quality wise, consider the following: “Some women and girls indulge in transactional sex thereby being exposed to HIV infec-tion.” (NAC Malawi, 2009, p.20) “Still in some areas girls are given as bulageti la mfumu to a visiting chief.” (NAC Ma-lawi, 2009, p.20) While themes which describe the troubles exist, sentiments reflected here suggest that harmful phenomena are scattered, that problems are contained inside the phenomena listed. 26 Meanwhile, Kenyan and Tswana governments intersect the “wrongs” to the current social (Botswana) or economic (Kenya) context. Regarding condoms and cultural issues, they have noted the following: “Most believe that sexual intercourse is required as a proof of love or cultural identity, modernity … making everyone more vulnerable to infection.” (NACA Botswana, 2006, pp.9–10) “About 22% males and 31% females persist in unprotected sex with non-regular part-ners … 12% males and 25% females continue to report more than one partner.” (NACA Bot-swana, 2006, p.13) “Material gain, sexual gratification, and recognition from peers override concern for STI/HIV risk. Women's ability to negotiate condom use is compromised by age and economic disparity.” (NACC Kenya, 2009, p.24). Here, NACC Kenya (2009) causalises economic poverty to the perpetuation of societal norms, that in turn affects behaviours particularly of people (especially women) of “low status”. (pp.30–31). Botswana would notion that “modern” tabooed yet status-quo-showing culture in sex is “at the heart of the HIV epidemic” (MoH Botswana, 2006, p.9). Overall, they intend to com-municate the issue salience that everyone living under the national society is vulnerable and re-sponsible to act critically to mitigate AIDS, by tracing back the roots of issues, societally and/or individually. 5.2.2 Contents and Quality of IEC Agendas States are encouraged by the World Health Organization to “foster positive interpersonal communications for populations to evaluate and change their sexual behaviours” (World Health Organization, 2000, pp.1–2) with “information, education and communication” (IEC) 27 programmes. As in state’s specific understandings in the deep-rootedness of cultural connections to AIDS, they apply and position IEC distinctively. In spite of aiming at a fixed audience (the general public), the qualitative differences are reflected in the meaning of “IEC” in their Preven-tion Strategies. Below are snapshots of the positioning of IEC in Malawi and Kenya: “Condom distribution programme … will be expanded to cover all provinces, supported by an IEC strategy targeting vulnerable groups.” (NACC Kenya, 2005, p.21) “Produce IEC materials targeting men and community leaders on PMTCT … addressing issues of culture, gender-based violence, stigma and discrimination.” (NAC Malawi, 2009, pp.31, 36). In short, Kenya sees IEC as complimentary to addresses gaps on information; Malawi of-ten refer IEC as piles of distributable “materials” which cover topics of concerns. Although Bot-swana initially adopts the “material lens” of IEC as well in 2003 (NACA Botswana, 2003, p.47), it would later re-establish IEC as a framework to be “expanded/moved beyond.” (NACA Bot-swana, 2006, pp.2, 4). Application wise, Kenya mentions IEC sparsely within its Prevention document (only four times, NACC Kenya, 2009, pp.38, 48, 51; comparable to Botswana’s three times, in NACA Botswana, 2006, pp.2, 5) and positions it as an extra outlet to popularize “scientific knowledge”, reaching to previously unreachable groups. For Botswana, while not explicit, most mentions re-lated to IEC fall under “Goal 1”: “prevention of HIV infection” (e.g. NACA Botswana, 2003, pp.47, 48, 49, 50, 51), that confines its use to transmitting “basic knowledge”. Yet, Malawi often uses IEC as a “Chroma key” to spread new HIV-related information at public spaces, on “aware-ness”, “gender-based violence”, “PMTCT”, “PreP”, and so forth, with 14 unique mentions in the national Prevention Strategy (NAC Malawi, 2009, pp.22, 23, 25, 30, 31, 32, 36, 38, 52, 53). 28 States’ reliance and clarity (or lack thereof) on IEC (as a programme) may accelerate or limit the rate of societal penetration of discourses, as they affect efforts put into other programmes and the perceived “closeness” and “impact” of state’s messages felt by public members. 5.2.3 Formulation of BCI Policy Approaches States’ weighting on using IEC may affect the expandability of their policy directives to communicate about HIV-prevention measures. Below is a comparison of clauses from states regarding national condom programming, which, in SSA AIDS’ context, condoms are tangible, state-promoted instruments to foster people’s thoughtful deliberations to make their sex “safe”: Condoms have also been distributed in the communities through community-based distri-bution agents of which some are young people … Various IEC materials have also been produced and aired aimed at educating people on the benefits of condoms ... A series of training programmes on condom promotion have also been conducted … (NAC Malawi, 2009, p.23) Build capacity of females to negotiate partner/client acceptance use of condoms or initiate discrete use of female condom ... advocate for condom availability in prisons & same-sex facilities ... expand condom distribution in motels, hotels, high transit areas, construction, and trade industries. (MoH Botswana, 2006, p.28) Malawi’s statement emphasizes state’s (rather than citizens’) role to supply condoms and peripherals, evident in its use of passive voice above, and mentions of “TV/radio programming” and “HIV/IEC materials” in almost all of its other agendas in HIV Prevention Programmes (NAC Malawi, 2009, pp.23–25). Meanwhile, Botswana envisions how the society is ought to ex-pand condoms’ reach, through doing something for a group or in a place, consistent to its state 29 and societal “capacity building” agenda seen in almost all “Priority Areas of Focus for Preven-tion” (MoH Botswana, 2006, pp.26–29). 5.2.4 Patterns from Governments’ Behaviroual Change Policy Agendas When Separating I, E & C States’ deliberations to inform, communicate, and educate on “behavioural change” agendas can affect their ability to impose their “micro-managing” ideas to people’s everyday encounters in sexual interactions, dynamics, and disease prevention. In reference to Tables 5, 6 and 7, the three states share a similar volume of policies which come in IEC and stress in abstinence, condoms, and HIV-testing. One outstanding difference in Botswana’s communicative policies on behavioural change to Malawi and Kenya locates in its relative emphasis in “interactive” type of policies. It uniquely offers education in the social skills for negotiating sex, emotional concerns in abstaining sex, and the “rewards” of it (NACA Botswana, 2006, p.19). Although Malawi’s list of behavioural change policies does feature unique or crucial agendas, such as “theology of hope”, post-exposure prophylaxis, “positive living” and debunk of misconceptions, they often come as IEC programmes. Kenya focuses strongly in sex, and branches out its public outreach from “HIV risk reduction” to specific audiences in lieu of HIV knowledge or sex negotiations. These condition the views on how social members internalize the communicative data they have received, and execute changes based on their anticipation to societal receptions. 5.3 Observations from State’s proposals in HIV-Counselling 5.3.1 Types, Orientations and Derived Linkages & Networks of Counselling Agendas States hold hegemony in initiating, distributing, and offering facilities, standards, proce-dures and professionals to HIV diagnosis nationwide, to stage new settings to impose their “su-perstition-free” paradigms which link cognition of STIs to health science. The one-on-one or 30 small-group occasions constructed for “standard” HIV diagnosis, as opposed to “spiritual tests” by traditional “witch doctors” (Kielburger and Kielburger, 2008) for instance, leverage states to pitch to clients the new “scientific” discourses to communicating about HIV. However, as with BCI policy agendas, states can only capitalize on these opportunities if they can increase citi-zens’ networked participation and practical takeaways consistent with “science”, from pre/post-test counselling sessions. States’ “minimum packages” for pre/post-test counselling (see Table 8) can hint on the qualitative expandability of the scientific paradigm beyond the clinical setting. Proportionally, MoHs of Botswana and Kenya incorporate more “interactional” and “referral” policies, than “technical” ones (as MoH Malawi does). Botswana’s proposal uniquely mediates counsellors to “correct misconceptions” and “discuss positive living”: both open-ended components, while Kenya emphasizes more in referrals, of partners (twice), family members, and exclusively, to maternal services. Peripherally, they also advocate for counselling between counsellors for their well-being (NASCOP, 2008, p.34; MoH Botswana, 2009, p.31), by fostering collective peer dis-cussions related to the “scientific” sessions off-hours. They also link HIV counselling to other infectious diseases (e.g. TB, Malaria), and draw the support network to other public goods off the health system, such as “child welfare card” (MoH Botswana, 2007, p.26) and “food aid” (MoH Kenya, 2006, p.36). Malawi meanwhile spends large passages on pediatric disclosures (MoH Malawi, 2007, pp.15–18), but not in interactions and third-person referrals moving for-ward from the test results. 5.3.2 The Articulations on “Consent” States’ articulations in “consent”, a singled-out “issue” within HIV-counselling (MoH Malawi, 2007, p.14) stated in their Testing and Counselling Guidelines, indicate their visions in 31 how “scientific dialogues” shall be initiated in clinical settings. Consent is generally designed to empower clients to realize their voluntary decision-making power, enabling them to engage in “scientific” diagnosis as “informed” persons. The specific attentions states pay to the communications of “consent” can cultivate differ-ent clinician-client power dynamics, should clinicians follow the Guidelines. Indicated in Table 9, While both MoH Kenya and Botswana stress on patients’ right to decline testing, Botswana exclusively prints out clinicians’ obligations to convey on it, to ensure their “best interests”. Ma-lawi meanwhile urges clinicians to question adolescents’ reasons in seeking individual consent and trace their sexual-medical history that supports the decision, without highlighting the right to decline a test to teens. MoH Malawi (2007) also authorizes health providers explicitly to deter-mine the occasions to breach “consent” for the clients’ “best interests” (p.14). In Botswana’s vi-sion, clinicians serve as information providers for client’s deliberations, who would then “ac-cept” (MoH Botswana, 2009, p.8) to proceed to a service or not; in Malawi, the opposite stands. These differences in dynamics and the meaning behind “best interests” matter to the clients in the perceived empowerment, as compared to traditional institutions, from the operations of healthcare providers, and the morale to comply to “scientific” exchanges. How do states expand the meaning of “consent” from strictly the act to “obtain clients’ agree-ment” decides the boundaries of “consent”, and what clients may learn from it. Indicated by the subjects associated with the term laid out in Table 9, both Kenya and Malawi regard “con-sent” as part of a linear legal procedure, as they elaborate on technical legal details; Botswana perceives this as a preparation to counselling dialogues, as it lays-outs the affects from a test. MoH Botswana (2009) outlines in the Guidelines to introduce “confidentiality” and “HIV-related services” (p.26), as warrants which clients may accept. Although Malawi also introduces “HIV- 32 related services”, they are offered only when clients address abnormalities (MoH Malawi, 2007, p.14), signaling a difference in informational reach compared to Botswana. Both Kenya and Bot-swana guide clinicians to provide clients opportunities to ask questions, but they apply different modalities (Kenya’s “should” versus Botswana’s “will”, see Table 9) to address the point. Such divergences in characteristics can alter “consent’s” connection back to the network of counsel-ling ideas, and hence, clients’ view in how enabling and relevant is it to their daily lives as a so-cial good under “science”. 5.4 Discussion Positive changes in all 4 categories in Tables 10, 11, 12 and 13 can indicate state’s lever-age of authoritative power amidst of the AIDS epidemic, from fostering a paradigm shift towards “sexual health”. “Adequacy” (Table 10) shows state’s changes in “raw power” to gather re-sources, backed by public approval; “Trust and reliance” (Table 11) reflects people’s direction of mobilization in everyday issues; “HIV knowledge and misconceptions” (Table 12) signals peo-ple’s cognitive absorption to government’s ideas; “Behavioural compliance” (Table 13) tells us the social commitment and compliance to government’s agendas. In this regard, whilst both Botswana and Kenya are relatively capable to gather public ap-proval and improve healthcare knowledgeability and access, only Botswana has achieved a criti-cal paradigm shift. This is indicated with many additions of health personnel, a shift from ap-proaching social actors (i.e. traditional and religious leaders) to government agencies, much im-proved literacy rates and relatively high condom use rate. Despite a rise in public disapproval to-wards government’s dealings in distributing public health, the approval rate remains overall high (Armah-Attoh et. Al, 2016, p.11). The Malawian state remains weak in leveraging its discourses, as reflected by the low (yet undeniably rising) presence of health facilities, knowledge and 33 compliance rates, political trust, and a rise in inclination towards societal leaders. This is also re-flected laterally in state’s intended move to decriminalize homosexuality in 2011 but was later rescinded due to intense public pressure (Human Rights Watch, 2012). The Kenyan government, despite capable in raising public awareness and HIV literacy via intense “education” campaigns, is unable to establish an open environment (reflected from high-level HIV-related stigma) for its “sexual health” paradigm (e.g. in condom use). Social members have strong reservations to com-ply to state’s action codes and support state-led public health regime at their expense. Somewhat surprisingly similar to Malawi, people turn away from the government, and to traditional or reli-gious leaders for trusty advices. This weakness is also laterally reflected in Kenya’s high score in Fragile State Index in mid-2010s (TheGlobaleconomy.com, n.d.). Connecting back to DI and “3i”s, the potential reasons for such comparative differences will be elaborated below. 5.4.1 Power in Ideas: Conceptual Qualities put forth by the Governments to Alter the Problem Definition Social members in the states panic over the AIDS epidemic with deaths and its “tradi-tional” connotations (e.g. “evil spirits’ takeover”). The state intervenes to ease the panic by bringing in a new “non-superstitious” paradigm that “will work”, proven by treatment and healthcare instructions and advices, to defy existing superstitions and people’s thought process. States’ articulation on the policy contexts is the first determinant of the power in the ideas of its “evidence-based” paradigm, as states attempt to reorient cognitively the “problem” and nature of HIV infection with newly defined root causes foreign to societal understandings. The government of Botswana critically pinpoints the “key problems” of the epidemic of AIDS as a result of societal “misconceptions”. This leaves the situation cognitively changeable by directly confronting existing beliefs during counselling sessions, and replacing them with a 34 rights-based interactive model based on negotiations, dedicated legal rights education, and quali-tative “consent”. While integrative visions like embedding regional-specific messages and less technical languages in IECs (NACA Botswana, 2003, pp.34, 51) set the government up strongly to penetrate the messages, the model is ultimately backed by sufficient material supply (e.g. con-doms, abided clinicians under universal healthcare) to sustain the “safe” behavioural practices. Botswana’s successful paradigm shift may also be complimented by a relatively liberal social en-vironment (i.e. “mo sephiring’, McAllister, 2013, p.92), which may ease the societal adaptation to government’s beliefs. Contrastingly, although MoH Kenya also politicizes the issue of sex, its predominantly socio-economic lens, elaborated in lengths in its Prevention Response (NACC Kenya, 2009, pp. 22, 24, 27–32), actualizes the sentiment on “individual empowerment” in its policy program-ming. Compliance then appears optional since knowledge proficiency takes priority for “self-em-powerment” in later informationally-biased policy approaches (seven informational versus four interactional policies, Tables 5 and 6), and is matched with state’s failure to deliver to fulfill the needs to operate the “scientific” regime. Yet, it localizes cultural impacts to communities (e.g. Luo) or specific groups (e.g. fishermen) (NACC Kenya, 2009, pp.29, 31), and notions that tradi-tional beliefs must “be approached with some caution” (NACC Kenya, 2009, p.29), signaling re-sentment from the state to directly confront with them fullscale. Even weaker in power, Malawi bypasses the challenge against “traditional practices” altogether through depoliticization, and does not challenge the local-level discursive power hierarchy. Its proposal in “consent” to in-struct healthcare providers to ask teen clients to explain their case with “respect” and “sensitiv-ity” may not prevent judgments in clinician-client exchanges (Magak, 2022), which may under-mine the sense of privacy and the cognitive distance between “scientific” versus “traditional” 35 communications. Neither state reminds the repulsion between their and society’s “superstitious” paradigms to the public; the common sense is not that “common” after all in public interactions. 5.4.2 Power through Ideas: Appealing for Expanded Public Interests from State-Modified Problem Definitions to the Public To install the new “scientific health” discourses to mitigate the societal spread of HIV, states compete ideationally with local influences which may suggest alternative causalities, solutions for survival (e.g. burying girls alive, Schons, 2022), with different agents (e.g. witch doctors). For this reason, states need to appeal beyond survival and apparent health status, to well-being and lifestyle, to demonstrate that subscribing to “science” can yield more (intersubjectively) compelling interests. The quality of policy approaches/programming can affect persuasion to lower people’s perceived opportunity cost to forgo existing customs and cognitive understandings, and connect to state-envisioned “scientific” pursuits instead. The Tswana government is aware to branch out from IEC and holds an advocative atti-tude to reach distinct public members. This awareness warrants the government to increase the versatility of its idea transmissions, to leap beyond basic HIV-health knowledge to well-being issues when interacting on HIV’s theme, and beyond the general public to specific targeted groups. The high salience in “negotiations” and “emotions” in its behavioural change policies can help women to achieve and interact with a “scientific” cognition over traditional influences, that intersects with their interest towards gender equity. The skew to “interactive” agendas (rela-tive to “technical” and “referral”) in both Behavioural Change and HIV-Testing-Counselling Programs also encourage people to practice the discourses every day for critical thinking sur-rounding sex and diseases. Combined with fixes in misconceptions, these points connect sensibly for people to pursue “safer”, “rewarding” (NACA Botswana, 2006, p.19) sex(ual relationships). 36 The success is reflected in increased people’s condom use rate when having intimacies with non-martial partner(s). Meanwhile, MoH Malawi’s reliance on IEC constrains its agenda-setting abilities owing to the nature of the medium. The state holds less control in IEC than in-person programmes in mediating focuses of interactions, and risks objectifying “science” as something cognitively dis-tant and irrelevant to everyday people with its “material” approach. Receiving the messages with little mediations in follow-ups, HIV-Knowledge to people is merely presented as alternatives with “benefits”, which, as noted in Botswana’s observations, “cannot eliminate misconceptions” (NACA Botswana, 2006, p.2). This leaves MoH Malawi a small radius off IEC to impose dis-courses: only seven behavioural change policy agendas are not delivered by IEC (versus Bot-swana’s 16; see Tables 5, 6 and 7). As such, “science” related to HIV infection is separated from “sex”, and is perceivably communicated as an “add-on” which only people under high risks or in an ‘unhealthy” state need. Although the Kenyan government moves beyond IEC and makes HIV education more accessible, its programmes internalize and weight up the significance of individual knowledge, and scales down interactions. Emphases in individual empowerment as in abstinence, protection, and life skills, disincentivize people’s ‘undoing’ of pre-existing sexual codes as a collective. Government’s “scientific” paradigm under this context is manifested as “privatization” in health matters that can co-exist with superstitions and stigmas. People may opt for its advices in actions a-la-carte as choices, but without being compelled to follow all of its principles when they are doing “fine” in private. This hence may explain the persisting high stigmas on HIV and low compliance rate in condom uses in Kenya, despite deepened knowledge level. In sum, in both states, the interests to subscribe to “science” in sexual health are not presented compulsively in 37 the realm of interpersonal interactions to replace existing normative orders. A cultivated “com-mon sense” is indeed, not supported by “common” practices, which may disincentivize one to practice it every day. 5.4.3 Power over Ideas: Assigning Responsibilities and Networking Strategies from State-Modified Problem Definitions To sustain and mainstream its paradigm shift, states seek to broaden its sphere of influence and squad of agents to trump its ethos in the subject of sex (or sexual health) over influences behind existing “unhealthy” sexual phenomena. This will require cooperations, and ideally cognitive conversions, of non-state actors who subscribe to alternative paradigms and people connected or tied to them. And to solidify the connections, states need to reassure the (inter) active roles they may play in the new paradigm. Ambitions to expand the depth and quality of referrals, as well as the diversity of actors incorporated, can be pivotal to foster a lasting, comprehensive, knowledge-based network to flex enforcement and support for the discourses. The Tswana government institutionalizes support to health in light of sex diseases by making the counselling support ongoing, interdisciplinary and multi-levelled: in (HIV-positive) life, diet, male circumcision and psychosocial support; proposing to form a “scientific” support network featuring healthcare provider to clients (i.e. referrals), the traditional leaders, and counsellors themselves. It is the only state that explicitly expresses “education” or “training” (on top of cooperation) of traditional leaders on HIV prevention and NGOs on the quality of counselling (NACA Botswana, 2003, pp.49, 60). The cognitive assimilation on the common “scientific language” fosters relatively equal and mutually-respectful relationship between them and HIV-related people. These can enhance the appeals of people’s contact with state-influenced 38 actors, and integrate all directly under government’s sphere of influence. The decisive identification of “unhealthy” sexual behaviours, from “unhealthy” yet ubiquitous cultural influences, once again sets up foundation for this success. Comparatively, the patterns of connections and scope of programme contents within Malawi and Kenya’s policies cultivate cliental relationships, unfavourable for popularizing the “scientific” mindset off clinical settings and to the public realm. By stressing the need for HIV testers to bring their partners and family members to receive testing, and offering mostly family-centered referral services (e.g. maternal support, family planning), the design of Kenya’s counselling referral scheme cultivates a family-oriented sentiment. However, be it also the limit of its variety of referral offerings, it confines the issue of HIV infection and hence, the behavioural changes, as a domestic matter, rather than a matter of social good. The education on self-protection/empowerment, addressed in “power through ideas”, also fueled up the discourse of “fortress bodies” (Danil, 2020, p.382), which further turns responsibilities for one to keep distance from sexual diseases (by whatever means) inwards. These discourage facilitations of an open atmosphere for conversations, compounded by the privatization and a shortage of labour supply in the public healthcare system (see Table 10). Local organizations are to follow National AIDS Control Council’s cooperative instructions (NACC, 2009, p.55), but are not expected to involve beyond HIV service executions (e.g. male circumcision) to uphold the new sex-health paradigm every day. Their normative authority off the services is not challenged, nor are they “counselled” to a different mode to communicate about AIDS. Though the institutions of the state-led public health regime are present, the discourses are not ubiquitous (i.e. existing everywhere, everyday). The situation in Malawi follows a roughly similar line, except the state is even weaker in 39 “power over ideas”: less supply in health care resources, more responsibilities to higher risk or infected individuals, and more reliance to local organization’s authority. Its “Theology of Hope” (MoH Malawi, 2005, p.31) programme even “supports faith-based organizations to provide spiritual counseling”, that it uncritically legitimizes the local influences. The implication here is twofold. First, it may shift the issue and cognitive cure of AIDS away from sexual-cultural practices, working against government’s “scientifically-based” paradigm; second, people may connect to these organizations rather than the government for support, owing to their relative closeness, both physically and cognitively. In sum, in both states, states face challenges to cohere all levels of society to their sexual health discourses because the connection patterns fail to mediate people to regard sex and healthy practices as “scientific” matters to the public. The weakness is captured by people’s relative distrust to the state and the increasing resort to local authorities, thus states are losing power over ideas. 40 Chapter 6 – Implications: Legacies from Policy Discourses 6.1 Implications to States’ HIV Human Rights Policy Agendas: Universality to Access Versus Universality in Access States such as Botswana and Kenya increasingly recognize hard-to-reach “key populations” (KPs) in the epidemic beginning in the 2010s, typically of MSMs, (female) sex workers and people who injected drugs, with surveys geared to understand them better. Vastly invisible from state’s policy plannings previously, states aim to explore the factors behind their apparently higher HIV prevalence rate, concerning the higher risk factors in sexual practices which make them vulnerable to transmit HIV virus in clusters (NASCOP, 2014b, p.96). Simultaneously, states often frame their HIV Policy Programmes as guided by “human rights principles” (NACA Botswana, 2006, p.20, NACC Kenya, 2005, p.25), meaning they subscribe to uphold their self-entitled rights from discrimination, and to health and life (Office of the United Nations High Commissioner for Human Rights, n.d.). While Botswana and Kenya both reveal key populations’ struggles sufferings from violence and (sexual) coercion from social actors, they place different salience on aspects of “human rights” differently, resulting in different policy solutions and impacting the outcome of societal and legal discrimination against them. The questions put into and prioritized in Botswana and Kenya’s key population behavioural surveys reflect states’ view on the “key-ness” of the populations: drivers behind their higher-than-normal rate of HIV spread (NASCOP, 2014b, p.viii), and the attributions of their “riskiness”. While statistical outcomes and answers from open-ended questions set the level of certain policy agendas, the design of questions themselves hint at prototypes in policy ideas, and the type of “human right” agenda they primarily aspire to develop via policies: “positive” or “negative”. “Positive” right implies individual rights claims to access services and information 41 for empowerment; “negative” right restrains certain actions from social members which violate other individuals’ (e.g. KPs’) right to exercise their freedoms (Alabama Policy Institute, n.d.). Surveyed MSMs in Kenya have to face five questions in “anal sex” and 15 questions in “sex” (11 for sex workers) right when the KP survey starts (NASCOP, 2014a, pp.52–53, 58–61); Botswana first concerns about key populations’ individual profiles, and presumptively allocates proportionally less focus in sex than Kenya (MoH Botswana, 2013, pp.36–37, 46–47). Qualitatively throughout the questionnaire, Kenya focuses more on individual behaviours and happenings during sex; Botswana separates partners and sexual behaviours, and diverges the peoples’ “risky traits” off sex to everyday behaviours and interactions. For instance, Kenya’s questionnaire chains sex, condom, and alcohol together (NASCOP, 2014a, p.61), whereas Botswana separates the two subjects. On top, while both countries reserve 2-3 questions on violence they suffer from, Kenya’s quantitative approach compresses the qualities of violence between sex clients and police; Botswana’s open-ended, qualitative format allows interviewees to systemize their articulations of undesirable interactions with state apparatuses (NASCOP, 2014a, p.55; MoH Botswana, 2013, p.21). 6.2 The Divergence: Botswana As explained, states are influenced by both the data collected from the questions and the research design itself when drawing policies and context on (KPs’) human rights. Botswana has attempted to extend the coverage of its ARV to hard-to-reach populations under the “treat all” strategy to simplify the medical procedures and dosage since 2016 (Ramogola-Masire et. Al., 2020, p.1068). Inferably, this can reduce “HIV footprints” of KPs, both HIV-positive or negative (MoH Botswana, 2016, p.7), to disassociate themselves from the label. Extending from community leaders’ training, its latest Comprehensive Plan to Removing Human Rights and 42 Gender Related Barriers vows to “Review and update the Patients’ Rights Charter to address the rights of key and vulnerable populations” (National AIDS and Health Promotion Agency, 2019, p.31). These negative right initiatives align with state’s vision to change client-clinician interactional dynamics as in “consent” (refer to chapter 5.3.2), which also intersect with KPs’ concerns recorded from the focus group responses in the KP survey (MoH Botswana, 2013, pp. 32–34). Although the plans themselves fail to draw MSMs and FSWs to utilize the services (Jefferis et. Al., 2021, p.8) per se, state’s aspirations of it motivate the open-up of societal environment for more toleration, or, refrainment from systemic discrimination, towards MSMs. After initial appeal to High Court on its decision to decriminalize same-sex activities in 2019, state chose to “respect the decision” in 2022 when the appeal, claimed to be driven by legislators, got turned down in 2021 (Osazuwa, 2022, para.3). The discourses did play a part, as judges did consider how “criminalisation makes it hard for them to access vital messages about safe sexual conduct, essential in the age of HIV/AIDS.” (AfricanLII, 2019, Article 128). A state-facilitated open environment aligns with state’s interest to mainstream “sexuality talks”, a vital facilitator of behavioural change, stated back in 2006 (NACA Botswana, 2006, p.9). These being said, signals in interpersonal acceptance remain mixed (see Table 14). Violence from authorities, especially towards female sex workers, still persist (though slightly less than Kenya), perhaps signaling deeper issues in gender inequality and representation (UN Women, n.d., para. 1). 6.3 The Divergence: Kenya Two weeks before Botswana’s decriminalization, the Kenyan court upheld the legal pun-ishments in “carnal acts against the order of nature”. The High Court’s sentiment, that “there was not enough evidence of discrimination against the LGBT+ (i.e. lesbian, gay, bisexual, 43 transgender, and other sexual minorities) community” from the laws (Busari et. Al., 2019), re-flects the discourses from state’s positive-driven human rights approach. MoH Kenya pro-grammes the “empowerment” policies with prime focus on individual choice, which it briefs through KPs’ suffering from brutality by authorities (NASCOP, 2014b, pp.8–9), yet elaborates in lengths on their sexual habits/ identifications and infection risks from these behaviours. Portray-ing the responsibility to HIV-related issues under control back to the KPs, MoH Kenya strives to deepen their education and own practices on safe sex, via targeted IECs, behavioural change schemes, and condoms supply (NASCOP, 2014b, pp.34–42), as consistent to its Prevention Strategies back in 2009 (NACC, 2009; Table 5). Such discourse is evident in detailing the opera-tions of peer educators (with intense training), and singling out the support locations to “hotspots”/ “serve points”, or safe spaces, as part of “community approach” (NASCOP, 2014b pp.19–21, 37–38) for their self-empowerment. Meanwhile, top-down addresses to marginalizing legal and social norms come merely as “shoulds” (NASCOP, 2014b, p.62), as similar to the “questioning right” in “consent” (see Chapter 5.3.2). These “empowerment” policies, with lackluster social power restructuring, awareness to within-group differences, and support in community-wide protections (e.g. mandatory sensitivity training for police on top of “workshops”, MoH Kenya, p.74), intensify the labelling effect of “key” populations, as prime targets of discrimination. As Table 14 shows, both intolerance and unacceptance towards female sex workers and MSMs (and broadly speaking, LGBT+s) are perpetuated, of which almost all sex workers suffered from violence and police coercion in 2019 (Aidsfonds, 2020, p.21). The workability of the state-proposed “peer educator” scheme is put into scrutiny, as 61% of humiliations which sex workers suffered are indeed from their fellows (Aidsfonds, 2020, p.31). Subsequently, HIV-mitigating instruments become emblems which 44 incite discrimination, as police identifies sex workers and MSMs based on the presence of condoms (Open Society Foundation, 2013, p.14) and relinquishes them and their properties. Some positive signs are shown in “acceptability” however (see Table 14), possibly owing to their sheer increase in socio-media presence, which may stimulate some social members to objectively understand them more, notably after High Court’s case (Frontline AIDS, 2020). In verdict, with insufficient “negative” balances, the “positive rights” approach, stemmed from previous “privatization” of health matters, blinds governments’ visions from factoring in local contexts of political power, and ultimately worsens social security concerns for the already disadvantaged. Or, paradoxically, state’s “human rights” policies to gather KPs at hotspots perpetuate their socio-economic struggles: state’s own problem definition on why they get into sex work and/or are “high-risk” at the first place. 45 Chapter 7 – Research’s Applicability and Limitations 7.1 Applicability of This Research’s Approach: Discursive State Development Combining DI and “3i”s to conduct a discourse analysis on a public policy theme in rela-tion to state’s leverage and human rights outcomes is admittedly experimental. Positively, it may open a new avenue for researchers to approach topics in comparative politics, and yield insights in states’ motives, successes, and gains (or lack thereof) from new discourses/paradigms derived from new policy programmes. Particularly, Part A’s approach can be applicable to study cases which a state government deliberates a public campaign to calibrate societal cognition towards a subject or phenomena, claiming for the “people’s good”. In optimum to the approach, the politi-cal context of the object state(s) shall be relatively democratic, and the availability of policy doc-uments and/or leader’s political speeches shall be ample, for one to dissect states’ “thought pro-cesses”. Ultimately, this can contribute to a better understanding in how states foster “social de-velopment”, from (re)creating and institutionalizing “collectively recognized beliefs and ways of doing things”, that “constrain but not immobilize (human actions)” (Bacchi and Rönnblom, 2014, pp.211, 212). Examples wise, this research’s approach may be ideal for a comparative institutional study between Ecuador’s “anti-gang” campaign since 2021 and Philippines’ anti-drug crack-downs under Duterte’s reign. Through media campaigns, declaration(s) of state of emergency, and neighbour reporting system (Philippines) (Conde, 2017; Collyns, 2022; Solomon, 2016), both states try to penetrate their influence societally and mobilize societies against the “gang/ drug blocs”, in order to bolster their social presence (via police crackdowns and use of prison systems) for “public security”. In public health politics, a study similar in format on state’s 46 interactions with monkeypox (Xinhua, 2022) can be made possible in future, when more policy programmes and documents are formulated and published by states. 7.2 Limitations: Contextual Incomprehensiveness and Imprecision Being explorative yet condensing, this study hits its limits with its narrow scope of “pol-icy context”: the variables that matter to state’s understandings on a subject’s situation. The ho-mogeneity in understanding “traditional/religious leaders” as “alternative opinion sources”, and ignorance to Botswana’s visible atheist or Kenya’s Muslim population (see Pew Research Cen-tre, 2016b), may neglect the complexity of normative communications and moral politics within states. It also pays little consideration to material abundance, or as the saying goes, the “mindset of the rich vs poor”, as well as geography (e.g. rural-urban divide). States’ realization regarding the level of domestic productions may condition their policy visions moving forward. It also fac-tors out temporality, of when do states start to realize AIDS as a (socio)political issue. An early start in HIV policy programming in Botswana (since 1993, Central Statistics Office, Republic of Botswana, 2005b, p.9) may give the state a head start to build authority compared to Kenya and Malawi. But, the recent decline in Botswana’s condom use rate (United Nations Population Fund, 2022) reminds us that the policy effects may not be ever-lasting. Yet, the time point of when shall states vitalize their programmes and innovate on communications is out of this re-search’s agenda. Methodology wise, in spite of being a qualitative report, the paper relies heavily on state/institution-provided quantified indicators, and scarcely incorporates qualitative recitals from social members to draw the conclusions, owing to time constraints from decoding the recit-als. This mismatch may undermine the quality in understanding individuals’ struggles regarding HIV and human rights within societies realistically. Finally, this research maybe focusing on too 47 many items, that compromise insights yielding within specific HIV-related programs (e.g. con-dom strategy, human rights). Points may be missed when states signal communications to a cer-tain audience without using keywords like “communicate”, “educate”, or “counsel”, that the “bird’s eye view” used here may reduce accuracy in interpretations to states’ ideas. Researchers who wish to follow this format may consider narrowing down the scope of focus before proceed-ing to data collection. 48 Chapter 8 – Conclusion 8.1 Comprehensive, Open Communicative Policy Programmes and Resource Capacity Needed to Pursue the New Social Goods This research does not aim to cast moral judgments on states’ or traditional approaches towards HIV/AIDS or rights of LGBT+s and sex workers. It instead attempts primarily to ex-plore the necessary conditions, aside from material adequacy, for states to leverage their political power against traditional societal authorities, from establishing new (policy) discourses in public (sexual) health amidst of AIDS epidemic. They strive to problematize and “win” a discursive battle against traditional influences in drawing public support to impose their solution: a “scien-tific” paradigm as the “truth” to mitigate AIDS. While their effectiveness in programming and fostering interactions from policy discourses cast different outcomes in public reception and state’s societal influential power, the policymaking’s legacies may carry to subsequent “empow-erment” measures towards KPs, and hence, societal stigmas against them. Both a state-initiated problem definition dichotomous to societal (mis)perceptions, and a comprehensive programme aligned with the paradigm’s core principle and societal wants, are significant and necessary to form a successful paradigm shift, observable as an episode of Dis-cursive Institutionalization in Schmidt’s (2008) analogy. States must draw enough cognitive dis-tance of their perception on the issue of HIV/AIDS from existing normative beliefs, to invoke an authority to upset social orders. This paves way to insert new interests, made recognizable via communications, off and beyond pre-existing (mis)conceptions in AIDS. States’ “scientific” ideas embed power when the ideas’ qualities appeal to social members to become critical to pre-existing societal beliefs in HIV. Their power mediates through ideas when behavioural change policies make the “scientific” paradigm approachable to people’s everyday interactions, which, 49 with constant practices, decrease their perceived opportunity cost to forgo (cultural) “values” be-hind pre-existing socio-sexual norms. Power carries over ideas, when states form new coalitions not through status, but practices, to solidify their sphere of influence and limit non-state authori-ties’ political power in the issues of sex and health. These must be backed by ample material ca-pacity for states to permeate its presence via objects and/or agencies, to make the practices feasi-ble (e.g. condoms for safe sex), and to cultivate hegemony in the national health regime. In short, Botswana succeeds to mainstream HIV-behavioural changes, thanks to the com-prehensiveness, equitable and negotiable elements, and universality of its policy programming, backed by adequate condoms, health personnel and facilities. MoH’s “scientific” language trans-cends out to the society from clinics, as its communication-provoking programme designs sell to one’s “well-being”, “autonomy” (MoH Botswana, 2009, p.8), and cultivate a knowledge-based network of support. Kenya is capable but unable to permeate, as its knowledge-focused pro-grammes privatizes health matters (i.e. the “treatment over prevention” phenomenon, NACC Kenya, 2009, p.37) and perpetuates acceptability in stigmatized views as “choices”. Despite in-tents to facilitate normative changes, Malawi is too weak ideationally and resourcefully to chal-lenge existing beliefs, and is forced to rely on their authorities. On the other hand, imposing policy approaches to “empower” KPs alone cannot turn so-cietal stigma against them around, although negatively-leaned “human rights” approach can in-crease institutional tolerance towards them. States carry the legacies from prior policymaking principles on HIV/AIDS to agenda setting in the surveying on KPs, which foreshadows their fo-cuses in “empowerment”. Sole focus in enabling KPs’ positive rights in physical access to re-sources and service, as in Kenya, cannot help achieving human rights progression for them, be-cause it does not induce cognitive changes to normalize KPs to the mainstream. Instead, state 50 and social authorities can counter the “empowerment” and reinforce stereotypes by manipulating the meaning of new constructs, e.g. using “safe” condoms to discriminate MSMs/sex workers. A universalist approach to deprioritize one’s perceived identity (e.g. MSM) from profiled behav-iours (e.g. anal sex), and to facilitate equity in quality access (than access per se), can instead re-establish the value of members in other attributes (e.g. MSM’s high education) for recognition. This may potentially foster social members to re-calculate the opportunity costs to devalue iden-tified minorities overtly. As such, Botswana progresses in tolerance to KPs, with its prior survey preparations then a “treat-all” approach, that solidify “human rights” framework as equitable dig-nity, ultimately spilled over to legal rights. This being said, it may still take another exogenous hit or influence for the state to head towards full stigma eradication, whereas KPs’ increase in sheer exposure, with much sweat and blood, seems to be helping themselves on that in Kenya. Figure 3 in Appendix 2 sums up and theorizes the “findings” from this research. 8.2 New Scholarly Value to Existing Literature This research can prospectively add to the existing literature in Global South’s moral and HIV politics. Briefly in response to rational choice analogies, resource abundance is relevant to “successes” in HIV policies and policy equity, only if national governments manage to centralize ideas and reform social interests surrounding AIDS. Social morality, as sociological analogists would concern, become a primary issue when states face significant socio-economic and/or polit-ical insecurities and decide to cultivate a sense of “unity” through “stability”, which undermine their tolerance to new discourse formation. Therefore, as DI positions states as having more sov-ereignty than previous institutional analogies, using DI to see state-with-society interactions to mitigate uncertainties can help deepening understandings in state’s proactive role to impose or mediate social influences. 51 Bibliography AfricanLII (2019, June 12). Botswana: Criminalisation of consensual gay sex is unconstitutional. AfricanLII. Retrieved November 25, 2022, from https://africanlii.org/ar-ticle/20190612/botswana-criminalisation-consensual-gay-sex-unconstitutional Osazuwa, I. (2022, January 24). Botswana president vows to honour gay rights judgment. WuzUpNigeria. Retrieved November 25, 2022, from https://www.afri-canews.com/2022/01/25/botswana-president-vows-to-honour-gay-rights-judgment/ Aidsfonds (2017). Sex work & violence in Botswana. Needs Assessment Report. Aidsfonds. Retrieved November 19, 2022, from https://aidsfonds.org/assets/re-source/file/Needs%20Assessment%20Handsoff%20Botswana.pdf Aidsfonds (2020). Sex work & violence in Kenya: A participatory research. Aidsfonds. Retrieved November 19, 2022, from https://aidsfonds.org/assets/re-source/file/0469%20Rapport%20Kenya_WEB.pdf Akenroye, A. O. (2010). HIV/AIDS as a human security threat in West Africa. [Master Thesis, The University of Manitoba, Winnipeg]. mSpace. Retrieved December 23, 2021, from https://mspace.lib.umanitoba.ca/xmlui/bitstream/handle/1993/4365/Ayo-dele%20Akenroye.pdf?sequence=1&isAllowed=y Alabama Policy Institute (n.d.). Understanding the differences between positive and negative rights. Alabama Policy Institute, Retrieved November 22, 2022, from https://alabamapol-icy.org/research/understanding-the-difference-between-positive-and-negative-rights/ Ananga, M. K., Kugbey, N., Akporlu, J. M., & Asante, K. O. (2017). Knowledge, acceptance and utilisation of the female condom among women of reproductive age in Ghana. Contracept Reprod Med, 2(2017), Article 15. https://doi.org/10.1186/s40834-017-0042-9 52 Arcus Foundation (2019). Data collection and reporting on violence perpetrated against LGBTQI persons in Botswana, Kenya, Malawi, South Africa and Uganda. Arcus Founda-tion/Iranti.org. Retrieved November 21, 2022, from https://www.arcusfounda-tion.org/wp-content/uploads/2020/04/Iranti-Violence-Against-LGBTQI-Persons-in-Bot-swana-Kenya-Malawi-South-Africa-Uganda.pdf Armah-Attoh, D., Selormey, E., and Houessou, R. (2016). Despite gains, barriers keep health care high on Africa’s priority list. Afrobarometer. Retrieved November 19, 2022, from https://www.afrobarometer.org/wp-content/uploads/migrated/files/publications/Policy%20papers/ab_r6_policypaperno31_health_a_priority_in_africa1.pdf Arreola, S., Doan, T. T., Walimbwa, J., & Solares, D. (2020). Structural violence, community and access to HIV services: Participatory action research & new findings from the Global Men’s Health & Rights Study. MPacgt Global Action. Retrieved November 20, 2022, from https://mpactglobal.org/wp-content/uploads/2020/12/MPACT_GMHRRe-port2020_REVIEW-FINAL-3.pdf Asante, G. A. (2020). Anti-LGBT violence and the ambivalent (colonial) discourses of Ghanaian Pentecostalist-Charismatic church leaders. Howard Journal of Communications, 31(1), 20-34. https://doi.org/10.1080/10646175.2019.1590255 Atuguba, R. A. (2019). Homosexuality in Ghana: Morality, law, human rights. Journal of Politics and Law, 12(4), 113–126. https://doi.org/10.5539/jpl.v12n4p113 53 Asylos and Asylum Research Centre Foundation (2021). Ghana: State treatment of LGBTQI+ persons. Asylos and Asylum Research Centre Foundation. Retrieved May 20, 2022, from https://www.ecoi.net/en/file/local/2046533/Final-Ghana-state-treatment-of-LGBTQI-per-sons.pdf Bacchi, C. & Rönnblom, M. (2014). Feminist discursive institutionalism—A poststructural alternative. NORA - Nordic Journal of Feminist and Gender Research, 22(3), 170–186. https://doi.org/10.1080/08038740.2013.864701 Baisley, E. (2015) Framing the Ghanaian LGBT rights debate: competing decolonisation and human rights frames. Canadian Journal of African Studies, 49(2), 383–402. https://doi.org/10.1080/00083968.2015.1032989 Barker, G. & Ricardo, C. (2005). Young men and the construction of masculinity in Sub-Saharan Africa: implications for HIV/AIDS, conflict, and violence. World Bank. Retrieved November 26, 2022, from https://documents1.worldbank.org/cu-rated/en/481401468101357773/pdf/327120rev0PAPER0AFR0young0men0WP26.pdf Bartelink, B. E. (2021). The ambivalence of the immanent human security and the development response to HIV and AIDS in Uganda. In Tarusarira, J., & Chitando, E. (eds.), Themes in Religion and Human Security in Africa (pp.180–198). https://doi.org/10.4324/9781003017080 Berman, L., Nkhoma, L., Prust, M., McKay, C., Teshome, M., Banda, D., Kabambe, D. & Gunda, A. (2021). Analysis of policy interventions to attract and retain nurse midwives in rural areas of Malawi: A discrete choice experiment. PLoS ONE, 16(6): e0253518. https://doi.org/10.1371/journal.pone.0253518 54 Bhalla, N. (2018, August 14). 'Put up and shut up': Polygamy breeds poverty for Kenyan women and children. Reuters. Retrieved October 21, 2022, from https://www.reuters.com/arti-cle/us-kenya-women-polygamy-insight-idUSKBN1L0009 Botswana Network of People Living with HIV & AIDS (2014). Stigma Index survey report: Botswana. Stigmaindex.org. Retrieved November 11, 2022, from https://www.stigmain-dex.org/country-reports/#/m/BW Bratton, M. (2007). Are you being served? Popular satisfaction with health and education services in Africa. Afrobarometer. Retrieved November 13, 2022, from https://www.files.ethz.ch/isn/92123/AfropaperNo65_Are%20You%20Be-ing%20Served.pdf Busari, S., Sevenzo, F. & Leposo, L. (2019, May 24). Kenyan court upholds law making gay sex illegal. CNN. Retrieved November 24, 2022, from https://www.cnn.com/2019/05/24/health/kenya-lgbtqi-ruling-intl Carstensen, M. B. & Schmidt, V. (2015). Power through, over and in ideas: Conceptualizing ideational power in discursive institutionalism. Journal of European Public Policy, 23(3), 318–337. https://doi.org/10.1080/13501763.2015.1115534 Central Bureau of Statistics [Kenya], Ministry of Health [Kenya], and ORC Macro (2004). Kenya Demographic and Health Survey 2003. Central Bureau of Statistics, Republic of Kenya. Retrieved December 22, 2022, from https://dhspro-gram.com/pubs/pdf/fr151/fr151.pdf Central Statistics Office, Republic of Botswana (2005a). Botswana AIDS Impact Survey II Statistical Report. Republic of Botswana. Retrieved November 15, 2022, from https://cat-alog.ihsn.org/catalog/2048/related-materials 55 Central Statistics Office, Republic of Botswana (2005b). Health Statistics Report 2005. Republic of Botswana. Retrieved November 14, 2022, from https://dataspace.princeton.edu/han-dle/88435/dsp017s75dg513 Central Statistics Office, Republic of Botswana & National AIDS Coordinating Agency (2009). 2008 Botswana AIDS impact survey III: Statistical report. Central Statistics Office, Re-public of Botswana. Retrieved December 23, 2022, from https://catalog.ihsn.org/cata-log/2045/related-materials Collyns, D. (2022, August 15). Ecuador city declares state of emergency amid dramatic rise in gang bombings. The Guardian. Retrieved October 30, from https://www.theguard-ian.com/world/2022/aug/15/ecuador-state-emergency-guayaquil-rise-bombings-gangs-cocaine Conde, C. H. (2017, September 25). Deadly drop boxes fuel Philippine’s ‘War on drugs’: Anonymous informant system risks more arbitrary arrests, killings. Human Rights Watch. Retrieved October 30, from https://www.hrw.org/news/2017/09/25/deadly-drop-boxes-fuel-philippines-war-drugs Coulas, M. (2021) Discursive institutionalism and food policy research: The case study of Canada’s national food policy. Frontiers in Communication, 6(2021), Article 749027. https://doi.org/10.3389/fcomm.2021.749027 Crossman, A. (2019). Emile Durkheim's examples of social facts and their negative impact: How society exerts control on individuals. Thoughtco. Retrieved October 24, 2022, from https://www.thoughtco.com/social-fact-3026590 56 Danil, L. R. (2020). Queerphobic immunopolitics in the case of HIV/AIDS: Political economy, the dark legacy of British colonialism, and queerphobia in Sub-Saharan Africa. Sexuality and Culture, 25(2021), 377–395. https://doi.org/10.1007/s12119-020-09774-w Ecumenical Pharmaceutical Network (2005). Results of Malawi Baseline Survey. Ecumenical Pharmaceutical Network. Retrieved November 15, 2022, from https://www.rhsup-plies.org/uploads/tx_rhscpublications/EPN_Access%20assessment%20church%20ser-vices_study%20report_Malawi_2005.pdf Flores, A. R. (2019). Social acceptance of LGBT people in 174 Countries, 1981 to 2017. Institute, School of Law, UCLA. Retrieved April 23, 2022, from https://williamsinsti-tute.law.ucla.edu/wp-content/uploads/Global-Acceptance-Index-LGBT-Oct-2019.pdf Frontline AIDS (2020, October 2). Growing a movement: Uniting the Kenyan LGBTQ community. Frontline AIDS. Retrieved November 25, 2022, from: https://front-lineaids.org/growing-a-movement-uniting-the-kenyan-lgbt-community/ Garegae, K. G., Mogotsi, M. S., Gobagoba, M. R. (2017). Exploring the status of HIV/AIDS related stigma among students in Botswana learning institutions: a comparison of BAIS II and BAIS IV. Journal of the Botswana Educational Research Association, 20(1), 88-99. Retrieved December 23, 2022, from https://ubrisa.ub.bw/handle/10311/2411 Gauvin, P. (2014). Understanding policy developments and choices through the “3-i” framework: Interests, ideas and institutions. Retrieved September 5, 2022, from https://www.ncchpp.ca/docs/2014_ProcPP_3iFramework_EN.pdf Genuis, S. J. & Genuis, S. K. (2005). HIV/AIDS prevention in Uganda: Why has it worked? Postgraduate Medical Journal, 81(960), 615–617. http://dx.doi.org/10.1136/pgmj.2005.034868 57 Ghana AIDS Commission (2005). National HIV/AIDS Strategic Framework II, 2006-2010. Republic of Ghana. Retrieved June 11, 2022, from https://www.ilo.org/wcmsp5/groups/public/---ed_protect/---protrav/---ilo_aids/docu-ments/legaldocument/wcms_126718.pdf Global Burden of Disease Health Financing Collaborator Network (2018). Spending on health and HIV/AIDS: Domestic health spending and development assistance in 188 countries, 1995–2015. Lancet, 391(2018), 1799–1829. https://doi.org/10.1016/S0140-6736(18)30698-6 Global Network of Sex Work Projects (2015). Stigma and discrimination experienced by sex workers living with HIV. Global Network for Sex Work Projects. Retrieved May 23, 2022, from https://nswp.org/sites/default/files/Stigma%20and%20Discrimina-tion%20Experienced%20by%20Sex%20Workers%20Liv-ing%20with%20HIV%2C%20NSWP%20-%20December%202015.pdf Gore, E. (2021). From recognising health rights to realising labour protections? Sex work, ILOAIDS and the Decent Work Agenda in Ghana. Global Public Policy and Govern-ance, 1(2021), 340–360. https://doi.org/10.1007/s43508-021-00016-9 Government of the Republic of Malawi (2017). Health Sector Strategic Plan II (2017-2022). Government of the Republic of Malawi. Retrieved December 1, 2022, from https://www.csogffhub.org/resources/health-sector-strategic-plan-ii-2017-2022-malawi/ Grossman, G. (2015). Renewalist Christianity and the political saliency of LGBTs: Theory and evidence from Sub-Saharan Africa. The Journal of Politics, 77(2), 337–351. https://doi.org/10.1086/679596 58 Gyasi-Gyamerah, A. A., Amissah, C. M., and Danquah, S. M. (2019). Changing attitudes toward homosexuality in Ghana: The power of attributional discourse. SAGE Open, 9(2), 1-9. https://doi.org/10.1177/2158244019856712 Hamda, S. G., Tshikuka, J. G., Joel, D., Monamodi, G., Masupe, T., Setlhare, V. (2020). Sociodemographic predictors of HIV infection among pregnant women in Botswana: Cross-sectional study at 7 health facilities. Journal of the International Association of Providers of AIDS Care (JIAPAC), 19(2020), 1-8. https://doi.org/10.1177/2325958220925659 Home Office (2020). Country policy and information note – Kenya: Sexual orientation and gender identity and expression. Independent Advisory Group on Country Information, Home Office, gov.uk. Retrieved November 18, 2022, from https://www.jus-tice.gov/eoir/page/file/1269491/download Human Rights Watch (2012, November 6). Malawi: Courageous move to suspend anti-gay laws. Human Rights Watch. Retrieved July 14, 2022, from https://www.hrw.org/news/2012/11/06/malawi-courageous-move-suspend-anti-gay-laws Human Rights Watch (2014, May 13). Uganda: Deeply flawed HIV bill approved. Human Rights Watch. Retrieved October 12, 2022, from https://www.hrw.org/news/2014/05/13/uganda-deeply-flawed-hiv-bill-approved Institute for Development Studies, University of Nairobi & Michigan State University (2008). Summary of results – Round 4 Afrobarometer survey in Kenya. Afrobarometer. Retrieved November 19, 2022, from https://www.afrobarometer.org/wp-content/up-loads/2022/02/ken_r4_sor.pdf 59 Institute for Development Studies, University of Nairobi (2015). Summary of results – Afrobarometer round 6. Afrobarometer. Retrieved November 11, 2022, from https://www.afrobarometer.org/wp-content/uploads/2022/02/ken_r6_sor_en.pdf Institute for Development Studies, University of Nairobi (2021). Summary of results – Afrobarometer Round 8 survey in Kenya, 2019. Afrobarometer. Retrieved November 23, 2022, from https://www.afrobarometer.org/publication/summary-results-afrobarometer-round-8-survey-kenya-2019-0/ Jefferis, K., Avalos, A., Phillips, H., Mmelesi, M., Ramaabya, D., Nkomo, B., Muthoga, C., Jarvis, J. N., Ratladi, S., Selato, R., & Stover, J. (2021). Five years after Treat All implementation: Botswana’s HIV response and future directions in the era of COVID-19. S Afr J HIV Med, 22(1), Article 1275. https://doi.org/10.4102/sajhivmed.v22i1.1275 Jimu, S. E., Ntoimo, L. F. C., & Okonofua, F. E. (2022). Prevalence and determinants of condom use among youth in Malawi: Evidence from the 2015/16 Malawi Demographic and Health Survey. Research Square. Retrieved November 2, 2022, from https://doi.org/10.21203/rs.3.rs-1893031/v1 Johnson, C. A. (2007). Off the map: How HIV/AIDS programming is failing same-sex practice people in Africa. International Gay and Lesbian Human Rights Commission. Retrieved June 6, 2022, from http://www.archive.kubatana.net/html/archive/hivaid/070709ig-lhrc.asp?sector=CACT&year=2009&range_start=1 Kalimbuka-Mana, S. (2017, November 18). Schools warned against distribution of condoms. Nyasa Times. Retrieved November 24, 2022, from https://www.nyasatimes.com/schools-warned-distribution-condoms/ 60 Kasonde, M. (2013). Perception of teachers to sexuality education in secondary schools in Gaborone, Botswana. Stellenbosch University. Retrieved November 22, 2022, from https://core.ac.uk/download/pdf/37410628.pdf Kenya National Bureau of Statistics, Ministry of Health, National AIDS Control Council, Kenya Medical Research Institute, National Council for Population and Development, & The DHS Program, ICF International (2015). Kenya Demographic and Health Survey 2014. Kenya National Bureau of Statistics, Republic of Kenya. Retrieved November 8, 2022, from https://dhsprogram.com/pubs/pdf/fr308/fr308.pdf Kielburger, C. & Kielburger, M. (2008, February 18). HIV in Africa: Distinguishing disease from witchcraft. Toronto Star. Retrieved November 12, 2022, from https://www.thestar.com/opinion/columnists/2008/02/18/hiv_in_africa_distinguish-ing_disease_from_witchcraft.html Kirigia, J. M., Kathyola, D. D., Muula, A. S., & Ota, M. M. (2015). National health research system in Malawi: Dead, moribund, tepid or flourishing? BMC health services research, 15(2015), Article 126. https://doi.org/10.1186/s12913-015-0796-1 Kushwaha, S., Lalani, Y., Maina, G., Ogunbajo, A., Wilton, L., Agyarko-Poku, T., Adu-Sarkodie, Y., Boakye, F., Zhang, N., & Nelson, L. E. (2017). “But the moment they find out that you are MSM…”: A qualitative investigation of HIV prevention experiences among men who have sex with men (MSM) in Ghana’s health care system. BMC Public Health 17 (1), Article 770. https://doi.org/10.1186/s12889-017-4799-1 Laar, A. & DeBruin, D. (2017). Key populations and human rights in the context of HIV services rendition in Ghana. BMC International Health and Human Rights, 17(20), 1–10. https://doi.org/10.1186/s12914-017-0129-z 61 Letamo, G. (2019) Misconceptions about HIV transmission among adolescents: levels, trends and correlates from the Botswana AIDS impact surveys, 2001–2013: A short report. AIDS Care, 31(1), 48-52. https://doi.org/10.1080/09540121.2018.1488030 Magak, E. (2022, August 8). In Africa, ‘The heart of HIV stigma’ is within healthcare settings. AIDSMAP. Retrieved September 4, 2022, from https://www.aidsmap.com/news/aug-2022/africa-heart-hiv-stigma-within-healthcare-settings Mandal, A. (2011, March 23). Kenya’s condom shortage. News Medical. Retrieved December 9, 2022, from https://www.news-medical.net/news/20110323/Kenyas-condom-short-age.aspx Malawi Network of People Living with HIV and AIDS (2012). The People Living With HIV Stigma Index (Malawi). Stigmaindex.org. Retrieved November 7, 2022, from https://www.stigmaindex.org/country-reports/#/m/MW McAllister, J. (2013). Tswanarising global gayness: The ‘unAfrican’ argument, Western gay media imagery, local responses and gay culture in Botswana. Culture, Health & Sexuality, 15(1), 88–101. https://doi.org/10.1080/13691058.2012.742929 McGill University (n.d.). Problem Definition. McGill University. Retrieved September 8, 2022, from https://www.mcgill.ca/engineeringdesign/step-step-design-process/design-phases-practice/problem-definition Matlapeng, K. M., Babatunde, G. B. & Akintola, O. (2020). How do HIV/AIDS policies address access to HIV services among men who have sex with men in Botswana? African Journal of AIDS Research, 19(3), 165–176. https://doi.org/10.2989/16085906.2020.1782446 62 Ministry of Health, Republic of Botswana (2007). National nutrition and HIV/AIDS guidelines for service providers of people living with HIV/AIDS. Ministry of Health, Republic of Botswana. Retrieved October 20, 2022, from https://www.yumpu.com/en/docu-ment/read/22051804/national-nutrition-and-hiv-aids-guidelines-for-service-providers-of- Ministry of Health, Republic of Botswana (2009). National guidelines: HIV testing and counsel- ling. Ministry of Health, Republic of Botswana. Retrieved October 10, 2022, from https://www.medbox.org/document/national-guidelines-hiv-testing-and-counselling#GO Ministry of Health, Republic of Botswana (2013). 2012 Mapping, size estimation & behavioral And biological surveillance survey (BBSS) of HIV/STI among select high-risk sub-popu-lations in Botswana. Ministry of Health, Republic of Botswana. Retrieved November 7, 2022, from https://www.fhi360.org/sites/default/files/media/docu-ments/BBSS%202012%20Final.pdf Ministry of Health, Republic of Kenya (2006). Kenyan national guidelines on nutrition and HIV/AIDS. Government of Kenya. Retrieved October 22, 2022, from https://www.ilo.org/wcmsp5/groups/public/---ed_protect/---protrav/---ilo_aids/docu-ments/legaldocument/wcms_127535.pdf Ministry of Health, Kenya (2015). Kenya health workforce report: The status of healthcare professionals in Kenya, 2015. Government of Kenya. Retrieved November 7, 2022, from https://taskforce.org/wp-content/uploads/2019/09/KHWF_2017Report_Fullre-port_042317-MR-comments.pdf Ministry of Health, Republic of Kenya. (2019). Kenya national health accounts 2015/2016. Government of Kenya. Retrieved November 16, 2022, from http://www.healthpolicy-plus.com/ns/pubs/16339-16616_KenyaNHAmainreport.pdf 63 Ministry of Health, Malawi (2005). National HIV/AIDS action framework (2005–2009). Ministry of Health, Republic of Malawi. Retrieved May 23, 2022, from https://www.ilo.org/wcmsp5/groups/public/---ed_protect/---protrav/---ilo_aids/docu-ments/legaldocument/wcms_125537.pdf Ministry of Health, Republic of Malawi (2007). Guidelines for pediatric HIV testing and counselling. Ministry of Health, Republic of Malawi. Retrieved October 18, 2022, from https://www.ilo.org/wcmsp5/groups/public/---ed_protect/---protrav/---ilo_aids/docu-ments/legaldocument/wcms_151227.pdf Ministry of Health, Republic of Malawi (2016). Malawi guidelines for HIV clinical management in children & adults. Ministry of Health, Republic of Malawi. Retrieved October 18, 2022, from https://www.childrenandaids.org/sites/default/files/2017-04/Malawi_Clinical-HIV-Guidelines_2016.pdf Mitchell, T. (1991). The limits of the state: Beyond statist approaches and their critics. The American Political Science Review, 85(1), 77–96. https://doi.org/10.2307/1962879 Motswapong, P.E. (2021). The church in Botswana: An ally or an enemy of the lesbian, gay, bi sexual, transgender and intersex community? In Tarusarira, J. & Chitando, E. (eds.), Themes in Religion and Human Security in Africa (pp. 225–237). Taylor & Francis Group. Retrieved September 30, 2022, from https://www.taylorfrancis.com/chap-ters/edit/10.4324/9781003017080-15/church-botswana-pulane-elizabeth-motswapong Muula, A. S. (2006). Condom and sexual abstinence talk in the Malawi National Assembly. Afr Health Sci, 6(1), 21–26. Retrieved May 14, 2022, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1831960/ 64 National AIDS and Health Promotion Agency (2019). Removing human rights and gender related barriers to HIV/AIDS and TB services in Botswana. Republic of Botswana. Retrieved November 27, 2022, from https://www.theglobalfund.org/me-dia/10418/crg_humanrightsbotswana2020-2025_plan_en.pdf National AIDS and STI Control Programme, Republic of Kenya (2008). National guidelines for HIV testing and counselling in Kenya. Ministry of Public Health and Sanitation, Republic of Kenya. Retrieved October 21, 2022, from https://www.ilo.org/wcmsp5/groups/public/---ed_protect/---protrav/---ilo_aids/documents/legaldocument/wcms_127533.pdf National AIDS and STI Control Programme, Republic of Kenya (2014a). National Behavioral Assessment of Key Populations in Kenya Polling Booth Survey Report. Ministry of Health, Republic of Kenya. Retrieved November 19, 2022, from https://hivpreventionco-alition.unaids.org/wp-content/uploads/2020/02/National-Behavioral-Assessment-of-Key-Population-in-Kenya.-Polling-Booth-Survery-Report-November-2014.pdf National AIDS and STI Control Programme, Republic of Kenya (2014b). National Guidelines for HIV/STI Programming with Key Populations. Ministry of Health, Republic of Kenya. Retrieved November 9, 2022, from https://www.icop.or.ke/wp-content/up-loads/2016/10/KP-National-Guidelines-2014-NASCOP.pdf National AIDS Commission, Republic of Malawi (2009). National HIV prevention strategy, 2009-2013. Republic of Malawi. Retrieved October 8, 2022, from https://www.ilo.org/wcmsp5/groups/public/---ed_protect/---protrav/---ilo_aids/docu-ments/legaldocument/wcms_125539.pdf 65 National AIDS Commission, Republic of Malawi (2017). Malawi national condom strategy, 2015–2020. National AIDS Commission, Republic of Malawi. Retrieved December 9, 2022, from http://www.healthpolicyplus.com/ns/pubs/7184-7325_MalawiNationalCon-domStrategyJuly.pdf National AIDS Control Council of Kenya (2005). Kenya national HIV/AIDS strategic plan, 2005/6- 2009/10. National AIDS Control Council, Republic of Kenya. Retrieved August 2, 2022, from https://gcwa.unaids.org/sites/womenandaids.net/files/Kenya-AIDS-National-Strategic-Plan-2005-2010.-doc.pdf National AIDS Control Council, Kenya (2014). Kenya AIDS Response Progress Report – 2014 – Progress towards zero. UNAIDS. Retrieved November 12, 2022, from https://www.un-aids.org/sites/default/files/country/documents/KEN_narrative_report_2014.pdf National AIDS Control Council of Kenya (2018). The national HIV and AIDS stigma and dis crimination index: summary report. Ministry of Health, Republic of Kenya. Retrieved November 12, 2022, from http://www.kelinkenya.org/wp-content/uploads/2018/12/HIV-stigma-index.pdf National AIDS Coordinating Agency, Republic of Botswana (2003). The national HIV/AIDS strategic framework 2003–2009. Republic of Botswana. Retrieved May 5, 2022, from https://extranet.who.int/countryplanningcycles/sites/default/files/country_docs/Bot-swana/botswana_national_hiv_aids_stragetic_framework_2003-2009.pdf National AIDS Coordinating Agency, Republic of Botswana (2006). National strategy for behavioural change interventions and communications for HIV and AIDS. Republic of Botswana. Retrieved October 21, 2022, from http://www.ilo.int/wcmsp5/groups/public/---ed_protect/---protrav/---ilo_aids/documents/legaldocument/wcms_125679.pdf 66 National AIDS Coordinating Agency, Republic of Botswana (2014). Botswana 2013 global AIDS response report. UNAIDS. Retrieved December 23, 2022, from https://www.unaids.org/sites/default/files/country/documents/BWA_narrative_re-port_2014.pdf National Coordinating Agency for Population and Development [Kenya], Ministry of Health [Kenya], Central Bureau of Statistics [Kenya], & ORC Macro (2005). Kenya service provision assessment survey 2004. National Coordinating Agency for Population and De-velopment, Republic of Kenya. Retrieved November 12, 2022, from https://dhspro-gram.com/pubs/pdf/spa8/00FrontMatter.pdf#[1,{%22name%22:%22FitH%22},786] National Statistical Office, Republic of Malawi & The DHS Program (2017). Malawi demo- graphic and health survey 2015–16. National Statistical Office, Republic of Malawi. Re-trieved November 11, 2022, from https://dhsprogram.com/pubs/pdf/FR319/FR319.pdf Ngwanaamotho, M. (2010, January 10). Polygamy still popular for many. Mmegionline. Retrieved October 22, 2022, from https://www.mmegi.bw/news/polygamy-still-popular-for-many/news Nkomazana, O., Peersman, W., Willcox, M., Mash, R., Phaladze, N. (2014). Human resources for health in Botswana: The results of in-country database and reports analysis. African Journal of Primary Health Care & Family Medicine, 6(1), Article 716. https://doi.org/10.4102/phcfm.v6i1.716 Nolen, S. (2005, November 21). Deaths rob Malawi of warriors. The Globe and Mail. Retrieved December 22, 2022, from https://www.theglobeandmail.com/news/world/deaths-rob-ma-lawi-of-warriors/article20430357/ 67 North, D. (1990). Institutions, institutional changes and economic performance. Cambridge University Press. Retrieved September 19, 2022, from https://jonnyphillips.github.io/FLS6415/Class_2/North%201990.pdf Ntata, P. R. T. (2007). Equity in access to ARV drugs in Malawi, SAHARA-J. Journal of Social Aspects of HIV/AIDS, 4(1), 564-574. https://doi.org/10.1080/17290376.2007.9724818 Office of the United Nations High Commissioner for Human Rights (n.d.). International Bill of Human Rights. United Nations. Retrieved November 21, 2022, from https://www.ohchr.org/en/what-are-human-rights/international-bill-human-rights Okall D. O., Ondenge, K., Nyambura, M., Otieno, F. O., Hardnett, F., Turner, K., & Gust, D. A. (2014). Men who have sex with men in Kisumu, Kenya: comfort in accessing health ser-vices and willingness to participate in HIV prevention studies. Journal of Homosexual-ity, 61(12), 1712–1726. https://doi.org/10.1080/00918369.2014.951261 Opendataforafrica.org (n.d.). Statistics Botswana data portal: “Hospital”. Retrieved December 22, from https://botswana.opendataforafrica.org/search?query=hospital Open Society Foundation (2013). Criminalizing condoms: How policing practices put sex workers and HIV services at risk in Kenya, Namibia, Russia, South Africa, the United States, and Zimbabwe. The Centre for HIV Law and Policy. Retrieved November 22, 2022, from https://www.hivlawandpolicy.org/resources/criminalizing-condoms-how-po-licing-practices-put-sex-workers-and-hiv-services-risk-kenya 68 Oti-Boadi, M. & Dziwornu, E. (2014). Ghanaian students' attitude towards homosexuality: a study among students of Ghana Technology University College. Journal of Scientific Research and Studies,1(1), 28–34. Retrieved May 25, 2022, from https://www.seman-ticscholar.org/paper/Ghanaian-students%27-attitude-towards-homosexuality%3A-Oti-Boadi-Dziwornu/1e936ae17cb084346a6b2e2dc6d63883b08968db Pallin, S. C., Meekers, D., Lupu, O. & Longfield, K. (2013). Botswana: A total market approach: PSI/UNFPA joint studies on the total market for male condoms in six African countries. PSI.org. Retrieved December 10, from https://www.psi.org/publication/total-market-approach-botswana/ Pew Research Center (2016a). Christians. Pew Research Center. Retrieved October 21, 2022, from http://www.globalreligiousfutures.org/religions/christians Pew Research Center (2016b). Muslims. Pew Research Center. Retrieved October 21, 2022, from http://www.globalreligiousfutures.org/religions/muslims Pew Research Center (2013, June 4). The global divide on homosexuality. Pew Research Center. Retrieved November 27, 2022, from https://www.pewre-search.org/global/2013/06/04/the-global-divide-on-homosexuality/ Pew Research Center (2020, June 25). The global divide on homosexuality persists. Pew Research Center. Retrieved November 27, 2022, from https://www.pewre-search.org/global/2020/06/25/global-divide-on-homosexuality-persists/ Politifact (2016, February 25). Does Malawi have just 300 doctors for 16 million people. Africa Check. Retrieved November 13, from https://africacheck.org/fact-checks/reports/does-malawi-have-just-300-doctors-16-million-people 69 Qiao, X. & Ma, X. (2019). The image of China in English versions of state leaders’ address — A case study of Xi Jinping’s address from 2016 to 2018. Open Journal of Modern Linguistics, 9(6), 591–606. https://doi.org/10.4236/ojml.2019.96043 Rakner, L. (1996). Rational choice and the problem of institutions: A discussion of rational choice institutionalism and its application by Robert Bates. Chr. Michelsen Institute. Re-trieved September 17, 2022, from https://core.ac.uk/download/pdf/59168387.pdf Rasiński, L. (2011). The idea of discourse in poststructuralism: Derrida, Lacan and Foucault. Teraźniejszość – Człowiek – Edukacja, 1: A quarterly of social and educational ideas,7–22. University of Lower Silesia, Opub. Retrieved April 25, 2022, from https://core.ac.uk/download/51278827.pdf Remme, M., Siapka, M., Sterck, O., Nbube, M., Watts, C. & Vassall, A. (2016). Financing the HIV response in sub-Saharan Africa from domestic sources: Moving beyond a normative approach. Social Science & Medicine, 169(2016), 66–76. https://doi.org/10.1016/j.socscimed.2016.09.027 Reniers, G. & Tfaily, R. (2008). Polygyny and HIV in Malawi. Demogr Res., 19(53),1811–1830. https://doi.org/10.4054/DemRes.2008.19.53 Reproductive Health Supplies Coalition (2013, July 15). Shortage of condoms in Ghana. BERNAMA. Retrieved November 15, 2022, from https://www.rhsupplies.org/news-events/news/shortage-of-condoms-in-ghana-1430/ Roura, M., Busza, J., Wringe, A., Mbata, D., Urassa, A. & Zaba, B (2009). Barriers to sustaining antiretroviral treatment in Kisesa, Tanzania: A follow-up study to understand attrition from the Antiretroviral Program. AIDS Patient Care and STDs, 23(3), 203–210. https://doi.org/10.1089/apc.2008.0129 70 Sano, Y., Antabe, R., Atuoye, K. N., Hussey, L. K., Bayne, J., Calaa, S. Z., Mkandawire, P., & Luginaah, I. (2016). Persistent misconceptions about HIV transmission among males and females in Malawi. In BMC Int Health Hum Rights, 16(2016), Article 16. https://doi.org/10.1186/s12914-016-0089-8 Schmidt, V. (2008). Discursive Institutionalism: The explanatory power of ideas and discourse. Annual Review of Political Science, 11(2008), 303–332. https://doi.org/10.1146/an-nurev.polisci.11.060606.135342 Schons, M. (2022, September 15). Witch trials in the 21st century. National Geographic. Retrieved October 28, 2022, from https://education.nationalgeographic.org/re-source/witch-trials-21st-century Shangani, S., Naanyu, V., Operario, D., & Genberg, B. (2018). Stigma and healthcare-seeking practices of men who have sex with men in western Kenya: A mixed-methods approach for scale validation. AIDS patient care and STDs, 32(11), 477–486. https://doi.org/10.1089/apc.2018.0101 Skocpol, T. (1985). Bringing the state back in: Strategies of analysis in current research. In P. Evans, D. Rueschemeyer, & T. Skocpol (Eds.), Bringing the State Back In (pp. 3–38). Cambridge University Press. https://doi.org/10.1017/CBO9780511628283.002 Snowden, C. J. & Carlsson, L. E. (2021). A critical discourse analysis of representations of travellers in public policies in Ireland. Societies, 11(1), Article 14. https://doi.org/10.3390/soc11010014 Solomon, F. (2016, September 6). Rodrigo Duterte declares a State of Emergency in the Philippines. Time. Retrieved November 19, 2022, from https://time.com/4479616/ro-drigo-duterte-philippines-obama-davao-blast/ 71 Star Awards (Ply) Ltd (2014). Afrobarometer Round 6 Survey in Botswana, 2014. Afrobarometer. Retrieved November 19, 2022, from https://www.afrobarometer.org/wp-content/uploads/2022/02/bot_r6_sor_en.pdf Star Awards (Pty) Ltd (2020, February 17). Intolerance of same-sex relationships may be on the decline in Botswana, Afrobarometer survey suggests. Afrobarometer. Retrieved Novem-ber 21, 2022, from https://www.afrobarometer.org/articles/intolerance-same-sex-relation-ships-may-be-decline-botswana-afrobarometer-survey-suggests/ Tambunan, R. W., Muchtar, H. M., Agustian, R., Salim, A., Aisyah, L., Marpaung, L. A., & Nasution, M. M. (2018). Critical discourse: Applying Norman Fairclough theory in recep Tayyip Erdogan’s balcony speech. Proceedings of the ICOELT-6, 6(2018), 174–183. Re-trieved October 25, 2022, from http://ejournal.unp.ac.id/index.php/selt/arti-cle/view/100167 Tenkorang, E. Y., Gyimah, S. O., Maticka-Tyndale, E. & Adjei, J. (2011). Superstition, witchcraft and HIV prevention in sub-Saharan Africa: the case of Ghana. Health & Sexuality, 13(9), 1001–1014. https://doi.org/10.1080/13691058.2011.592218 TheGlobaleconomy.com (n.d.). Fragile State Index. TheGlobaleconomy.com. Retrieved November 10, 2022, from https://www.theglobaleconomy.com/rankings/fragile_state_in-dex/ Tsoga, M. G. & Chinsinga, B. (2015). Summary of Results – Round 4 Afrobarometer Survey in Malawi. Afrobarometer. Retrieved November 19, 2022, from https://www.afrobarome-ter.org/wp-content/uploads/2022/02/mlw_r4_sor.pdf . 72 Uganda AIDS Commission (2011). National HIV & AIDS Strategic Plan, 2011/12 -2014/15. The Republic of Uganda. Retrieved September 29, 2022, from http://www.antonio-casella.eu/archila/Uganda_dec2011.pdf UNAIDS (2001). Summary of the Declaration of Commitment on HIV/AIDS. UNAIDS. Retrieved June 2, 2022, from https://www.unaids.org/sites/default/files/sub_land-ing/files/jc668-keepingpromise_en.pdf UNAIDS (2011, March 15). Zimbabwe: an HIV prevention success story. UNAIDS & UNFPA. Retrieved October 24, 2022, from https://www.unaids.org/en/resources/presscentre/fea-turestories/2011/march/20110315zimbabwe UN Women (n.d.). Botswana. UN Women, United Nations. Retrieved December 24, 2022, from https://data.unwomen.org/country/botswana United Nations Population Fund (2022). Terms of Reference for an Individual Consultant to review existing condom distribution channels and propose additional innovative condom distribution channels. United Nations Population Fund. Retrieved November 20, 2022, from https://botswana.unfpa.org/en/vacancies/terms-reference-individual-consultant-re-view-existing-condom-distribution-channels-and United Nations - World Population Prospects (2022a). Life Expectancy in Botswana, 1950-2022. Macrotrends. Retrieved October 10, 2022, from https://www.macro-trends.net/countries/BWA/botswana/life-expectancy United Nations - World Population Prospects (2022b). Life Expectancy in Kenya, 1950-2022. Macrotrends. Retrieved October 10, 2022, from https://www.macrotrends.net/coun-tries/KEN/kenya/life-expectancy 73 United Nations - World Population Prospects (2022c). Life Expectancy in Malawi, 1950-2022. Macrotrends. Retrieved October 10, 2022, from https://www.macrotrends.net/coun-tries/MWI/malawi/life-expectancy University of Botswana (2008). Summary of results – Round 4 Afrobarometer Survey in Botswana. Afrobarometer. Retrieved November 19, 2022, from https://www.afrobarome-ter.org/wp-content/uploads/migrated/files/publications/Summary%20of%20re-sults/bot_r4_sor.pdf University of Malawi (2017). Afrobarometer Round 6 Survey in Malawi, 2014. Afrobarometer. Retrieved November 19, 2022, from https://www.afrobarometer.org/wp-content/up-loads/2022/02/mlw_r6_sor.pdf Wahlström, N. & Sundberg, D. (2018) Discursive institutionalism: towards a framework for analysing the relation between policy and curriculum. Journal of Education Policy, 33(1), 163–183. https://doi.org/10.1080/02680939.2017.1344879 World Health Organization (2000). Information, Education and Communication: A guide for AIDS programme managers. World Health Organization. Retrieved June 6, 2022, from https://apps.who.int/iris/bitstream/handle/10665/205344/B0224.pdf Xinhua (2022, June 27). Botswana intensifies surveillance on monkeypox. Xinhua. Retrieved November 18, 2022, from https://eng-lish.news.cn/20220627/0c6ebb317f09448aa0a53ff31b6b824b/c.html Zahn, R., Grosso, A., Scheibe, A., Bekker, L. G., Ketende, S., Dausab, F., Iipinge, S., Beyrer, C., Trapance, G., & Baral, S. (2016). Human rights violations among men who have sex with men in Southern Africa: Comparisons between legal contexts. PloS One, 11(1), e0147156. https://doi.org/10.1371/journal.pone.0147156 74 Appendices Appendix A: List of Tables Table 1 Fairclough’s Tri-layered Model of Critical Discourse Analysis Layer Title Meaning Possible Objects to look for in this research Applicability in Chapter 5 of this research 1 (Micro) Textual analysis Dissecting signifi-cance behind sym-bolic signals within words and sen-tences (Within policy recommenda-tions) Quality of word choices/verbs 5.2.3, 5.3.2 2 (Meso) Dis-course practice analysis Connecting policy contents to cogni-tive understanding in power rela-tions/dynamics (Policy recommendations) Varieties/ types of/ interactional effects from policies 5.2.4, 5.3.1 3 (Macro) Socio cultural practice Demonstrating how states leverage their power in the situational context Descriptions of policy con-text, of which state govern-ments/ executive bodies ad-dress or establish their stand-points and positionality on the problem of AIDS, in rela-tion to socio-cultural context 5.2.1, 5.2.2 Note: Table constructed with inferences and references to “Critical discourse: Applying Norman Fairclough theory in recep Tayyip Erdogan’s balcony speech”, by R.W. Tambunan, H.M. Much-tar, R. Agustian, A. Salim, L. Aisyah, L.A. Marpaung, & M.M. Nasution, 2018 (pp.179, 182), Proceedings of the ICOELT-6, 6(2018), 174-183, (http://ejournal.unp.ac.id/index.php/selt/arti-cle/view/100167). Copyright 2018 by Universitas Negeri Padang. 75 Table 2 List of Documents Examined Country Official Title Published & Years of Application Botswana National HIV/AIDS Strategic Framework 2003/ 2003–2009 National Guidelines — HIV Testing AND Counselling 2009/ 2009–2012 National Strategy for Behaviour Change Interventions and Communications for HIV and AIDS 2006 2012 Mapping, Size Estimation & Behavioral and Biolog-ical Surveillance Survey (BBSS) of HIV/STI Among Select High-Risk Sub-Populations in Botswana 2012 Removing Human Rights and Gender Related Barriers to HIV/AIDS and TB Services in Botswana 2019 Kenya Kenya National HIV/AIDS Strategic Plan 2005/2005–2010 HIV Prevention Response and Modes of Transmission Analysis 2009 National Behavioral Assessment of Key Populations in Kenya: Polling Booth Survey Report 2014 National Guidelines for HIV/STI Programming with Key Populations 2014 Malawi National HIV/AIDS Action Framework 2005/2005–2009 Guidelines for Pediatric HIV Testing and Counselling 2007 National HIV Prevention Strategy 2009/2009-2013 76 Table 3 Country Profiles: Botswana, Kenya, and Malawi Indicators Botswana Kenya Malawi Indicators on HIV/AIDS and coun-tries’ social context HIV prevalence, 2005 (%)a 24.1 6.1 14.1 Life expectancy, both sexes, in 2007 (in years) 55b 57c 50d Annual life expectancy growth rate, 1995 (%) -1.36b -1.42c -0.26d Christians as % of coun-try’s population, 2010e 72.4 84.8 82.7 Women in polygamous relationship “many”f 10%g 11.3% (Central District)h aUNAIDS (2007, p.11). bUnited Nations - World Population Prospects (2022a). cUnited Nations - World Population Prospects (2022b). dUnited Nations - World Population Prospects (2022c). ePew Research Center (2016). fNgwanaamotho (2010, para.4). gBhalla (2018). hReniers and Tfaily (2008, p.10). iEconomist Intelligence Unit (2008, pp.5–6). jPuddington et. Al. (2010, pp. 815–816). Note: Life expectancy is rounded to the nearest integral. 77 Table 4 States’ Remarks on National Condom Policy Directives from Prevention/BCC Strategies Country Doc. Page Clause Bot-swana 28 “Build capacity of females to negotiate partner/client acceptance use of condoms or initiate discrete use of female condom … advocate for condom availability in prisons & same-sex facilities … expand con-dom distribution in motels, hotels, high transit areas, construction and trade industries.”a Kenya 21 “KNASP continues to promote correct and consistent condom use among the general population and those at higher risk of HIV infec-tion. Social marketing programmes will be expanded to enhance availability … particularly in high-risk locations. An accelerated con-dom distribution programme will be expanded to cover all provinces, supported by an IEC strategy targeting vulnerable groups. KNASP also supports the distribution of female condoms as a means of em-powering women to choose safer sex.”b Malawi 23 “Condoms have also been distributed in the communities through community-based distribution agents (CBDAs) of which some are young people … Various IEC materials including radio and TV pro-grammes have also been produced and aired aimed at educating peo-ple on the benefits of condoms and dispelling rumours ... A series of training programmes on condom promotion, storage, usage and dis-posal have also been conducted …”c aNACA Botswana (2006, p.28). bNACC Kenya (2005, p.21). cNAC Malawi, (2009, p.23). 78 Table 5 All Ideational-Type “Informative”, “Educating”, “Communicating”, Policies Regarding Behavioral Changes from States’ Prevention/BCC Documents and National Strategies Policies Target Audience Botswana Kenya Malawi Abstinence Youths Presenta Presentb Presentc Child exploitation laws Communities Presentd Concern of alcohol Public (IEC) Presente HIV knowledge/ infection/ protection Public Presentf Hospitality Presentg Youths Presenth Presentc HIV risk reduction / BCI MSMs Presenti Public Presentj Public (work) Presenti Women Presentk Traditional Leaders Presentl HIV sexual empowerment Women Presentk Life skills People who work for youths Presentm Youths Presentn Presento Presentp Positive living PLWHA Presentq Presentr Prevention of Mum-to-child transmission Public (IEC) Presents Presentt Sexual debut Public (IEC) Presentm Presentu “Theology of hope” Public (IEC) Presentt Total 9 7 6 79 aNACA Botswana (2006, p.9). bNACC Kenya (2009, p.44). c NAC Malawi (2005, p.19). dNACA Botswana (2006, p.27). eNACA Botswana (2003, p.54). fNAC Malawi (2005, p.22). gNACA Botswana (2003, p.41). hNACC Kenya (2005, p.23). iNACC Kenya (2009, p.48). jNACA Bot-swana (2003, p.51). kNACC Kenya (2009, p.32). lNACA Botswana (2003, p.49). mNACA Bot-swana (2006, p.27). nNACA Botswana (2006, p.25). oNACC Kenya (2009, p.49). pNAC Malawi (2009, p.22). qNACA Botswana (2003, p.44). rNAC Malawi (2009, p.35). sNACA Botswana (2006, p.28). tNAC Malawi (2009, p.31). uNACC Kenya (2005, p.22). Note: policies are considered communicatively “present” when the policy title/agenda is attached with the keywords “inform”, “educate” or “communicate” in the same bullet point or sentence. 80 Table 6 All Interactive-Type “Informative”, “Educating”, “Communicating”, Policies Regarding Behavioral Changes from States’ Prevention/BCC Documents and National Strategies Policies Target Audience Botswana Kenya Malawi Condoms and safe(r) sex Public (IEC) Presenta Presentb Presentc Discouragement in inter-gen sex abuse Public Presentd Emotions, risk and self-confi-dence with abstinence Teens Presente Fidelity/ Reduce sex partners Individuals Presentf Public (IEC) Presentg Gender based violence/ equal-ity/ sensitivity Public (IEC) Presenth Presenti Misconceptions Public Presentj Public (IEC) Presentk Patient’s rights and confidentiality Public Presentl Positive attitude Caregivers (IEC) Presentm Public (IEC) Presentn Respect of human/ legal rights Public Presento Public (IEC) Presentc Sex negotiation Female Youth Presenta Presentp Sex-gender relations and cul-ture Public (IEC) Presentq Sexual relationships and rewards Teens Presentr Sexuality communication Parents Presents Presenti 81 Table 6 (Cont’d) Policies Target Audience Botswana Kenya Malawi Social skills for sex/ absti-nence negotiation Youths Presentr Stigma and discrimination Public (IEC) Presentt Presentu Total 12 4 9 aNACA Botswana (2006, p.16). bNACC Kenya (2009, p.48). cNAC Malawi (2009, p.23). dNAC Malawi (2005, p.20). eNACA Botswana (2006, pp.5, 19). fNACA Botswana (2006, p.32). gNACC Kenya (2009, p.39). hNACA Botswana (2003, p.33). iNAC Malawi (2009, p.27). jNACA Botswana (2006, p.25). kNAC Malawi (2009, p.29). lNACA Botswana (2006, p.38). mNAC Ma-lawi (2005, p.29). nNACC Kenya (2005, p.41). oNACA Botswana (2006, p.29). pNAC Malawi (2009, p.28). qNAC Malawi (2009, p.36). rNACA Botswana (2006, p.19). sNACA Botswana (2006, p.27). tNACA Botswana (2003, pp.53, 56). uNACC Kenya (2005, p.25). Note: policies are considered communicatively “present” when the policy title/agenda is attached with the keywords “inform”, “educate” or “communicate” in the same bullet point or sentence. 82 Table 7 All Referral-Type “Informative”, “Educating”, “Communicating”, Policies Regarding Behavioral Changes from States’ Prevention/BCC Documents and National Strategies Policies Target Audience Botswana Kenya Malawi Referral Type HIV, PMTCT, and high active ART services Public (IEC) Presenta Presentb HIV testing High risk population Presentc Public (couples) Presentd Public (IEC) Presentc Presente Post-exposure prophylaxis Public (IEC) Presentf Total 2 1 3 aNACA Botswana (2003, p.55). bNAC Malawi (2009, p.33). cNACC Kenya (2009, p.48). dNACA Botswana (2006, p.25). eNAC Malawi (2009, p.30). fNAC Malawi (2009, p.32). Note: policies are considered communicatively “present” when the policy title/agenda is attached with the keywords “inform”, “educate” or “communicate” in the same bullet point or sentence. 83 Table 8 Categorization of State Governments’ HIV Pre/post-test Counselling Strategy Agendas Agenda Pre or Post Test Bot-swana Kenya Malawi Technical Type Policies Addressing/obtaining consent Pre Presenta Presentb Presentc Assessing one’s HIV knowledge Pre Presentc Discussing potential challenges of HIV testing Pre Presenta Presentb Presentc Explaining (rapid) test process Pre Presenta Presentb Presentc Provisioning/discussing meaning of HIV test results Pre and post (Botswana only) Presentad Presentc Total (technical type policies only) 4 3 5 Interactive Type Policies Assessing clients' readiness for HIV testing Pre Presenta Presentb Presentc Correcting misconceptions Post Presentd Discussing disclosure Post and pre (all but Malawi) Presentad Presente Presentcf Discussing family planning Post Presentd Presente Discussing HIV prevention Post Presente Discussing positive living Post Presentd Discussing risk reduction Post Presentd Presente Presentf Educating on condoms Post Presentd Presente Exploring personal HIV risk reduction Pre Presenta Presentf Total (interactive type policies only) 8 5 4 84 Table 8 (Cont’d) Agenda Pre or Post Test Botswana Kenya Malawi Referral Type Policies Discussing emotional support Post Presente Discussing family member for HIV testing Post and pre (Malawi only) Presente Presentcf Discussing referral of partner for HIV testing Post and pre (Kenya only) Presentd Presentbe Discussing referrals to other maternal services Post Presente Discussing referrals to other (public) health services Post and pre (Kenya only) Presentd Presentbe Presentf Discussing repeat testing Post Presentd Presentf Exploring support system Pre Presenta Total (referral type policies only) 4 5 3 aMoH Botswana (2009, p.25). bNACSOP (2008, p.15). cMoH Malawi (2007, p.13). dMoH Bot-swana (2009, p.25). eNACSOP (2008, p.18). fMoH Malawi (2007, p.14). Note: “Post-test” policies include policies which target HIV-negative clients only. 85 Table 9 Discourses on the Agenda of “Consent” in State Governments’ HIV Pre/post-test Counselling Strategies Theme Country Quote/Remarks “Informed-ness” of consent Botswana “The fundamental value to be applied (on obtaining informed consent) is respecting the choices and decisions of individuals. All those offered the test should receive sufficient information and should be helped to reach an adequate understanding what is involved.”a Kenya “Generally, all persons receiving an HIV test must give informed consent prior to being tested. The HIV and AIDS prevention and control Act (2006) states that ‘no person shall be tested without their consent’.”b Malawi “Group information and education about HIV infection should be given … to ensure informed consent.”c Matter of “question-ing” and other rights in services under “consent” Botswana “The patient will be afforded an opportunity to ask the health care provider questions.”d “Declining the test will not affect the patient's access to services that do not depend on knowledge of HIV status” “Clients attending health facilities have a right to decline HIV testing if they do not think that it is in their best interest or if they need more time to consider”d Kenya “All persons should be given time to ask questions” “HIV testing must be accompanied by pre-test information, including referrals to appropriate services.”e Malawi “Once these questions or issues have been addressed, the clinician can test the child.”f “Determine if there is a history of sexual abuse, and then refer to appropriate counselling and legal services.”f “In this case, the best interest of the child and the obvious benefits of post-exposure prophylaxis are paramount.”g 86 Table 9 (Cont’d) Theme Country Quote/Remarks Role(s) which clini-cians serve in relation to infor-mation Botswana “Minimum information to be provided to patients by service providers includes potential risks of testing e.g. discrimination, abandonment or violence; services available in case of an HIV negative or HIV positive result”d Kenya “Counselling should provide adequate information to clients for proper decision making.”b Malawi “The health provider must: Obtain a thorough social history, focusing on the reasons why a child wants to be tested without knowledge of a parent or guardian … With respect and sensitivity, inquire as to why the child believes he/she may be infected with HIV … Determine whether the child understands what HIV is.”f aMoH Botswana (2009, p.8). bNASCOP (2008, p.15). cMoH Malawi (2007, p.6). dMoH Bot-swana (2009, p.26). eNASCOP (2008, p.19). fMoH Malawi (2007, p.14). gMoH Malawi (2007, p.13). 87 Table 10 Country Indicators on National Socio-Political Changes between Mid-late 2000s to Early-mid 2010s: Adequacy (Category 1) Sub-categories Botswana Kenya Malawi National total number of hospitals and health clinics 295 (2005)a; 353 (2015)b 1253 (2004)c; 1847 (2015)d 165 (2005)e; 488 (2014)f Spending per HIV Case (total / from government) $1648 / $1203 (73%) (2015)g $1165 / $182 (16%) (2015)h $691 / $80 (12%) (2015)i Number of doctors and nurses 466 doctors and 4468 nurses (2005)j; 1820 doctors and 9297 nurses (2012)k 5016 doctors and 40772 nurses (2005)l; 51649 nurses and 5660 doctors (2015)m Approx. 2000 nurses and 100 doctors (2005)n; approx. 600 doctors (2015)o and 5441 nurses (2017)p National demand and supply of condoms, annual 34 million; 32 million (94% of demand) (2012)q 240 million; 180 mil-lion (75 % of de-mand, with unstable supply, 2011)r 363 million; 56 mil-lion (condoms used, 15% of demand) (2014)s People who receive no medical care in the clinic (%) 37 (2005); 36 (2014)t 68 (2005); 48 (2014)t 54 (2005); 59 (2014)t Public disapproval in improving basic health services by gov’t (%) 15 (2005); 26 (2014)u 30 (2005); 33 (2014)u 56 (2005); 51 (2014)u aCentral Statistics Office, Botswana (2005b, p.26). bopendataforafrica.org (n.d.). cNational Coor-dinating Agency for Population and Development [NCAPD] et. Al. (2005), p.17. dMoH Kenya (2019, p.4). eEcumenical Pharmaceutical Network (2005, p.12). fGovernment of the Republic of Malawi (2017, p.15). gGlobal Burden of Disease Health Financing Collaborator Network 88 [GBDHFCN] (2018, p.1816). hGBDHFCN (2018, p.1818). iGBDHFCN (2018, p.1819). jCentral Statistics Office, Botswana (2005b, p.1). kNkomazana et. Al. (2014, p.6). lNCAPD et. Al. (2005, p.21). mMoH Kenya (2017 p.10). nNolen (2005). oPolitifact (2016). pBerman et. Al. (2021, p.2). qPallin et. Al. (2013, p.11). rMandal (2011). sNAC Malawi (2017, p.2). tArmah-Attoh et. Al. (2016, pp.5, 6). uArmah-Attoh et. Al. (2016, pp.11, 12). Note: All non-integral figures are rounded to the nearest integral. 89 Table 11 Country Indicators on National Socio-Political Changes between Mid-late 2000s to Early-mid 2010s: Bottom-up Trust and Reliance (Category 2) Sub-categories Botswana Kenya Malawi People’s trust (“somewhat” or “a lot”) towards parliament - towards traditional leaders (%) 69 - 80 = -11 (2008) 55 - 71 = -16 (2014) 48 - 56 = -8 (2008) 53 - 70 = -17 (2014) 53 - 73 = -20 (2008) 50 - 69 = -19 (2014) People’s trust (“somewhat” or “a lot”) towards parliament - towards religious leaders (%) 55 - 67 = -12 (2014) 53 - 81 = -28 (2014) 53 - 80 = -27 (2014) People’s support towards paying more taxes for public health spending (support - oppose) (%) 48 - 39 = 9 (2014) 22 - 65 = -41 (2014) 34 - 59 = -25 (2014) Citizens’ reliance (at least a few times) to government agency - traditional leaders about problems or views (%) 14 - 16 = -2 (2008) 18 - 17 = 1 (2014) 16 - 30 = -14 (2008) 12 - 28 = -16 (2014) 5 - 29 = -24 (2008) 7 - 29 = -22 (2014) Citizens’ reliance (at least a few times) to government agency - religious leaders about problems or views (%) 14 - 38 = -24 (2008) 18 - 24 = -6 (2014) 16 - 41 = -25 (2008) 12 - 44 = -32 (2014) 5 - 24 = -19 (2008) 7 - 40 = -33 (2014) Note: All data for Botswana in 2008 are from Summary of Results: Round 4 Afrobarometer Sur-vey in Botswana, by University of Botswana, 2008 (pp.12–13, 22–23), 90 (https://www.afrobarometer.org/publication/botswana-round-4-summary-results-2008/). Copy-right 2008 by Afrobarometer. All data for Botswana in 2014 are from Summary of Results: Round 6 Afrobarometer Survey in Botswana, 2014, by Star Awards (Ply) Ltd, 2014 (pp.13–14, 28–29, 40, 41), (https://www.afrobarometer.org/publication/botswana-round-6-summary-results-2014/). Copyright 2014 by Afrobarometer. All data for Kenya in 2008 are from Round 4 Afroba-rometer Survey in Botswana, 2008, by Institute for Development Studies, University of Nairobi and Michigan State University, 2008 (pp.13, 14, 24, 25), (https://www.afrobarometer.org/survey-resource/kenya-round-4-data-2008/). Copyright 2008 by Afrobarometer. All data for Kenya in 2014 are from Summary of Results: Round 6 Afrobarometer Survey in Kenya, 2014, by Institute for Development Studies, University of Nairobi, 2015 (pp.14, 15, 30, 32, 45), (https://www.afrobarometer.org/publication/kenya-round-6-summary-results-2014/). Copyright 2015 by Afrobarometer. All data for Malawi in 2008 are from Malawi Round 4 Afrobarometer Survey, 2008, by M.G. Tsoga & B. Chinsinga, 2015 (pp.14, 15, 25, 26), (https://www.afrobarom-eter.org/publication/malawi-round-4-summary-results-2008/). Copyright 2015 by Afrobarometer. All data for Malawi in 2014 are from Afrobarometer Round 6 Survey in Malawi, 2014, by M.G. Tsoga & Centre for Social Research, University of Malawi, 2017 (pp.12, 25, 26, 37), (https://www.afrobarometer.org/publication/malawi-round-6-summary-results-2014/). Copyright 2017 by Afrobarometer. 91 Table 12 Country Indicators on National Socio-Political Changes between Mid-late 2000s to Early-mid 2010s: HIV Knowledge, Misconceptions and Stigma (Category 3) Sub-categories Botswana Kenya Malawi People age 15-19 who know condom uses can prevent HIV (%) 94 (2013)a 76 (2014)b 70 (2015)c People age 15-24 who have compre-hensive knowledge on HIV (%) 47 (2013)d 57 (2014)e 42 (2015)f People age 15-19 who would not buy food from HIV-in-fected shopkeepers (%) 24 (2004)a; 12 (2013)a 40 (2003)g; 25 (2014)h 23 (2015)i People age 15-24 who think HIV in-fected people (stu-dent or teacher) should not attend/ teach in school (%) 8 (2013, age 15–24)j 13 (2014, age 15–24)h 11 (2015, age 15–24)i PLWHAs who were excluded from fam-ily activities (%) 5 (2014, past 12 months)k 9 (2014, Nairobi)l 14 (2012)m PLWHAs who were gossiped, past 12 months (%) 39 (2014)k 23 (2014, Nairobi)l 48 (2012)m aLetamo (2019, p.50). bKenya National Bureau of Statistics et. Al. (2015, p.210). cNational Sta-tistical Office, Republic of Malawi and The DHS Program [NSO Malawi and DHS] (2017, p.213). dHamda et. Al. (2020, p.6). eKenya National Bureau of Statistics et. Al. (2015, pp.214– 92 215). fNSO Malawi and DHS (2017, p.214). gCentral Bureau of Statistics [Kenya] et. Al. (2004, pp.192–193). hKenya National Bureau of Statistics et. Al. (2015, pp.221, 223). iNSO Malawi and DHS (2017, p.215). jGaregae et. Al. (2017, p.93). kBotswana Network of People Living with HIV & AIDS (2014, p.1). lNACC Kenya (2018, p.24). mMalawi Network of People Living with HIV and AIDS (2012), p.39. Note: All non-integral figures are rounded to the nearest integral. 93 Table 13 Country Indicators on National Socio-Political Changes between Mid-late 2000s to Early-mid 2010s: Behavioral Compliance (Category 4) Sub-Categories Botswana Kenya Malawi People age 15-24 who have ever had an HIV test (%) Unavailable 61 (2012)a 65 (2015)b People who had an HIV test past year (%) 63 (2013, age 15+)c 42 (2012, age 15–49)d 43 (2015, age 15–49)b Condom use rate: non-martial sex part-ners (%) 72 (2013)c 42 (2012)e 28 (2015)f Support to contracep-tive education for school children 72% (high school teachers, 2013)g 60% (2012)h “Unfavourable” (2017)i People age 15-49 whose sexual debut is before 15 (%) 8 (2004)j ; 5 (2008, age 10-64)k 16 (2008)l; 15 (2014)l 15 (2004)m; 17 (2015)m aKenya National Bureau of Statistics et. Al. (2015, p.253). bNSO Malawi and DHS (2017, pp.219–220). cNACA Botswana (2014, p.12). dNACC Kenya (2014, p.14). eKenya National Bu-reau of Statistics et. Al. (2015, p.207). fNSO Malawi and DHS (2017, pp.219–220). gKasonde (2013, p.3). hKenya National Bureau of Statistics et. Al. (2015, p.226). iKalimbuka (2017, para. 4). jCentral Statistics Office(2005a, p.29). kCentral Statistics office and NACA Botswana (2009, p.172). lKenya National Bureau of Statistics et. Al. (2015, p.248). mNSO Malawi and DHS (2017, p.210). Note: All non-integral figures are rounded to the nearest integral. 94 Table 14 Indicators on Tolerance and Acceptability Regarding Key Populations Categories Botswana Kenya Societal Tolerance Violence against sex workers, past 12 months (%) 66 (2017)a 97 (2020)b Police violence against sex workers, past 12 months (%) 39 (2017)a 63 (2020)c Police arrest against sex workers, past 12 months (%) 48 (2017)d 58 (2020)e Police assistant positive reception rate, sex workers (%) 52 (2017)d 47 (2020)f Police violence rate, MSMs, past 12 months (%) 2 (2009)g; 2 (2016)h 27 (2015)i Legal status of homosexuality Legal (since 2019; appeal from state denied in 2021; state has “hon-oured” court’s decision since 2022)j Illegal k Categories Botswana Kenya Interpersonal Acceptance Judgement or verbal abuse from healthcare workers against sex workers, past 12 months (%) 51 (2017)l 48 (2020)m LGBT acceptance index (out of 10) 4.5 (2009–13)n; 4.5 (2014–17)o 3.2 (2009–13)p; 3.4 (2014–17)q Neighbour acceptance: homosexuals (%) 43 (2014)r; 48 (2019)r 14 (2014)s; 9 (2019)t Homosexuality acceptance (%) Unavailable 8 (2013)u; 14 (2019)v 95 aAidsfonds (2017, p.15). bAidsfonds (2020, p.17). cAidsfonds (2020, p.17). d IDSfonds (2017, p.18). eAidsfonds (2020, p.26). fAidsfonds (2020, p.31). gZahn et. Al. (2016, p.7). hARCUS Foundation (2019, p.26). iARCUS Foundation (2019, p.41). jOsazuwa (2022, para. 1, 3). KBusari (2019, para. 1). lAidsfonds (2017, p.19). mAidsfonds (2020, p.19). nFlores (2019, p.32). oFlores (2019, p.33). pFlores (2019, p.35). qFlores (2019, p.34). rStar Awards Pty Ltd (2020, p.2). sInsti-tute for Development Studies, University of Nairobi (2015, p.65). tInstitute for Development Studies, University of Nairobi (2021, pp. 72–73). uPew Research Center (2013). vPew Research Center (2020). 96 Appendix B: List of Figures Figure 1 The Logic Behind State's (Discursive) Power-making in the Lens of DI 97 Figure 2 Summative Figure on Theoretical Concepts Addressed in This Research 98 Figure 3 Summative Diagram on The Relationship between the Quality of Policy Programming and Outcomes in Social Stigma
Thesis/Dissertation
eng
Political Science
Vancouver : University of British Columbia Library
Graduate
Tiberghien, Yves
“Let’s talk sex scientifically!” : examining sub-Saharan states’ communication strategies in sexual health from AIDS programming in relation to their political leverage and stigmas against HIV’s key populations
Text