A narrative analysis positioning HIV relative to personal (sexual) relationship challenges in an agony aunt column in the Western Cape, South Africa – Aunty Mona’s “love advice”

ABSTRACT HIV prevalence and incidence in South Africa remain high, making HIV a part of everyday life. Community narratives on HIV treatment and prevention are important and influence official and unofficial health messaging and community perceptions and understandings of HIV. We explore how contributors and the columnist of an agony aunt column position HIV relative to choices made about love, partnership, and sex over three years. We analysed all columns of an agony aunt series (Antie Mona) published between December 2012 and November 2015. The column is published in a South African, Afrikaans-language newspaper “Son”, prioritising sensationalist news items. Trends were identified through narrative analysis. Data were managed in ATLAS.ti and inductive, iterative coding conducted. It was found that letters to the agony aunt rarely refer to HIV directly (less than 7%). Euphemisms such as diseases of the flesh and the great flu were more commonly used instead of HIV or AIDS. Letters addressed HIV in three ways: direct references to experiences living with HIV; direct questions about HIV prevention; and scenarios where HIV could (from a public health perspective) have been the main concern, but everyday issues took precedence. The majority of letters fell into this latter category where the writers focused on the immediate concerns of good sexual relations, problems related to love and romantic relationships, good moral behaviour of others, and issues of oppressive life conditions rather than on HIV directly. The findings illustrate that informal, public contributions to health information, such as agony aunts, are important narratives that inform popular perspectives on HIV and health. A better appreciation of this context would allow health implementers to ensure that these role players receive updated health messaging to avoid the risk of HIV-related stigma where HIV is used as a moral rod to punish perceived moral transgressions.


Introduction and background
Over six million South Africans are currently living with HIV and the incidence remains high and stable (Shisana et al., 2014). HIV is both a driver and a symptom of broader social challenges of inequity, poverty, and disenfranchisement (Auerbach, Parkhurst, & Cáceresc 2011;Hargreaves, Davey, Fearon, Hensen, & Krishnaratne, 2015;Magadi, 2013;Seeley et al., 2012). In parallel, HIV imposes into the most personal part of social beingintimate relationships and sexual relationsin various ways.
Even in sexually active relationships, discussions about intimacy and sex can be awkward and are often avoided. Public platforms to raise issues about relationships, intimacy, and sex are similarly limited. Agony aunt columns provide one such platform.
While the main aim of newspapers is to inform readers of current events, newspapers also aim to connect with their readership, thereby reinforcing the notion of a virtual community (Villi & Jung, 2015). Agony aunt columns create a space where readers can anonymously raise concerns or ask advice about subjects that might otherwise be too sensitive to discuss in public (Boynton, 2003). Agony aunts potentially act as projections of current social issues experienced by readers. The agony aunt column in the British newspaper Daily Mail, for example, is described by Engel as providing the opportunity to "to cast aside Victorian morality by giving readers robust daily common sense" (1996, p. 159). Agony aunts gain popularity for being able to portray their topic in language which resonates with the everyday talk used by their readership. Similarly, the credibility of the advice given is dependent on it being consistent with the readership's shared moral perspective. In this way, letters to agony aunts and their replies are representative of social norms of talking (and thinking). Agony aunts can thus offer researchers insights into current concerns and norms in specific communities or sub-cultures (Jackson, 2005;Mutongi, 2009). These everyday concerns, occasionally bordering on the taboo, provide a valuable space to study narratives about love, partnerships, and sexual relations.
In South Africa, the Afrikaans-language newspaper "Son" (Sun), features an agony aunt column under the moniker "Antie Mona" (Auntie Mona, where Mona is a deliberate wordplay on "moan"). Three writers, one man and two women, are currently responsible for assuming the role of Antie Mona on a rotating basis (personal communication with Son). Typically, the column features two to four letters from readers describing personal dilemmas and a response to each from Antie Mona. Letters can be submitted via mail, email, or text messages.
The newspaper has an annual readership of approximately one million and is available in three provinces in South Africa. The readership consists of mostly coloured, 1 Afrikaans-speaking people (South African Audience Research Foundation, 2015). Daily editions are printed in the Western Cape and weekly in other regions. The newspaper is available for ZAR 3.50 (USD: 0.21) in print or free online. The paper prioritises sensationalist news items and targets mostly the lower income, lower education market (Smith, 2012).
The Western Cape, Northern Cape, and the Eastern Cape, the provinces where the paper is available, have HIV prevalence rates of 5%, 7.4%, and 11.6%, respectively, compared to a national prevalence of 12.2% (Shisana et al., 2014). Many South Africans experience the effects of high levels of intimate partner violence and rape (Jewkes, Dunkle, Nduna, & Shai, 2010); substance abuse (Mayosi et al., 2012;Wong, Huang, DiGangi, Thompson, & Smith, 2008); and poverty, unemployment, and food insecurity (Amoateng & Setlalentoa, 2015). This context increases structural vulnerability to HIV, and simultaneously imposes more immediate concerns (such as food, employment, and avoiding violence) into daily lives (Hoddinott et al., 2014).
Several changes are also currently occurring in the HIV landscape. The World Health Organisation (WHO) has recently recommended initiation of antiretroviral therapy (ART) regardless of CD4 count (2015) for all people living with HIV (PLWH). Several studies are currently under way to determine the effectiveness of such "universal" access to treatment for HIV prevention (Hayes et al., 2014;Orne-Gliemann et al., 2015).
In this article, we explore how contributors and the columnists of an agony aunt column position HIV relative to choices made about love, partnership, and sex over three years. This was done in the context of a changing HIV treatment and prevention landscape to inform HIV prevention and treatment programme implementation.

Methods
Data were collected as part of a broader programme of social science research linked to an HIV prevention trial evaluating a combination prevention package including universal access to HIV testing and treatment being implemented in the Western Cape, South Africa. Longitudinal observations and discussions with residents indicated that Son has wide readership in some trial communities. In this context, letters to the agony aunt offered insight into the wider public discourse about HIV and sexual health.
Antie Mona columns published in the Western Cape between December 2012 and November 2015 2 were sourced from the archives at the National Library in Cape Town or online. The time frame was selected to include letters from a year prior to trial intervention implementation and to further overlap with the trial.
Letters were scanned and entered into ATLAS.ti (2015) for analysis by a team of six graduate social scientists (all proficient in Afrikaans). Each researcher read through at least five months of editions. Initial coding aimed to identify letters relating to relationships, love, and sex. Discussions were held to ensure a mutual understanding of article categories. A total of 2415 letters were published in the time period with 1709 related to relationships, love, and sex. Excluded letters dealt with general health, substance abuse, financial woes, schooling and career objectives, and community morale. The format of the letters varied from serious questions, to thinly veiled community gossip and boastful, detailed descriptions of sexual exploits posed as advice requests.
An inductive code list was generated for finer analysis of the 1709 selected letters. The researchers coded 15 letters each to iteratively refine this code list. Finally, the first and last author analysed all relevant letters using narrative analysis (Frank, 2012) to identify trends in how HIV is positioned relative to relationships, love, and sex.

Findings
Letters addressing HIV either directly or indirectly account for less than 7% of the total. The words HIV or AIDS are used in only 45 of 1709 letters. These references were in relation to personal health concerns, transmission or disclosure fears, and (occasionally) in stigmatising or accusatory terms. For example, the letter below is characteristic: I recently met a 32-year old lady and we developed feelings for each other … She told me that she is HIV-positive. … How do I tell my son? … -Via SMS [text message] You should act with the greatest of care. It was very brave of this girl to tell you about her status. (Antie Mona, 21 September 2015) Euphemisms for HIV were used 121 times, mostly positioning HIV as a potential consequence of moral transgressions and unsafe sex practices and as something that should be feared, as in the following example: My guy doesn't believe in using condoms. He says he is a real man that doesn't believe in things like that … Antie, do you think I should sleep with him? He is just so cute.
-Real man's girl Antie Aida [Aunty Aida/AIDS] is just as "cute". Sweetheart, you must remember that "real men" can also pick up that fatal flu of the lower body. With how many girls has your "real man" slept where he could have picked up "bird flu"? (Antie Mona, 1 September 2013) Here, bird flu, translated from "voëlgriep", is used as a euphemism where "bird" is also slang for "penis" in Afrikaans. Other terms related to disease are often used as a proxy for HIV, such as "siekte" or "vleeslike siektes" (diseases/sickness or diseases of the flesh), and "die groot griep" (the great flu).
Letters focusing on love, relationships, and sex addressed HIV in three ways: direct reference to experiences living with HIV; direct questions on HIV prevention for HIV-negative people; and scenarios where HIV could (from a public health perspective) have been the main concern, but everyday issues take precedence.

Living with HIV
In the letters explicitly mentioning HIV, the content focused on two aspects: avoiding HIV transmission and avoiding HIV-related stigma. The narratives were also interlaced with detailed descriptions of the complex and often emotional experiences of living with HIV or living affected by HIV.

Avoiding transmission
Letters from people in sero-discordant relationships consisted of technical questions on how to avoid HIV transmission between partners. Antie Mona's advice was generally to "use condoms" and to "disclose to partners". Treatment support for positive partners was mentioned on several occasions but treatment as prevention (TasP) and pre-or post-exposure prophylaxis (P(r)EP) were mentioned in only one letter. Antie Mona's responses dealt mainly with the moral, social, or romantic overtones of the question rather than the HIV prevention or treatment fact. In the following example, it is apparent that while the writer of the letter had questions on HIV transmission and oral sex, Antie Mona's advice focused on disclosure for reasons of honesty and avoiding criminal liability. The letter illustrates how even when practical questions on HIV transmission are raised, what is actually perceived to be at stake by Auntie Mona are issues related to love, trust, relationships, and morality. Lovie, first I want to commend you because you are thinking through these things first … It remains your choice, but Antie feels you must tell your guy about your HIV-status. It is such a big risk (not even considering it is a crime) to remain silent about it. … (Antie Mona, 8 May 2014) There are also letters promoting the stigmatisation of PLWH which remain largely unchallenged by Antie Mona. Some of her responses actively demonise PLWH. For example, in July 2013, several letters were published where readers accused young, single women in their communities of purposefully infecting (mostly married) men with HIV. These women were labelled with phrases such as vengeful (9 July 2013), "AIDSslut" and "bitch" (12 July 2013), "rotten with AIDS" (13 July 2013), "AIDS-monster" (14 July 2013), "serial killer" and "emaciated whore" (27 August 2013) by the submitters of letters. Similarly, Antie Mona's responses included language like "a remorseless murderer" (9 July 2013), a "common killer … using her body as weapon of mass destruction of families" (12 July 2013).
These stigmatising narratives illustrate the tension between everyday popular language and public health agendas to actively reduce stigma.

Avoiding stigma
Letters referring to experiences of living with or being affected by HIV were also concerned with fears of stigma. In the following letter (Antie Mona, 31 August 2015), a woman voices her fears of disclosing that she is living with HIV to her multiple partners: Antie, [one] night an old friend made a move on [made sexual advances towards] me and we had nice/good sex. He definitely loosened up something inside me … Every night of the week men are visiting me. The other day I went to the clinic to get my HIV/AIDS test. I was sad to find out that I was diagnosed as positive. I am now scared … to tell the men about my status. … Antie, how am I going to tell these men? -Via email The response from Antie Mona is unsympathetic. She repeats the mantra of disclosure as the best policy to avoid transmission and legal consequences of non-disclosure. Fears about disclosure leading to HIV-related stigma are not addressed, neither is prevention advice given.
It is a crime not to disclose your HIV/AIDS status to your partners. … Your letter is dripping with boastfulness about all the men you have managed to reel in … Or are you scared that one of your secret lovers will no longer want to have anything to do with you once they find out your status? (Antie Mona, 31 August 2015) In South Africa, there is a legal distinction between intentional and negligent transmission. In theory, the PLWH could be charged with assault if wilful or intentional transmission can be proven while culpable homicide can also be argued in terms of the negligent result of death (Singh, 2013). However, this distinction is not clarified in the column, which rather equates lack of disclosure with intention to infect.

HIV-negative and avoiding infection
The central HIV prevention discourse from Antie Mona is focused on avoiding disease and leaving unfaithful partners who might be the source of "diseases of the flesh". This is illustrated in the example below: D and I started dating last year, but then his eyes started wandering. Now he wants me again, but he has several girlfriends. He says he still loves me, Antie. What should I do? -Via SMS line [text message] Lovie, if you can't be number "only one" in his life, it would be better to not have him in your life at all … Or are you so abashed that you even want to run the risk of picking up diseases of the flesh? (Antie Mona, 2 July 2015)

Everyday relationships: HIV is not the issue
Many of the letters concerned with relationships, love, and sex address scenarios that public health practitioners would describe as directly linked to HIV and risk. These letters, which could have addressed issues of HIV but did not, fall into four general categories: good sexual relations, love and romantic relationships, good moral behaviour, and issues relating to oppressive life conditions.

Good sex
Several readers posed questions to Antie Mona about sexual relationships. These letters requested advice on how to improve sex lives and portray stories of unprotected sex, sex with multiple partners and other behaviours that could be considered to place the writer at risk of HIV. However, the request for advice was not about the potential risk of HIV but rather about having satisfying or "good" sex: I wanted to spice up our marriage and suggested we started swinging … that business where you swop partners … We met [a couple] at their house and started drinking heavily. It wasn't long before my wife disappeared with D. D's wife and I stayed behind … to let their living room couch make some noise [have sex]. Afterwards … I told my wife that I am no longer interested in swinging and she agreed that we should stop. Now I found out that she is still seeing D … and they are still having sex. Antie, she admitted that she likes sex with D more than with me. She also developed feelings for D. -Anonymous from S Do you see what your horniness brought you? You have awakened the horny whore in your wife and now you can't keep up with that monster … Antie is struggling to feel sorry for you. (Antie Mona, 3 December 2012)

Love and romance
Letters requesting advice for problems of a romantic nature make up the bulk of the letters to Antie Mona. Many also relate scenarios where those who write letters are either engaging in behaviour that put them at risk of HIV or are involved in relationships with partners who place them at risk. Again, the romantic concerns and not HIV risks are the focus of the correspondence.
I am a single parent who dated a guy for six years. A month ago he left me for a girl … [who has] two children. We had plans to get married next year, but everything is ruined now … I also realised that he has cheated on me with many other girls. This new girlfriend's name goes ahead of her [she has a bad sexual reputation], but he doesn't want to hear anything about it. I still love him and can't get him off my mind. -Sad girlfriend It happens so often to good women like yourself. Find solace in the fact that that man doesn't deserve you. Somewhere on the horizon a good man is waiting for you. The hurt will go away if you catch the right man's eye. (Antie Mona, 5 February 2013) 6.3. Morality and good moral behaviour Some letters are also complaints about the perceived immoral behaviour of people in the community. These letters are posed as requests for advice, but are often actually gossip.
In the following example, it becomes evident that readers are concerned with the moral behaviour of their community members, friends, and in this case adopted family. While the scenario in the letter described HIV risk behaviour, perceived immoral behaviour was seen as the central concern.
It is about a foster child. Antie, I am tired of the whoring of this child. This girl-child started whoring around with married men at age 15. She started sleeping with men without conscience/remorse. She is messing with their marriages. This child is completely out of control. She even has a child. The worst is that she doesn't even know who the child's father is, because she whores with everyone. -B Antie [I] can't make out if you are the foster parent of the child or if you are concerned citizen … I would urgently contact the social worker. … Antie is old school and believes a child can't try and raise another child. Especially not this child who is turning into a fullblooded jintoe [loose woman, whore]. With regards to the 15 year old horny mommy, she urgently needs to get back on the school benches -I am reading between the lines that she is a dropout. (Antie Mona, 12 February 2014)

Oppressive life conditions
Many of the letters reflect the socio-economic hardship that readers deal with on a daily basis. This includes conditions of domestic abuse, substance abuse, and poverty/ income inequality. The factors are viewed as contributing to vulnerability to HIV; however, as with the previous sections, HIV is not the focus of the letters. For example, the letter below illustrates how "A" faces multiple HIV risks but that this is a consequence of social vulnerability:

Conclusion
In letters to Antie Mona, two broad narratives were identified as characteristic of how HIV is positioned relative to people's relationship woes. Firstly, a small number of letters with direct reference to HIV, either explicitly or euphemistically, focus on experiences related to living with HIV (such as avoiding stigma and avoiding transmission to negative partners) or HIV prevention. Secondly, the majority of letters focus on general concerns such as good sexual relations, love and romantic relationships, good moral behaviour, and issues relating to oppressive life conditions. In these letters, scenarios emerge that public health practitioners would identify as directly linked to HIV risk, but it is also clearly and evocatively articulated as "not the issue" by the writers. As such, despite the widespread public health acknowledgement of HIV's importance and presence, for many of the contributors, it is not a priority.
The analysis illustrates that Antie Mona is perceived to play an important informative role in terms of issues relating to love, relationships, and sex. Even with the absence of direct reference to HIV in letters, Antie Mona is a potential source of health information. Health implementers aiming to implement ART scale-up and universal testing and treatment (UTT) should take into consideration the wider context of opinion makers outside of those traditionally considered "health stakeholders". Popular narratives (underpinned by such opinion makers) reinforce information that is sometimes limited, inaccurate or stigmatising. In a time of changing HIV prevention messaging, unofficial providers of information on HIV prevention, treatment, and care (like Antie Mona and the "everyday" conversations they are indicative of) need to be better informed.
Implementers of the scale-up of ART cannot ignore the everyday concerns of community members and the background against which HIV is poised. If contextual factors and the primary concerns of the public are not taken into account during the implementation of UTT, there is a real risk that the implementation programme will fail to reach optimal delivery. Furthermore, HIV is consistently used as a moral rod, often by Antie Mona, to blame PLWH for HIV incidence. This includes reference to the legal obligations of PLWH to inform others of their status. As access to HIV testing and treatment is expanded, this moral rod becomes all the more easily wielded by positioning uptake of HIV services as something that people should (rather than can choose to) do. If opinion makers, such as Antie Mona, are not well informed by public health implementers, this message of the moral obligation, as opposed to individual choice, of the uptake of testing and treatment is unlikely to change.
The scope of the study was limited to the inclusion of one media publication for analysis. While the letters represent one type of narrative present in the regions where the paper is published, the attitudes represented in the letters (and in the responses) do not necessarily reflect all societal attitudes in South Africa or the Western Cape. The analysis provides a learning opportunity to better understand the everyday concerns of community members and future analyses should be extended to other media platforms and languages. Notes 1. Classification based on "race" is a highly problematic feature of post-Apartheid South Africa. According to Newham, Masaku, and Dlamini (2006, p. 11) "Four racial classifications [White, Black, Indian, and Coloured] were invented as legal classifications during the apartheid era and are still in use today (Newham, Masaku, & Dlamini, 2006, p. 11)". We use the term "coloured" consistently with how readership is classified in media coverage statistics. 2. The analysis excludes columns from July 2014, as archives were not available in the library or online.

Disclosure statement
No potential conflict of interest was reported by the authors.