HIV and AIDS in South Africa

An estimated 5.6 million people were living with HIV and AIDS in South Africa in 2009, the highest number of people in any country.1 In the same year, it is estimated that 310,000 South Africans died of AIDS-related causes,2 reflecting the huge number of lives that the country has lost to AIDS over the last three decades.

Prevalence is 17.8 percent among those aged 15-49, with younger adults being particularly affected.3 HIV prevalence among those aged two and older also varies by province with the Western Cape (3.8 percent) and Northern Cape (5.9 percent) being least affected, and Mpumulanga (15.4 percent) and KwaZulu-Natal (15.8 percent) at the upper end of the scale.4

Marking a change in South Africa's history of HIV the South African Government launched a major HIV counselling and testing campaign (HCT) in 2010.5 Since its implementation, the HCT campaign has had a notable impact on the availability and uptake of HIV testing and treatment.

back to top Impact of HIV upon South Africa

Map of South Africa showing population and life expectancy Map of South Africa showing population and life expectancy

The impact of the AIDS epidemic is seen in the dramatic change in South Africa’s general mortality rates. The overall annual number of deaths increased sharply between 1997, when 316,559 people died, and 2006 when 607,184 people died.6 This rise is not necessarily due solely to HIV and AIDS but those who are particularly shouldering the burden of the increasing mortality rate are young adults, the age group most affected by the epidemic;7 almost one-in-three women aged 25-29, and over a quarter of men aged 30-34, are living with HIV.8 The link suggests that AIDS is the principle factor in the overall rising number of deaths.

We have more about South African HIV and AIDS statistics.

Impact upon children and families

South Africa’s HIV and AIDS epidemic has had a devastating effect on children. There were an estimated 330,000 under-15s living with HIV in 2009, a figure that has almost doubled since 2001.9 10 HIV in South Africa is transmitted predominantly through heterosexual sex, with mother-to-child transmission being the other main infection route. 11 percent of children born to HIV positive mothers become infected with HIV in South Africa.11 Because the virus is transmitted from the child's mother in cases of mother-to-child transmission, the HIV-infected child is born into a family where the virus may have already had a severe impact on health, income, productivity and the ability to care for each other.

The age bracket that AIDS most heavily targets – younger adults – means it is not uncommon for one or more parents to die from AIDS while their offspring are young. The number of premature deaths due to HIV/AIDS has risen significantly over the last decade from 39 percent to 75 percent in 2010.12

A grandmother with children orphaned by AIDS AIDS orphans with their grandmother

The loss of a parent not only has an immense emotional impact on children but for most families can spell financial hardship. One survey on HIV’s impact on households found that, “80 percent of the sample would lose more than half their per capita income with the death of the highest income earner, suggesting a lingering and debilitating shock of death.”13

It is estimated there are 1.9 million AIDS orphans where one or both parents are deceased in South Africa,14 and that the HIV and AIDS epidemic is responsible for half of the country’s orphans.15 Another estimate puts the proportion of maternal orphans – those who have lost their mother – orphaned by AIDS as over 70 percent.16 Orphans may put pressure on older relatives who become their primary carers; they may have to relocate from their familiar neighbourhood; and siblings may be split apart, all of which can harm their development. The National Strategic Plan 2012-2016 aims to lessen the impact of HIV on orphans, vulnerable children and youth by ensuring they have access to the social services they need, including basic education.17

In some cases orphaned, often HIV infected, children are cared for by institutions, such as the Mohau Centre in Pretoria.18 Institutions such as this deliver essential care and support for children throughout their childhood years, many of whom have special needs. As treatment has improved and become more available, children are surviving beyond childhood. Whilst this is a great achievement, governments now need to consider how to deliver care and support for HIV infected orphans that have survived into adulthood.19

back to top HIV prevention in South Africa

Prevention of mother-to-child transmission

A child of an HIV positive mother, at the Raphael Centre in Grahamstown, South Africa. A child of an HIV positive mother, at the Raphael Centre in Grahamstown, South Africa.

An estimated 63,000 children in South Africa were infected with HIV in 2011, reflecting poor prevention of mother-to-child transmission (PMTCT).20  The impact of HIV and AIDS on children has been vast, but in the last few years the situation has improved. Between 1990 and 2001 the infant mortality rate increased significantly from 44 deaths per 1000 infants21 to 56.9 per 1000 infants.22 The trend continued into the early 2000s, when South Africa was one of the few countries of the world where child and maternal mortality increased.23  Although infant mortality remains high in South Africa, it has declined steadily since 2003 to a rate of 37.9 per 1000 infants in 2011.24

Around 30 percent of pregnant women in South Africa's 2009 National Antenatal Survey were HIV positive, demonstrating the need for South Africa to deliver effective PMTCT programmes.25 South African guidelines for PMTCT issued in 200826 were heavily criticised for not meeting World Health Organization recommendations. The WHO recommended a 'cover-the-tail' strategy, which used antiretroviral drugs AZT and 3TC for the mother during labour and postpartum to reduce the risk of HIV transmission and drug resistance.27 The Treatment Action Campaign responded to South Africa's omission of using this strategy in the guidelines, stating,

“The ‘cover-the-tail’ strategy was strongly recommended by expert HIV paediatricians who advised the Department of Health on the new protocol; we are disappointed that this well-founded recommendation has been ignored.”28

In 2010 South Africa released new PMTCT guidelines, which are more in line with WHO recommendations. In South Africa's guidelines HIV-positive pregnant women are advised to start treatment when their CD4 count drops below 350 cells/mm3; all pregnant women who test HIV-positive will begin receiving treatment at 14 weeks rather than in the last term of pregnancy; and HIV-positive women are advised to receive antiretroviral drugs postpartum.29

South Africa's National Strategic Plan of 2007-2011 set out a target to reach 95 percent of HIV positive pregnant women with PMTCT prophylaxis by 2011.30 By 2010 coverage was estimated to be greater than 95 percent31 and a review of the National Strategic Plan found that in 2010, the rate of transmission from mother to child (MTCT) at six weeks after birth had been reduced to 3.5 percent.32 The latest National Strategic Plan aims to reduce MTCT to less than 2 percent at six weeks after birth and less than 5 percent at 18 months by 2016.33

AIDS awareness

There are a number of large scale communication campaigns related to raising awareness of HIV and AIDS as well as broader health-related issues.

A principle part of the HIV counselling and testing (HCT) campaign launched in April 2010, is to scale up awareness of HIV.34 The government aims to bring about general discussion of HIV throughout the country by using the media. Strategies include publicising the availability of free testing and counselling in health clinics through door-to-door campaigning and billboard messages, and using vox pops to highlight personal experiences and expel the myths and stigma of HIV. The government aims to cover 50 percent of the population with the campaign message.

Khomanani, meaning ‘caring together’, ran since 2001 and was the health department’s premier AIDS-awareness campaign. It used the mass media to broadcast its messages including radio announcements and the use of situational sketches on television.35 However, following allegations of financial discrepancies and the termination of government funding in March 2010, this campaign appears to have been significantly downgraded.36 37

Soul City and Soul Buddyz are two multi-media campaigns – targeted at adults and children, respectively – that have a combined annual budget of R100 million (around 13 million US$), and utilize broadcast, print and outdoor media to promote good sexual health and well being.38 In 2011, research into the impact of the Soul City campaign found that it was having a positive effect on the sexual behaviour of adults that had been exposed to the campaign message.39

The campaign loveLife has run since 1999 and uses a wide range of media directed mainly towards teens.40 It also runs youth centres or ‘Y-centres’ around the country, which provide sexual health information, clinical services and skills development.41 In 2005, The Global Fund to Fight AIDS, Tuberculosis and Malaria withdrew funding for loveLife questioning its performance, accounting procedures, and governance structure among other aspects.42

loveLife advertising HIV prevention HIV awareness billboard by loveLife

A major survey in 2008 assessed how these campaigns are being received by the population. Over four-fifths of South Africans had seen or heard at least one aspect of the four campaigns, up from less than three-quarters in 2005. Awareness messages were best received by 15-24 year olds, the target audience of many of these campaigns, 90 percent of whom had experienced at least one of the campaigns. This declined with age so that just over 60 percent of those aged 50 and above had seen or heard at least one of the four campaign messages.43

Despite the improved reach of these awareness campaigns, accurate knowledge about HIV and AIDS is poor. Of particular worry is the lack of knowledge regarding how to prevent sexual transmission of HIV. Across all age groups and sexes less than half of all people surveyed knew of both the preventive effect of condoms and that having fewer sexual partners could reduce the risk of becoming infected. More troubling still is the fact that accurate knowledge has significantly decreased in recent years.44

Condom use and distribution

Condom use in South Africa is growing, with the percentage of adults aged 15-49 using a condom during their last sexual encounter increasing from 31 percent in 2002 to 64.8 percent in 2008.45 Younger people show the highest rates of condom use, which bodes well for the future of prevention, and could explain the decline in HIV prevalence and incidence among teenagers and younger adults.46

The 2009 National Communication Survey on HIV and AIDS also found that 15 percent of married men and women used a condom at last sex compared to 74-83 percent men and 55-66 percent of women who had casual sex or one night encounters, identifying the need for prevention programmes to further target married couples.47

In 2007, 256 million male condoms were distributed by the government, down from 376 million in 2006. Over 3.5 million female condoms were distributed in 2006 and 2007.48

HIV and sex education

HIV and sex education exists in schools as part of the wider Life Orientation curriculum which was implemented in 2002 and also covers subjects such as nutrition and careers guidance.49 According to a comparative risk assessment for South Africa, unsafe sex ranks as the number one risk factor associated with the loss of potential years of life.50

The quality of the education, however, is hindered due to a lack of training of teachers, and an unwillingness on the part of teachers and schools to provide this education. Training for Life Orientation often takes place outside of school hours which acts as a disincentive to training. The shortage of trained teachers may result in just one teacher in a school being able to teach such classes, and school management could be resistant to what is being taught. This has led teaching unions to call for a Life Orientation module to be included in all teacher training.51 In some cases, gaps in the delivery of the Life Orientation curriculum may be filled by independent organisations.52

In one survey, some teachers reported feeling uncomfortable about teaching a curriculum that contradicted with their own values and beliefs. Another problem was believed to be the disadvantaged home life of the students, with some teachers believing poor role models at home did not help to reinforce HIV prevention messages received in the classroom.53

The high dropout rate in South African schools could also compromise effective HIV and sex education. This could mean it is all the more necessary to direct prevention programmes towards younger children while more of them are in education and before most are sexually active.54

Circumcision

Several large studies of male circumcision and HIV have produced firm evidence that the procedure reduces by 60 percent the risk of sexual transmission of HIV from women to men.55 As a result, the government has included voluntary medical male circumcision (VMMC) as an integral part of its HIV counselling and testing (HCT) campaign.56 The campaign aims to offer all men aged 15-49, and the guardians of infants below 6 months of age, voluntary medical circumcision at public health facilities in all provinces by 2011. In April 2010, KwaZulu-Natal became the first province to offer VMMC services. It is evident that circumcision has some popularity. According to a 2011 youth sex survey in South Africa, 78 percent of women prefer their partner to be circumcised.57

The scale-up of VMMC has meant that the country, along with Kenya and Zambia, was ranked one of the highest globally, in terms of number of circumcisions performed in 2010. In 2009 9168 men were circumcised and in 2010 this increased to 131,117.58 It is estimated that a programme with full coverage of male circumcision could prevent half a million infections and 100,000 deaths within a decade, with these figures rising in the decades to follow.59

back to top People more at risk of HIV

Certain groups of people are more at risk of becoming infected with HIV, such as men who have sex with men (MSM), sex workers and their clients and people who use drugs.60 Other at-risk groups in South Africa include people with disabilities, young people not attending school and people who live in informal settlements known as squatter camps. Often, individuals that fall under these groups have a low socio-economic status, which is also a factor that increases vulnerability to HIV.

One of South Africa’s current objectives, in the National Strategic Plan, is to address wider problems that much of the population face, such as poverty, in their HIV prevention efforts. The plan also addresses social factors, such as stigma and discrimination. These factors can act as a barrier to accessing prevention, treatment and care and therefore facilitate the spread of HIV among high-risk groups and the general population.61

HIV services that target specific groups can help to overcome the barriers inhibiting access to healthcare.  However, as of 2011, there were no national services within South Africa to address the needs of key populations, such as men who have sex with men (MSM), to overcome some of these specific barriers.62

Gay men and HIV in South Africa

In South Africa an estimated 9.2 percent of all new HIV infections are related to men who have sex with men.63 Prevalence among this group varies geographically and is particularly high in some parts of the country.  In a study of MSM in Johannesburg, half the participants were living with HIV.64 Many men find it hard to disclose their sexuality to mainstream health–care workers, and of those that have, reports of homophobic attitudes are common. There is a great need for targeted services for MSM and for health-care workers in general to receive sensitivity training around the needs of this at-risk group.65 South Africa is one of the few countries in Africa where homosexuality is legal and there are national polices that emphasize social justice and non-discrimination. Therefore the country has the potential to develop these policies into effective HIV services that address the needs of MSM. This would lead the way for other low- and middle-income countries towards meeting the specific needs of gay men in Africa and elsewhere.66

Sex workers and HIV in South Africa

Commercial sex work is a big aspect of the epidemic in South Africa, with an estimated 19.8 percent of all new HIV infections relating to transactional sex in 2010.67 Sex workers are often exposed to various factors that make people more vulnerable to HIV. They may inject drugs, live in poverty and be subjected to gender-based violence.68 One study found that a group of women working at a truck stop were often unable to ask clients to use condoms, as violent reactions to the request were common.69 Educational organisations have reported difficulties in delivering HIV prevention services to sex workers due to constant police harassment. Addressing the rights and prevention needs of this group is vital in preventing the spread of HIV nationally.

back to top Gender violence, inequality and HIV in South Africa

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Heroes of HIV: The Motivator

Violence against women, including sexual violence, is widespread in South Africa. In a large survey, more than four-in-ten South African men reported having been physically violent to an intimate partner.70 Over a quarter of men reported raping a woman in their lifetime with nearly one-in-twenty committing rape in the previous year.71 The sample included men of all racial groups and of a range of different socio-economic backgrounds. The generally high HIV prevalence among all men surveyed means there is a high chance that a man who commits rape could transmit HIV.

The violence that many South African women face – revealed by such high levels of rape and domestic abuse – is a factor in the country’s HIV epidemic. Women who are unable to negotiate safer sex and the use of condoms will inevitably be at a greater risk of HIV. Research has found that women who have been physically and sexually assaulted by their partners, as well as those who are in relationships with men who have a greater degree of control over them, are at a higher risk of HIV infection.72 It is estimated that nearly one in seven cases of young women acquiring HIV could have been prevented if the women had not been subjected to intimate partner violence.73 This highlights how HIV and healthcare services cannot be separated from women’s rights, and that HIV prevention strategies need to challenge social norms around masculinity and sexual entitlement.74

One intervention that has been found to be successful in preventing HIV and providing other assistance among women who have been victims of sexual violence is the Refentse model for post-rape care.75 76 This approach was trialled in a rural hospital and involved integrating violence counselling, HIV testing services and nurse dispensed post-exposure prophylaxis into HIV and health services that already existed. The hospital now provides one service for women in need of timely post-rape care. The model has improved access to trauma counselling, emergency contraception and referrals.77

back to top HIV testing in South Africa

HIV testing is vitally important in order to access treatment, and knowledge of one’s positive status can lead to behaviours to protect other people from infection. The 2007-2011 National Strategic Plan aimed for one quarter of all people to take a test every year by 2011, with the proportion of those ever taking a test rising to 70 percent.78 The latest National Strategic Plan has set out more ambitious targets, aiming to ensure that everyone in South Africa is voluntarily tested every year.79

There is evidence that testing levels have improved as the 2009 National Communications Survey found 60 percent of all men and women studied had been tested in the last 12 months, an increase of 36 percent since 2006.80 The percentage of those ever tested also increased significantly as 2009 figures showed 32 percent of men and 71 percent of women had been tested at least once compared to 2006 figures (17 percent men and 38 percent of women). The survey also identified a link between the amount of exposure a person had to communication programmes and whether the individual had been tested. These results indicate a positive development in the effectiveness of programmes and the general perception towards testing in South Africa.

An HIV rapid test kit used in voluntary counselling and testing in rural South Africa An HIV rapid test kit used in voluntary counselling and testing in rural South Africa

According to UNAIDS, almost 7 million South Africans aged 15 years and over (or one quarter of the adult population) received HIV testing and counselling in 2009.81 82 Moreover, the launch of the national HIV counselling and testing (HTC) campaign in April 2010 resulted in a remarkable increase in the number of people accessing testing. In his 2011 health budget policy speech, health minister Motsoaledi announced that 11.9 million people now test for HIV each year.

When testing does occur it is very often at a late stage of infection. It is hoped that the HCT campaign will lead to earlier diagnosis of HIV.83 Additionally, routine testing at healthcare facilities could prove to be a way of working round the stigma attached to HIV testing.

It is evident that there is a link between an individual’s socio-economic background and the likelihood that they will test for HIV. For example, those who have taken an HIV test and know their result are more likely to have a higher level of education, be in employment, have accurate HIV knowledge, and a higher perception of risk, among other factors.84 These links suggest that an improvement in the general standard of living would be beneficial to the uptake of testing. Another significant factor determining HIV testing is whether an individual lives in a rural or urban setting, with those residing in the latter almost twice as likely to have been tested than those in the former. Testing facilities should therefore be made more accessible for hard to reach rural populations, possibly with mobile testing units.85

HIV prevalence within prisons is often far higher than in the general community, yet prisoners are often neglected and overlooked by HIV testing. In an attempt to provide vulnerable populations with HIV testing services, South Africa's corrections service has stepped up testing for prisoners and correctional service staff in Kwazulu-Natal's prisons. In mid- 2010 it was announced that around 21,000 prisoners would receive HIV counselling and testing.86

One creative way of providing testing for the general population has been demonstrated by a colourful camper-van, the Tutu Tester, that tours Cape Town neighbourhoods, testing around 50 people per day. Its success is largely due to the fact that it offers testing for a number of chronic illnesses.87

“Many of our patients have told us that they prefer not to go to public clinics for an HIV test because they are afraid of being seen by people they know. Because we test for other diseases too, like diabetes and high blood pressure, the outside world does not know for what reason patients are waiting at our doors.” Liz Thebus, Tutu Tester health worker

Home testing is also advocated for, as a way to bring HIV testing into the privacy of peoples homes.(WAD REPORT)

“ (Knowing your HIV status) simply ought to be a part of life ” - Edwin Cameron, Justice of the Constitutional Court in South Africa, talking about home testing88

Improving testing, however, can only be part of broader efforts to tackle the epidemic. Unless people who do test positive are able to receive appropriate care following their diagnosis, individuals may see little value in being tested.

back to top Antiretroviral treatment in South Africa

South Africa has the largest antiretroviral therapy programme in the world, but given it also has the world’s largest epidemic, access to treatment is low. At the end of 2010, an estimated 55 percent of people who needed it were receiving treatment for HIV, according to the latest WHO guidelines (2010).89

However, the country is making progress towards its goal of 80 percent coverage.90 In mid-2011, following the launch of the HCT campaign in early 2010, it was announced that the number of people on antiretroviral treatment had increased significantly from 923,000 in February 2010 to 1.4 million in May 2011.91

Demonstrations at the 2009 South African AIDS Conference in Durban. Demonstration at South African AIDS Conference

The state of HIV treatment in South Africa can only be seen in the context of years of doubting the effectiveness of treatment at the highest levels of government, and the initial delay and slow pace of delivering a public ARV programme.

Thabo Mbeki, president of South Africa from 1999 to 2008, often sought the opinions of AIDS denialists, including many of them on his Presidential AIDS Advisory Panel. Both Mbeki and his health minister, Manto Tshabalala-Msimang, questioned the effectiveness of ARVs, with the latter infamously promoting beetroot and garlic consumption as a way of fighting HIV infection.

South Africa’s poor response to the epidemic becomes clear when compared with another middle-income country, Brazil, that was swift to provide near universal access to antiretroviral therapy in the mid-1990s:

“Brazil’s story contrasts starkly with that of South Africa, which had similar HIV prevalence in 1990 but only began providing treatment on a large scale in recent years and now has the most HIV/AIDS cases of any country.” Amy Nunn92

The government published its plan to provide public access to ARVs in November 2003, many years after the evidence of the effectiveness of combination therapy in reducing mortality was reported. In contrast, many of South Africa’s poorer neighbours had already begun to make treatment available, including Botswana, whose MASA programme began to distribute ARVs in early 2002. Furthermore, rollout of the South African programme was very slow.93

The departure of President Mbeki, health minister Manto and others who doubted the science behind AIDS and ARVs, signified an end to the kind of barriers which had held back progress in treating HIV and AIDS in South Africa. See AVERT's History of HIV and AIDS in South Africa page for more information.

The task of providing a high level of access to antiretroviral therapy in South Africa now faces a set of new challenges.

Treatment guidelines

The level at which someone begins antiretroviral therapy has a great impact on their chances of responding well to treatment. The WHO now recommends that all countries, including those that are poorly resourced, begin treatment at a CD4 count of <350 cells/mm3.94

In 2010, the South African government released guidelines that did not adhere to WHO recommendations. Except for certain groups such as pregnant women and people who have TB, who were eligible for treatment at <350 cells/mm3, the treatment threshold remained at 200 cells/mm3.95 Some researchers predicted 76,000 deaths could be prevented over five years if treatment was initiated below 350 cells/mm3, compared with below 250 cells/mm3, assuming that 30 percent of eligible patients were identified and linked to care.96

Advocates of raising the treatment threshold to <350 cells/mm3 acknowledged that this would require greater expenditure but argued it would be cost effective in the long run. A representative from the Treatment Action Campaign said,

“This is going to be expensive to implement, but these recommendations will eventually lead to cost savings. It’s a cost that has simply been deferred.”97

Others, such as Dr Francois Venter, of the Southern African HIV Clinicians Society, argued that amending guidelines to raise the treatment threshold neglects the fact that many patients are currently starting treatment long after becoming eligible for it, only once they have become seriously ill.98

However, research found that overall delivery of treatment at a CD4 count of <350 cells/mm3 would not be as expensive as previously thought.99 Under guidelines initiating treatment at <200 cells/mm3, overall government spending will be $9.8 billion during the period 2010 to 2017, whilst under new guidelines this figure would only increase to $11 billion.100

In 2011 the government amended treatment guidelines so that treatment is initiated at a cell count of <350 cells/mm3.101 102 This is a hugely positive step towards universal access to treatment in South Africa.

Late initiation of treatment

Delays in initiating treatment mean that the average starting point of antiretroviral therapy is a CD4 count of 87 cells/mm3. Dr Francois Venter remarked that patients in his Johannesburg clinic commence treatment at a CD4 count of 80-100 cells/mm3, a level that has not changed in four years.103

A study based in two Durban clinics found most patients were tested at a late stage of infection with over 60 percent of CD4 counts below 200 cells/mm3. Of these patients just 42 percent had begun treatment within 12 months. The late stage at which people with HIV and AIDS in South Africa are diagnosed and the subsequent delay in getting these people on to treatment has devastating consequences. Of those who were eligible for treatment, more than a fifth died, mostly before beginning treatment.104

Failure to begin or late initiation of treatment is usually attributed to a lack of HIV testing and problems accessing treatment. However, it has been reported that some individuals refuse antiretroviral treatment, despite being eligible. A study in Soweto, South Africa found that of 743 newly diagnosed, HIV-infected adults eligible to immediately begin treatment, 20 percent refused referral to treatment.105 More than a third gave "feeling healthy" as the reason for refusing treatment. This research indicates a need for further research into why individuals refuse treatment and how to increase treatment uptake among ART refusers.106

Child treatment

Children at the Raphael Centre in Grahamstown, South Africa in July 2003.HIV-positive children, Grahamstown

According to the South African government, provision of HIV treatment for children has greatly increased in recent years. In 2007, more than 32,000 children were receiving antiretroviral therapy, a 250 percent increase on 2005’s figure, though still only meeting half of the estimated need.107 108

A major trial in South Africa, the CHER study, found the risk of death decreased by about three-quarters when infected infants under 12 months began treatment immediately after being diagnosed with HIV, compared with a control group which received treatment at a late stage of infection.109

During late 2009 and early 2010 the government committed to testing all children exposed to HIV and providing all HIV-positive children with antiretroviral drugs.110 111 However, in November 2010 it was reported that almost a third of KwaZulu-Natal hospitals in a survey had no recent records of ARV treatment initiation for HIV-positive infants. Authors of the research blamed mothers' reluctance to get their children tested for HIV and health workers' confusion over the national treatment guidelines.112

In 2010, 108,682 children were receiving treatment. This means that 36 percent of children eligible for HIV treatment (according to WHO recommendations) in South Africa have access to it, leaving 196,000 children still in need.113

Sustaining treatment programmes

For antiretroviral therapy to work, patients must adhere to a daily regimen of ARVs for life. Interrupting treatment can result in HIV becoming drug resistant, making first-line therapy no longer effective. Therefore, keeping patients on treatment programmes is imperative and the rise in patients failing to follow up their ART after 36 months is particularly worrying.114

Stockouts in Free State show how ARV treatment programmes can be victims of poor management and budgetary constraints, factors that could worsen as treatment programmes aim to expand, and if poor economic conditions continue.

After overspending and a failure to apply for emergency funding, in November 2008 the provincial government of Free State stopped initiating new patients on antiretroviral therapy. It was estimated by the Southern African HIV Clinicians Society that at least 30 people were dying daily due to an inability to access ARVs, and 15,000 people were put on waiting lists for treatment. Patients who had been taking ARVs also had to interrupt their treatment.115 A Treatment Action Campaign worker said, “It makes me feel bad when people come here and find that there are no drugs; they come back to me and say, ‘What are we supposed to do with no drugs? Should we wait and develop resistance?’”116

The national HIV counselling and testing (HCT) campaign aimed to test 15 million by 2011.117 As of that year, over 14 million people were counselled and almost 13 million people were tested for HIV.118 This likely resulted in an increase in demand for treatment. However, reports in early 2010 of drug and equipment stock outs, and some hospitals without electricity or running water, prompted concerns about the administrative capacity of health authorities to deal with an influx of new patients.119

The TAC identified that the government must eliminate the barriers that hinder positive developments in policy.120 These include the shortfall between the amount of drugs purchased and those needed, the delay in the registration of new drugs and the level of debt in provincial Departments of Health.

Nevertheless, since the beginning of 2010 there have been some notable improvements regarding the delivery of antiretroviral treatment. For example, only 490 health centres provided ARV's in early 2010 compared with 2205 health centres in late May 2011.121

Moreover, under previous tender prices it would have cost the government more than R8.8 billion to treat people with antiretrovirals.122 However, a tender awarded to 10 pharmaceutical companies, at the end of 2010, cost 53.1 percent less than had been paid previously.123 124 Following this massive reduction in the price of antiretroviral drugs, the government can now treat twice as many people as before.

Food insecurity also has considerable implications on whether individuals remain on treatment. Many people living with HIV in South Africa are unable to access nutritious food, which can result in malnutrition. Malnutrition can impact significantly on both a person’s ability to adhere to treatment and on the effectiveness of antiretroviral drugs. In some cases, individuals living with HIV are faced with the dilemma that access to antiretrovirals has made them too healthy to qualify for a disability grant, and without the this source of income people cannot afford food.125 Often this means they choose not to adhere to their HIV treatment properly so that their cell count remains at a level where they are considered disabled.

Task-shifting

One measure seen as vital in scaling-up treatment access, while making best use of available resources, is task-shifting in the health sector. This means permitting health care workers to become involved in particular stages of treatment provision where currently they are not allowed.

Under task-shifting, nurses, rather than doctors, can initiate antiretroviral therapy; lay counsellors, rather than nurses, can carry out HIV tests, as well as provide support for orphans usually done by social workers; and pharmacy assistants, rather than pharmacists themselves, can prescribe ARV drugs.126 127 It is believed task-shifting vastly increases the access points to treatment and care by reducing the ‘bottlenecks’ in the system created by a lack of staff able to perform certain tasks.

Many campaign groups supported task-shifting and claim it is crucial to the goal of making HIV treatment much more widely available. Four prominent HIV/AIDS organisations called on the national and regional health departments to issue directives permitting the transfer of certain responsibilities and asked professional medical, nursing and pharmacist bodies to support task-shifting.128 A recent study in South Africa supported task-shifting to nurses, after it found that the care of patients receiving antiretroviral treatment was not inferior when they were monitored by nurses rather than by doctors.129

Dr Eric Goemaere, Medical Coordinator for MSF in South Africa and Lesotho, said, “Our experience in Khayelitsha and Lusikisiki, as well as from other countries shows that unless we are able to utilise the skills and capacity of professional nurses at the primary health clinics, the congestion and overwhelming demand will negatively impact patient care. Other countries have changed their regulations to allow nurses to start patients on antiretroviral treatment and lay counsellors to administer HIV tests. When will South Africa wake up?”130 In the 2010 budget speech, the Health Minister, Motsoaledi announced that “human resource capacity” was one of the “teething problems” experienced whilst implementing plans to increase the number of health facilities providing ARVs from 496 to 4,333.131

It wasn’t until May 2010 that South Africa implemented task-shifting. Health minister Motsoaledi approved the new regulations, which allow a person who is not a healthcare provider (such as a lay counsellor who has received training in taking blood) to do so.132 The government's HIV counselling and testing (HCT) campaign133 is expected to have widespread reach and with task-shifting now approved, the success of this campaign is promising. However, although task shifting by nurses has been encouraged by Motsoaledi it is unclear whether this has been officially approved by a change in legislation.134 Nevertheless, in 2011 it was announced that the number of nurses trained to administer ARVs has increased from only 250 nurses in early 2010 to 2000 nurses in May 2011.

It is evident that these changes have resulted in some success. In Johannesburg, a comparison was made between a group of people who were treated at a nurse-managed primary health centre and a group who were treated at a doctor-managed, hospital-based, specialised ARV clinic. After 12 months, the combined rate of death and loss to follow up was found to be 1.7 percent versus 6.2 percent respectively.135

As task-shifting spreads among health facilities it is important that the potential benefits are not lost due to logistical planning failures, for example shortages of HIV testing equipment.136 During 2010 some provinces experienced widespread wage shortages for lay counsellors, which disrupted the delivery of the HCT campaign.137

The future of AIDS treatment in South Africa

Treatment scale-up in South Africa in recent years has succeeded in vastly increasing the numbers of people receiving HIV treatment. At the end of 2007, it was estimated that only 27 percent of people in need of treatment were receiving it, below the average at the time for low and middle-income countries.138 By the end of 2009, this had increased to 56 percent, above the average for low and middle-income countries. However, these estimates are based on the previous WHO guidelines.139 The latest guidelines (2010) recommend starting treatment earlier, and have therefore increased the number of people estimated to be in need of HIV treatment, so that the calculated treatment coverage for 2009 went down to 37 percent140 (monitoring from 2010 has updated this estimate to 42 percent141 ). 55 percent of those who need it now have access to antiretroviral therapy. As more people have access to life-saving treatment, small steps can be seen in reducing the impact of AIDS on South Africa; between 2001 and 2010 AIDS-related mortality decreased by 21 percent.142 However, the risk of losing HIV patients to follow-up has increased recently, suggesting that this may be a side effect of the strain of rolling out such a large ARV programme.143

The National Strategic Plan (NSP), a multisectoral response to South Africa’s AIDS epidemic, aims to ensure that 80 percent of people who are eligible for treatment have access to it, along with care and support, by 2016.144

The Health Systems Trust released a review in 2012 which predicted that the country will need up to US$5.3 billion extra every year to sustain its HIV and AIDS response, particularly in financing treatment.145 Human resource shortages, late initiation of treatment, and sustaining the increasing numbers of people who start treatment will all need to be addressed in order for the NSP to be achieved. Greater resources are crucial to achieving this, as well as a more effective use of existing resources.

In Spring 2009, then health minister, Barbara Hogan said,

“Let me state unequivocally, government is committed to the NSP and its effective implementation. We are committed to reaching the targets.”146

back to top HIV and tuberculosis in South Africa

“We cannot fight AIDS unless we do much more to fight TB.”

Nelson Mandela

Tuberculosis (TB) is the leading cause of death in South Africa,147 a trend that needs to be seen in the context of the HIV epidemic. People living with HIV are at a far higher risk of developing active tuberculosis as a weakened immune system will facilitate the development of the disease. Similarly, TB can accelerate the course of HIV. In 2010, about 210,000 people in South Africa with TB were tested for HIV, and 60 percent were HIV-positive.148 In countries with high HIV prevalence, TB has tripled in the past two decades, which clearly illustrates the link between the two diseases.149

South Africa has one of the highest coinfection rates with an HIV prevalence of almost three-quarters among people with incident tuberculosis. Despite accounting for just 0.7 percent of the global population, the country accounts for 28 percent of the world’s people living with both HIV and TB.150 Fighting both diseases together, where appropriate, is seen as crucial:

“We cannot fight AIDS unless we do much more to fight TB.” Nelson Mandela151

The high level of HIV and TB coinfection led the South African National AIDS Council to call for an integration of care for the two diseases in their National Strategic Plan.152 153 Integrating HIV and TB systems means it is easier for people with one disease to be tested and treated for the other, where elements of care are otherwise handled separately. The Ubuntu clinic, offering what it terms ‘one-stop’ HIV and TB care in the Khayelitsha township, on the edge of Cape Town, illustrates the benefits of this approach to the twin epidemics. In the township, the number of people diagnosed with TB who were offered HIV counselling increased from 50 percent in 2002 to 97 percent by mid-2007.154

The principal medical officer of the clinic highlighted how Ubuntu’s integrated approach benefits co-infected people: “It makes it easier for the patients. You know your patient doesn’t have to go in your queue and tomorrow stand in another one.”155

The success of the HIV/TB service integration has led Western Cape to adopt this integrated approach as well. In 2007 over one-third of South African HIV-positive TB patients were provided with antiretroviral therapy and two-thirds received co-trimoxazole prophylaxis in 2007. The WHO has stated that “collaborative TB/HIV activities are being scaled up across the country”.156

As a sign that HIV/TB coinfection is being taken seriously, as of April 2010, the treatment threshold for coinfected people was raised from 200 to 350 cells/mm3, despite, at the time, the threshold for most people remaining at 200 cells/mm3.157 Rising cases of Multi-Drug Resistant (MDR) and Extensively Drug Resistant (XDR) TB suggests a need for an overall improved response to avoid a spread of resistant TB. XDR-TB has been recorded in 60 hospitals in KwaZulu-Natal.158 It is suggested that earlier testing and diagnosis, greater adherence and drug resistance surveillance will help to control the threat of resistant TB in South Africa.159

back to top The way forward

As President Zuma outlined in a landmark 2009 World Aids Day speech, South Africa has had to overcome massive challenges in its past:

"At another moment in our history, in another context, the liberation movement observed that the time comes in the life of any nation when there remain only two choices: submit or fight. That time has now come in our struggle to overcome AIDS. Let us declare now, as we declared then, that we shall not submit."160

South Africa has come a long way in responding to its HIV epidemic, but is still falling short of what is possible, and has lacked the progress that has been made by its neighbours and other countries of a similar economic standing.

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A speech by Barbara Hogan, former South African health minister, in 2009.

Whereas previous administrations sowed confusion at best, and at worst were responsible for the deaths of hundreds of thousands of people, efforts to tackle HIV are now at least facilitated by government acceptance of the science behind HIV and ARVs. However, the vast majority of those who need treatment still do not receive the drugs they need, and for those that can access treatment, this begins too late.

Drug stockouts, continued use of ARVs with severe side effects, and a lack of entry points to care, are additional factors that must be overcome in order to scale-up effective treatment provision, and to reach the national goal of providing ARVs to 80 percent of those who require them.

Recent trends indicate a possible turning point in the epidemic, with infections decreasing among youth. Condom use has increased throughout the decade across all age groups and is highest among younger people, a notable achievement in South Africa’s fight against HIV. However, despite reductions in new infections from 640 000 in 2000 to 390 000 in 2009, the country’s goal of halving its 2007 infection rate by 2011 is likely not to have been reached.161 Far more will need to be done if South Africa is to meet its latest goal of halving the current infection rate by 2016.162

“If we stop anything, we will just reverse all our gains”

Health Minister, Dr. Aaron Motsoaledi

The South African National AIDS Council (SANAC) is the national HIV coordinating body responsible for overseeing the implementation of the country's HIV National Strategic Plan NSP) 2007-2011. An independent review of the NSP in 2009 produced a number of recommendations to ensure that NSP targets are reached.163 The review suggested that reforming the SANAC was essential for improving the management and coordination of the National Strategic Plan. Making SANAC more accountable for reaching the NSP targets, increased resources at provincial and district level, an annual review of targets, and surveillance of how funding is spent were further recommendations included in the review.

To avoid decisions being "taken in a vacuum, disconnected from real problems and evidence of what is working" it was recommended that HIV/AIDS data from district and provincial level is also brought together at a more central level where it can be analysed by SANAC and used to inform national strategic decisions on the epidemic.

Continued pressure from activists and civil society, and sustained commitment by the government, including increased funding, are needed to see South Africa effectively bring its AIDS epidemic under control. As Health Minister Dr. Aaron Motsoaledi said in 2010,

"If we stop anything, we will just reverse all our gains"Health Minister, Dr. Aaron Motsoaledi164

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