Copyright © AVERT

South Africa is currently experiencing one of the most severe AIDS epidemics in the world. By the end of 2005, there were five and a half million people living with HIV in South Africa, and almost 1,000 AIDS deaths occurring every day.¹

A number of factors have been blamed for the increasing severity of South Africa’s AIDS epidemic, and debate has raged about whether the government’s response has been sufficient. This page looks at the impact that AIDS has had on South Africa, the historical context of the epidemic, and the major issues surrounding the crisis.

The scale of South Africa’s AIDS crisis

It is difficult to overstate the suffering that HIV has caused in South Africa. With statistics showing that almost one in five adults are infected, HIV is widespread in a sense that can be difficult to imagine for those living in less-affected countries. For each person living with HIV, in South Africa and elsewhere, not only does it impact on their lives, but also those of their families, friends and wider communities.

With antiretroviral drug treatment, HIV-positive people can maintain their health and often lead relatively normal lives. Sadly, few people in South Africa have access to this treatment. This means that AIDS deaths are alarmingly common throughout the country. It is thought that almost half of all deaths in South Africa, and a staggering 71% of deaths among those aged between 15 and 49, are caused by AIDS.² So many people are dying from AIDS that in some parts of the country, cemeteries are running out of space for the dead.³ A recent survey found that South Africans spent more time at funerals than they did having their hair cut, shopping or having barbecues. It also found that more than twice as many people had been to a funeral in the past month than had been to a wedding.⁴

As well as the death and suffering that HIV has caused on an individual and community level, South Africa’s AIDS epidemic has also had a substantial impact on the country’s overall social and economic progress:

• Average life expectancy in South Africa is now 54 years – without AIDS, it is estimated that it would be 64. Over half of 15 year olds are not expected to reach the age of 60.⁵
• Between 1990 and 2003 – a period during which HIV prevalence in South Africa increased dramatically – the country fell by 35 places in the Human Development Index, a global directory that ranks countries by how developed they are.⁶
• Hospitals are struggling to cope with the number of HIV-related patients that they have to care for. In 2006 a leading researcher estimated that HIV-positive patients would soon account for 60-70% of medical expenditure in South African hospitals.⁷
• Schools have fewer teachers because of the AIDS epidemic. In 2006 it was estimated that 21% of teachers in South Africa were living with HIV.⁸

It is clear that AIDS is having a devastating impact on South Africa. There are many possible reasons why South Africa has been so badly affected by AIDS, including poverty, social instability and a lack of government action. One way to gain a better insight into the situation is to look back on the history of AIDS in South Africa.

The history of AIDS in South Africa

South Africa has had a turbulent past, and this history is relevant to the explosive spread of HIV in the country.

1980s - In 1985, a State of Emergency was declared in South Africa that would last for five years. This was a result of riots and unrest that had arisen in response to Apartheid, the system of racial segregation that had been in place since the 1950s. Apartheid prohibited mixed-race marriages and sex between different ethnic groups, and categorised separate areas in which different races lived. In the same year, the government set up the country’s first AIDS Advisory Group in response to the increasingly apparent presence of HIV amongst South Africans. The first recorded case of AIDS in South Africa was diagnosed in 1982, and although initially HIV infections seemed mainly to be occurring amongst gay men, by 1985 it was clear that other sectors of society were also affected. Towards the end of the decade, as the abolition of Apartheid began, an increasing amount of attention was paid to the AIDS crisis.

1990 - The first national antenatal survey to test for HIV found that 0.8% of pregnant women were HIV-positive.⁹ It was estimated that there were between 74,000 and 120,000 people in South Africa living with HIV. Antenatal surveys have subsequently been carried out annually.

1991 - The number of diagnosed heterosexually transmitted HIV infections equalled the number transmitted through sex between men. Since this point, heterosexually acquired infections have dominated the epidemic. Several AIDS information, training and counselling centres were established during the year.

1992 - The government’s first significant response to AIDS came when Nelson Mandela addressed the newly formed National AIDS Convention of South Africa (NACOSA). The purpose of NACOSA was to begin developing a national strategy to cope with AIDS. The free National AIDS Helpline was founded.

1993 - The National Health Department reported that the number of recorded HIV infections had increased by 60% in the previous two years and the number was expected to double in 1993. The HIV prevalence rate among pregnant women was 4.3%.

1994 - The Minister for Health accepted the basis of the NACOSA strategy as the foundation of the government's AIDS plan. There was criticism that the plan, however well intended, was poorly thought-out and disorganised. The South African organisation Soul City was formed, with the aim of developing media productions to educate people about health issues, including HIV/AIDS.

1995 - The International Conference for People Living with HIV and AIDS was held in South Africa, the first time that the annual conference had been held in Africa. The then Deputy President Thabo Mbeki, acknowledged the seriousness of the epidemic, and the South African Ministry of Health announced that some 850,000 people - 2.1% of the total population - were believed to be HIV-positive.¹⁰

1996 - The HIV prevalence rate among pregnant women was 12.2%.

1997 - The HIV prevalence rate among pregnant women was 17.0%. A national review of South Africa's AIDS response to the epidemic found that there was a lack of political leadership.

1998 - The pressure group Treatment Action Campaign (TAC) was founded, to campaign for the rights of people living with HIV, and to demand access to HIV treatment in South Africa for all those who were in need of it. Deputy President Thabo Mbeki launched the Partnership Against AIDS, admitting that 1,500 HIV infections were occurring every day.

1999 - The HIV prevalence rate among pregnant women was 22.4%.

2000 - The Department of Health outlined a five-year plan to combat AIDS, HIV and STIs.¹¹ A National AIDS Council was set up to oversee these developments. At the International AIDS Conference in Durban, the new South African President Thabo Mbeki made a speech that avoided reference to HIV and instead focused on the problem of poverty, fuelling suspicions that he saw poverty, rather than HIV, as the main cause of AIDS. President Mbeki consulted a number of ‘dissident’ scientists who rejected the link between HIV and AIDS.

2001 - The HIV prevalence rate among pregnant women was 24.8%.

2002 - South Africa's High Court ordered the government to make the drug nevirapine available to pregnant women to help prevent mother to child transmission of HIV. Despite international drug companies offering free or cheap antiretroviral drugs,¹² the Health Ministry remained hesitant about providing treatment for people living with HIV.

2003 - In November, the government finally approved a plan to make antiretroviral treatment publicly available. The HIV prevalence rate among pregnant women was 27.9%.

2004 - The South African government’s treatment program began to take effect in Gauteng in March, followed shortly afterwards by other provinces.

2005 - At least one service point for AIDS related care and treatment had been established in all of the 53 districts in the country by March, meeting the government’s 2003 target. However, it was clear that the number of people receiving antiretroviral drugs was well behind initial targets. The HIV prevalence rate among pregnant women was 30.2%.

2006 – Jacob Zuma, the Former South African Deputy-President, went on trial for allegedly raping an HIV-positive woman. He argued that she had consented to sex and was eventually found not guilty, but attracted controversy when he stated that he had showered after sex in the belief that this would reduce his chances of becoming infected with HIV. Criticism of the government’s response to AIDS heightened, with UN special envoy Stephen Lewis attacking the government as ‘obtuse and negligent’ at the International AIDS Conference in Toronto. At the end of the year, the government announced a draft framework to tackle AIDS and pledged to improve antiretroviral drug access. Civil society groups claimed that this marked a turning point in the government’s response.

Why did South Africa’s AIDS epidemic go unchecked for so long?

The most rapid increase in South Africa’s HIV prevalence took place between 1993 and 2000, during which time the country was distracted by major political changes. While the attention of the South African people and the world's media was focused on the political and social changes occurring in the country, HIV was rapidly becoming more widespread. Although the results of these political changes were positive, the spread of the virus was not given the attention that it deserved, and the impact of the epidemic was not acknowledged. It is likely that the severity of the epidemic could have been lessened by prompt action at this time.

HIV treatment in South Africa

South Africa’s national HIV treatment programme has been the topic of much debate. The South African government was initially hesitant about providing antiretroviral treatment to HIV-positive people, and only started to supply the drugs in 2004 – years after many other nations had begun to do so – following pressure from activists. Even since 2004, the distribution of antiretroviral drugs has been relatively slow, with only around 33% of people in need receiving treatment at the end of 2006.¹³

The government was also initially reluctant to provide drugs that could prevent HIV-positive mothers from passing HIV on to their babies, and has been accused of not making enough effort to get these drugs to women that need them.

The slow provision of treatment has been linked to unconventional views about HIV and AIDS amongst the government. Alongside President Mbeki’s questioning of whether HIV really causes AIDS, his health minister Manto Tshabalala-Msimang has caused controversy by promoting nutrition rather than antiretroviral drugs as a means of treating HIV. These views have caused widespread criticism, both within South Africa and amongst the international community.

See our AIDS in South Africa: treatment, transmission and the government page for a full account of the issues surrounding antiretroviral drug provision, misinformation, and mother-to-child transmission of HIV in South Africa.

HIV testing in South Africa

HIV voluntary counselling and testing (VCT) should be an important part of any country’s response to AIDS. The number of VCT sites in South Africa has increased significantly in recent years, with 4,172 operational by November 2006. Despite this progress, there are concerns about the quality of VCT services in some areas. Reports suggest that counsellors are not always adequately trained, may lack medical knowledge about HIV, and are often overworked.¹⁴

Another problem is that women seem to be accessing testing more readily than men in South Africa. Researchers believe that this is due to fears amongst men that their HIV-positive status will be disclosed through testing, and that stigmatisation will follow. Surveys have also suggested that some men see no value in knowing their HIV status, viewing such knowledge as a burden.¹⁵

HIV prevention campaigns in South Africa

The issue of HIV prevention in South Africa has attracted less controversy and debate than other aspects of the country’s response to AIDS. There have been some notable national efforts, including:

• ‘The Soul City Project’, which was started in 1994 and educated people about AIDS through radio, print, and television, using dramas and soap operas to promote its message.
• The ‘Beyond Awareness’ campaign, which ran between 1998 and 2000 and concentrated on informing young people about AIDS through the media.
• The 'Khomanani' (‘caring together’) campaign, run by the Aids Communication Team (ACT), a group that was set up by the government in 2001. The Khomanani campaign has used the mass media and celebrity endorsement to get across HIV prevention messages, with a particular emphasis on encouraging HIV testing.
• loveLife, the most prominent HIV prevention campaign to be carried out in South Africa, which specifically targets young people and attempts to integrate HIV prevention messages into their culture. It was launched in 1999, with the aim of reducing rates of teenage pregnancy, HIV and sexually transmitted infections amongst young South Africans. The campaign attempts to market sexual responsibility through the media as if it were a brand. It also operates a network of telephone lines, clinics and youth centres that provide sexual health facilities, as well as an outreach service that travels to remote rural areas, to reach young people who are not in the educational system.

Although these campaigns have probably saved many lives, the actual difference they have made in reducing the number of new HIV infections is very difficult to measure. The prevailing high rates of HIV found across South Africa suggest that either the message isn’t getting through to many people, or that people are receiving information but not acting upon it.

In some cases the problem may lie with the campaigns themselves. Some AIDS activists have criticised the ongoing loveLife campaign, arguing that it is poorly targeted and ineffective.¹⁶ In December 2005, loveLife suffered a major set back when the Global Fund, one of its main financial backers, withdrew funding, stating that the campaign ‘was deemed to not have sufficiently addressed weaknesses in its implementation’.¹⁷

However, the seeming lack of progress made by HIV prevention campaigns does not necessarily reflect a lack of effort. Various social factors make it difficult to carry out effective HIV prevention campaigns in South Africa, as the population is highly diverse and divided by deeply rooted social inequalities. South Africans have a mixture of ethnic backgrounds: black people account for 75% of the population, whites make up around 13%, Asians make up about 3%, and other people of mixed racial heritages account for about 9%. There are 11 official languages and many dialects; around 86% of the population is literate.¹⁸ Some live in large, crowded cities, while others live in sparsely populated rural areas, many of which are isolated, underdeveloped and lacking infrastructure. This diversity has made it very difficult to carry out AIDS awareness campaigns that actually influence people’s behaviour.

Stigma and discrimination in South Africa

The prevalence of misinformation about AIDS in South Africa has not only hampered efforts to increase access to treatment, but has also created a climate of confusion in which prejudice towards people living with HIV thrives.

HIV is sometimes seen as being a disease of the poor. In South Africa, there is some correlation between extreme poverty and high HIV prevalence, although HIV is prevalent across all sectors of society.¹⁹ By 1998, although people from more affluent, largely white society were starting to come out as being HIV-positive, stigmatisation of the condition remained still deeply rooted in township areas. In October 1998, the then Deputy President Thabo Mbeki made the Declaration of Partnership Against AIDS, in which he called for an end to discrimination against people living with HIV.²⁰ However, it was clear that there was a long way to go before this goal could be achieved; less than two months later, Gugu Dlamini, an AIDS activist in Durban, was beaten to death by her neighbours after declaring that she was HIV-positive on World AIDS Day.

In 2000, Justice Edwin Cameron of the South African court announced in a speech that he was HIV-positive. The public response to this declaration was, on the face of it, largely supportive. However, coming out as HIV-positive can in many cases have a negative effect on employment and housing opportunities, as well as social relationships. A study in 2002 revealed that only one third of respondents who had revealed their HIV-positive status were met with a positive response in their communities. One in ten said that they had been met with outright hostility and rejection.²¹

When his son died of AIDS in 2005, Nelson Mandela publicised the cause of his death in an effort to challenge the stigma that surrounds HIV infection:

"Let us give publicity to HIV/AIDS and not hide it, because [that is] the only way to make it appear like a normal illness."²²

Gender inequality and sexual abuse in South Africa

Although HIV prevention campaigns usually encourage people to use condoms and have fewer sexual partners, women and girls in South Africa are often unable to negotiate safer sex and are frequently involved with men who have several sexual partners. They are also particularly vulnerable to sexual abuse and rape, and are economically and socially subordinate to men. Police reports suggest that in 2004-2005 there were at least 55,114 cases of rape in South Africa ²³, although the actual figure is undoubtedly higher than this since the majority of cases go unreported. In a 2006 study of 1,370 South African men, nearly one fifth revealed that they had raped a woman.²⁴ Rape plays a significant role in the high prevalence of HIV among women in South Africa.

Women often face more severe discrimination than men if they are known to be HIV-positive. This can lead to physical abuse and the loss of economic stability if their partners leave them. Since antenatal testing gives them a greater chance of being identified as HIV-positive, women are sometimes branded as ‘spreaders’ of infection.

The government has acknowledged that many women face ‘triple oppression’ in South African society – oppression on the grounds of race, class and gender – and has been making efforts to address this problem, through education and skills development schemes.²⁵ In September 2007 rape laws were strengthened to stop judges and magistrates taking into account factors such as a rape victim's sexual history, their apparent lack of physical injury, or the relationship between the victim and the perpetrator, when deciding on the length of the perpetrator's sentence. ²⁶

Children, HIV and AIDS in South Africa

With many women who are HIV-positive still not receiving drugs that could prevent them passing HIV to their babies, HIV infections are alarmingly common amongst children in South Africa. According to government antenatal surveys, there were around 260,000 children aged below 15 living with HIV in South Africa in 2006.²⁷

Children who are living with HIV are highly vulnerable to illness and death unless they are provided with paediatric antiretroviral treatment. Unfortunately there is still a shortage of such treatment in South Africa. The AIDS Law Project, an NGO based in Johannesburg, estimated that 50,000 children in South Africa were in need of antiretroviral drugs at the beginning of 2006, but that only around 10,000 were receiving them.²⁸ UNAIDS estimates that at the end of 2005, children accounted for 8% of those receiving antiretroviral drugs in South Africa.²⁹

As well as many children being infected with HIV in South Africa, many more are suffering from the loss of their parents and family members from AIDS. UNAIDS estimated that there were 1.2 million South African children orphaned by AIDS in 2005, compared to 780,000 in 2003.³⁰ Once orphaned, these children are more likely to face poverty, poor health and a lack of access to education.

The way forward for South Africa

In recent years, antenatal survey results have led the South African government to claim that the HIV epidemic is beginning to stabilise. The Democratic Alliance (the main opposition party in South Africa) argues that such claims detract from the seriousness of the country’s AIDS crisis. Even if the epidemic is stabilising, it is doing so at a very high level. Following the antenatal survey in 2004, Democratic Alliance health spokesman Ryan Coetzee stated:

“The figures continue to increase, and that is not 'stabilising'. The report proves the government's prevention campaign is not succeeding”³¹

The high level of new HIV infections occurring in South Africa reflects the difficulties that have been faced by AIDS education and prevention campaigns. In addition, the high number of AIDS deaths occurring in the country reflects the continuing lack of antiretroviral treatment available.

The future of the epidemic at least partly depends on the direction of the government’s HIV and AIDS policies. Although the government has been widely criticised in the past for its AIDS policies, recent events (including the development of a new framework to guide the national response to AIDS from 2007 until 2011) suggest that they are now more committed to improving the situation.

In the face of such a terrible epidemic, there is a tendency for some people to adopt a fatalistic attitude. However, as Justice Cameron once said:

"We don't accept 'sad realities' in South Africa. If we accepted sad realities, we would still have a racist oligarchy here."³²

What's this?

WHERE NEXT ?

AVERT.org has more about:

• HIV and AIDS in Africa
• Treatment, transmission and the government's response to AIDS in South Africa
• HIV and AIDS in a South African township
• How you can and can’t become infected with HIV