An estimated 5.7 million people were living with HIV and AIDS in South Africa in 2009, more than in any other country.¹ It is believed that in 2008, over 250,000 South Africans died of AIDS.² National prevalence is around 11%, with some age groups being particularly affected. Almost one-in-three women aged 25-29, and over a quarter of men aged 30-34, are living with HIV.³ HIV prevalence among those aged two and older also varies by province with the Western Cape (3.8%) and Northern Cape (5.9%) being least affected, and Mpumulanga (15.4%) and KwaZulu-Natal (15.8%) at the upper end of the scale.

Marking a welcome change from South Africa's history of HIV the South African Government launched a major counselling and testing campaign (HCT) in 2010.⁴ By raising awareness of HIV the campaign aims to reduce the HIV incidence rate by 50% by June 2011.⁵

Impact of HIV upon South Africa

The impact of the AIDS epidemic is reflected in the dramatic change in South Africa’s mortality rates. The overall number of annual deaths increased sharply from 1997, when 316,559 people died, to 2006 when 607,184 people died. This rise is not necessarily due solely to HIV and AIDS but it is young adults, the age group most affected by AIDS, who are particularly shouldering the burden of the increasing mortality rate. In 2006, 41% of deaths were attributed to 25-49 year olds, up from 29% in 1997.⁶ This is a strong indicator that AIDS is a major, if not the principal, 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 in a number of ways. There were an estimated 280,000 under-15s living with HIV in 2007, a figure that almost doubled since 2001.⁷ HIV in South Africa is transmitted predominantly heterosexually between couples, with mother-to-child transmission being the other main infection route. The national transmission rate of HIV from mother to child is approximately 11%.⁸ In most instances the virus was transmitted from the child’s mother. Consequently, 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% to 75% in 2010.⁹

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% 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.”¹⁰

It is estimated there are between 1.5 and 3 million AIDS orphans where one or both parents are deceased in South Africa,¹¹ and it is estimated that the HIV/AIDS epidemic has created half of the country’s orphans.¹² Another estimate puts the proportion of maternal orphans – those who have lost their mother – orphaned by AIDS as over 70%.¹³ 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.

HIV prevention in South Africa

Prevention of mother-to-child transmission

An unacceptably high number of babies, around 70,000, are born with HIV every year, reflecting poor prevention of mother to child transmission. HIV and AIDS is one of the main contributors to South Africa’s infant mortality rate,¹⁴ which increased significantly between 1990 (44 deaths per 1000 infants) and 2008 (48 per 1000), when all regions of the world saw decreases.^15 16

“The lack of improvement in child mortality in South Africa is largely due to the HIV epidemic, specifically the transmission of HIV from mother to child (MTCT).”¹⁷

In the past, the Department of Health recommended mothers take the drug zidovudine (AZT), by week 28 and single-dose nevirapine during labour. The infant took single-dose nevirapine after birth followed by seven days of AZT. The guidelines were issued in 2008 and were criticised for not meeting World Health Organization recommendations that are considered more effective. In 2008 the WHO recommended that mothers take AZT and lamivudine (3TC) during and following birth to prevent transmission and to reduce the risk of resistance to nevirapine.¹⁸ The Treatment Action Campaign responded to the omission of using AZT/3TC, known as the ‘cover-the-tail’ strategy, in the updated 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.”¹⁹

As part of 2010 guidelines, pregnant women who are HIV-positive will receive treatment when their CD4 count dips below 350 cells/mm³, a welcome change from the 200 cell threshold.²⁰ In another policy change, all other pregnant women who test HIV-positive will begin receiving treatment at 14 weeks rather than in the last term of pregnancy.^21 22 Postnatal treatment for mothers has been revised since 2008 and mothers now receive Tenofovir (TDF) and Emtracitabine (FTC) to avoid developing drug resistance.²³

“The lack of improvement in child mortality in South Africa is largely due to the HIV epidemic, specifically the transmission of HIV from mother to child (MTCT).”

These positive changes to the guidelines move South Africa’s approach to PMTCT closer to the WHO recommendations. The WHO advises treatment for pregnant women from 14 weeks or earlier if CD4 count is below 350 cells/mm³. This includes an extensive drug regimen of either triple ARVs for the mother and/or nevirapine for the infant, depending on their clinical requirements.^24 25 Should these changes be implemented effectively, it is hoped they will be reflected by a decrease in child mortality.

Testing uptake among women attending antenatal clinics rose from 69% in 06/07 to 80% in 07/08. Furthermore, 83% of HIV-positive pregnant women received ART for PMTCT in 2009.²⁶ The National Strategic Plan target is to reach 95% of HIV positive pregnant women with PMTCT services by 2011. Figures estimating PMTCT coverage in public sector antenatal sites vary, with UNAIDS and WHO reporting 73% and the South African government reporting more than 95% in 2008.²⁷

A problem with South Africa’s PMTCT programme is seen in its poor monitoring. The District Health Barometer report, which compiles data from a range of sources, stated, “Most of the indicators continue to be plagued by major data collection and quality issues.”²⁸

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 HCT campaign is to scale up awareness of HIV.²⁹ 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% 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.³⁰ However, following allegations of financial discrepancies and the termination of government funding in March 2010, this campaign appears to have been significantly downgraded.^31 32

Soul City and Soul Buddyz – targeted at adults and children, respectively – have a combined annual budget of R100 million, and utilize broadcast, print and outdoor media.³³

The campaign loveLife has run since 1999 and also uses a wide range of media directed mainly towards teens. ³⁴ It also has many ‘Y-centres’ around the country which function as youth centres that also offer clinics and counseling.³⁵ 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.³⁶

A major survey assessed how these campaigns are being received by the population. In 2008, over four-fifths of South Africans had seen or heard at least one aspect of the four campaigns, from less than three-quarters in 2005. Understandably, awareness messages were best received by 15-24 year olds, the target audience of many of these campaigns, with 90% coverage. This declined with age so that just over 60% of those aged 50 and above had seen or heard at least one of the four campaigns’ messages.³⁷

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 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.³⁸

Condom use and distribution

Condom use in South Africa is growing with the percentage of those using a condom during their last sexual encounter increasing from 27% in 2002, 35% in 2005 to 62% in 2008. 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.³⁹

The 2009 National Communication Survey on HIV/AIDS also found that 15% of married men and women used a condom at last sex compared to 74-83% men and 55-66% of women who had casual sex or one night encounters, identifying the need for prevention programmes to further target married couples.⁴⁰

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 2007.⁴¹

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.⁴² 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.⁴³

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.⁴⁴

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.⁴⁵

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.⁴⁶

Circumcision

Several large studies of male circumcision and HIV have produced firm evidence that the procedure reduces by 60% the risk of sexual transmission of HIV from women to men. Currently, though, just one clinic offers free male circumcisions, with public facilities only offering the service for medical reasons.⁴⁷ The government is reviewing evidence on circumcision but has yet to issue further guidance on the practice.

It was 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.⁴⁸

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 National Strategic Plan is aiming 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%.⁴⁹

There is evidence that testing levels have improved as the 2009 National Communications Survey found 60% of all men and women studied had been tested in the last 12 months, an increase of 36% since 2006.⁵⁰ The percentage of those ever tested also increased significantly as 2006 figures showed 17% men and 38% of women had been tested at least once compared to 2009 figures showing almost 32% of men and 71% of women. Further to this the survey 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.

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.⁵¹ The link between testing levels and several socio-economic indicators suggests an improvement in the general standard of living would be beneficial to 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.⁵²

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.⁵³ HIV prevalence within prisons if often far higher than in the general community, yet prisoners are often neglected and overlooked.

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.⁵⁴

“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

When testing does occur it is very often at a late stage of infection. The HCT campaign launched in April 2010 aims to offset the problem of late or no diagnosis.⁵⁵ The HCT campaign is a widespread strategy implemented in all health authorities whereby all patients will be counselled on the importance of knowing their HIV status and will be offered a test. Through this proactive approach the government of South Africa aim to test 15 million people for HIV by June 2011.⁵⁶

By making testing and counselling provider-initiated it is hoped diagnosis of HIV will take place earlier and treatment be started sooner. Routine testing at healthcare facilities could prove to be a way of working round the stigma attached to HIV testing.

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.

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 2007, an estimated 28% of infected people were receiving treatment for HIV, below the average across lower- and middle-income countries.⁵⁷

The state of HIV treatment in South Africa is disappointing and can only be seen in the context of years of doubting the effectiveness of treatment at the highest levels of government, and the 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 Nunn⁵⁸

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.

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 that hindered progress in treating HIV and AIDS in South Africa. The task of providing a high level of access to antiretroviral therapy in South Africa now faces a set of new challenges.

See AVERT's History of HIV and AIDS in South Africa page for more information.

Late initiation of treatment

The level at which someone begins antiretroviral therapy has a great impact on their chances of responding well to treatment. In well-resourced countries the threshold is generally <350, and there is discussion of raising this level even higher. In poorly-resourced countries, including South Africa, it is recommended that treatment begins after someone’s CD4 count dips below 200 cells/mm3.

However, in South Africa, delays in initiating treatment mean that the average starting point of antiretroviral therapy is a CD4 count of 87 cells/mm3. Dr Francois Venter, of the Southern African HIV Clinicians Society, 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.⁵⁹

A study based in two Durban clinics found most patients were tested at a late stage of infection with over 60% of CD4 counts below 200 cells/mm³. Of these patients just 42% 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.⁶⁰

Treatment guidelines

The South African National AIDS Council (SANAC), which advises the government on AIDS policy, recommended to raise the CD4 treatment threshold from 200 to 350 cells/mm³, this was reviewed by the National Health Council.⁶¹ Some researchers predicted 76,000 deaths could be prevented over five years if treatment was initiated below 350 cells, compared with below 250, assuming that 30% of eligible patients were identified and linked to care.⁶²

Advocates of raising the treatment threshold to <350 cells acknowledge that this would require greater expenditure but 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.”⁶³

Others, such as Dr Venter, argue 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.⁶⁴ 

The 2010 antiretroviral treatment guidelines released in February, did not adhere to the WHO recommendations to initiate ARV at a CD4 count of <350 cells/mm³.⁶⁵ Instead, HIV patients will continue to begin treatment at <200 cells/mm³. The guidelines did state that for certain groups, such as pregnant women, treatment will begin at <350 cells/mm³.

Child treatment

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% increase on 2005’s figure, though still only meeting half of the estimated need.⁶⁶ However, the Treatment Action Campaign (TAC) claims the methodology behind figures is not clear and they ‘should be treated with great caution’.⁶⁷

A major ongoing 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 diagnosis. The control group received treatment at a later stage of infection similar to current South African recommendations.⁶⁸

However, as of April 2010, all children with HIV exposure will be tested and all HIV-positive children under 12 months will receive antiretroviral drugs.^69 70

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, with first-line therapy no longer being effective. Therefore, keeping patients on treatment programmes is imperative.

However, 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.⁷¹ 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?’”⁷²

The 2010 HCT campaign aims to test 15 million by 2011 and will inevitably lead to an increase in demand for treatment.⁷³ Ongoing reports in early 2010 of drug and equipment stock outs and some hospitals without electricity or running water, call in to question whether health authorities have the administrative capacity to deal with this influx.⁷⁴

The TAC identified that government must eliminate the barriers which hinder positive developments in policy.⁷⁵ Such as 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.

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.^{76 77} 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 claimed it was 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.⁷⁸ A recent study in South Africa supported task-shifting to nurses, after it found that the care of patients receiving ART was not inferior when they were monitored by nurses rather than by doctors.⁷⁹

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 ART and lay counsellors to administer HIV tests. When will South Africa wake up?”⁸⁰ 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 4,333.⁸¹

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.⁸² The government's recent HCT campaign⁸³ is envisaged to have widespread reach and with task-shifting now approved, the success of this campaign is promising. However, task shifting only applies to lay counsellors at this time, yet the capability of healthcare facilities will improve further if task-shifting is expanded to include nurses. 

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.⁸⁴ During 2010 some provinces experienced widespread wage shortages for lay counsellors, which disrupted the delivery of the HCT campaign.⁸⁵

The future of AIDS treatment in South Africa

The National Strategic Plan (NSP), a multisectoral response to South Africa’s AIDS epidemic, calls for treatment, care and support for 80% of HIV positive people by 2011. Given the current low level of treatment coverage, and the potential barriers to its achievement, attaining near-universal coverage within such a short time would be an immense task.

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 as set out by 2011.”⁸⁶

Greater resources are crucial to achieving this, as well as a more effective use of existing resources. Failure to achieve one year’s target will make the task of achieving goals in subsequent years that much harder.

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,⁸⁷ 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 countries with high HIV prevalence, TB has tripled in the past 15 years, which clearly illustrates the link between the two diseases.⁸⁸

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% of the global population, the country accounts for 28% of the world’s people living with both HIV and TB.⁸⁹ Fighting both diseases together, where appropriate, is seen as crucial:

“We cannot fight AIDS unless we do much more to fight TB.” – Nelson Mandela⁹⁰

The high level of HIV and TB coinfection led the National Strategic Plan to call for an integration of care for the two diseases.⁹¹ 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% in 2002 to 97% by mid-2007.⁹²

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.”⁹³

The success of the HIV/TB service integration is such that the Western Cape has adopted this as policy. 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”.⁹⁴

In a sign that HIV/TB coinfection is being taken seriously, as of April 2010, the treatment threshold for coinfected people will rise from 200 to 250 cells/mm3.⁹⁵ 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.⁹⁶ 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.⁹⁷

Gender violence, inequality and HIV in South Africa

Violence against women, including sexual violence, is very widespread in South Africa. In a large survey, more than four-in-ten South African men reported to have been physically violent to an intimate partner. Over a quarter of men reported ever having raped a woman with nearly one-in-twenty committing rape in the previous year. Little difference was found in the HIV prevalence of men who had raped a woman compared to those who had not. However, the generally high HIV prevalence among all men surveyed means there is a good chance that a man who commits rape has HIV.⁹⁸

The disempowerment of South African women – 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.⁹⁹

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."¹⁰⁰

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.

Efforts to tackle HIV are now at least facilitated by government acceptance of the science behind HIV and ARVs, where previous administrations sowed confusion at best, and at worst were responsible for the deaths of hundreds of thousands of people. 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% 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, far more needs to be done if the country is to achieve its goal of halving its 2007 infection rate by 2011.

A recent review of the National Strategic Plan (NSP) 2007-2011 produced a number of recommendations to ensure 2011 and future NSP targets are reached.¹⁰¹ The South African National AIDS Council (SANAC) is the national HIV coordinating body responsible for overseeing the implementation of the NSP.¹⁰² A significant step towards achieving NSP targets is, it is recommended, to improve the management and coordination of the National Strategic Plan through reforming and strengthening SANAC. As part of this, SANAC members would become more accountable for reaching NSP targets.¹⁰³

Increasing resources at provincial and district level, to aid the implementation of the NSP in these areas, the need for a rolling annual implementation plan, as well as funding surveillance were further recommendations.¹⁰⁴

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 needs to be collected in a central location, from which intelligence can be extracted, to inform decision making.¹⁰⁵

Continued pressure from activists and civil society, and radical measures by the government are needed to see South Africa effectively bring the epidemic under control.

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References

1. UNGASS (2010, 31st March) 'South Africa UNGASS Country Progress Report'
2. Statistics South Africa (2009, July), ‘Mid-year population estimates 2009’
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4. SANAC (2010, February) 'The national HIV counselling and testing campaign strategy'
5. UNGASS (2010, 31st March) 'South Africa UNGASS Country Progress Report'
6. Statistics South Africa (2008, October), ‘Mortality and causes of death in South Africa, 2006: Findings from death notification’
7. UNAIDS (2008), ‘2008 Report on the Global AIDS epidemic’
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16. Unicef (2009), ‘State of the World’s Children’
17. Health Systems Trust (2009), ‘District Health Barometer 2007/08’
18. WHO (2006, August), ‘Antiretroviral drugs for treating pregnant women and preventing HIV infection in infants: towards universal access’
19. Treatment Action Campaign (2008, January), ‘Department of Health Announces New PMTCT Guidelines’
20. UNGASS (2010, 31st March) 'South Africa UNGASS Country Progress Report'
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