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HIV & AIDS in South Africa
An estimated 5.6 million people were living with HIV and AIDS in the Republic of South Africa in 2011, the highest number of people in any country. 1 In the same year, 270,190 South Africans died of AIDS-related causes. Although this number reflects the huge amount of lives that the country has lost to AIDS over the past three decades, it is 100,000 fewer deaths than in 2001, demonstrating the many lives that have been saved through a massive scale-up of treatment in the last few years. 2
The initial response to the HIV epidemic in South Africa was slow and interrupted as many political leaders in the country doubted the science behind both HIV and AIDS and antiretroviral treatment.
However, in the last few years, South Africa has become home to the largest antiretroviral treatment roll-out programme in the world. Life expectancy has also increased by 5 years. 3 Moreover, these efforts have been largely financed from its own domestic resources. The country now invests more than $1 billion annually to run its HIV and AIDS programmes. 4
HIV prevalence is 17.3 percent among the general population, but varies a lot by region. 5 In KwaZulu-Natal, the region with the highest prevalence, just under 40 percent of 15-49 year-olds are living with HIV. 6 Provinces at the lower end of the scale include Western Cape and Northern Cape. 7
Impact of HIV upon South Africa
The impact of the HIV and AIDS epidemic has been 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. 8 Those who are particularly shouldering the burden of the increasing mortality rate are young adults, the age group most affected by the epidemic; 9 almost one-in-three women aged 25-29, and over a quarter of men aged 30-34, are living with HIV. 10 The link suggests that AIDS was the principle factor in the overall rising number of deaths. However, life-expectancy has risen vastly since 2005. 11
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. 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
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 children orphaned by AIDS 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-positive orphans that have survived into adulthood. 19
HIV prevention in South Africa
Prevention of mother-to-child transmission
The impact of HIV and AIDS on children has been vast, but since 2009 South Africa has had one of the sharpest declines in new infections among children. 20 In 2011, more than 95 percent of pregnant women with HIV received treatment to prevent the infection of their child. 21 Yearly infections in children have dropped from 56,500 in 2009 to 29,100 in 2011. 22
Between 1990 and 2001 the infant mortality rate increased significantly from 44 deaths per 1000 infants 23 to 56.9 per 1000 infants. 24 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. 25 Although infant mortality remains high in South Africa, it has declined steadily since 2003 to a mid-year estimated rate of 37.9 per 1000 infants in 2011. 26 In contrast, maternal mortality has not followed this trend, with a review of a large district referral hospital in Johannesburg showing there had been no reduction in the proportion of maternal deaths since 2007, despite improvements in PMTCT. 27
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. 28 South African guidelines for PMTCT issued in 2008 29 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. 30 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.” 31
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. 32
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, which was met. 33 34 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. 35 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. 36
HIV and AIDS awareness
In April 2010, a large HIV counselling and testing (HCT) campaign was launched, a principle part of which was to scale up awareness of HIV. 37 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. A 2010 survey found evidence of a link between the amount of exposure a person has had to communication programmes and whether the individual had been tested. 38
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. 39 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. 40
The campaign loveLife has run since 1999 and uses a wide range of media directed mainly towards teens. 41 It also runs youth centres or ‘Y-centres’ around the country, which provide sexual health information, clinical services and skills development. 42 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. 43
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. 44
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. 45
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. 46 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. 47
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. 48
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. 49
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. 50 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. 51
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. 52 In some cases, gaps in the delivery of the Life Orientation curriculum may be filled by independent organisations. 53
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. 54
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. 55
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. 56 As a result, the government has included voluntary medical male circumcision (VMMC) as an integral part of its HIV counselling and testing (HCT) campaign. 57 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. 58
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. 59 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. 60
Groups most at risk of HIV in South Africa
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. 61 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. 62
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. 63
MSM 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. 64 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, 65 but across South Africa prevalence amongst this group is 9.9 percent. 66
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. 67 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. 68
Sex workers and HIV in South Africa
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. 69 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. 70 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. 71 Educational organisations have reported difficulties in delivering HIV prevention services to sex workers due to constant police harassment.
Another study found that 70 percent of women who sold sex had experienced abuse by police. 72
“He put me on the floor. The police officer raped me, then the second one, after that the third one did it again. I was crying after the three left without saying anything. Then the first one appeared again… He let me out by the back gate without my property. I was so scared that my family would find out. ” - Female sex worker, Cape Town 73
To curb the HIV epidemic in South Africa, it is vital that sex workers have the ability to protect themselves through access to the same legal protection that other citizens have.
Women and HIV in South Africa
A HIV survey in 2012 identified HIV-incidence among women nearly twice that found in men. Rates of new infections among young women aged 15-24 were more than four times greater than that of men in the same age range, and accounted for 25 percent of new infections in the country. Among the analysed populations, the highest HIV prevalence was detected among black African females aged 20-34 at 4.5 percent. 74
A number of reasons have been reported for this disparity between men and women. For example, studies have shown how due to the high HIV man-to-woman ratio in South Africa, the 'efficiency' of the male transmitter and the susceptibility of the woman are increased. 75 Poverty, the low status of women, and gender based violence and rape against women, have all been cited as reasons for the disparity in HIV prevalence between men and women. 76 77
Despite this, HIV prevalence among women aged 15-24 is thought to have declined overall between 2002 and 2012. 78
Gender violence, inequality and HIV in South Africa
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. 79 Over a quarter of men reported raping a woman in their lifetime with nearly one-in-twenty committing rape in the previous year. 80 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. 81 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. 82 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. 83
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. 84 85 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. 86
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. 87 The latest National Strategic Plan has set out more ambitious targets, aiming to ensure that everyone in South Africa is voluntarily tested every year. 88
In 2010, a quarter of the population aged between 15 and 49 had been tested for HIV in the last 12 months. 89 The launch of the national HIV counselling and testing (HTC) campaign in April 2010 had resulted in a remarkable increase in the number of people accessing testing. Between 2008 and 2012, annual HIV testing increased from an estimated 19.9 percent to 37.5 percent for men, and from 28.7 percent to 52.6 percent for women. The higher testing figures seen among women have been attributed to the added effect of the PMTCT programme which enables women to access HIV testing services when they go for antenatal appointments. 90
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. 91 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. 92
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. 93
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. 94
“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:
“ (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 testing 95
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 ART roll-out programme in the world, 96 benefitting from a 75 percent increase in HIV treatment services between 2009 and 2011. 97 By October 2012, over two million people were on antiretroviral drugs, surpassing the country's universal access target (80 percent). 98
The huge scale-up of treatment in South Africa is especially impressive 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.
The task of continuing to provide a high level of access to antiretroviral therapy in South Africa now faces a set of new challenges.
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. 99
In 2010, the South African government released guidelines that did not adhere to WHO recommendations. 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.” 100
In 2011 the government amended treatment guidelines so that treatment is initiated at a cell count of <350 cells/mm3. 101 102 This was 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
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
A government guide to treating HIV-infected children in South Africa is available here.
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. 113
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. 114 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?’” 115
The national HIV counselling and testing (HCT) campaign aimed to test 15 million by 2011. 116 As of that year, over 14 million people were counselled and almost 13 million people were tested for HIV. 117 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. 118
The TAC identified that the government must eliminate the barriers that hinder positive developments in policy. 119 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. 120
Moreover, under previous tender prices it would have cost the government more than R8.8 billion to treat people with antiretrovirals. 121 However, a tender awarded to 10 pharmaceutical companies, at the end of 2010, cost 53.1 percent less than had been paid previously. 122 123 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 this source of income people cannot afford food. 124 There have been instances where people have chosen not to adhere to their HIV treatment properly so that their cell count remains at a level where they are considered disabled.
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. 125 126 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. 127 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. 128
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?” 129 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. 130
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. 131 The government's HIV counselling and testing (HCT) campaign 132 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. 133 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. 134
To support this task shifting initiative, the Iteach Programme in KwaZulu-Natal is training traditional healers (Sangomas) at local health institutions, to gain counselling qualifications so they are qualified to provide counselling and condoms. Around 80 percent of people living with HIV in the province visit a traditional healer before seeing a doctor. 135 Increasing the knowledge and skills of traditional healers and giving them legal authorisation to carry out certain tasks, will further reduce the workload on doctors and nurses. It is hoped that this initiative will help curb the epidemic by developing existing tradition-based healthcare points, rather than through national health facilities alone, which are often inaccessible for rural people.
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 HIV/AIDS treatment in South Africa
South Africa is facing up to the necessary challenge of finding greater resources for the epidemic. Of all low- and middle-income countries, South Africa has made the highest domestic investment in HIV/AIDS services. 138 As more people have access to life-saving treatment, large steps can be seen in reducing the impact of AIDS on South Africa; between 2001 and 2010 AIDS-related mortality decreased by 21 percent. 139 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. 140
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 continue to have access to it, along with care and support, in 2016. 141 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. 142 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.
In South Africa, employment prospects for a person living with HIV increase sharply with access to antiretroviral treatment. 143 In order to ensure access to HIV treatment for their workers, an increasing number of companies in South Africa provide HIV treatment through workplace health schemes and, following a study demonstrating the positive impact of such programs, these numbers a likely to rise. 144 These schemes have the potential to, not only attain greater health and well-being among people with HIV, but also to strengthen South Africa's companies and economy.
HIV and tuberculosis in South Africa
“We cannot fight AIDS unless we do much more to fight TB.”
Tuberculosis (TB) is the leading cause of death in South Africa, 145 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 two decades, which clearly illustrates the link between the two diseases. 146
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. 147 Fighting both diseases together, where appropriate, is seen as crucial:
“We cannot fight AIDS unless we do much more to fight TB.” - Nelson Mandela 148
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. 149 150 In 2010, about 210,000 people in South Africa with TB were tested for HIV, and 60 percent were HIV-positive. 151 Between 2010 and 2011, the number of people living with HIV who received preventative TB medication nearly tripled, from 146,000 in 2010 to 373,000 in 2011. 152
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. 153
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.” 154
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. 155
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." 156
South Africa has come a long way in responding to its HIV epidemic. Life expectancy has increased by 10 percent since 2005 - this level of improvement in a country's mortality is usually associated with 'a huge change in society'. 157 158
Drug stockouts, continued use of ARVs with severe side effects, and a lack of entry points to care, are factors that must still be overcome in order to continue to scale-up effective treatment provision. 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 will need to be done if South Africa is to meet its latest goal of halving the current infection rate by 2016. 159
“If we stop anything, we will just reverse all our gains”
Health Minister, Dr. Aaron Motsoaledi
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 HIV/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 Motsoaledi 160
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