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HIV & AIDS in South Africa
South Africa has the biggest and most high profile HIV epidemic in the world. In 2012, an estimated 6.1 million people were living with HIV, with 240,000 South Africans dying from AIDS-related illnesses. 1
South Africa has the largest antiretroviral treatment rollout programme in the world. Life expectancy has also increased by 5 years since the height of the epidemic. 2 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. 3
However, HIV prevalence remains high (17.9 percent) among the general population, although it varies markedly between regions. 4 For example, HIV prevalence is almost 40 percent Kwazulu Natal compared with 18 percent in Northern Cape and Western Cape. 5 For a more detailed breakdown, visit our South Africa HIV and AIDS statistics page.
Key affected populations in South Africa
South Africa's National Strategic Plan 2012-2016 identifies a number of key affected populations that are at risk of HIV transmission. 6 Just a few of these groups are discussed in more detail below.
Men who have sex with men (MSM) and HIV in South Africa
HIV prevalence among men who have sex with men (MSM) in South Africa is an estimated 9.9 percent with roughly 9.2 percent of all new HIV infections in the country related to this group. HIV prevalence among MSM varies geographically. For example, one study reported an HIV prevalence of 43.6 percent among MSM in Johannesburg and Durban. 7 By contrast, 10 percent of self-identified MSM from urban areas in Western Cape are reportedly living with HIV. 8
Many MSM still face high levels of social stigma and homophobic violence due to traditional and conservative attitudes that have persisted from the apartheid era. Indeed, a 2013 study found that only 32 percent of South Africans said that homosexuality should be accepted by society. 9 As a result, MSM find it difficult to disclose their sexuality to healthcare workers, limiting their access to HIV services. 10
That said, South Africa is the only country in sub-Saharan Africa where gay rights are formally recognised. 11 Moreover, national policies strongly emphasise equity, social justice and forbid discrimination based on sexual orientation. These are prerequisites for the provision of HIV services for MSM as well as other members of the lesbian, gay, bisexual and transgender (LGBT) community. As a result, South Africa has the potential to provide a leading role in the improvement of HIV service provision for MSM throughout sub-Saharan Africa. 12
Sex workers and HIV in South Africa
HIV prevalence among sex workers varies between 34 and 69 percent depending on the geographical area. 13 14 15 In 2010, sex work accounted for an estimated 19.8 percent of all new HIV infections in South Africa. 16
Sex workers in South Africa also face high levels of stigma and discrimination and are restricted by the by the laws under which they have to work. Moreover, many sex workers also inject drugs exacerbating their vulnerability to HIV infection. 17 Female sex workers (FSW) are particularly affected with one study reporting an HIV prevalence of nearly 60 percent among FSW compared to 13 percent among women in the general population. 18
Educational organisations have reported difficulties in delivering HIV prevention services to sex workers due to on-going police harassment. One study found that up to 70 percent of women who sold sex had experienced abuse by the authorities: 19
“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 20
In light of this, the South African National AIDS Council (SANAC) recently commissioned the first ever study assessing the number of sex workers in the country. It is hoped that this report will enable South Africa to develop policy and better estimate the need for HIV services among this group. 21
People who inject drugs (PWID) and HIV in South Africa
In 2012, an estimated 16.2 percent of people who inject drugs (PWID) in South Africa were living with HIV. However, PWID account for a comparatively low 1.3 percent of new HIV infections. 22 Data on HIV prevalence among PWID in South Africa is very limited, and where it does exists, is based on small sample sizes. 23
One study has reported that up to 86 percent of South Africans who inject drugs share injection equipment such as syringes and other drug paraphernalia. 24 Another study reported that some PWID re-use equipment between 2 and 15 times. 25
PWID are also associated with other high-risk behaviours such as sex work and unsafe sexual practices. For example, the IRARE study demonstrated a strong link between drug use and risky sexual practices with up to 65 percent of PWID in South Africa thought to practice unsafe sex. 26
Children, orphans and HIV in South Africa
In 2012, an estimated 410,000 children aged 0 to 14 were living with HIV in South Africa. From 2002 to 2012, HIV prevalence declined among children, due mainly to the programme to prevent mother-to-child transmission of HIV. The scaling up of antiretroviral treatment has reduced child mortality by 20 percent. 27
There are over 2.5 million children in South Africa who have been orphaned by HIV and AIDS. 28 Orphans are particularly vulnerable to HIV transmission; they are often at risk of being forced into sex, have sex in exchange for support, and typically become sexually active earlier than other children. 29
Orphans often have to relocate, 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 vital social services, including basic education. 30
Women and HIV in South Africa
An HIV survey in 2012 found that HIV prevalence among women was nearly twice that 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 South Africa. Among the analysed populations, the highest HIV prevalence was detected among black African females aged 20-34 (4.5 percent). 31
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-positive man-to-woman ratio in South Africa, HIV transmission rates from men to women have increased. 32 Poverty, the low status of women and gender-based violence have also been cited as reasons for the disparity in HIV prevalence between men and women in South Africa. 33 34
Despite these barriers, HIV prevalence among women aged 15-24 is thought to have declined overall between 2002 and 2012. 35
HIV testing and counselling (HTC) in South Africa
The National Strategic Plan 2007-2011 aimed to get 25 percent of all South Africans to test annually and 70 percent of all people to have at least one HIV test. 36 In 2010, a quarter of the population aged between 15 and 49 had been tested for HIV in the previous 12 months. 37
The launch of the national HIV counselling and testing (HTC) campaign in April 2010 resulted in a remarkable increase in the number of people accessing testing. Between 2008 and 2012, annual HIV testing increased from an estimated 19.9 percent to 37.5 percent among men, and from 28.7 percent to 52.6 percent among 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. 38
In South Africa, the link has also been made between an individual’s socio-economic background and the likelihood that they will test for HIV. Those who have taken an HIV test and know their status, are more likely to have a higher level of education, be employed, have accurate HIV knowledge and a higher perception of risk. 39 This suggests that an improvement in the general standard of living would lead to an increase in the uptake of HTC services.
Another determining factor is whether an individual lives in an urban or rural setting. One study revealed that people living in rural areas are only half as likely to have been tested as those in urban areas, with mobile testing units suggested as a means of reaching rural populations. 40
The latest National Strategic Plan has set out more ambitious targets aiming to overcome these barriers to ensure that everyone in South Africa is voluntarily tested annually. 41
Mobile HIV testing in South Africa
Mobile HIV testing has become increasingly popular in South Africa in recent years. For example, in 2008, the Desmond Tutu HIV Foundation (DTHF) launched the Tutu Tester Mobile Clinics. The mobile clinics offer immediate HIV testing as well as testing for tuberculosis, diabetes, high blood pressure as well as breast and testicular cancer. 42
Since its inception, over 35,000 people have used the service. 43 Its success is largely due to the fact that it offers testing for a number of chronic illnesses, so patients can avoid HIV-related stigma:
“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 44
Some have argued that adding mobile HIV clinics to existing testing programs in South Africa would improve survival rates and be cost-effective in resource-limited settings. 45
Home-based HIV testing in South Africa
Other innovative ways of delivering HTC services have also been explored in South Africa such as home-based HIV counselling and testing (HBHCT). HBHCT enables individuals to perform some, or all aspects of an HIV test in a location chosen by them. As a result, home testing has the potential to increase HIV testing uptake, enabling more people to know their status and subsequently present for treatment. 46
One study of door-to-door rapid testing offered by trained counsellors in Kwazulu-Natal had a 75 percent acceptance rate showing the potential of HBHCT in rural areas. However, the study stressed that future programmes should consider community context and tailor messages to a range of key affected groups in order to achieve a high acceptance rate. 47
HIV prevention in South Africa
HIV prevention in South Africa is centred on the National Strategic Plan (NSP). The previous NSP (2007-2011) oversaw a dramatic scaling up of South Africa's antiretroviral treatment (ART) programme with the purpose of decreasing the number of new HIV infections.
The current National Strategic Plan 2012-2016 is framed primarily around the UNAIDS vision of "zero new HIV infections, zero discrimination and zero AIDS-related deaths." Perhaps more significantly, it has also committed to "zero new infections due to mother-to-child transmission." 48 49
Preventing mother-to-child transmission (PMTCT) in South Africa
The latest NSP highlights South Africa's commitment to ending mother-to-child transmission (MTCT) of HIV. Over the past decade, the country has made great progress in this area due largely to improvements in the choice of antiretroviral drugs (ARVs) and the widespread accessibility of the PMTCT programme. 50
When South Africa first launched its PMTCT programme in 2001, there was very limited intervention before and after childbirth. Guidelines have since been revised several times and are now largely based on recommendations from the World Health Organisation. 51
By 2010, PMTCT services were being offered at 98 percent of all healthcare facilities in the country. Moreover, by June 2011, the national HTC campaign had tested 274,000 women with 78.5 percent of those diagnosed as positive being referred onto treatment. 52 As a result, mother-to-child transmission of HIV in South Africa has fallen to 3.5 percent - meeting the previous NSPs target of less than 5 percent. 53 Between 2009 and 2011, new annual HIV infections among children fell from 56,500 to 29,100. 54
However, maternal mortality has not followed this trend. A review of a large district referral hospital in Johannesburg showed there had been no reduction in the proportion of maternal deaths since 2007, despite improvements in PMTCT. 55
The current National Strategic Plan aims to reduce MTCT rates to under 2 percent at six weeks after child birth and less than 5 percent at 18 months by 2016. 56 Moreover, with the latest WHO-based PMTCT guidelines implemented as of April 2013, it is widely believed that South Africa has reached a point where the elimination of paediatric HIV is a distinct possibility. 57
Condom use and distribution in South Africa
South Africa has responded to its HIV epidemic with a rapid expansion of its condom programme. Male condoms are widely available and the female condom programme is one of the biggest and most established in the world. 58
Between 2007 and 2010, the distribution of male condoms increased by 60 percent, from 308.5 million to 495 million. However, in terms of condoms per adult male (15-49) this only represents a small increase - from 12.7 in 2007 to 14.5 in 2010. In the same period, the number of female condoms distributed increased from 3.6 million to 5 million (a 39 percent increase). However, it is widely acknowledge that female condoms are not a readily available as they should be. 59
Moreover, in recent years, condom usage in South Africa has fallen. In 2008, 85 percent of 15-24 year males reported using a condom during their last sexual encounter - by 2012, this had fallen to 68 percent. Condom use among men aged 25-49 also decreased, from 44 percent to 36 percent. The same survey reported that 53 percent of participants had never used condoms. 60
Voluntary medical male circumcision (VMMC) in South Africa
During the development of the 2007-2011 National Strategic Plan, research emerged in sub-Saharan Africa that voluntary medical male circumcision can reduce the risk of HIV transmission by up to 60 percent. 61 When it was found that some men on the waiting list in South Africa failed to have the procedure, a second analysis reported a 76 percent reduction in the risk of HIV infection for circumcised men compared to non-circumcised men. 62
As a result, in 2010, the South African government quickly rolled out a national voluntary medical male circumcision (VMMC) programme, which aimed to reach 80 percent of HIV-negative men (4.3 million) by 2016. Specifically, the programme aims to offer all men aged 15-49 VMMC at public health facilities in all provinces by 2011. In April 2010, KwaZulu-Natal became the first province to offer VMMC services and by late 2012, there were over 80 VMMC sites. 63
By April 2011, more than 150,000 operations had been conducted with an estimated one new HIV infection averted for every 5 VMMCs conducted. 64 The VMMC programme in South Africa has mostly been well received with 78 percent of women preferring their partner to be circumcised according to the 2011 youth sex survey. 65
HIV education in South Africa
Since 2000, the HIV and AIDS Life Skills Education Programme has been implemented in all public primary and secondary schools in South Africa. The main objectives of the programme are to integrate HIV and AIDS education into the school curriculum as a means of averting new HIV infections as well as to provide care and support for pupils already living with HIV. The programme is mostly implemented through Life Orientation lessons, with other aspects (such as nutrition) covered in other subjects. 66
However, in many places there is a shortage of teacher training on these issues. This means that many schools have few, if any teachers who are able to provide HIV and AIDS education. Furthermore, some schools are resistant to the subject matter. In 2008, teaching unions called for a Life Orientation module to be included in all teacher training. 67 In some cases, gaps in the delivery of the Life Orientation curriculum are filled by independent organisations. 68 In other instances, teachers report feeling uncomfortable about teaching a curriculum that contradicts with their own values and beliefs. 69
High dropout rates in schools also compromise effective HIV, AIDS and sex education. It has been suggested that prevention programmes should be focussed towards younger children while more of them are in education and before they become sexually active. 70
HIV awareness in South Africa
In South Africa, there have been a number of HIV awareness campaigns, which have been supported by the government, the private sector or both.
The 2012 National Communication Survey on HIV/AIDS found that the country's HIV and AIDS communication programmes were overall having a positive effect, particularly on youth (aged 15-24) with an increase in condom usage, uptake of HTC and male circumcision. By contrast, knowledge around safe breast-feeding practices among pregnant mothers living with HIV remains low. 71 The main HIV awareness campaigns are detailed below.
- Soul City and Soul Buddyz
Soul City and Soul Buddyz were two government multi-media campaigns targeting adults and children respectively. Soul City utilised the concept of 'edutainment' to broadcast TV dramas and radio programmes to audiences at prime time to maximise its reach. Soul City is widely regarded as the leading source of information on HIV and AIDS in South Africa (72 percent). The intervention was thought to have reached over 70 percent of all over 16s in the country including 65 percent of rural people and 50 percent without any formal education. Indeed, the initiative has lead to a significant increase in HIV knowledge and has encouraged positive behaviour change. 72
Soul Buddyz was the judged to be the most successful family television show to be produced in South Africa. 67 percent of 8-12 year olds had watched, read or listened to Soul Buddyz (about 4 million children). 73
Since 1999, the loveLife campaign utilised a range of media in order to reduce the number of new HIV infections among young people (aged 12-19). It engages with South Africa youth through outreach and support programmes facilitated by peer educators. loveLife also runs youth centres or 'Y-centres' providing sexual health information, clinical services and skills development. 74
Khomanani was an AIDS awareness campaign launched by the Department of Health. The campaign utilised mass media including radio announcements and situational sketches on television. It aimed to reduce the rate of new HIV infections by 50 percent. Compared with other campaigns, Khomanani had fairly mixed outcome with condom usage unchanged but knowledge of safe sex practices did improve significantly. 75
Antiretroviral treatment (ART) in South Africa
By October 2012, over two million people were receiving ART, surpassing the country's universal access target (80 percent) in accordance with the 2010 WHO treatment guidelines (offering treatment to people with a CD4 count under 350). 78
In three provinces, the life expectancy of people receiving ART is now about 80 percent of normal life expectancy provided they do not start treatment late. One study from rural South Africa found that HIV incidence has fallen by 17 percent for every 10 percent increase in the number of people receiving ART. 79
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 antiretroviral drug (ARV) programme.
Late initiation of treatment
Though the antiretroviral treatment programme was expanding rapidly, many South Africans were starting treatment with particularly low CD4 counts. Current World Health Organisation guidelines call for initiation onto treatment when a person's CD4 count drops below 500cells/mm3.
In 2009, it was reported that the average CD4 count at which patients started on treatment in South Africa was just 87 cells/mm3 - a level unchanged in four years. 80 One study based in two Durban clinics found that 60 percent of patients were tested when their CD4 counts were below 200 cells/mm3. Of these patients, just 42 percent had begun treatment within 12 months. Of those who were eligible for treatment, more than a fifth died, mostly before beginning treatment. 81
In other cases, individuals simply refuse treatment despite being eligible. A study in Soweto found that of 743 newly diagnosed HIV-positive adults eligible to begin treatment immediately, 20 percent refused. More than a third gave "feeling healthy" as the reason for refusing treatment despite having a low CD4 count with many also co-infected with tuberculosis. 82
In order reach 80 percent of those in need of antiretroviral treatment (ART) by 2011, the South African government employed task shifting. Task shifting refers to the reallocation of tasks among available staff.
ART services in South Africa had initially been hospital-based and doctor-led. However, the rapid rollout of ART overburdened HIV and AIDS clinics demanding that nurses (rather than doctors) initiated antiretroviral therapy; lay counsellors (rather than nurses) carried out HIV tests; and pharmacy assistants (rather than pharmacists) prescribed ARVs. This increased the number access points to treatment and care by reducing the ‘bottlenecks’ in the healthcare system created by a shortage of staff able to provide vital HIV services. 83
Indeed, task shifting proved very successful. As well as increasing access to ART, quality of HIV care remained stable and even increased in some places. Moreover, a number of clinics reported higher job satisfaction, lower workloads and less usage of sick leave among their staff. 84
The future of antiretroviral treatment in South Africa
The new 2013 WHO guidelines (treatment for those with CD4 counts under 500) have since made many more people eligible for treatment in South Africa. 85 The South African government is yet to make this move primarily due to the cost yet it is argued that early treatment would actually save money by preventing illnesses like tuberculosis in people living with HIV:
“The prevention benefit of early ARV therapy cannot be overlooked and contributes also to improved life expectancy to (HIV-negative) partners and decreased costs over time.” - Rochelle Walensky, Harvard University 86
HIV and tuberculosis (TB) in South Africa
South Africa currently has the world's third largest tuberculosis (TB) epidemic - TB prevalence has increased by over 400 percent in the last 15 years. 87 TB is the leading cause of death in South Africa. In 2011, of the half a million people who died in South Africa, 12 percent of men and 10 percent of women died from TB. 88
The HIV epidemic in South Africa fuels the TB epidemic. People living with HIV are at a far higher risk of developing active tuberculosis as a weakened immune system facilitates the development of the disease. Similarly, TB can accelerate the course of HIV. 89
Roughly 1 percent of the South African population develops TB every year and the number of TB cases continues to rise. 70 percent of people living with HIV in South Africa are co-infected with TB.
However, more promisingly, the TB cure rate has improved in the last decade, from 54 percent in 2000 to 71 percent in 2009. 90 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. 91
The 2007-2011 NSP promoted the integration of HIV and TB services to ensure that people who are co-infected receive the appropriate treatment and care.
“We cannot fight AIDS unless we do much more to fight TB.” - Nelson Mandela 92
Funding the response to the HIV epidemic in South Africa
Despite having the world's biggest antiretroviral treatment programme, South Africa had been paying significantly more than other low and middle-income countries for its antiretroviral drugs. In 2010, bound by the terms of its existing tender for ARVs, the government only bought one third of its products at internationally completive prices. 93
Over the following two years, a 53 percent reduction in the cost of ARV drugs with savings of $640 million was made. 94 This new tender introduced a three-in-one or fixed-dose combination (FDC) drugs helping to reduce the pill burden and improve adherence. 95
South Africa largely funds its HIV and AIDS programmes, with donors accounting for less than 25 percent of its HIV response. 96 However, based on National Strategic Plan 2012-2016 targets, the gap between funding requirements and available funding for HIV, Sexually Transmitted Infections (STIs) and TB is expected to grow.
The future of HIV and AIDS in South Africa
Now, over 2.5 million people are on antiretroviral treatment making the country's public HIV treatment programme the biggest worldwide. Moreover, these efforts are now largely funded from South Africa's own resources, enabled by the introduction of a three-in-one or FDC ARV, which has already saved billions of rands.
HIV prevention initiatives are having a significant impact on mother-to-child transmission rates in particular, which are falling dramatically. New HIV infections overall have fallen by half in the last decade. Moreover, while South Africa is yet to make significant inroads into the reduction to TB deaths, the country has made great progress in the scaling up of ARV access for co-infected people.
However, there were still 370,000 new HIV infections in 2012, the world's highest. While the short term financing of South Africa's HIV epidemic is secure, in the longer term, the South African government needs to explore other strategies in order to sustain and expand its progress to date.
- History of HIV and AIDS in South Africa
- South Africa HIV and AIDS statistics
- HIV and AIDS in sub-Saharan Africa
- Impact of HIV and AIDS in sub-Saharan Africa
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