South Africa has the biggest and most high profile HIV epidemic in the world, with an estimated 6.3 million people living with HIV in 2013. In the same year, there were 330,000 new infections while 200,000 South Africans died from AIDS-related illnesses.1
South Africa has the largest antiretroviral treatment programme globally and 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.2
However, HIV prevalence remains high (19.1%) among the general population, although it varies markedly between regions.3 For example, HIV prevalence is almost 40% Kwazulu Natal compared with 18% in Northern Cape and Western Cape.4
Key affected populations in South Africa
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% with roughly 9.2% of all new HIV infections among this group. HIV prevalence among MSM varies geographically. For example, one study reported an HIV prevalence of 43.6% among MSM in Johannesburg and Durban.6 By contrast, 10% of self-identified MSM from urban areas in Western Cape are reportedly living with HIV.7
Many MSM still face high levels of social stigma and homophobic violence due to traditional and conservative attitudes. A 2013 study found that only 32% of South Africans said that homosexuality should be accepted by society.8 As a result, MSM find it difficult to disclose their sexuality to healthcare workers, limiting their access to HIV services.9
However, South Africa is the only country in sub-Saharan Africa where gay rights are formally recognised.10 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.11
Sex workers and HIV in South Africa
Female sex workers (FSW) are particularly affected with studies suggesting that HIV prevalence among this group ranges from 40% to 88%, significantly higher than among women in the general population (14.4%).16 17 Young female sex workers under 25 in particular carry a heavy HIV burden, highlighting the need for focused interventions for sex workers from an early age.18
Sex workers in South Africa face high levels of stigma and discrimination and are restricted by the laws under which they have to work. Moreover, many sex workers also inject drugs, exacerbating their vulnerability to HIV infection.19
Educational organisations have reported difficulties in delivering HIV prevention services to sex workers due to ongoing police harassment. One study found that up to 70% of women who sold sex had experienced abuse by the authorities:20
"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 21
In light of these issues, in 2016, the South African National AIDS Council (SANAC) launched South Africa's National Sex Worker HIV Plan, 2016-2019 that aims to ensure equitable access to health and legal services for sex workers in the country.22
People who inject drugs (PWID) and HIV in South Africa
Data on HIV prevalence among people who inject drugs (PWID) in South Africa is very limited and where it does exists, is based on small sample sizes. In 2012, an estimated 16.2% of PWID in South Africa were living with HIV. However, PWID account for a comparatively low 1.3% of new HIV infections.23
One study has reported that up to 86% 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% of PWID in South Africa thought to practice unsafe sex.26
Children and 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 programmes to prevent the mother-to-child transmission of HIV (PMTCT). The scaling up of antiretroviral treatment has reduced child mortality by 20%.27
There are also 2.3 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
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
A survey in 2012 found that HIV prevalence among women was nearly twice as high as 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 this age group accounted for 25% of new infections in South Africa.31
Despite these barriers, HIV prevalence among women aged 15-24 is thought to have declined between 2002 and 2012.34
HIV testing and counselling (HTC) in South Africa
The National Strategic Plan 2007-2011 aimed to get 25% of all South Africans to test annually and 70% of all people to have at least one HIV test.35 In 2010, a quarter of the population aged between 15 and 49 had been tested for HIV in the previous 12 months, meeting this target.36
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% to 37.5% among men, and from 28.7% to 52.6% 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.37
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.38
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.39
In May 2015, the Pharmacy Council of South Africa lifted a ban preventing pharmacies from selling take-home HIV testing kits. It is hoped this will encourage more people to test for HIV.
"There are many people who want to test and who do not want to interface with the healthcare system. We believe the more people testing, the better. Let's get as many people to test as possible." 40
Antiretroviral treatment (ART) in South Africa
South Africa has the largest antiretroviral treatment (ART) rollout programme in the world, achieving a 75% increase in HIV treatment access between 2009 and 2011.41 42 In three provinces, the life expectancy of people receiving ART is now about 80% of normal life expectancy provided they do not start treatment late.43
By October 2012, over two million people were receiving ART, surpassing the country's universal access target (80%) in accordance with the 2010 World Health Organisation treatment guidelines (offering treatment to people with a CD4 count under 350).44 However, the new 2013 WHO treatment guidelines (treatment for those with CD4 counts under 500) have since made many more people eligible for ART and coverage has fallen to 42%.45
In order to achieve higher levels of ART coverage, the South African government employed task shifting. Task shifting refers to the reallocation of tasks among available staff. In this case, nurses (rather than doctors) initiate ART; lay counsellors (rather than nurses) carry out HIV tests; and pharmacy assistants (rather than pharmacists) prescribe ARVs. This increases 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.46
Though treatment programmes have expanded rapidly, many South Africans still begin treatment with a very low CD4 count. In 2009, it was reported that the average CD4 count at which patients started treatment in South Africa was just 87.47 One study based in two Durban clinics found that 60% of patients were tested when their CD4 counts were below 200. Of these patients, just 42% had begun treatment within 12 months. Of those who were eligible for treatment, more than a fifth died, mostly before beginning treatment.48
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% 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.49
HIV prevention programmes 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 by reducing viral load.
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." It has also committed to "zero new infections due to mother-to-child transmission."50 51
Prevention of mother-to-child transmission (PMTCT)
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.52
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 WHO recommendations.53
By 2010, PMTCT services were being offered at 98% of all healthcare facilities in the country. Moreover, by June 2011, the national HTC campaign had tested 274,000 women with 78.5% of those diagnosed as positive being referred onto treatment.54 As a result, mother-to-child transmission of HIV in South Africa has fallen to 3.5% - meeting the previous NSPs target of less than 5%.55 Between 2009 and 2011, new annual HIV infections among children fell from 56,500 to 29,100.56
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.57
The current National Strategic Plan aims to reduce MTCT rates to under 2% at six weeks after child birth and less than 5% at 18 months by 2016.58 With the latest WHO 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 possible.59
Condom use and distribution
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.60
Between 2007 and 2010, the distribution of male condoms increased by 60%, from 308.5 million to 495 million a year. However, in terms of condoms per person 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. However, it is widely acknowledge that female condoms are not as readily available as they should be.61
In recent years, condom usage in South Africa has fallen. In 2008, 85% of 15-24 year old males reported using a condom during their last sexual encounter - by 2012, this had fallen to 68%. Condom use among men aged 25-49 also decreased, from 44% to 36%. The same survey reported that 53% of participants had never used condoms.62
Voluntary medical male circumcision (VMMC)
During the development of the 2007-2011 National Strategic Plan, research emerged in sub-Saharan Africa that voluntary medical male circumcision (VMMC) can reduce the risk of female- to-male HIV transmission by up to 60%.63
As a result, in 2010, the South African government quickly rolled out a national VMMC programme, which aimed to reach 80% of HIV-negative men (4.3 million) by 2016. In April 2010, KwaZulu-Natal became the first province to offer VMMC services and by late 2012, there were over 80 VMMC sites.64
By April 2011, more than 150,000 circumcisions had been conducted with an estimated one new HIV infection averted for every five VMMCs conducted.65 The VMMC programme in South Africa has mostly been well received with 78% of women preferring their partner to be circumcised according to the 2011 youth sex survey.66
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 education into the school curriculum to avert new HIV infections and provide care and support for pupils already living with HIV. The programme is mostly implemented through Life Orientation lessons.67
However, in many places there is a shortage of teacher training on these issues. Moreover, 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.68 In some cases, gaps in the delivery of the Life Orientation curriculum are filled by independent organisations. 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 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
In South Africa, there have been a number of HIV awareness campaigns. The 2012 National Communication Survey on HIV/AIDS found that the country's HIV communication programmes were 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 breastfeeding practices among pregnant mothers living with HIV remains low.71 The main HIV awareness campaigns include:
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%. Compared with other campaigns, Khomanani had fairly mixed outcome with condom usage unchanged but knowledge of safe sex practices did improve significantly.72
Since 1999, the loveLife campaign has used a range of media to reduce new HIV infections among young people aged 12-19. It engages with 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.73
- Soul City and Soul Buddyz
Soul City and Soul Buddyz were two government multi-media campaigns targeting adults and children respectively.
Soul City broadcasted TV dramas and radio programmes to audiences at prime time to maximise its reach. The intervention reached 70% of over 16s including 65% of rural people and 50% without any formal education. The initiative lead to a significant increase in HIV knowledge and encouraged positive behaviour change.74
Soul Buddyz was judged to be the most successful family television show to be produced in South Africa. 67% of 8-12 year olds had watched, read or listened to Soul Buddyz (about four million children).75
HIV and tuberculosis (TB) in South Africa
South Africa also has the world's third largest tuberculosis (TB) epidemic. The HIV epidemic in South Africa fuels the TB epidemic as people living with HIV are at a far higher risk of developing TB as a weakened immune system allows the development of the disease. 70% of people living with HIV in South Africa are also co-infected with TB.76
However, the TB cure rate has improved in recent years. Between 2010 and 2011, the number of people living with HIV who received TB treatment nearly tripled, from 146,000 in 2010 to 373,000 in 2011.77
"We cannot fight AIDS unless we do much more to fight TB." - Nelson Mandela 78
HIV funding 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 competitive prices.79
Over the following two years, a 53% reduction in the cost of ARVs saved the country $640 million.80 This new tender introduced three-in-one or fixed-dose combination (FDC) drugs helping to reduce the pill burden and improve adherence to treatment.81
South Africa largely funds its HIV and AIDS programmes domestically. However, based on National Strategic Plan 2012-2016 targets, the gap between funding requirements and available funding for HIV is expected to grow.82
The future of HIV and AIDS in South Africa
South Africa has made great strides in tackling its HIV epidemic in recent years and now has the biggest HIV treatment programme in the world. Moreover, these efforts are now largely funded from South Africa's own resources.
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, however, there are still too many.
While the short term financing of South Africa's HIV epidemic is secure, in the longer term, the government needs to explore other strategies in order to sustain and expand its progress.
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