South Africa has the biggest and most high profile HIV epidemic in the world, with an estimated 7.1 million people living with HIV in 2016. One third of all new infections in the region in 2016 were in one country: South Africa.1
In the same year, there were 270,000 new infections while 110,000 South Africans died from AIDS-related illnesses.2
South Africa has the largest antiretroviral treatment (ART) programme globally and these efforts have been largely financed from its own domestic resources. The country now invests more than $1.5 billion annually to run its HIV and AIDS programmes.3
However, HIV prevalence remains high (18.9%) among the general population, although it varies markedly between regions.4 For example, HIV prevalence is almost 40% in Kwazulu Natal compared with 18% in Northern Cape and Western Cape.5
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 (sometimes referred to as MSM) in South Africa is now estimated at 26.8%.7 HIV prevalence among men who have sex with men varies geographically but it is reported to have risen by more than 10% in Johannesburg, Cape Town and Durban.8
Many men who have sex with men still face high levels of social stigma and homophobic violence due to traditional and conservative attitudes. As a result, men who have sex with men find it difficult to disclose their sexuality to healthcare workers, limiting their access to HIV services.9
However, there is evidence that attitudes are changing. In 2013 a study found that only 32% of South Africans said homosexuality should be accepted by society.10 A more recent study in 2016 found 55% of South Africans would accept a gay family member; 51% said gay people should have the same human rights as others; and two thirds supported keeping the constitutional protections against discrimination on the basis of sexual orientation.11
However, the same study also found that 72% of people said same-sex sexual activity was morally wrong. 18% either had, or would consider, verbally abusing someone who is not gender conforming – and nearly 10% had, or would consider, physically abusing them.12
South Africa remains the only country in sub-Saharan Africa where gay rights are formally recognised.13 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 men who have sex with men, as well as other members of the lesbian, gay, bisexual and transgender community. As a result, South Africa has the potential to provide a leading role in the improvement of HIV service provision for men who have sex with men throughout sub-Saharan Africa.14
Sex workers and HIV in South Africa
Nationally, HIV prevalence among sex workers is estimated at 57.7% although this varies between areas, with prevalence estimated at 72% in Johannesburg, 54% in Durban and 40% in Cape Town.15 16 In 2010, sex work accounted for an estimated 19.8% of all new HIV infections in South Africa.17
Female sex workers are particularly affected, with studies finding HIV prevalence among this group to range from 40% to 88%, significantly higher than among women in the general population (14.4%).18 19In particular, young female sex workers (under 25) carry a heavy HIV burden, highlighting the need for focused interventions for sex workers from an early age.20
Sex workers in South Africa face high levels of stigma and discrimination and are restricted by the laws under which they work. Moreover, many sex workers also inject drugs, exacerbating their vulnerability to HIV infection.21
Although South Africa is moving towards decriminalising sex work, carrying condoms can still be considered an offence and in 2016 UNAIDs reported that 86% of female sex workers reported using a condom with their last partner.22
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:23
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…let me out by the back gate without my property. I was so scared that my family would find out.
-Female sex worker, Cape Town24
In light of these issues, the South African National AIDS Council (SANAC) has launched South Africa's National Sex Worker HIV Plan, 2016-2019, which aims to ensure equitable access to health and legal services for sex workers.25
People who inject drugs (PWID) and HIV in South Africa
Data on HIV prevalence among people who inject drugs (sometimes referred to as PWID) in South Africa is very limited and, where it does exist, is based on small sample sizes. In 2015, an estimated 19.4% of people who inject drugs in South Africa were living with HIV.26 However, people who inject drugs account for a comparatively low 1.3% of new HIV infections.27
A 2015 study of people who inject drugs in five South African cities found 32% of men and 26% of women regularly shared syringes and other injecting equipment and nearly half reused needles.28
People who inject drugs are also associated with other high-risk behaviours such as sex work and unsafe sexual practices. For example, the above study reported fewer than half of those surveyed used a condom during their last sexual encounter.29
Children and orphans and HIV in South Africa
In 2013, an estimated 360,000 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 mother-to-child transmission of HIV (PMTCT).30 The scaling up of antiretroviral treatment (ART) has reduced child mortality by 20%.31
More than 2.3 million children in South Africa have been orphaned by HIV and AIDS.32 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.33
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.34
Women, adolescent girls and HIV in South Africa
A 2012 survey found HIV prevalence among South African women was nearly twice as high as men. Rates of new infections among women aged 15-24 were more than four times greater than that of men the same age, and this age group accounted for 25% of new infections in South Africa.35
Poverty, the low status of women and gender-based violence (GBV) have been cited as reasons for the disparity in HIV prevalence between genders, with GBV attributable to an estimated 20–25% of new HIV infections in young women.36 37
Intergenerational relationships - between older men and younger women - are also seen to be driving a cycle of infections. Sexual partnering between young women and older men, who might have acquired HIV from women of a similar age, is a key factor driving transmission. Expansion of treatment and combination prevention strategies that include interventions to address age-disparate sexual partnering is crucial to reducing HIV incidence.38
Case Study: Sugar daddies
Lebogang Motsumi was 27 when she was infected with HIV by a “sugar daddy” – a man significantly older than her who was capable of showering her with the gifts she believed she needed to fit in with her friends and feel more accepting of herself. She was reluctant to use a condom because she feared being perceived as promiscuous by men and felt she was “not in control” of the situation when she was with her sexual partners.
Now a mother, Motsumi says she wishes she had received more information at home and at school about risky sexual behaviour, and is using her experience to advocate non-judgemental, face-to-face conversations with young people about relationships with older men.39
HIV testing and counselling (HTC) in South Africa
The launch of the national HIV testing and counselling (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 during antenatal appointments.40
South Africa developed an HCT revitalisation strategy in 2013, which focused on the private sector, farms and those in higher education. This strategy set a target of 10 million HIV tests to be carried out by 2015, of which 9.5 million were achieved, taking the total number of HIV tests since the 2010 campaign began to 35 million.41
In South Africa, the link has been made between an individual’s socio-economic background and the likelihood 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.42
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.43
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.44
Antiretroviral treatment (ART) in South Africa
South Africa has the largest ART programme in the world. In 2016, more than 3 million people were receiving ART, which equates to 56% of people living with HIV in the country. In 2012, just 31.2% of people living with HIV were on ART.4546
South Africa’s accomplishments in expanding its ART programme can be attributed to a number of initiatives including its 2010 HTC campaign mentioned above and changes to its policy on when a person living with HIV is eligible for treatment.47
South Africa has kept in step with World Health Organization (WHO) guidelines, which previously recommended treatment initiation should be based on a person’s CD4 count. CD4 cells fight germs and infections and are attacked by HIV, which generally means the lower a person’s CD4 count, the more HIV has advanced. In 2013, South Africa changed the CD4 level at which people could start ART from 200 to 350, making more people eligible for treatment. By the end of 2014, it increased the level to 500, expanding eligibility further.48
In 2015, WHO released guidelines recommending people living with HIV be offered ART immediately following diagnosis, regardless of CD4 count. South Africa has began implementing this recommendation also known as ‘test and treat’.49
HIV prevention programmes in South Africa
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
In December 2015 South Africa became the first country in sub-Saharan Africa to fully approve pre-exposure prophylaxis (PrEP), the use of antiretroviral drugs to protect HIV-negative people from HIV before potential exposure to the virus. It is currently investigating the uptake and impact of PrEP on young women and girls in high HIV prevalence areas.52
Prevention of mother-to-child transmission (PMTCT)
The current NSP aims to reduce mother-to-child transmission (MTCT) of HIV rates to under 2% at six weeks after childbirth and less than 5% at 18 months by 2016.53
Over the past decade, the country has made great progress in this area due largely to improvements in the choice of ARVs and the widespread accessibility of the PMTCT programme.54
It is widely believed that South Africa has reached a point where the elimination of paediatric HIV is possible.55
In 2015, more than 95% of HIV-positive pregnant women received antiretroviral medicine to reduce the risk of MTCT. As a result, MTCT of HIV in South Africa has fallen to 1.5% - meeting the current NSP target.56 In 2009 there were 56,500 new annual HIV infections among children, by 2010 this had fallen to 15,000, rising to 16,000 in 2013.57
Maternal mortality looks to be declining but at a much slower rate. South Africa’s current target is to reduce its maternal mortality rate by three quarters between 1990 and 2015, from 150 deaths per 100,000 live births to 38/100,000. Initially, this rate increased but is now declining with the last estimate measured at 141/100,000.58
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.59
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 acknowledged that female condoms are not as readily available as they should be.60
Condom distribution targets for 2016 are set at 1 billion male condoms and 25 million female condoms, with 2015 distribution levels at 723 million male condoms and 20.7 million female condoms.61
However, in recent years condom usage 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)
In 2010, research emerged from sub-Saharan Africa suggesting that voluntary medical male circumcision (VMMC) can reduce the risk of female-to-male HIV transmission by up to 60%.63 This led the South African government to rapidly roll out a national VMMC programme, which aimed to reach 80% of HIV-negative men (4.3 million) by 2016.
By April 2011, more than 150,000 circumcisions had been conducted with an estimated one new HIV infection averted for every five VMMCs.64 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.65 The 2016 circumcision rate remains stable with 50-79% of eligible men reached.66
The HIV and AIDS Life Skills Education Programme was implemented in all public primary and secondary schools in South Africa from 2000 onwards. HIV education now comes under the Integrated School Health Programme (ISHP), which aims to make youth-friendly, sexual and reproductive health (SRH) services accessible in school, enrich HIV prevention efforts and support young people who are HIV negative to remain so. However, the percentage of schools implementing the ISHP has dropped significantly from 160% in 2013 to 20% in 2014.67
Factors include a shortage of teacher training on SRH issues and resistance from some schools due to the subject matter.68
High dropout rates in schools also compromise effective HIV and sex education. It has been suggested that prevention programmes should focus on younger children while more of them are in education and before they become sexually active.69
In South Africa, there have been a number of HIV awareness campaigns. The 2012 National Communication Survey on HIV/AIDS found 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.70 The main HIV awareness campaigns include:
The main HIV awareness campaigns include:
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 and runs youth centres providing SRH information, clinical services and skills development 71
- Soul City and Soul Buddyz
Soul City and Soul Buddyz were two government multi-media campaigns targeting adults and children respectively.
Soul City broadcast TV dramas and radio programmes to primetime audiences, reaching 70% of over 16s, including 65% of rural people and 50% without any formal education. The initiative led to a significant increase in HIV knowledge and encouraged positive behaviour change.72
Soul Buddyz was judged to be the most successful family television show produced in South Africa. 67% of 8-12 year olds watched, read or listened to Soul Buddyz (about four million children).73
- MTV Shuga
MTV Shuga is a mass-media behaviour-change campaign that aims to improve the SRH of young people and is funded by a range of international and national donors. It began in 2009 and centres around an awarding-winning TV series, supported by radio, digital, social media and mobile elements.
Series 1 and 2 were set in Kenya and Series 3 and 4 in Nigeria, but it has global appeal and has been shown by 169 broadcasters around the world. It has reached more than 719 million households and connected with more than 42 million people on social media.74
Series 5 is due to be set in South Africa and will begin production in September 2016. It will be funded by South Africa’s Ministry of Basic Education, PEPFAR (The US President’s Emergency Plan for AIDS Relief), Marie Stopes International and Positive Action.75
HIV and tuberculosis (TB) in South Africa
South Africa has the world's sixth largest tuberculosis (TB) epidemic. The HIV epidemic in South Africa fuels the TB epidemic because people living with HIV are at a far higher risk of developing TB due to their weakened immune system. It is estimated that 60% of people living with HIV in South Africa are also co-infected with TB.76
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 This dipped to 337,000 in 2014, failing to meet the national target of 450,000.78
We cannot fight AIDS unless we do much more to fight TB.
- Nelson Mandela79
HIV funding in South Africa
South Africa largely funds its HIV and AIDS programmes domestically, only receiving 20% of its HIV funding from external sources.80 However, based on its National Strategic Plan 2012-2016 targets, the gap between funding requirements and available funding for HIV is expected to grow. This is due in part to the country’s middle income status which is leading to a reduction in funding from external donors. Its commitment to enrol people who test positive for HIV onto treatment immediately after diagnosis may also become a factor.81
In recent years South Africa has been working hard to negotiate better prices for ARVs, having previously been paying more than most other low and middle income countries despite having the world’s largest procurement programme.
In 2013, through a more competitive bidding process, South Africa managed to reduce the cost of buying ARVs to the lowest price anywhere in the world. This resulted in a 53% reduction in spending on ART for South Africa.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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