WOMEN IN ACTION

An estimated 5.2 million people were living with HIV and AIDS in South Africa in 2008, more than in any other country.¹ It is believed that in 2008, over 250,000 South Africans died of AIDS.²

National prevalence is around 11%, with some age groups being particularly affected. Almost one-in-three women aged 25-29, and over a quarter of men aged 30-34, are living with HIV.³

HIV prevalence among those aged two and older also varies by province with the Western Cape (3.8%) and Northern Cape (5.9%) being least affected, and Mpumulanga (15.4%) and KwaZulu-Natal (15.8%) at the upper end of the scale.

HIV in South Africa is transmitted predominantly heterosexually between couples, with mother-to-child transmission being the other main infection route.

Impact of HIV upon South Africa

The impact of the AIDS epidemic is reflected in the dramatic change in South Africa’s mortality rates. The overall number of annual deaths increased sharply from 1997, when 316,559 people died, to 2006 when 607,184 people died. This rise is not necessarily due solely to HIV and AIDS but it is young adults, the age group most affected by AIDS, who are particularly shouldering the burden of the increasing mortality rate. In 2006, 41% of deaths were attributed to 25-49 year olds, up from 29% in 1997.⁴ This is a strong indicator that AIDS is a major, if not the principal, factor in the overall rising number of deaths.

Read more about South African HIV and AIDS Statistics

Impact upon children and families

South Africa’s HIV and AIDS epidemic has had a devastating effect on children in a number of ways. There were an estimated 280,000 under-15s living with HIV in 2007, a figure that almost doubled since 2001.⁵ In most instances the virus was transmitted from the child’s mother. Consequently, the HIV-infected child is born into a family where the virus may have already had a severe impact on health, income, productivity and the ability to care for each other.

AIDS orphans with their grandmother

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 loss of a parent not only has an immense emotional impact on children but for most families can spell financial hardship. One survey on HIV’s impact on households found that, “80% of the sample would lose more than half their per capita income with the death of the highest income earner, suggesting a lingering and debilitating shock of death.”⁶

There are 1.4 million AIDS orphans in South Africa,⁷ and it is estimated that the HIV/AIDS epidemic has created half of the country’s orphans.⁸ Another estimate puts the proportion of maternal orphans – those who have lost their mother – orphaned by AIDS as over 70%.⁹ 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. In South Africa, the proportion of orphaned 10-14 year olds attending school is only 80% of the level of non-orphaned children of the same age.¹⁰

Prevention in South Africa

Prevention of mother-to-child transmission

An unacceptably high number of babies, around 70,000, are born with HIV every year, reflecting poor prevention of mother-to-child transmission. HIV and AIDS is one of the main contributors to South Africa’s infant mortality rate,¹¹ which barely declined between 1990 (49 deaths per 1000 infants) and 2007 (46 per 1000), when all regions of the world saw far greater decreases.¹²

“The lack of improvement in child mortality in South Africa is largely due to the HIV epidemic, specifically the transmission of HIV from mother to child (MTCT).”¹³

The Department of Health recommends mothers take the drug zidovudine (AZT), by week 28 and single-dose nevirapine during labour. The infant should take single-dose nevirapine after birth followed by seven days of AZT. The guidelines were issued in 2008 and were criticised for not meeting World Health Organization recommendations that are considered more effective. The WHO recommends that mothers take AZT and lamivudine (3TC) during and following birth to prevent transmission and to reduce the risk of resistance to nevirapine.¹⁴ The Treatment Action Campaign responded to the omission of using AZT/3TC, known as the ‘cover-the-tail’ strategy, in the updated guidelines, stating,

“The ‘cover-the-tail’ strategy was strongly recommended by expert HIV paediatricians who advised the Department of Health on the new protocol; we are disappointed that this well-founded recommendation has been ignored.”¹⁵

PMTCT guidelines have also been criticised for not recommending pregnant mothers begin antiretroviral therapy at a CD4 threshold of <350 cells/mm3. Despite many calling for the treatment threshold to be raised for all people, it is argued that pregnant women in particular should be prioritised for earlier treatment until widespread change occurs.

The guidelines also fall short of the standard of treatment used in wealthier countries which use combination therapy during the late stages of pregnancy and following labour and which have drastically reduced MTCT.

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

Testing uptake among women attending antenatal clinics rose from 69% in 06/07 to 80% in 07/08. Another positive sign is seen in nevirapine coverage increasing from 65% to 76% of HIV positive pregnant women (data from before the guidelines were updated to include AZT). If similar progress continues South Africa may meet the National Strategic Plan target for reaching 95% of HIV positive pregnant women with PMTCT services by 2011.¹⁶

A further problem with South Africa’s PMTCT programme is seen in its poor monitoring. The District Health Barometer report, which compiles data from a range of sources, stated, “Most of the indicators continue to be plagued by major data collection and quality issues.”¹⁷

Aids awareness

There are a number of large scale communication campaigns related to raising awareness of HIV and AIDS as well as broader health-related issues.

Khomanani, meaning ‘caring together’, has run since 2001 and is the health department’s premier AIDS-awareness campaign. It has used the mass media to broadcast its messages including radio announcements and the use of situational sketches on television.¹⁸

Soul City and Soul Buddyz – targeted at adults and children, respectively – have a combined annual budget of R100 million, and utilize broadcast, print and outdoor media.¹⁹

The campaign loveLife has run since 1999 and also uses a wide range of media directed mainly towards teens. ²⁰ It also has many ‘Y-centres’ around the country which function as youth centres that also offer clinics and counseling.²¹ 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.²²

HIV awareness billboard by loveLife

A major survey assessed how these campaigns are being received by the population. In 2008, over four-fifths of South Africans had seen or heard at least one aspect of the four campaigns, from less than three-quarters in 2005. Understandably, awareness messages were best received by 15-24 year olds, the target audience of many of these campaigns, with 90% coverage. This declined with age so that just over 60% of those aged 50 and above had seen or heard at least one of the four campaigns’ messages.²³

Despite the improved reach of these awareness campaigns, accurate knowledge about HIV and AIDS is poor. Of particular worry is the lack of knowledge regarding how to prevent sexual transmission of HIV. Across all age groups and sexes less than half of all people knew of both the preventive effect of condoms and that having fewer sexual partners could reduce the risk of becoming infected. More troubling still is the fact that accurate knowledge has significantly decreased in recent years.²⁴

Condom use and distribution

Condom use in South Africa is growing with the percentage of those using a condom during their last sexual encounter increasing from 27% in 2002, 35% in 2005 to 62% in 2008. Younger people show the highest rates of condom use which bodes well for the future of prevention, and could explain the decline in HIV prevalence and incidence among teenagers and younger adults.²⁵

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 2007.²⁶

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.²⁷

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.²⁸

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.²⁹

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.³⁰

Circumcision

Circumcision has been found to reduce by 60% the risk of sexual transmission of HIV from women to men. Currently, though, just one clinic offers free male circumcisions, with public facilities only offering the service for medical reasons.³¹ The government is reviewing evidence on circumcision but has yet to issue further guidance on the practice.

It was estimated that a programme with full coverage of male circumcision could prevent half a million infections and 100,000 deaths within a decade, with these figures rising in the decades to follow.³²

HIV testing

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. In 2007, just a quarter of adults had ever taken an HIV test, and only 7% had taken a test in the previous 12 months. In a country with such high prevalence, testing needs to vastly improve. The National Strategic Plan is aiming for one quarter of all people to take a test every year by 2011, with the proportion of those ever taking a test rising to 70%.³³

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.³⁴ The link between testing levels and several socio-economic indicators suggests an improvement in the general standard of living would be beneficial to testing. Another significant factor determining HIV testing is whether an individual lives in a rural or urban setting, with those residing in the latter almost twice as likely to have been tested than those in the former. Testing facilities should therefore be made more accessible for hard to reach rural populations, possibly with mobile testing units.³⁵

When testing does occur it is very often at a late stage of infection. Routine testing at healthcare facilities could result in people being diagnosed earlier so they could be referred to treatment in time. Such provider-initiated testing could be a way of working round the stigma attached to HIV testing. One creative way of providing testing 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.³⁶

“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

Other innovative ways of providing testing to a hugely diverse population, where many factors such as stigma, lack of awareness and lower socio-economic status act as barriers to testing, are greatly needed. 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.

Treatment for AIDS in South Africa

South Africa has the largest antiretroviral therapy programme in the world, but given it also has the world’s largest epidemic, access to treatment is low. At the end of 2007, an estimated 28% of infected people were receiving treatment for HIV, below the average across lower- and middle-income countries.³⁷

Demonstration at South African AIDS Conference

The state of HIV treatment in South Africa is disappointing and can only be seen in the context of years of doubting the effectiveness of treatment at the highest levels of government, and the delay and slow pace of delivering a public ARV programme.

President Thabo Mbeki (1999-2008) often sought the opinions of AIDS denialists, including many of them on his Presidential AIDS Advisory Panel. Both Mbeki and his health minister, Manto Tshabalala-Msimang, questioned the effectiveness of ARVs, with the latter infamously promoting beetroot and garlic consumption as a way of fighting HIV infection.

South Africa’s poor response to the epidemic becomes clear when compared with another middle-income country, Brazil, that was swift to provide near universal access to antiretroviral therapy in the mid-1990s:

“Brazil’s story contrasts starkly with that of South Africa, which had similar HIV prevalence in 1990 but only began providing treatment on a large scale in recent years and now has the most HIV/AIDS cases of any country.” – Amy Nunn³⁸

The government published its plan to provide public access to ARVs in November 2003 many years after the evidence of the effectiveness of combination therapy in reducing mortality was reported. In contrast, many of South Africa’s poorer neighbours had already begun to make treatment available, including Botswana, whose MASA programme began to distribute ARVs in early 2002. Furthermore, rollout of the South African programme was very slow.

The departure of President Mbeki, health minister Manto and others who doubted the science behind AIDS and ARVs, signified an end to the kind of barriers that hindered progress in treating HIV and AIDS in South Africa. The task of providing a high level of access to antiretroviral therapy in South Africa now faces a set of new challenges.

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

Late initiation of treatment

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

However, in South Africa, delays in initiating treatment mean that the average starting point of antiretroviral therapy is a CD4 count of 87 cells/mm3. Dr Francois Venter, of the Southern African HIV Clinicians Society, remarked that patients in his Johannesburg clinic commence treatment at a CD4 count of 80-100 cells/mm3, a level that has not changed in four years.³⁹

A study based in two Durban clinics found most patients were tested at a late stage of infection with over 60% of CD4 counts below 200 cells/mm3. Of these patients just 42% had begun treatment within 12 months. The late stage at which people with HIV and AIDS in South Africa are diagnosed and the subsequent delay in getting these people on to treatment has devastating consequences. Of those who were eligible for treatment, more than a fifth died, mostly before beginning treatment.⁴⁰

Treatment guidelines

Currently a debate is gathering pace in South Africa regarding whether treatment guidelines should be revised to raise the CD4 treatment threshold from 200 to 350 cells/mm3. The South African National AIDS Council (SANAC), which advises the government on AIDS policy, has recommended this proposal which is being reviewed by the National Health Council.⁴¹

One projection compared raising the treatment threshold to either 250 or 350 cells/mm3. The researchers’ model predicted 76,000 deaths could be prevented over five years if treatment was initiated below 350 cells, compared with below 250, assuming that 30% of eligible patients were identified and linked to care.⁴²

Advocates of raising the treatment threshold to <350 cells acknowledge that this would require greater expenditure but would be cost effective in the long run. A representative from the Treatment Action Campaign said,

“This is going to be expensive to implement, but these recommendations will eventually lead to cost savings. It’s a cost that has simply been deferred.”⁴³

Others, such as Dr Venter, argue that amending guidelines to raise the treatment threshold neglects the fact that many patients are currently starting treatment long after becoming eligible for it, only once they have become seriously ill. Venter has also said there are reservations among doctors about earlier treatment using the antiretroviral drug, stavudine (or d4T), used in South Africa’s first-line treatment, which has major side effects.⁴⁴

Child treatment

HIV-positive children, Grahamstown

According to the South African government, provision of HIV treatment for children has greatly increased in recent years. In 2007, more than 32,000 children were receiving antiretroviral therapy, a 250% increase on 2005’s figure, though still only meeting half of the estimated need.⁴⁵ However, the Treatment Action Campaign claims the methodology behind figures is not clear and they ‘should be treated with great caution’.⁴⁶

A major ongoing trial in South Africa, the CHER study, found the risk of death decreased by about three-quarters when infected infants under 12 months began treatment immediately after diagnosis. The control group received treatment at a later stage of infection similar to current South African recommendations.⁴⁷

Unlike some other countries, South Africa has yet to revise its guidelines to reflect these findings. Guidelines still recommend deferring paediatric treatment until the child’s immune system has been significantly affected or is showing specific symptoms. Some clinics are initiating immediate treatment though it is reported that other doctors and nurses are reluctant to do so without the official protocol being updated.⁴⁸

Sustaining treatment programmes

For antiretroviral therapy to work, patients must adhere to a daily regimen of ARVs for life. Interrupting treatment can result in HIV becoming drug resistant, with first-line therapy no longer being effective. Therefore, keeping patients on treatment programmes is imperative.

However, stockouts in Free State show how ARV treatment programmes can be victims of poor management and budgetary constraints, factors that could worsen as treatment programmes aim to expand, and if poor economic conditions continue.

After overspending and a failure to apply for emergency funding, in November 2008 the provincial government of Free State stopped initiating new patients on antiretroviral therapy. It was estimated by the Southern African HIV Clinicians Society that at least 30 people were dying daily due to an inability to access ARVs, and 15,000 people were put on waiting lists for treatment. Patients who had been taking ARVs also had to interrupt their treatment.⁴⁹ 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?’”⁵⁰

Task-shifting

One measure seen as vital in scaling-up treatment access, while making best use of available resources, is task-shifting in the health sector. This means permitting health care workers to become involved in particular stages of treatment provision where currently they are not allowed.

This would mean nurses, rather than doctors, could initiate antiretroviral therapy; lay counsellors, rather than nurses, could carry out HIV tests, as well as provide support for orphans usually done by social workers; and pharmacy assistants, rather than pharmacists themselves, could prescribe ARV drugs.^{51 52}

It is believed this would vastly increase 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.

However, South Africa has yet to implement task-shifting despite the National Strategic Plan calling for such a measure and with many campaign groups believing this is crucial to the goal of making HIV treatment much more widely available. Part of the resistance to task-shifting lies with professional trade councils – such as doctors or nurses organizations – that may see task-shifting as a threat to their areas of work and expertise.

Four prominent HIV/AIDS organizations have called on the national and regional health departments to issue directives permitting the transfer of certain responsibilities, as well as asking professional medical, nursing and pharmacist bodies to support task-shifting.⁵³

Dr Eric Goemaere, Medical Coordinator for MSF in South Africa and Lesotho, said, “Our experience in Khayelitsha and Lusikisiki, as well as from other countries shows that unless we are able to utilise the skills and capacity of professional nurses at the primary health clinics, the congestion and overwhelming demand will negatively impact patient care. Other countries have changed their regulations to allow nurses to start patients on ART and lay counsellors to administer HIV tests. When will South Africa wake up?”⁵⁴

The future of AIDS treatment in South Africa

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

In Spring 2009, then health minister, Barbara Hogan said,

“Let me state unequivocally, government is committed to the NSP and its effective implementation. We are committed to reaching the targets as set out by 2011.”⁵⁵

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

HIV and Tuberculosis

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

- Nelson Mandela

Tuberculosis (TB) is the leading cause of death in South Africa,⁵⁶ a trend that needs to be seen in the context of the HIV epidemic. People living with HIV are at a far higher risk of developing active tuberculosis as a weakened immune system will facilitate the development of the disease. Similarly, TB can accelerate the course of HIV. In countries with high HIV prevalence, TB has tripled in the past 15 years, which clearly illustrates the link between the two diseases.⁵⁷

South Africa has one of the highest coinfection rates with an HIV prevalence of almost three-quarters among people with incident tuberculosis. Despite accounting for just 0.7% of the global population, the country accounts for 28% of the world’s people living with both HIV and TB.⁵⁸ Fighting both diseases together, where appropriate, is seen as crucial:

“We cannot fight AIDS unless we do much more to fight TB.” – Nelson Mandela⁵⁹

The high level of HIV and TB coinfection led the National Strategic Plan to call for an integration of care for the two diseases.⁶⁰ Integrating HIV and TB systems means it is easier for people with one disease to be tested and treated for the other, where elements of care are otherwise handled separately. The Ubuntu clinic, offering what it terms ‘one-stop’ HIV and TB care in the Khayelitsha township, on the edge of Cape Town, illustrates the benefits of this approach to the twin epidemics. In the township, the number of people diagnosed with TB who were offered HIV counselling increased from 50% in 2002 to 97% by mid-2007.⁶¹

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.”⁶²

The success of the HIV/TB service integration is such that the Western Cape has adopted this as policy. In 2007 over one-third of South African HIV-positive TB patients were provided with antiretroviral therapy and two-thirds received co-trimoxazole prophylaxis in 2007. The WHO has stated that “collaborative TB/HIV activities are being scaled up across the country”.⁶³

Gender violence, inequality and HIV

Violence against women, including sexual violence, is very widespread in South Africa. In a large survey, more than four-in-ten South African men reported to have been physically violent to an intimate partner. Over a quarter of men reported ever having raped a woman with nearly one-in-twenty committing rape in the previous year. Little difference was found in the HIV prevalence of men who had raped a woman compared to those who had not. However, the generally high HIV prevalence among all men surveyed means there is a good chance that a man who commits rape has HIV.⁶⁴

The disempowerment of South African women – revealed by such high levels of rape and domestic abuse – is a factor in the country’s HIV epidemic. Women who are unable to negotiate safer sex and the use of condoms will inevitably be at a greater risk of HIV. Research has found that women who have been physically and sexually assaulted by their partners, as well as those who are in relationships with men who have a greater degree of control over them, are at a higher risk of HIV infection.⁶⁵

The way forward

South Africa has come a long way in responding to its HIV epidemic, but is still falling short of what is possible, and has lacked the progress that has been made by its neighbours and other countries of a similar economic standing.

A speech by Barbara Hogan, former South African health minister, in 2009.

Efforts to tackle HIV are now at least facilitated by government acceptance of the science behind HIV and ARVs, where previous administrations sowed confusion at best, and at worst were responsible for the deaths of hundreds of thousands of people. However, the vast majority of those who need treatment still do not receive the drugs they need, and for those that can access treatment, this begins too late. HIV-positive pregnant women and infants are among those who could benefit greatly from a government decision to initiate treatment earlier.

Drug stockouts, continued use of ARVs with severe side effects, and a lack of entry points to care, are additional factors that must be overcome in order to scale-up effective treatment provision, and to reach the national goal of providing ARVs to 80% of those who require them.

Recent trends indicate a possible turning point in the epidemic, with infections decreasing among youth. Condom use has increased throughout the decade across all age groups and is highest among younger people, a notable achievement in South Africa’s fight against HIV. However, far more needs to be done if the country is to achieve its goal of halving its 2007 infection rate by 2011.

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

Source: www.avert.com

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