South Africa is the industrial powerhouse of Africa, one of the world’s youngest and most progressive democracies, with a rapidly growing economy located in a stable region. Fourteen years of democracy have shown major progress, but three profound problems remain: poverty, unemployment - and HIV/Aids.
Sections in this article:
Despite earlier controversies, the South African government acknowledges that the human immunodeficiency virus (HIV) is the cause of Acquired Immune Deficiency Syndrome (Aids).
"In conducting [the HIV/Aids and STI Strategic Plan for South Africa, 2000 - 2005], government's starting point is based on the premise that HIV causes Aids," the South African Cabinet said in a statement on their meeting of 17 April 2002. "It is also critical for us, as a nation, to note that there is no cure for Aids."
When Aids was first identified in the early 1980s it was seen as an immediate death sentence. Since then, advances in treatment means a significant number of those infected with the virus live healthily for many years without succumbing to full-blown Aids. For that reason it is often journalistic practice in South Africa to refer to "HIV and Aids" rather than "HIV/Aids", to distinguish the lives, experience and challenges of those who are HIV-positive and healthy from those who are seriously ill with Aids. But for reasons of brevity, this article uses the term "HIV/Aids".
South Africa has one of the fastest HIV-infection rates in the world. Statistics South Africa's 2007 population estimates put the South Africa's overall HIV-prevalence rate at about 11%, much higher than that of sub-Saharan Africa as a whole, and among the highest in the world. Others put the figure higher; UNAids estimates South Africa's HIV/Aids prevalence rate to be 18% to 19% (18.8% in 2005 and 18.3% in 2006), significantly higher than the rate in sub-Saharan Africa (5.9%) and the world (1%).
In 2006, an estimated 350 000 South Africans died of HIV/Aids - nearly half of all deaths for that year, and the leading cause of death for the country’s adult population. Between 1997 and 2004 death rates from all causes increased by about 80%, largely due to HIV/Aids. Some 290 000 South African children were estimated to be living with HIV/Aids in 2006, and the country has more than 1-million Aids orphans.
The Department of Health, in collaboration with UNAids, the World Health Organisation and other groups in South Africa, have undertaken mathematical modelling to estimate the HIV prevalence in the general population. Using the spectrum model, the number of South Africans estimated to be HIV-positive some 5.41-million (5.3-million according to according to Statistics South Africa). This estimate is lower than the 2005 estimate of 5.54-million.
But HIV prevalence in South Africa may be beginning a downward trend. This has been predicted in the UNAids spectrum model, as well as by independent South African models.
The antenatal HIV prevalence report is a yearly study that has thus far been trusted as an indicator of the progression of HIV/Aids in the country. The 2006 results have shown some decreases in HIV prevalence among younger age groups. According to the report, HIV prevalence in women under 20 years has dropped to 13.7% from 15.9% in 2005, and HIV prevalence in women between the ages of 20 and 24 years has dropped to 28% from 30.6% in 2005. The report indicates that this drop may be suggestive of a decrease in new HIV infections due to better HIV prevention programmes.
There was also a significant decline in prevalence in the 15-to-24-year and 20-to-24-year age groups. But the HIV prevalence has increased among women above 30 years.
According to the Human Sciences Research Council's Household Survey, people living in rural and urban informal settlements seem to be at highest risk of HIV infection.
The survey reveals large difference in prevalence rates between the provinces. KwaZulu-Natal has the highest rate of infection, and the Western Cape the lowest - with the difference between the two provinces as high as 19%.
Further research aims to uncover the cause of the decrease in HIV prevalence in younger age groups and to plan a strategy accordingly, on the basis that prevention campaigns need to be streamlined to suit all age groups. Research into the reasons for the difference in HIV/Aids infection in the provinces will also be undertaken.
An estimated 6-million South Africans are expected to die from Aids-related diseases over the next 10 years. In addition, new threats such as the emergence of extensively drug resistant tuberculosis (XDR-TB) in South Africa may further complicate the response, given the high rates of HIV/TB co-infection and the high mortality associated with XDR-TB.
The epidemics of HIV and tuberculosis (TB) are interlinked: in southern Africa, between 50% and 80% of TB patients are HIV positive. While a primary risk factor for TB infection is overcrowding, the development of the disease is significantly more likely where there is co-infection with HIV as a product of immunosuppression. In the presence of HIV, TB is associated with substantially higher case fatality rates.
Tremendous efforts to combat Aids are being mounted around South Africa by local, provincial and national government agencies, as well as myriad nongovernmental organisations, by creating awareness around the disease, promoting behaviour change and providing medical, social and economic assistance to those infested or affected by the epidemic.
The South African government's HIV/Aids response is primarily financed through the national health Budget, with an estimated R2.4-billion earmarked for combating the disease in 2007. In February 2007 the National Treasury provided the Department of Health with R5.3-billion to be spent on human resources, HIV/Aids, hospital revitalisation and tertiary services.
The first official policy response to the epidemic was in 1992, when the government established the National Aids Coordinating Committee of South Africa, followed by the creation of the South African National Aids Council in 2000. In March 2007, the government released its National HIV/Aids and STI Strategic Plan for South Africa 2007 to 2011 (NSP), designed to guide the country's multi-sectoral response to HIV/Aids.
The plan was adopted by Cabinet in 2007. It aims to achieve 50% reduction rate of new infections by 2011 and provide an appropriate package of treatment, care and support services to at least 80% of people living with HIV and their families by 2011.
The interventions needed to reach the NSP's goals are structured under four key priority areas:
The package of care includes:
The plan also includes a monitoring and evaluation component critical in assessing progress and sharing research on the pandemic.
The NSP is an outcome of the National Strategic Plan of 2000-2005, the Operational Plan for Comprehensive HIV/Aids Care, Management, and Treatment as well as other HIV/Aids strategic frameworks developed for government and sectors of civil society in the past five years. It represents the country's multi-sectoral response to the challenge with HIV infection and the wide-ranging impacts of Aids.
The NSP also forms part of an initiative by the member states of the Africa Region of the World Health Organisation which committed 2007 to "The Year for Accelerating HIV Prevention". More than 1 060 health professionals have been recruited to support the programme. Some 7 600 health professionals have been trained in the management, care and treatment of HIV/Aids.
The NSP is based upon a set of key guiding principles, including:
The government budget allocated for NGOs involved in the response to Aids and TB funding has been increased from R56 million in 2006/2007 to R62 million in 2007/2008 financial year. The funds will be made available to eligible organisations providing the following services:
Government interventions also place a strong emphasis on promoting abstinence and faithfulness, with a massive condom distribution programme that provides some 300 million free condoms to the public every year.
Cabinet is the highest political authority, and responsibility for dealing with ongoing HIV/Aids related matters has been deferred to the Inter-Ministerial Committee on Aids (IMC) composed of eight ministries. The South African National Aids Council (Sanac) is the highest national body to provides strategic and political guidance as well as support and monitoring of sector programmes.
Sanac was reconstituted in April 2007, officially bringing together government and civil society in a renewed partnership against HIV/Aids. The newly-strengthened SANAC will operate at three levels through:
The cluster of government bodies involved in trying to combat HIV/Aids is called the HIV/Aids and TB Cluster, which is made up of the directorate for HIV/Aids and STIs, the Government Aids Action Plan (GAAP) and the directorate for tuberculosis.
The Department of Health has also introduced a Healthy Lifestyle Programme that aims to promote regular physical activity and good nutrition, control the use of tobacco, reduce the levels of alcohol and substance abuse, and promote safe sexual behaviour.
The South African government's treatment initiative falls under the Comprehensive HIV/Aids Care, Management and Treatment Plan to address the challenges posed by HIV/Aids. South Africa has an extensive antiretroviral (ARV) treatment programme, with 213 000 patients initiated on ARV treatment by the end of September 2006, and an estimated additional 90 000 to 100 000 patients initiated in the private and non-government sector.
The country already has the largest number of people on antiretroviral therapy (ART) in the world, but with an estimated 1-million people in need of ART, South Africa also has one of the highest unmet needs for ART in the world. But progress has been made. At the end of 2006, an estimated 287 000 to 363 000 people in the country were receiving ART, about 33% of those in need.
By 2002, the government had set up 597 testing and counselling sites for HIV as a strategy for prevention and care of HIV. At these sites treatment for opportunistic infections is available for both HIV-positive and HIV-negative patients.
The government is working with pharmaceutical companies to lower the costs of drugs to treat these infections. In December 2000, an agreement was signed with pharmaceutical company Pfizer to provide Fluconazole (Diflucan) to public hospitals and clinics for two years. Funding was provided for the training of healthcare workers in diagnosing and managing oral thrush and cryptococcal meningitis.
In the belief that antiretrovirals can cause harm if not administered correctly or if health services are inadequate, the government will intensify its campaign to make sure that patients infected with HIV, TB, thrush and meningitis follow the correct treatment advice.
The government continues to lobby drug companies to lower the cost of antiretrovirals and investigate the production of generic equivalents. In the knowledge that poverty increases vulnerability to illness, it will also work towards poverty alleviation and provision of nutrition for those lacking it; as well as encourage investigation into alternative treatments, particularly those that boost the body's immune system.
In September 2001, the South African government initiated a national programme to prevent mother-to-child transmission of HIV. In 2005, Prevention of Mother-To-Child Transmission programme (PMTCT) services were available at over 3 000 health sites nationwide, making the programme among the largest PMTCT programs in the world. More than 80% of government clinics are currently providing a PMTCT programme and the target is to have these services available in all clinics by December 2007.
Postnatal transmission of HIV from mother-to-child through breast milk remains a key challenge despite the availability of replacement feeds as part of the national Perinatal and Maternal Morbidity and Mortality Rate programme.
The percentage of HIV positive pregnant women who received antiretrovirals to reduce the possibility of transmitting HIV to their infants increased from 22% to 30% between 2004 and 2005. At least 580 880 pregnant women accessed the PMTCT services during the calendar year 2006, and of these, 74 052 antenatal clients received Nevirapine prophylaxis.
In the same period, a total of 19 758 babies born to mothers living with HIV were tested for HIV infection. 16 288 babies tested HIV-negative while 3 470 babies tested HIV-positive.
According to figures released in 2005, women are disproportionately affected by Aids, accounting for some 55% of HIV-positive people. Many of those with HIV/Aids depend on home-based care, placing a further burden on women, and often resulting in child-headed households.
Maternal deaths are on the increase, mostly fuelled the HIV epidemic, and for many HIV-infected women, decision making in regard to pregnancy and childbirth is hampered by a lack of information on contraception, interactions between ART, drugs for treatment of opportunistic infections and lack of knowledge about their HIV status when they become pregnant.
An outcome of the NSP has been the introduction of dual therapy for reduce Mother-to-child-transmission of HIV. The move from single dose nevirapine to dual therapy (nevirapine and AZT) was based on the recommendations of the Medical Research Council (MRC) and the National Essential Drugs Committee and the Medicines Control Council (MCC).
There has been a reversal in the prevalence of syphilis among pregnant women in the past five years and this has been attributed to the introduction of syndromic executive summary management of sexually transmitted infections (STIs) in 1995 as well as the introduction of the primary health care system.
The incidence of violence against women in South Africa is high and contributes to the spread of HIV. The government is endeavouring to provide antiretrovirals to survivors of sexual assault and those with needle stick injuries, as well as counselling and testing for HIV, STIs and pregnancy.
Families affected by the epidemic are being helped with foster care grants, assistance to child-headed households, food parcels and other interventions. The government budget for home-based and community-based care for people suffering with Aids in 2004/5 was R138-million.
The government promotes voluntarism as an answer to the demand for home-based caregivers to cope with the rising number of people infected with HIV, and because hospitals cannot cope with the number of people needing care. Most care programmes in rely on unemployed volunteers from affected communities, who are usually female and unsalaried or, in a few cases, paid a small stipend.
But this approach has drawn criticism from the Health Economics and Aids Research Division (Heard), of the University of KwaZulu-Natal, which recommends that the Department of Health reviews primary health care models and refine volunteer-based programmes, provide stipends and assist caregivers to ultimately obtain formal employment.
Several NGOS, some supported by government, have set up home-based care projects to help those families in need, including:
The government's strategy emphasises HIV/Aids prevention by promoting public awareness and delivering life skills and HIV/Aids education. The many Aids awareness campaigns run by government and NGO partners such as LoveLife and Soul City are bearing fruit. There is now a high level of awareness among youth on HIV/Aids - around 90% - but the pressing challenge is to ensure that this awareness translates into behaviour change. Life skills education, which incorporates HIV/Aids education, is now a compulsory part of the school curriculum.
Khomanani is a government-led communication campaign that provides an awareness-raising drive to mobilise individuals and organisations to respond to the challenges of HIV/Aids, TB and STIs. Besides a national media campaign, it works through outreach programmes to organisations, towns and villages. Between 2004 and 2006, the government invested R165-million in Khomanani.
LoveLife is a nationwide campaign which aims to promote healthy sexual behaviour among adolescents, reduce the incidence of HIV/Aids, sexually transmitted diseases and teenage pregnancies. LoveLife uses a widespread media campaign targeting adolescents, and offers educational, recreational and sexual health services in under-resourced areas.
Soul City uses the mass media to promote awareness around health issues. It has won international awards for its success in integrating education and entertainment using popular radio and television drama.
Documents and policies
Education and awareness
Aids and the law