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AIDS in Africa - South Africa
Chronology
What are the current issues?
What needs to happen?
What are the major challenges?
The Republic of South Africa is a comparatively
large country, covering 1,221,042 square kilometres and with an
estimated population of about 40 million. 28% of people in South
Africa have been affected by HIV / AIDS, and 13% of all the people
in the world living with HIV can be found in South Africa. UNAIDS
estimates that at the end of 2003 there were 5.3 million people in
South Africa living with HIV - 21.5% of the population.
The country is comprised of large, crowded cities
and sparsely populated rural areas. The average density of the
population works out at 29 people per square kilometre, with 59.5%
of these in urban areas and 40.5% in rural areas. Some parts of the
country, especially in the rural areas, are very isolated and
underdeveloped. This lack of infrastructure is one of several
factors that make it difficult to get a clear picture of the size of
the population and the HIV / AIDS prevalence.
A common method of measuring HIV prevalence in South
Africa is by looking at HIV test results taken from pregnant women
who attend antenatal clinics. Some areas of South Africa, however,
lack antenatal facilities and many women will not have the
opportunity to see a midwife during their pregnancy or to take a HIV
test. There has also been criticism that this method of measuring
prevalence only gives a picture of HIV rates amongst sexually active
women, some of whom, due to the stigmatisation experienced by people
with HIV, are naturally reluctant to have a test.
A survey published in March 2004 shows that South
Africans spend more time at funerals than they do having their hair
cut, shopping or having Bar-B-Qs. It found that over twice as many
people had been to a funeral in the past month as had been to a
wedding1. It is estimated that about 600 people in South Africa die
of HIV-related illnesses each day.
Whatever the precise levels of infection are, what
is certainly clear is that the problem is a huge one. For more
information about the demographics and statistics of the epidemic in
South Africa, see our statistics page.
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Historically, South Africa has had a turbulent past,
and this history is relevant to the explosive spread of HIV in the
region.
Apartheid was legislated into force in the 1950s,
with the prohibition of mixed marriages, and the categorisation of
separate areas in which different races might live. Sex between
different ethnic groups was prohibited. In 1955 the African National
Congress (ANC) demanded equal political rights, and 1956 Nelson
Mandela and other political activists were arrested for high
treason. A period of increasing unrest followed, arising from the
increasingly militarised discrimination growing in South Africa. In
1985 and 1986, a State of Emergency was declared in response to
serious riots, and the violence increased. In 1990 Nelson Mandela
was released from prison, and the pace of political unrest and
change accelerated.
It was during this chaotic time, in 1982, that the
first cases of HIV were diagnosed in South Africa, and for the first
few years of the epidemic, cases were mainly amongst white gay men.
Following the same trends seen in other countries, as the number of
cases increased, the virus began spreading to all other areas of
society.
In 1985 an AIDS Advisory Group was appointed.
In 1990 the first antenatal surveys to test for HIV
were carried out. 0.8% of women were found to be HIV positive. It
was estimated that there were between 74000 and 120000 people in
South Africa then living with HIV. Since this time, antenatal
surveys have been carried out annually.
In 1991 the number of heterosexually contracted
infections equalled the number homosexually contracted. Since that
point, the number of heterosexually acquired infections has
dominated the face of the epidemic. The prevalence rate was 1.4%
based on antenatal testing. Several AIDS information, training and
counselling centres were established.
In 1992 the prevalence rate was 2.4% based on
antenatal testing. The first governmental response to AIDS came when
Nelson Mandela addressed the newly-formed National AIDS Convention
of South Africa (NACOSA), although there was little action from the
government in the following few years. The purpose of NACOSA was to
begin developing a national strategy to cope with AIDS5. The free
National AIDS helpline was started.
In 1993 the prevalence rate was 4.3% based on
antenatal testing. The National Health Department reported that the
number of recorded HIV infections had increased 60% in the previous
two years and the number was expected to double in 1993. A survey of
women attending health clinics indicated that nationally some
322,000 people were infected.
In 1994 the prevalence rate was 7.6% based on
antenatal testing. The Minister for health accepted the basis of the
NACOSA strategy as the foundation of the governments AIDS plan.
There was criticism, that the plan, however well intended, was
poorly thought-out and disorganised. The South African organisation
Soul City was formed, developing media productions with the
intention of educating people about health issues, including
HIV/AIDS.
In 1995 the prevalence rate was 10.4% based on
antenatal testing. Much of the collection of AIDS data stopped in
South Africa.
In 1996 the prevalence rate was 14.2% based on
antenatal testing. The International Conference for People Living
with HIV and AIDS was held in South Africa, the first time that the
annual conference had been held in Africa. The then-deputy
President, Thabo Mbeki, acknowledged the seriousness of the
epidemic, and the South African Ministry of Health announced that
some 850,000 people, 2.1% of the total population were believed to
be HIV positive and that in some groups, such as pregnant women, the
figure had reached 8% and was rising.
In 1997 the prevalence rate was 17.0% based on
antenatal testing. A national review of South Africa's AIDS response
to the epidemic found that there was a need for political
leadership.
In 1998 the prevalence rate was 22.8% based on
antenatal testing. The pressure group Treatment Action Campaign (TAC)
was started to advocate for the rights of people living with HIV /
AIDS and to demand a national treatment plan for those who were
infected. The then Deputy President Thabo Mbeki launched the
Partnership Against Aids, admitting that 1500 infections were
occurring every day.
In this year alone, 49,280 incidences of rape and
sexual assault were reported, indicating that sexual violence is
likely to be an important factor involved in the transmission of
HIV. Sexual assaults in South Africa are thought to go largely
unreported, so the true figure is undoubtedly much higher.
Gugu Dlamini, a health worker and AIDS activist,
made her HIV status public on World AIDS day, and was stoned to
death by a mob which included her own neighbours.
50% of adult medical admissions in hospitals in
Gauteng province were AIDS related.
In 1999 the prevalence rate was 22.4% based on
antenatal testing. Over 160 million free condoms were distributed.
An educational campaign called 'Lovelife' was launched, a national
programme targeting 12- to 17-year-old South Africans.
In 2000 the prevalence rate was 24.5% based on
antenatal testing. At the International AIDS conference in Durban,
the South African president Thabo Mbeki said that AIDS was a disease
caused by poverty, not by HIV. While poverty can be more harmful to
people who are HIV+ and lack adequate nutrition, this comment is
untrue. It was also extremely unhelpful in promoting the adequate
provision of HIV education in South Africa.
President Mbeki set up a group charged with solving
the country's AIDS problems and has included HIV 'dissidents' such
as Peter Duesberg, who believe that anti-AIDS drugs such as AZT
actually cause AIDS, and that lifestyle choices such as
homosexuality or drug addiction can cause AIDS.
In 2001 the prevalence rate was 24.8% based on
antenatal testing. South Africa's High Court ordered the government
to make Nevirapine available to pregnant women to help prevent the
transmission of the virus to their babies. Despite international
drug companies offering free or cheap AIDS drugs10, the Health
Ministry still refused to provide these drugs on a large scale.
In 2002 the prevalence rate was 26.5% based on
antenatal testing.
In 2003, data showed that the HIV prevalence rate
amongst pregnant women was 27.9%. TAC campaigners embarked on a
strategy of civil disobedience and demonstrations to try to
embarrass the government into acting. In March 2003 TAC laid
culpable homicide charges against the Health Minister and her trade
and industry colleague. TAC claims the pair are responsible for the
deaths of 600 HIV-positive people a day in South Africa who have no
access to antiretroviral drugs.
These figures show that there was clearly an
explosion in HIV prevalence between 1993 and 2000. This was a time
when the country was distracted by the major political changes
through which it was going, and during which it is possible that the
severity of the epidemic might have been lessened by prompt action.
Whilst the attention of the South African people and the world's
media was focused on the political and social changes occurring in
South Africa, HIV was silently gaining a foothold. Although the
results of these political changes were positive, the spread of the
virus was not given the attention that it deserved, and people
didn't realise the impact of the epidemic in South Africa until
prevalence rates had began to accelerate rapidly.
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The population of South Africa is made up of a
mixture of races. Black South Africans account for 75% of the
population, whites make up around 13%, Asian people make up about 3%
of the population, and other people of mixed racial heritages
account for about 9%. There are 11 official languages in South
Africa and many dialects, which, obviously, makes the job of
informing people about the dangers of AIDS all the more difficult.
86% of the population are literate.
HIV education in South Africa, as in many countries,
only became seen as an important issue when HIV had already gained a
foothold.
Coming after the government's basic HIV education
campaigns, the 'Beyond Awareness'13 campaign which ran from
1998-2000, came from the perception that national mass-media
campaigns might inform people, but seldom had much effect in
changing behaviour. Beyond Awareness was a multi-media campaign
targeted mainly at young people, and backed by demographic research
evaluating the success of the campaign. They also produced and
supplied materials and resources for small organisations to use in
different contexts, and promoted the free National AIDS helpline,
started in 1992 as part of the initial AIDS awareness initiative.
Started by a number of different funders , the Soul
City project was designed to educate and empower people to make
better choices about their personal health. It used radio, print and
television, aiming to reach a wide audience. They use drama and soap
operas to disseminate their message, with their first series
broadcast in 1994. Their material has also been broadcast in many
other parts of Africa as well as Latin America, the Caribbean and
South East Asia. As with many HIV prevention education projects, it
is difficult to measure the success of the Soul City project.
In 1999, an educational campaign called 'Lovelife'
was launched. It's aim was to reduce teenage pregnancy, the spread
of HIV/AIDS and sexually transmitted infections among young South
Africans. The campaign aims to turn safe sexual behaviour into a
brand, in much the same way as Coca Cola or Nike. Funded mainly by
foundations set up by Henry Kaiser and Bill Gates, LoveLife involves
a glossy multimedia blitz promoting sexual responsibility and a
network of telephone lines, clinics and youth centres providing
recreational and sexual health facilities. They also have an
outreach service, travelling to remote rural areas, trying to reach
young people who are not in the educational system. In terms of
funding, Lovelife has become the largest campaign aimed at HIV
prevention in the world.
It is founded on the idea that previous campaigns of
sexual health education have largely failed to change sexual
behaviour - 90% of people in South Africa know the dangers of HIV
and how it is transmitted, yet infection rates continue to rise.
Lovelife aims to delay first sex, reduce the number of partners
people have, and encourage people to practise safer sex.
The Lovelife campaign has been criticised in some
circles for sexualising the epidemic, and, although it may have been
very effective, the actual difference it has made to reductions in
new HIV infections is very difficult to measure. Some AIDS activists
feel that the campaign is misguided, poorly targeted, and will be
ineffective.
In 2001 the government formed the AIDS Communication
Team (ACT) which involved a group of organisations including Soul
City, to develop and implement a two-year media campaign intended to
educate people about the dangers of HIV. The campaign is called 'Khomanani'
which means 'caring together', and produces material in several
languages.
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HIV is sometimes seen as being a disease of the
poor, and in South Africa there is some correlation between extreme
poverty and high levels of HIV prevalence18, although the virus is
prevalent across all sectors of society.
By 1998, in more affluent, largely white society,
people were starting to come out as being HIV positive,
stigmatisation of the condition still remained deeply rooted in
township areas. In 1998 Gugu Dlamini, an AIDS activist in Durban,
came out as being HIV positive on world AIDS day. She was beaten to
death by her neighbours.
The then-Deputy President Thabo Mbeki made the
declaration of Partnership against AIDS, in which he called for an
end to discrimination against people with HIV.
An important point came in 2000 when Justice Edwin
Cameron of the South African court came out at a speech in Durban as
being HIV positive. In spite of this, coming out as being HIV
positive can in many cases still negatively effect employment and
housing opportunities, and social relationships.
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The pressure group Treatment Action Campaign (TAC)
lead by Zackie Achmat, was started in 1998 in response to the
unwillingness or claims of inability of the South African government
to provide anti-retroviral treatment for people with AIDS.20 They
argued that the cost of providing antiretroviral medication,
Nevirapine, and preventative education will ultimately be less
expensive than the economic impact of an unchecked epidemic. They
felt that the decision of the South African government not to
provide antiretroviral drugs was inhumane, and spearheaded the fight
to persuade the government to provide drugs to prevent
mother-to-child transmission of HIV. Zachie Achmat, himself HIV
positive, drew publicity to the situation by refusing to take
antiretroviral medication until it was available to all South
Africans.
On an international scale, there was also inaction
and a tendency to take polarised views. When discussing the
provision of multi-drug medication in 2001, USAID head Andrew
Natsios argued that drug treatment is impractical because most
Africans "don't know what Western time is... and if you say one
o'clock in the afternoon, they don't know what you are talking
about"? This was seen as being a legitimisation of inaction.
In 2000, at the conference in Durban, Justice Edwin
Cameron said that the prospect of 25 million deaths in Africa is
fundamentally unacceptable. He described a growing fatalism in the
West's perception of the 'sad realities' of Africa's problems. "We
don't accept 'sad realities' in South Africa," he said. "If we
accepted sad realities, we would still have a racist oligarchy
here."
Justice Cameron described how he nearly died of the
disease three years before but was brought back to health by
antiretroviral drugs he was able to afford.
"I have the privilege of purchasing my health, for
about $400 a month. Why should I have the privilege of purchasing my
life, when 34 million people around the world are becoming ill and
dying? It is a moral inequity of fundamental proportions. No one can
look at it and not be spurred to action."
Many health-care professionals within the health
department became frustrated by the government's lack of progress in
supplying Nevirapine, proven to be effective and economical in
reducing the transmission of the virus from mothers to their babies.
Doctors began applying to NGOs for grants to pay for Nevirapine, and
in some cases used their own money to buy the drug. Official policy
stated that the doctors were forbidden to provide the drug, and
those who did so risked being disciplined or sacked.
In March 2003 TAC laid culpable homicide charges
against the health minister Health Minister and her trade and
industry colleague. TAC claims the pair are responsible for the
deaths of 600 HIV-positive people a day in South Africa who have no
access to antiretroviral drugs.
In August 2003, the government ordered the health
department to develop a detailed operational plan to provide
antiretroviral drugs to people living with HIV / AIDS. The
announcement was greeted with optimism, but also with an awareness
that rapid action was more important than the production of
operational documents.
In October 2003 the Clinton Foundation announced
that it had brokered a deal with four generics companies to provide
triple-drug antiretroviral therapy to governments in the developing
world at a cost of less than US $140 per patient per year, much
cheaper than the medication had previously cost.
The United States, which has promised to spend $15
billion fighting AIDS in the developing world in the next few years,
has recently annouced that Congress has approved $40 million funding
for South Africa.
On the 19th November 2003, the government approved
the Operational Plan for Comprehensive Care and Treatment for people
living with HIV and AIDS. In November 2003, the government in South
Africa reversed its views about the administration of ARVs, partly
as a result of Glaxo SmithKline and other Pharmaceutical companies
agreeing to allow low-cost generic versions of their drugs to be
produced. Since this reversal, they have produced a policy document
laying out their plans for addressing the HIV epidemic. Much of this
policy is very sound, as they admit the need for the provision of
ARVs and preventative education.
The policy also accepts that part of a valid
treatment package must be nutrition, which is of great importance
amongst poorer sections of the population. The South African health
minister has proposed that AIDS sufferers eat garlic, onions, olive
oil and African potatoes to boost their immune systems. While this
isn't going to 'cure' HIV, it is true that a good diet is an
important part of treatment.
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The Operational Plan for Comprehensive Care and
Treatment for people living with HIV and AIDS needs to be
implemented immediately, to the extent that South Africa's existing
infrastructure will allow. This means that ARVs need to be provided
to people with AIDS, and that Nevirapine needs to be provided to
pregnant mothers who may be HIV+. Testing facilities need to be
improved. The medical infrastructure needs to be built on before all
aspects of the plan can be put in place, but this should not stop
the health department from doing all that they are able to with
their current resources.
The educational package incorporated in the
treatment plan needs to be implemented, for both people who are HIV
negative and positive. As the antiretroviral rollout begins to save
the lives of people with HIV, then the pool of people able to
transmit the virus will increase. Education will be needed to
prevent an increase in new infections.
The World Health Organisation (WHO) has recently
published a plan outlining aims to bring antiretroviral (ARV)
treatment to 3 million people living with HIV in developing
countries by 2005.
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Three years after it was first introduced to South
Africa, Nevirapine is still not reaching many pregnant women.
Reasons for this are:
• The stigma of being known to be HIV positive
deters many pregnant women from taking a test.
• If pregnant women already know that they are HIV+,
the stigma may keep them from admitting their positive status to
midwives.
• That lack of healthcare infrastructure,
particularly in rural areas, means that many pregnant women may not
come into contact with the medical services during their
pregnancies.
• There are still national shortages of many drugs,
and medication is not getting to all of the areas in which it is
needed.
The issues experienced in the rollout of Nevirapine
illustrate the difficulties involved in providing antiretroviral
medication across the country.
However, some progress is being made. Western Cape,
KwaZulu-Natal and Gauteng claim to provide almost complete access to
the drug, and other states are doing well.
The policy promises that within a year there will be
"at least one [antiretroviral] service point in every health
district across the country, and within five years, one service
point in every local municipality". It also involves "upgrading our
national healthcare system . . . recruitment of thousands of
professionals and a very large training programme to ensure nurses,
doctors, laboratory technicians, counsellors and other health
workers have the knowledge and the skills to ensure safe, ethical
and effective use of medicines."
In February 2004, the government in South Africa
admitted that delays in the procurement process and lack of training
for doctors were still delaying the rollout of ARV treatment.
The policy states that they want to provide
comprehensive viral-load testing for HIV positive people, something
for which the countries' medical infrastructure in not equipped. The
government haven't stated yet whether they will allow the lack of
viral-load testing facilities hold up the provision of ARV
medication. This is going to be very demanding, given that the
health-care system is short on trained staff in some places, due to
the effects of HIV.
The policy may be attempting to be too ambitious.
The experiences of Botswana show that, even if sufficient funding is
available, implementing ambitious plans in short timescales can be
very difficult.
The experiences of other resource-poor countries
indicates that the time-period between HIV diagnosis and death, in
an impoverished area, can be as little as two years25. It will be
challenging to carry out the rollout of medication, but treatment
must be implemented immediately, or an estimated two million of
South Africa's population could be dead within the next year.
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