HIV in South Africa
An estimated 5.6 million people were living with HIV and AIDS in South Africa in 2009, more than in any other country.1 It is believed that in 2009, an estimated 310,000 South Africans died of AIDS Prevalence is 17.8 percent among those aged 15-49, 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 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.
Marking a welcome change from South Africa’s history of HIV the South African Government launched a major HIV counselling and testing campaign (HCT) in 2010. By raising awareness of HIV the campaign aims to reduce the HIV incidence rate by 50 percent by June 2011
Several large studies of male circumcision and HIV have produced firm evidence that the procedure reduces by 60 percent the risk of sexual transmission of HIV from women to men. As a result, the government has included voluntary medical male circumcision as an integral part of its HIV counselling and testing (HCT) campaign. The campaign aims to offer all men aged 15-49, and the guardians of infants below 6 months of age, voluntary medical circumcision at public health facilities in all provinces by 2011. In April 2010, KwaZulu-Natal became the first province to offer VMMC services.
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.
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 percent in 2002, 35 percent in 2005 to 62 percent 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.
The 2009 National Communication Survey on HIV/AIDS also found that 15 percent of married men and women used a condom at last sex compared to 74-83 percent men and 55-66 percent of women who had casual sex or one night encounters, identifying the need for prevention programmes to further target married couples.
HIV Testing in South Africa
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. 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%. According to UNAIDS, almost 7 million South Africans aged 15 years and over (or one quarter of the adult population) received HIV testing and counselling in 2009.
There is evidence that testing levels have improved as the 2009 National Communications Survey found 60 percent of all men and women studied had been tested in the last 12 months, an increase of 36 percent since 2006. The percentage of those ever tested also increased significantly as 2009 figures showed 32 percent of men and 71 percent of women had been tested at least once compared to 2006 figures (17 percent men and 38 percent of women). The survey also identified a link between the amount of exposure a person had to communication programmes and whether the individual had been tested. These results indicate a positive development in the effectiveness of programmes and the general perception towards testing in South Africa.
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.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.
In an attempt to provide vulnerable populations with HIV testing services, South Africa’s corrections service has stepped up testing for prisoners and correctional service staff in Kwazulu-Natal’s prisons. In mid- 2010 it was announced that around 21,000 prisoners would receive HIV counselling and testing. HIV prevalence within prisons if often far higher than in the general community, yet prisoners are often neglected and overlooked.
One creative way of providing testing for the general population 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.
“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
When testing does occur it is very often at a late stage of infection. The HIV counselling and testing (HCT) campaign launched in April 2010 aims to offset the problem of late or no diagnosis. The HCT campaign is a widespread strategy implemented in all health authorities whereby all patients will be counselled on the importance of knowing their HIV status and will be offered a test. Through this proactive approach the government of South Africa aims to test 15 million people for HIV by June 2011.
By making testing and counselling provider-initiated it is hoped diagnosis of HIV will take place earlier and treatment be started sooner. Routine testing at healthcare facilities could prove to be a way of working round the stigma attached to HIV testing.
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.
HIV Testing 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 2009, an estimated 37% percent of infected people were receiving treatment for HIV, according to the latest WHO guidelines (2010).
The state of HIV treatment in South Africa can only be seen in the context of years of doubting the effectiveness of treatment at the highest levels of government, and the initial delay and slow pace of delivering a public ARV programme.
Thabo Mbeki, president of South Africa from 1999 to 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 Nunn
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 which had held back progress in treating HIV and AIDS in South Africa. See AVERT’s History of HIV and AIDS in South Africa page for more information.
The task of providing a high level of access to antiretroviral therapy in South Africa now faces a set of new challenges.
The level at which someone begins antiretroviral therapy has a great impact on their chances of responding well to treatment. The WHO now recommends that all countries, including poorly-resourced countries, start treatment at a CD4 count of <350 cells/mm3.
In 2009, the South African National AIDS Council (SANAC), which advises the government on AIDS policy, recommended raising the CD4 treatment threshold from 200 to 350 cells/mm3, to be in line with the latest WHO guidelines. Some researchers predicted 76,000 deaths could be prevented over five years if treatment was initiated below 350 cells/mm3, compared with below 250 cells/mm3, assuming that 30 percent of eligible patients were identified and linked to care.
Advocates of raising the treatment threshold to <350 cells/mm3 acknowledge that this would require greater expenditure but argue it 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.”
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.
The 2010 antiretroviral treatment guidelines released in February, did not adhere to the WHO recommendations to initiate ARV at a CD4 count of <350 cells/mm3. Instead, those infected with HIV will continue to begin treatment at <200 cells/mm3. The guidelines did state that for certain groups, such as pregnant women, treatment will begin at <350 cells/mm3.
However, overall delivery of treatment at a CD4 count of <350 cells/mm3 may not be as expensive as previously thought. Research has shown that under current guidelines overall government spending will be $9.8 billion during the period 2010 to 2017, whilst under new guidelines this figure would only increase to $11 billion.
Late initiation of treatment
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.
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.
Are young gay men particularly affected by HIV and AIDS?
In the USA, the UK, and a number of other European countries, HIV and AIDS have affected young gay men more than any other group of people. In the UK and USA especially, the percentage of young gay men who have been infected with HIV and the percentage with AIDS is much higher than other groups such as heterosexual people or children. (These stats shown to be the total opposite in South Africa between Gay people.)
In the USA, it is estimated that nearly 255,000 men who have sex with men were living with HIV/AIDS in 2007, and nearly 5,400 had died. Around 48% of all people diagnosed with AIDS in America in 2007 were probably exposed to HIV through male-to-male sexual contact. In the UK, by the end of June 2009, around 45,947 diagnoses of HIV had been in men who had probably become infected through sex with another man. 53% of these men were aged below 35
There are also other parts of the world where men who have sex with men, many of whom do not identify themselves as gay, are affected by HIV. For example, the primary HIV transmission route in Latin America is sex between men. In Brazil, men who have sex with men accounted for 40% of all AIDS diagnoses among males between 2000 and 2005 In some cities in Colombia, estimates of HIV prevalence among men who have sex with men range from 10% to 25%
Despite the continuing impact of HIV & AIDS there are signs that awareness is waning among young people. For example, research with British teenagers has shown decreasing awareness of HIV & AIDS. The same pattern of increasing prevalence and decreasing awareness exists for STIs as a whole and many young people, including young gay men, may underestimate how likely they are to be exposed to sexually transmitted diseases including HIV. There is also evidence that in some places, even where they are otherwise well-informed about HIV and STIs, young people do not believe that they are vulnerable to contracting them
In the UK the numbers of young people with chlamydia, gonorrhea and genital herpes has risen by more than 100% since the 1990s.