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.

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% of these 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 day¹¹.

Whatever the precise levels of infection are, what is certainly clear is that the problem is a huge one.

Area 1,218,363 sq.km. A republic with nine provinces at the southernmost point of Africa.

Population (2000) 40,376,579 +1.51%AGR

Capital Cape Town (legislative) 2.6 million. Pretoria (administrative) 1.7m; Bloemfontein (judicial) 325,000.

Peoples

African 76.7%.

Caucasian 10.9%;

Coloured (mixed race) 8.9%.

Asian 2.6%.

Other 0.9%.

Literacy 82%. Functional literacy is much lower at around 62%. National languages 11 — all the major ethnic languages. English and Afrikaans are the main languages in higher education. All languages 32. Languages with Scriptures 19Bi 1NT 1w.i.p.

Economy

The richest and most industrialized country in Africa (25% of Africa’s GNP, 40% of its industrial output). Unemployment 25% (38% for youth and may be much higher). HDI 0.695; 101^st/174. Public debt 9% of GNP. Income/person $3,210 (10% of USA) — but big disparities between wealthy and poor.

Politics

The Union of South Africa was formed in 1910.

Religion

Chronology

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.²

In 1990 the first antenatal surveys to test for HIV were carried out.³ 0.8%⁴ 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.⁶

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.⁷

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.⁸

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.⁹

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.¹¹

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.

What are the current issues?

Education

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.¹²

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.¹⁴

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.^15,16

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.¹⁷

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.

Stigmatisation and attitudes

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.¹⁹

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.

Treatment, activism and ARVs.

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 it's 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 document²¹ 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.²²

There is more information about which people around the world are able to access ARV medication.

What needs to happen?

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.

What are the major challenges?

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 treatment²³

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.²⁴

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.

There is more information about organisations, countries, costs and challenges involved in providing ARV medication to resource-poor areas.

This page was written by Steve Berry, September 2004.