Figure 1: Number of Adults and Children infected with HIV worldwide
Source: UNAIDS Epidemic Update: November 2009

Figure 2: HIV prevalence epidemic curve among antenatal women, South Africa, 1990-2008

Source: 2008 National Antenatal Sentinel HIV & Syphilis Prevalence Survey, National Department of Health, 2009

Among females, HIV prevalence is highest in those between 25 and 29 years old; among males, the peak is in the group aged 30-34 years.

Figure 3: Estimated HIV prevalence among South Africans, by age and sex, 2008

Source: The South African National HIV Survey 2008, Human Sciences Research Council

Figure 4: HIV prevalence distribution among antenatal women by province, South Africa, 2008

Source: 2008 National Antenatal Sentinel HIV & Syphilis Prevalence Survey, National Department of Health, 2009

HIV and AIDS Indicators at end of 2008

People living with HIV and AIDS

Global total 33.4 million

Sub Saharan Africa total 22.4 million

South Africa 5 300 000

Adults (15+) 5 000 000 or 17.5% of adult population (of which 3 000 000 are female)

Male youth (15-24) 181 000

Female youth (15-24) 831 000

Children (0-14) 220 000

New infections 436 000

Paediatric new infections 56 000

AIDS orphans 1.8 million

Annual AIDS deaths 310 000

Births

Uninfected births (over calendar year) 1 057 000

HIV+ births (over calendar year) 38 000

Infected through breastfeeding 26 000

Sources

UNAIDS (2009), AIDS Epidemic Update: November 2009, http://www.unaids.org/en/KnowledgeCentre/HIVData/EpiUpdate/EpiUpdArchive/2009/default.asp

Department of Health (2009), 2008 National Antenatal Sentinel HIV & Syphilis Prevalence Survey, http://www.doh.gov.za/docs/reports/

Epidemic Trends

The global epidemic appears to have stabilized in most regions. The UNAIDS 2009 Report states that with 22.4 million HIV positive individuals, Sub-Saharan Africa remains the most heavily affected region, accounting for 67 per cent of all HIV infections worldwide, 68% of new infections among adults and 91% of new HIV infections among children (see Figure 1). Sub-Saharan also bore the brunt of the world’s AIDS-related deaths, at 72% of AIDS deaths worldwide (2008 National Antenatal Sentinel HIV & Syphilis Prevalence Survey).

South Africa has the highest number of people infected globally, estimated at around 5.3 million, including 220 000 children under the age of 15 years, in 2008 (UNAIDS 2009).

South Africa ranks in the top five highest HIV prevalence countries in the world, with 17.5% of the population estimated to be infected. The UNAIDS 2009 Global Report Epidemic Update estimated that in 2008, 310 000 people died from AIDS in South Africa. South Africa is regarded as having the most severe HIV epidemic in the world.

In South Africa, the National Antenatal Sentinel HIV & Syphilis Prevalence Survey 2008 reveals that the estimated national HIV prevalence amongst women has remained stable over the past three years at around 29% (see Figure 2). This concurs with the projections by UNAIDS that the HIV epidemic curve is reaching a plateau. However the UNAIDS Global Report on HIV 2008 suggests that this plateau does not appear to be indicative of major behavior change but rather the natural progress of a long wave epidemic.

The burden is not felt evenly across the country (see Figure 4). The results show that the highest HIV prevalences are recorded on the North-Eastern side of the country, and the lowest prevalences in the Western parts of South Africa. While the national average of HIV-positive women attending antenatal clinics in 2008 was 29.3%, the province of Kwa-Zulu Natal continues to have the highest prevalence at 38.7% followed by Mpumalanga at 35.5%. The lowest recorded prevalence of women attending antenatal clinics was in the Western Cape, at 16.1%. (2008 National Antenatal Sentinel HIV & Syphilis Prevalence Survey)

Hopeful signs of a determined and comprehensive response to the HIV and AIDS pandemic in South Africa emerged during 2008. After years of denialism and mixed messages from the Mbeki Presidency and the Ministry of Health under Dr Manto Tshabalala-Msimang, there was the prospect of committed leadership and an effective response. The appointment of a new Minister of Health, Barbara Hogan, the functioning of the reconstituted South African National AIDS Council (SANAC) and the promotion of a National Strategic Plan (NSP), with clear targets for prevention, care and treatment, all pointed towards a new era of joint action to save lives. The NSP articulated two major goals – to reduce the incidence of HIV in South Africa by 50% by 2011 and to ensure that at least 80% of those eligible are accessing antiretroviral therapy (ART).

In May 2009, Jacob Gedleyihlekisa Zuma was elected President of South Africa. He shortly appointed physician Aaron Motsoaledi as Health Minister, replacing Health Minister Barbara Hogan. Speaking on World AIDS Day 2009, President Zuma committed to expanding South Africa’s ART programme, already the world’s largest, in an effort to curb infant mortality and prevent new infections. Based on the World Health Organisation’s 2009 recommendations that promote earlier treatment intervention, South Africa’s revised treatment programme will see a significant scale up of ARV provision to infants and pregnant women with a CD4 count of 350 or less, as well as those co-infected with TB and HIV. The changes are effective from 1 April 2010.

South Africa faces significant capacity challenges in expanding the ART programme, especially during this climate of global economic recession. South Africa already has the world’s largest ART programme which must be expanded in a long-term, sustainable fashion. Once a patient begins on ART they must continue their treatment regime without interruption or else they risk developing a drug-resistant form of HIV, an issue which has huge implications for national and international treatment programmes. Therefore, treatment availability and delivery must be sustainable. Further, debate within the HIV and AIDS sector over appropriate treatment regimens has slowed the expansion of South Africa’s treatment programme, with cheaper ARV drugs which are seeing increased reported side effects in patients possibly being phased out and replaced.

Although these debates and capacity challenges have slowed South Africa’s alignment with WHO recommendations on HIV treatment provision, the revised guidelines are a positive step forward and reflect the message conveyed on World AIDS Day 2009 that government is committed to extending its ART programme. President Zuma also strongly reaffirmed the message that HIV education, testing and prevention is the key to reducing new infections and therefore HIV prevalence, and that, crucially, it is the responsibility of each individual.

Click here to read the address by President Jacob Zuma on the occasion of World AIDS Day, Pretoria Showgrounds, 1 December 2009.

The backdrop for such action remains ominous. Within Sub-Saharan Africa, the region worst-affected by HIV and AIDS, the countries of Southern Africa have the highest reported rates of infection.

Many factors contribute to the spread of HIV. These include: poverty; inequality and social instability; high levels of sexually transmitted infections; the low status of women; sexual violence; high mobility (particularly migrant labour); limited and uneven access to quality medical care; and a history of poor leadership in the response to the epidemic.

Efforts to stem the tide of new infections have only had limited success. Research shows high levels of knowledge about the means of transmission of HIV and understanding of methods of prevention. However, this does not translate into HIV-preventive behaviour. Behaviour change and social change are long-term processes, and the factors that predispose people to infection – such as poverty and inequality, patriarchy and illiteracy – cannot be addressed in the short term. Vulnerability to, and the impact of, the epidemic are proving to be most catastrophic at community and household level. Hundreds of people of all ages die in South Africa every day of AIDS-related diseases, mainly because they have not sought or been able to access effective treatment.

The hardship for those infected and their families begins long before people die. Stigma and denial related to suspected infection cause many people to delay or refuse testing; fear and despair often follow diagnosis, due to poor-quality counselling and lack of support; poverty prevents many infected people from maintaining adequate nutrition to help prevent the onset of illness; limited access to clinics, waiting lists for ARV treatment programmes and eligibility criteria for access to ARVs mean that many people become seriously ill before accessing treatment; loss of income and support when a breadwinner or caregiver becomes ill, and the diversion of household resources to provide care exacerbate poverty; the burden upon family members, particularly children and older people caring for terminally ill adults, and the trauma of bereavement and orphanhood compromise the physical and mental well-being of entire households. This all happens in a society where the majority of children live in poverty and 23.2% of the economically active population is unemployed (the figure rises to around 40% if people who have given up looking for work are included).

Obtaining accurate statistics on the number of children orphaned as a result of AIDS is problematic. If orphans are defined as children from birth up to the age of 17 whose mothers have died, UNAIDS estimates that there were 1 800 000 children orphaned due to AIDS living in South Africa at the end of 2008. This figure is higher than for any other country. However, it is estimated that Zimbabwe has 1 000 000 children orphaned due to AIDS among a total population of fewer than 13 million.

For many years, the burden of care and support has fallen heavily on the shoulders of impoverished rural communities, where sick family members return when they can no longer work or care for themselves. Community-based care has been promoted as the best option since it would be impossible to care properly for hundreds of thousands of people dying from AIDS in public hospitals. The resilience and capacity to care for dying people and provide for those they leave behind in impoverished communities is extremely overstretched. There remains an acute need for social protection and interventions to support the most vulnerable communities and households affected by this epidemic.

Women face a greater risk of HIV infection. On average in South Africa there are three women infected with HIV for every two men who are infected. The difference is greatest in the 15-24 age group, where three young women for every one young man are infected.

Progress

The approval of the HIV & AIDS and STI Strategic Plan for South Africa 2007-2011 (NSP) by the SA Cabinet and the reconstituted South African National AIDS Council (SANAC) marked a major breakthrough in the response to HIV and AIDS. The NSP provides the basis for a coordinated national response that sets out the roles of government, civil society, business and other stakeholders, and identifies clear goals and requirements for meeting them.

The implementation of the NSP will be driven by the Minister of Health, physician Aaron Motsoaledi, who replaced Ms Barbara Hogan in April 2009. As Health Minister, Hogan acknowledged that the rate of provision of ARVs needed to be sped up to act decisively on the AIDS pandemic in South Africa. This push for expanded treatment has been supported by President Zuma and Health Minister Motsoaledi.

NSP Download

There has been progress in increasing the uptake of Mother to Child Transmission Prevention (MTCTP) services and in providing dual ARV therapy to infants, which is more effective than the single dose Nevirapine first grudgingly provided by the government. There is also recognition of the need to focus on saving mothers’ lives and parents’ lives, not just babies lives. The needs for HIV to be integrated into health services and for TB and HIV to be addressed in tandem have also been acknowledged.

The NSP target is for 80% of all people who need ARVs to be receiving them by 2011. This is ambitious and it certainly represents progress that government is prepared to acknowledge the gap between policy and reality and take steps to bridge it.

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South Africa’s response to the epidemic

In 1987, the apartheid government recognised that HIV and AIDS had the potential to become ‘a major problem’, even though there were few reported infections.

The first antenatal survey, conducted in 1990, found that only 0.7% of pregnant women were infected. Yet, in the same year, ANC leader Chris Hani, speaking from exile, warned: Existing statistics indicate that we are still at the beginning of the AIDS epidemic in our country. Unattended, however, this will result in untold damage and suffering by the end of the century.”

This warning was not heeded, either by the outgoing regime or by the incoming democratic government as it faced the huge challenge of taking over political control of a divided country.

During the first decade of democracy in South Africa, the energies of civil society organisations in the HIV and AIDS sector  led by the Treatment Action Campaign (TAC) were largely focused on challenging the government to recognise the scale and depth of the emerging epidemic.

Former President Nelson Mandela acknowledged after leaving office that his government had not acted swiftly or decisively enough to address the crisis. His successor, Thabo Mbeki, far from redressing this failure, compounded it with a deadly denialism parading as intellectual inquiry. Under his presidency, more than 5 million people were living – and increasingly dying – with HIV. Yet Mbeki questioned the link between HIV and AIDS and said he had never met anyone with the disease.

Mbeki’s Minister of Health, Manto Tshabalala-Msimang, fought growing national and international appeals for a public treatment programme to save lives, all the way to the highest court in the land. Prevention, nutrition, traditional medicine and a ‘positive attitude’ were the Minister’s prescription. These were touted as an alternative to anti-retroviral treatment, rather than as important components of a comprehensive treatment and support programme. The body that was supposed to drive the national response to HIV and AIDS, the South African National AIDS Council (SANAC), chaired by then Deputy President Jacob Zuma, was dysfunctional and ineffective in the absence of political will. In 2003, the government produced an Operational Plan for the rollout of ARV treatment but lack of leadership and severe capacity problems in the health sector inhibited its implementation.

After Zuma was fired as Deputy President in 2005, SANAC was reconstituted under his replacement, Phumzile Mlambo-Ngcuka. As Minister Tshabalala-Msimang’s influence began to wane, reason began to prevail in the response to HIV and AIDS. Mbeki desisted from public contestation of HIV/AIDS science and, in 2007, government and representatives of labour, civil society and the private sector, through SANAC, finalised a new Strategic Plan for HIV and AIDS and STIs in South Africa, for 2007 to 2011.

When Mbeki fell from office in 2008, a new Health Minister, Barbara Hogan, was appointed, who immediately committed government to a concerted and decisive response to the epidemic. A new spirit of trust and cooperation between government and civil society bode well but the legacy of poor leadership and cooperation was daunting. New infections were still occurring at a rate of about 1500 a day and 1000 deaths per day were attributed to AIDS.

While the government response is a matter of national policy and has always been framed as a ‘partnership’, clearly the role of individual leaders is critical. Strong, visionary leadership is needed in all sectors to defeat an epidemic that is affecting all sectors. This is the context in which AFSA is supporting initiatives aimed at taking control of the HIV and AIDS epidemic from household to international level.

Community

Most care of people living with HIV in South Africa is provided at household level, by family members, CBOs and faith-based organisations (FBOs). In the early years of the epidemic, the ‘community’ was called upon to provide terminal care and support orphaned children with very little support. Families and neighbours responded, assisting those who had lost breadwinners and absorbing children who had lost parents. However, given prevailing levels of poverty, the impact of AIDS stretched survival strategies to breaking point in many cases.

Lack of access to ARV medicines in the public sector has meant that the face of HIV and AIDS at community level, especially in rural areas, has been one of wretched illness and certain death. This has added hopelessness to the physical and materials burdens of providing care in the community.

It is at this level, through people’s daily interactions with one another that attitudes are shaped and behaviour is influenced. The response people receive when they seek testing, or reproductive health services such as condoms or treatment for STIs, or when they disclose their status, or become sick, can be a much stronger influence than billboards or speeches. The reactions of family members, neighbours, friends, clinic staff, doctors and government officials help to spread hope and trust or fear and stigma.

It is true that the formal health care sector has been overwhelmed by HIV and AIDS. In the absence of ARV treatment, up to 80% of hospital beds in already under-staffed and under-resourced hospitals have been occupied by patients with AIDS-related illnesses. But it is in the area of informal and voluntary care that the burden has been greatest – and has fallen most heavily on women.

In response to this, government support for home and community-based carers employed by NGOs and CBOs has increased. The state has also promoted the training of lay counsellors to promote voluntary HIV testing. The national Department of Health estimated in 2004 that there were 40 000 community health workers (CHWs) in South Africa, nearly equal to the number of professional health workers in the public sector (fewer than 44 000). There are many problems associated with it, including the poor remuneration and resourcing of CHWs, their ‘Cinderella’ status in the health sector and the uneven quality of the training they receive. Nevertheless, community and home-based carers have been the backbone of the response to HIV and AIDS.

Funding targeted at CBOs providing small-scale day-to-day services to those in need, largely through volunteers, can make the difference between household resilience and breakdown. Among the kinds of support provided are initiatives to ensure people can access the documents they need to apply for grants, the services to which they are entitled, assistance with providing home-based care, information and counselling and training. These are not services directed only at people affected by HIV and AIDS but the epidemic has drastically increased the vulnerability of already poor communities.

As access to ARV treatment improves, community support will become increasingly critical in areas such as monitoring adherence to treatment and facilitating access to adequate nutrition and social benefits.

Health care workers

At least 70% of the caseload in the public health system is taken up by HIV and AIDS cases, many relating to increasingly drug-resistant TB.

Health care workers have been overwhelmed by the impact of the epidemic on the public health service, with the majority of resources in many facilities going to treat people presenting with opportunistic infections or dying from AIDS-related illnesses. This has resulted in overcrowding of under-resourced hospitals, meaning that patients cannot receive adequate care and health professionals are working in very difficult conditions. Many health workers are living with untreated HIV and AIDS and bear the brunt of complaints about the health system. The working conditions are made worse by lack of specialised training and staff shortages. In KZN, the worst affected province, 37% of health posts in the province were vacant in early 2005 – and some hospitals did not have pharmacists.

One research study (Centre for International Health, CIC) found the attrition rate among nurses in the public sector was more than 9% in 2004. In that study, the burden of work, excessive patient loads, poor working conditions and stress/depression from dealing with increased HIV-related morbidity and mortality were among the reasons that nurses gave for resigning.

Research into the prevalence of HIV infection among health care workers at two Johannesburg hospitals in 2005 (CIC) found that 11.5% of hospital employees were HIV-positive. Of these, at least 19% should have been on ART already since they had a CD4 count of less than 200.

While many health workers have responded to the crisis by leaving the country to work in better-resourced clinics and hospitals overseas, many others have joined the lobby for access to treatment as part of a wider campaign to build the public health service.

Labour

South African labour unions, through the Congress of SA Trade Unions (COSATU) have long supported the demand for adequate care and treatment for people living with HIV and AIDS. Workers are affected by HIV and AIDS as breadwinners who risk losing their income if they become sick, as partners of infected people, as caregivers to sick people, and as guardians to orphaned children.

Mineworkers were among the first group of workers recognised to be vulnerable to HIV infection, due in part to high levels of mobility (migration) and the tendency to have more than one sexual partner, often including sex workers. As infection rates among other workers, such as educators and health professionals have risen alarmingly, unions have individually and collectively sought equitable workplace HIV policies, including workplace testing, counselling and treatment programmes, and have fought for the legal rights of infected and affected workers. They have also highlighted the working conditions of health care workers.

COSATU, while a partner in the ANC-led government, opposed some aspects of government HIV and AIDS policy. It partnered the TAC on demands for access to treatment and the Basic Income Grant Coalition in the campaign for a universal grant to ensure all South Africans can meet their basic needs. It also engaged with business, the pharmaceutical companies and donors to improve access to affordable treatment. The labour sector is represented in SANAC.

An assessment of the role of labour in tackling HIV and AIDS, made by NALEDI (the National Labour and Economic Development Institute) in 2007 found that there was still a long way to go in ensuring workers in all sectors were protected by workplace HIV policies. Despite pressure from labour unions, the majority of bargaining councils still did not have HIV and AIDS policies in place and there was poor compliance. Sectors subject to high levels of casualisation of labour were less likely to have policies in place. The unions in South Africa have fought for labour legislation that protects workers but there are still incidents reported of workers being discriminated against or dismissed on the grounds of their HIV status.

NGOs

A wide range of local, national and international NGOs have responded to the HIV and AIDS crisis facing South Africa.

They are engaged in service delivery, including prevention, care and treatment programmes, human rights work, including paralegal advice and litigation on behalf of people living with and affected by HIV and AIDS, and in research and education, advocacy and lobbying.

Many NGOs have been established purely to address HIV and AIDS. Most NGOs working on other issues have integrated responses to the epidemic into their programmes. While this is a logical response, some HIV and AIDS interventions have been donor driven, since funds have been earmarked for HIV and AIDS in preference over other areas of need.

In the absence of an effective government response, NGOs drove the campaign for access to treatment, lower drug prices, improved care and more effective policy on HIV and AIDS. Much of this campaigning was led by the TAC and the AIDS Law Project, and included some notable court victories. TAC and ALP have been AFSA partners over several years.

Huge sums have been channelled to NGOs by donors but it has often been difficult for smaller organisations to access funds. Some donors have tended to push for particular responses, such as orphanages or high-profile prevention campaigns, instead of responding to local needs or priorities. Services initially tended to be fragmented but in recent years, NGOs have come together in coalitions to promote a more coherent response, directories of AIDS service organisations have been developed and information on funding for HIV and AIDS work has been collated.

Bodies such as the Joint Civil Society Monitoring Forum have brought together NGOs, business, government, donors and health professionals to work together in the fight against the epidemic. There have also been more efforts to identify good practice.

At the end of 2008, TAC was one of the victims of South Africa’s failure to secure R1.7 billion in funding from the Global Fund, due to the poor quality of the proposal submitted by SANAC. As a result of the consequent loss of some of its funding, TAC had to retrench staff and volunteers.

The NSP commits government to funding non-government initiatives that are aligned to the key priorities of the plan. The NSP is founded on the need for partnership across all sectors and paved the way for improved cooperation between government and NGOs in terms of policy and service delivery.

Government

The SA government’s response to the HIV and AIDS epidemic needs to be assessed and monitored against an ambitious but achievable National Strategic Plan to which all roleplayers have committed themselves.

The NSP identifies four priority areas:

Priority Area 1: Prevention

Target: reduce the national HIV incidence rate by 50% by 2011.

Priority Area 2: Treatment Care & Support

Target: provide an appropriate package of treatment, care and support services to 80% of people living with HIV and their families by 2011

Priority Area 3: Research, Monitoring and Surveillance

Objective: establish effective M&E as a policy and management tool. The NSP calls for a sustainable budget of 4% – 7% of the total HIV and AIDS budget for M&E in line with international trends.

Priority Area 4: Human Rights, Access to Justice and Law Reform

Objective: create a social environment that encourages people to test voluntarily for HIV and, when necessary, to seek and receive medical treatment and social support. Respect for and the promotion of human rights must be integral to all the priority interventions of the NSP.

These objectives and targets have been costed so that the resources required to achieve them can be budgeted. Action plans for their implementation, along with the lead agencies responsible, the indicators for success and the mechanisms for monitoring are spelled out.

It is the job of the Health Minister to keep this on track. It is the job of SANAC, in which every sector of society is represented, to hold government accountable for implementation of its plan.

AFSA’s own programmes are aligned with the NSP and it supports CBOs whose work is contributing to realisation of the plan’s Key Priority Areas.

NSP Download

Business

A survey on the impact of HIV and AIDS on more than 1000 businesses in the retail, manufacturing and construction sectors in South Africa was conducted by the University of Stellenbosch in 2004.

More than a third of the companies surveyed indicated that HIV and AIDS had reduced labour productivity or increased absenteeism, and had raised the cost of employee benefits. Some 34% of the companies reported that HIV and AIDS had already had a negative impact on profits, while more than half expected an adverse impact on profitability by 2009.

Of all the companies surveyed, manufacturers were the worst affected, while retailers were experiencing the smallest impact. The study concluded that, overall, the response of business to HIV and AIDS needed to be speeded up. Only a quarter of all the firms surveyed had implemented a formal HIV and AIDS policy, while less than a fifth had a voluntary counselling and testing programme or provided care, support and treatment to infected workers.

The mining industry was among the first to recognise the potential impact of HIV and AIDS on profits and the wider economy from the mid-1980s. Since HIV and AIDS was striking down the economically active age group, companies started seeing reduced productivity, absenteeism, sickness and then deaths among the workforce.

Many employers initiated workplace awareness and education programmes to help prevent the spread of HIV. However, as the infection rate increased and employee sickness and death rates rose, companies started to look at how they could minimise their losses and meet the needs of infected workers. The larger corporations soon recognised that, in addition to humanitarian and human rights considerations, it made economic sense to invest in workplace treatment programmes.

Since 2002, Anglo American, for example, has provided free ARV treatment for all employees who need it, and sees this as an important incentive for workers to find out their HIV status. All employees who test positive are enrolled into a wellness programme to ensure ongoing support and monitoring. The company had nearly 2500 employees on treatment by the end of 2004 and reported that 94% of them were able to carry out normal work. This experience along with other major employers, started to provide important models for workplace treatment and for public/private/community partnerships in the fight against AIDS.

The South African Business Coalition on HIV and AIDS (SABCOHA) aims to co-ordinate a private sector response to the epidemic. It is a member-organisation including big corporates, medium-sized enterprises, smaller companies and service providers.

SABCOHA focuses on research to develop and share best practice models, pioneering new business initiatives, information sharing and lobbying. It funded the survey of businesses outlined above.

SABCOHA quotes research showing that if companies invest in prevention and treatment programmes, the savings outweigh the costs. Providing care and treatment for HIV-positive employees can reduce the financial burden of HIV and AIDS by as much as 40%. Daimler Chrysler showed that the savings from preventing a new infection in its South African workforce ranged from $25 000 to $280 000, depending on the job level.

Donors

International and local donors have been channelling huge sums of money, human and technical resources into the fight against HIV and AIDS in the developing world since the mid-1990s. The Gates Foundation has put millions of dollars into the Global Fund for HIV/AIDS, TB and Malaria, as well as channelling millions more directly into country programmes to fight the epidemic. The Global Fund is a unique joint effort between UN agencies, governments, private and corporate donors and individuals and is focused on treatment. However, its effectiveness is undermined by the failure of some donors to honour their pledges and difficulties of potential beneficiaries in putting forward applications that meet the criteria.

Funding for South Africa was dogged by political controversy under Minister of Health Manto Tshabalala-Msimang. She delayed a grant to KwaZulu-Natal because it had not gone through her department and then in 2008 the Global Fund rejected a ‘poor’ proposal submitted by SANAC. This cost South Africa R1.1 billion in lost funding for national programmes and R600 million for the Western Cape over five years.

SANAC was reconstituted under new leadership and expected to participate successfully in the new round of applications to the Global Fund.

International donor policy favours certain types of responses to HIV and AIDS and often attaches conditions to grants related to donors’ domestic concerns. For example, under George W Bush, the US government (as well as faith-based donors) would only fund abstinence and prevention programmes. It excluded projects that distributed condoms or made available information on reproductive rights. President Barack Obama, elected in 2009, promised to remove this condition.

The US government also requires treatment programmes it funds to purchase US brand name drugs instead of cheaper generics. Some donors will only fund programmes targeting orphans. Priority was initially given to awareness-raising and behaviour-change issues but as hundreds of South Africans started to die untreated every day, more donors were prepared to put money into treatment programmes.

Research into initiatives that could benefit millions of people but will not generate profits is generally under-funded – notably the development of microbicides as a woman-controlled prevention option. A major challenge remains to align donor funding with local priorities and models of good practice. Other challenges are to ensure more coordination between donors and to improve access of community-based organisations to funding.

In 2008, the appointment of a new Health Minister in South Africa, with a stated commitment to turning around the HIV and AIDS epidemic, brought a swift reward from one bilateral donor. The UK’s Department for International Development (DFID) announced a £15 million boost to support the NSP.

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Prevention

In the first decade of democracy, South African HIV policy focused almost exclusively on prevention, even after acknowledging the worst infection levels in the world.

Since 2008, with a change of leadership, prevention, treatment and care have been recognised as inter-dependent strategies in the battle to reduce sickness and death from AIDS and cut the rate of infection.

There are several components of a successful HIV prevention strategy. They all present challenges, the greatest relating to behaviour change.

The challenge of behaviour change

Prevention of HIV transmission in South Africa has focused primarily on interventions to promote behaviour change.

One of the main strategies was to inform people about the existence of HIV, the means of transmission and the consequences of infections. It was believed that this would prompt peopled to abstain from sex, use condoms during every act of sexual intercourse, and move from high-risk to low-risk sexual activities, such as having fewer sexual partners.

However, it became clear, through the increase in infection rates, that knowledge of HIV has not led people to change their attitudes or behaviour. One factor is that prevention campaigns have not taken account of the dynamics of the epidemic in South African society. These include deep-rooted inequalities, which mean that girls and women, who are physiologically more susceptible to HIV infection, may be unable to negotiate safe sex, are vulnerable to rape and are often in relationships with men with multiple partners. The fact that most South Africans do not know their HIV status and the perception – fuelled by the slow pace of roll-out of ARVs – that a diagnosis of HIV/AIDS is a death sentence have also contributed to a high level of denial.

People will only change their behaviour or attitudes when they feel that they have a vested interest in change. That is, people must believe that their lives will improve as a result of knowing and being able to manage their HIV status.

Successful interventions show that a peer educator approach is most appropriate to convey the AIDS message to the target group. Since more than 60% of new HIV infections occur among young people aged 15 to 25, with adolescent girls and young women of childbearing age most affected, interventions that will reduce the vulnerability of these groups are needed.

AFSA supports HIV prevention interventions that address these challenges, such as life skills programmes, peer-based behaviour change programmes, and gender programmes targeting both the girl and boy child. AFSA believes that a better understanding is needed of the culture and health dynamics in South Africa to ensure that knowledge of risk and of effective prevention measures leads to behaviour change. This is one of the reasons that it embarked on a major Culture and Health Programme.

Mother to Child Transmission Prevention (MTCTP)

It is estimated that more than a third of children born to HIV positive mothers will be infected with the virus (during pregnancy, at birth or during breast-feeding) if they do not receive any preventive anti-retroviral treatment. Of those children, around a third will die before their first birthday if they are not diagnosed and treated.

With a properly managed Mother to Child Transmission Prevention (MTCTP) programme in place, the transmission rate can be reduced to well below 5%. It took until 2001 for the South African government to begin to implement an MTCTP programme – and then only after it was taken to court by the Treatment Action Campaign (TAC) and other civil society groups.

The programme is now widely available throughout the country. The NSP set a target of 100% coverage in public sector ante-natal service sites for 2009. By 2011, at least 95% of HIV-positive pregnant women should be receiving MTCTP services, wit the goal of reducing transmission to less than 5%.

However, uptake of VCT and MTCTP services has remained worryingly low. Increasing uptake through quality counselling and integrated HIV, reproductive health and ante-natal services is critical not only to saving the lives of babies but also to reducing infection rates among women and their partners.

Male circumcision

Three studies in Africa have found that medical male circumcision can reduce HIV transmission from HIV-positive females to their male partners by 60%. The evidence that male circumcision protects against STIs, including HIV, is now one of the strongest arguments that it should be part of and HIV prevention strategy.

The WHO/UNAIDS now recommendations that male circumcision should be integrated into a comprehensive HIV prevention package that includes the promotion of correct and consistent use of male and female condoms. This is because, compared to condom use, circumcision is only partially protective. It does not reduce the risk for the female partner, although it is expected that reduced infection levels in men will eventually lead to reduced infection levels among women. There is also evidence that female partners of circumcised men have decreased human papilloma virus (HPV), which is the precursor to cervical cancer. Findings on this were presented at the Mexico AIDS Conference in 2008.

Meanwhile, a study conducted by the Medical Research Council (MRC) and the Human Sciences Research Council (HSRC) found that men in South Africa were currently as likely to be HIV-positive as uncircumcised.

The study, reported in the SA Medical Journal in 2008, found that more than 40% of the men in their sample were circumcised after their first sexual activity. HIV prevalence was equal among circumcised and uncircumcised men, at around 11%, the researchers said.

Women’s groups, such as the International Community of Women Living with HIV/AIDS (ICW), have argued that male circumcision is being promoted as an HIV prevention strategy without taking into full account the possible impacts on women’s sexual and reproductive health (SRHR). One concern was that if men believed circumcision eliminated the risk of HIV infection, they would continue to have multiple sexual partners and penetrative sex without a condom.

The search for a vaccine

Since 1999, South Africa, through the Medical Research Council (MRC), has been at the forefront of the global search for an HIV vaccine.

Two HIV vaccines developed by the South African AIDS Vaccine Initiative (SAAVI), a lead programme of the MRC, began clinical testing in the United States in December 2008, and were due to begin testing in South Africa in January 2009.

A phase I safety trial called SAAVI 102/HVTN 073 is being conducted in the USA, jointly with the HIV Vaccine Trials Network and the US National Institute of Allergy and Infectious Diseases. It will test two vaccines developed by the University of Cape Town and based on HIV subtype C, the dominant strain in southern Africa. The test vaccines have shown promising results in animal testing. They are the first HIV test vaccines developed in Africa to make it into human clinical trials. The development of these vaccines is the culmination of eight years of research and development which has involved scientists across South Africa and globally.

The South African arm of the trial aims to recruit 36 participants from the Western Cape and Gauteng. A phase I trial for an HIV vaccine generally involves volunteers who do not engage in risky sexual behaviours or intravenous drug use and are therefore at low risk for infection. It primarily tests for safety, tolerability and side-effects but also starts to look at the effect of the vaccine on the human immune system. If successful, a phase I trial is followed by larger phase II and III trials which involve more volunteers and provide information on whether the product is able to protect against infection. A vaccine can only be licensed for public use after it has been tested and found successful in all three phases of clinical trials.

Glenda Gray, lead investigator on the clinical trials team, said in a media statement: “While there have been recent disappointments in vaccine research, we need to keep trying to find an HIV vaccine as this is our best hope of ultimately controlling this devastating epidemic.”

In July, 2009, SAAVI announced the start of the phase I safety trial in SA.

(Information from SAAVI news release 28 November 2008 and 20 July 2009, www.saavi.org.za)

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Treatment, care and support

A change of leadership finally saw the tide turning towards provision of anti-retroviral therapy (ART) for people living with HIV in 2008.

The South African Government first embarked upon an Operational Plan to provide to people with HIV through the public health sector in November 2003. This was achieved only after years of intensive lobbying, driven largely by the Treatment Action Campaign and supported by trade unions, civil society, including AFSA, and international activists and agencies.

Until 2003, ART was available only for people on medical aid (which ironically included the parliamentarians and politicians who refused to endorse it for public sector patients) or with private sponsorship. For the vast majority of the 5 million HIV-positive people in South Africa, the only ‘treatment’ available was for ongoing opportunistic infections or palliative and terminal care.

The Operational Plan committed the government to providing ARV treatment to the 1,650,000 people believed to need it by March 2008.

The Plan was rolled out slowly, obstructed both by the then Health Minister and by denialist provincial leaders. The criteria for access to ART included that a person’s CD4 count (which measures the number of disease-fighting cells in the blood) should be below 200. This meant that many people were sick by the time they qualified for ART and many died waiting to start the medication. By early 2005 only some 30 000 patients were receiving treatment through the state programme. By the end of 2008, fewer than 600 000 people were being treated.

It was calculated by Harvard School of Public Health in 2008 that 330 000 people died of AIDS in South Africa between 2000 and 2005 because of the government’s failure to implement an effective treatment programme. In addition, researchers estimated that 35 000 babies were born with HIV during that same period for want of an effective MTCT programme.

However, the year 2008 saw a turnaround in the government’s commitment to dealing effectively with the HIV and AIDS epidemic. A new Health Minister was appointed who pledged to implement a national strategic plan (NSP) that included a target of providing 80% of all people in need of antiretroviral (ARV) drugs with treatment by 2011.

The plan is ambitious given the poor state of public health services and infrastructure nationally. If it is fully implemented, there will still be huge numbers of people dying from AIDS-related illnesses due to their inability to access treatment in the next few years.

The plan therefore adopts an holistic approach that commits considerable resources to preventive measures and to the support and care of infected people, their caregivers and families.

While a new spirit of cooperation between government, health professionals and civil society began in 2008, thee CBOs and NGOs that AFSA supports still have an important role to play in promoting the take-up of voluntary counselling and testing, improving access to treatment, care and support, adherence, and monitoring and advocating around service delivery.

There are still many issues to resolve regarding treatment, including availability of ARVs, the high cost of the drugs and limited access to generic medicines.

Undoubtedly the most significant recent development in the HIV/AIDS struggle in South Africa was the decision taken by Government in 2003 to provide antiretroviral (ARV) therapy in the public health sector as part of the Operational Plan for the Comprehensive HIV and AIDS Care, Management and Treatment for South Africa.

This decision gives new hope to thousands of people who require this treatment to reduce morbidity levels and defer premature death. However this decision brings with it a new set of challenges, these include overcoming capacity constraints within the public health sector and issues of treatment literacy for patients to ensure treatment compliance and the avoidance of the emergence and spread of drug resistance strains of the virus.

Patient adherence in taking their medication is the key to the success of this programme: patients are required to take three types of tablets twice a day at the same time each day for the rest of their lives. Treatment preparedness and support for patients commencing ARV therapy is therefore imperative.

As ARV therapy is a life time commitment it is vital that patients in the earlier stages of HIV be educated on wellness management and encouraged to keep themselves healthy for as long as possible so that their CD4 counts remain high and thereby deferring the need to commence ARV therapy.

The ARV rollout is happening at different rates, on different scales and with different degrees of commitment and success from district to district and province to province.

The office of the national manager of the ARV programme released the national patient numbers by province and site for the first time in January 2005. The statistics showed that about 29 000 people were on ARV treatment at more than 113 public sector facilities by that time. The figure for KwaZulu-Natal was 8467, Gauteng had nearly 10 000 patients on ARVs, Northern Cape 515 and North West nearly 2800. Mpumalanga had almost 1000 patients on ARVs by the end of December, Free State 945 and Limpopo just 729, the Western Cape nearly 6 200.

The wide differences reflect the numbers needing treatment and the capacity of provinces to deliver. NGOs emphasise the benefits of having access to such data in order to monitor and support the Operational Plan. Most treatment is still hospital based and most patients are adults. There is an urgent need to support initiatives to devolve management of ARV treatment to local clinic level and to ensure that children have access to treatment.

It is also critical to improve access to generics, to bring down the price of drugs and the cost of diagnostic testing.

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Traditional medicine, culture and health

There are about 200 000 traditional healers in South Africa and just 25 000 biomedical doctors. Despite rapid urbanisation and in a context of poor access to quality public health services, these traditional healers are the primary medical carers for 85% of the African population. In remote rural areas, traditional practitioners are sometimes the only health care providers.

Apart from treating physical ailments, including sexually transmitted infections (STIs) and symptoms of AIDS, traditional healers address emotional, psychological and spiritual health. They treat a patient as part of a family and a community, not as an individual. They provide counselling and care for terminally ill people and their families.

Because of their intimate involvement with all aspects of community health and well-being, traditional healers are well-placed to educate people about HIV and AIDS. They are able to identify and advise on risky behaviour in the cultural context in which HIV is spreading.

Despite this tremendous potential to positively influence community responses to HIV and AIDS, the role of traditional healers has been controversial. This is largely due to the South African government’s promotion of traditional medicine as an alternative to ARVs, up until 2008. This included punting the untested claims and ‘cures’ of people such as Mathias Rath and Zebulon Gwala, who were making money out of people’s desperation while the government withheld ARV medication that was proven to be effective.

While the roll-out of ARVs in the public sector began in 2003, the then Health Minister Manto Tshabalala-Msimang continued to question their efficacy and to suggest that uptake of ARVs was low because people preferred to use traditional medicine. Such a stance undermined the opportunities for a holistic response to the epidemic that recognised the strengths and limitations of both traditional and biomedical approaches.

AFSA has long supported HIV and AIDS education and training for traditional healers. In 1995, the Foundation launched and managed a programme, in partnership with the National Traditional Healers’ Association of South Africa and a number of other local traditional healer associations that trained more than 6000 traditional medical practitioners in KwaZulu-Natal over six years.

The programme was the most extensive of its kind in South Africa and served as the benchmark for subsequent programmes implemented by the Department of Health. In 2005 AFSA, in partnership with traditional healer organisations, introduced a treatment literacy training course for traditional medical practitioners, to dispel myths and inaccuracies about HIV/AIDS being curable through the use of traditional medicines and alternative therapies and to help traditional healers to understand biomedical treatment of opportunistic infections, antiretroviral (ARV) therapy and the importance of promoting treatment compliance.

These training courses have enabled thousands of traditional healers to deal with HIV and AIDS prevention and management, and to improve their understanding of the relationship between HIV and AIDS, culture and gender. There are, however, many rural areas where this essential training and education are still urgently needed.

Further improving understanding and cooperation between different medical traditions is important to promote the well-being of people living with HIV/AIDS and to prevent unnecessary conflict and misinformation.

Cultural beliefs, traditions and practices have a direct influence on the health and wellbeing of communities. Some have the potential to strengthen or weaken the fight against HIV and AIDS.

For example, patriarchy is entrenched in most communities. It is often a factor in the increased risk of HIV infection among girls and women, due to unequal gender relationships and decision-making power.

Male circumcision, which takes place as part of initiation in some cultures, has been shown to reduce the risk of HIV infection for the circumcised male by 60%. This is now being promoted as part of a comprehensive HIV prevention strategy. However, other aspects of initiation, including instruction of initiates in their traditional roles as men and sexual partners, entrench the subordinate role of women and may encourage sexually risky behaviour.

Change in behaviour of individuals is unlikely to happen without change in cultural and social beliefs in the community, supported by traditional leaders, who are the custodians of culture. This is why AFSA supports interventions targeting traditional healers, traditional leaders and initiation schools. From 2009 it extended this support through a major focus on culture and health.

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Orphaned and vulnerable children

The vast majority of orphaned children and children living with HIV live in Sub-Saharan Africa, with the greatest numbers in South Africa.

UNAIDS estimates that there were 1 800 000 children up to the age of 17 whose mothers had died due to AIDS living in South Africa at the end of 2008. This figure is higher than for any other country, however, it is estimated that Zimbabwe has 1 000 000 children orphaned due to AIDS, among a total population of fewer than 13 million.

More than 10% of children in South Africa are orphaned. Where the cause is AIDS, there is a greater likelihood of vulnerability, due to the probability of the child concerned being infected with HIV.

The majority of orphaned children, regardless of their HIV status, live in deeply impoverished households. Apart from the loss of their parents, they face inadequate nutrition and poor access to education and health care.

The deterioration in the well-being of such children starts long before a parent dies. But by the time a child is orphaned, the extended family networks that have traditionally supported vulnerable members have been overstretched by the ravages of HIV and AIDS.

Experience in South Africa and the rest of the continent is that the best models of care for vulnerable and orphaned children are generally found within the children’s communities, not in institutions. Orphaned children fare better if they remain in familiar surroundings, in family units even if not with their biological families. At the same time, the pressures upon households absorbing orphaned children can be overwhelming.

Many are ‘skip generation’ households; that is, families in which the caregivers are older people whose own children have died and who are looking after grandchildren. They are often providing for the entire household from their pension, may have health problems themselves and may be ill-equipped for the demands of raising young children and adolescents.

The phenomenon of child-headed households has attracted a lot of attention. Older children have shown tremendous resourcefulness and resilience in caring for younger siblings. Depending on the ages and circumstances of the children concerned, a child-headed household may be a better option than for children to be separated and absorbed into other households. However, lack of adequate support means older children are often providing care at the expense of their own education or future plans.

Orphaned children in impoverished households are vulnerable to becoming involved in exploitative work, including the worst forms of child labour (trafficking, commercial sexual exploitation, being used by adults to commit crime or to do hazardous work). They are also vulnerable to neglect and abuse, if they are not cared for by an adult who is willing and able to protect their interests. They may be pressurised to engage in transactional sex in order to meet their material needs, putting them at risk of HIV infection.

The South African government has extended measures to support orphaned and vulnerable children, and the family networks and communities caring for them. For example, in 2009 it extended the Child Support Grant to all eligible children up to the age of 15 years and has committed to extending this up to 18 years. The Department of Social Development (DOSD) reported at the end of 2008 that 8.3 million children were receiving this grant, with almost half a million more children receiving a Foster Care Grant (FCG). However, there was a backlog at that time of 157 000 applications and a chronic and severe shortage of social workers to process these, monitor foster care and respond to a wide range of other child care and protection needs.

The DOSD funds a home-community-based care and support programme that assists more than 200 000 children affected by HIV and AIDS. It also provides social support to child-headed households and assists a network of local child care forums. Other forms of support available to children in impoverished homes include school fee exemptions and access to nutrition programmes (feeding schemes), which are also to be extended to secondary schools.

AFSA supports several community initiatives that address the needs of orphaned and vulnerable children and their caregivers. However the gap between need and provision will remain until HIV infection rates are reversed and all HIV-positive people are able to access life-prolonging treatment.

The impact of the HIV/AIDS epidemic is proving to be most catastrophic at household level. Increasing levels of HIV/AIDS morbidity and mortality pose a serious threat to food security and nutrition in households. Families lose income earners, household expenditure is redirected to cover non-food items such as medical costs and funerals, children are taken out of school for lack of fees or to care for sick relatives, workers have to take time off to provide terminal care, resources may have to be shared with more dependents, and productive assets are sold off.

The lack of a social security net and high levels of unemployment in South Africa mean that poor households and communities slip further and further into poverty and deprivation. Invariably the burden of coping falls on women, particularly girls and grandmothers.

Much of this deepening poverty is invisible to donors and policy makers. Local organisations find themselves overwhelmed with requests for support at the same time as they lose staff and volunteers to the epidemic.

AFSA recognises the need for social protection projects in vulnerable communities that promote and provide training for food security and nutrition support; access to social grants; income generation through micro-enterprises and community cooperatives; and community micro-financing schemes. It prioritises support for local projects focusing on these areas.