HIV/AIDS in South Africa

Lisa Garbus, MPP
AIDS Policy Research Center, University of California San Francisco


Published June 2002
Last Updated October 2003
(c) 2003 Regents of the University of California All Rights Reserved. 

Table of Contents

PREFACE	3
EXECUTIVE SUMMARY	5
EPIDEMIOLOGY	17
POLITICAL ECONOMY AND SOCIOBEHAVIORAL CONTEXT	29
IMPACT OF HIV/AIDS	55
RESPONSE	73
LINKS	108
REFERENCES	109



Preface

The Country AIDS Policy Analysis Project is managed by the AIDS Policy Research Center at the University of California San Francisco. The project is funded by the U.S. Agency for International Development, Cooperative Agreement PHN-A-00-01-00001-00. Stephen F. Morin, PhD, is the project's principal investigator. The project receives additional support from the International Training and Education Center on HIV (I-TECH), a collaboration of the University of Washington and UCSF funded through a cooperative agreement with the HIV/AIDS Bureau of the U.S. Health Resources and Services Administration. The views expressed in the outputs of the Country AIDS Policy Analysis Project do not necessarily reflect those of USAID or I-TECH.
The Country AIDS Policy Analysis Project is designed to inform planning and prioritizing of effective and equitable HIV/AIDS prevention and treatment interventions through multidisciplinary research on HIV/AIDS. The project evolved from the acute need for analysis of the epidemiology of HIV/AIDS in tandem with analysis of countries' political economy and sociobehavioral context¾at household, sectoral, and macro levels. This multidisciplinary analysis aims to: 
* help inform national HIV/AIDS policies 
* strengthen ability to plan, prioritize, and implement effective interventions 
* highlight the range of sectoral interventions that may affect or be affected by HIV/AIDS 
* facilitate multisectoral/interministerial coordination 
* facilitate intercountry information sharing 
* increase national and subregional capacity for effective partnerships 

The project develops and disseminates online, fast-download, continually updated analyses of HIV/AIDS in 12 USAID priority countries: Ethiopia, Kenya, Malawi, Senegal, South Africa, Uganda, Tanzania, Zambia, Zimbabwe, Brazil, Cambodia, and India <http://ari.ucsf.edu/ARI/policy/countries.htm>
Each analysis is linked with national strategic plans for HIV/AIDS prevention, care, and support. Analyses also include a comparative table of 70 key HIV/AIDS and socioeconomic. 
The primary audience for the country analyses is in-country HIV/AIDS planners, including those from government ministries and agencies, multi- and bilateral donors, international and local NGOs, health care institutions, prevention programs, academia, affected communities, and the private sector. International investigators and policymakers also report using the analyses in their work.

All country analyses undergo peer review at the AIDS Research Institute of the University of California San Francisco. In addition, two in-country experts from each profiled country serve as peer reviewers. A scientific advisory board also reviews all analyses.

Acknowledgments

The following individuals served as peer reviewers and provided valuable inputs to this paper: Dr. John S. Greenspan and Dr. William McFarland, both of the University of California San Francisco; Professor Helen Schneider, Center for Health Policy, School of Public Health, University of Witwatersrand, South Africa; and Professor Mary Crewe, Center for the Study of AIDS, University of Pretoria, South Africa. They are not responsible for any errors of fact or judgment.

Note on Terminology

All racial categorizations and nomenclature used in the data sources cited throughout this profile have been maintained; they do not constitute an endorsement of any particular terminology.

Users please note that this version contains two bibliographies; we will post a corrected version shortly.

Contact Information

Because this analysis is continually updated, comments and suggested sources of new data are welcome and may be sent to the coinvestigator/project director at UCSF's AIDS Policy Research Center: Lgarbus@psg.ucsf.edu


Executive Summary

Epidemiology

Since 1990, South Africa's Department of Health has conducted annual HIV sentinel surveys of public sector antenatal clinic attendees. In September 2003, the department released the 2002 HSS findings, which indicated that nationally, 26.5 percent of women attending ANCs were HIV-positive in 2002. The department states that although this estimate is higher than the 24.8 percent prevalence recorded in 2001, the increase is not statistically significant; however, the higher confidence interval of in 2002 does suggest a marginal increase in the estimate.

In 2002, KwaZulu-Natal recorded the highest HIV prevalence among all provinces; the lowest recorded prevalence was in the Western Cape. The 2002 ANC survey found that, as in 2000 and 2001, HIV prevalence peaked among women ages 25 to 29.

UNAIDS estimated that at the end of 2001, HIV prevalence among adults ages 15 to 49 was 20.1 percent.  Commissioned by the Nelson Mandela Foundation and conducted by South Africa's Human Sciences Research Council (HSRC), the survey found 11.4 percent of South Africans were living with HIV/AIDS at the end of 2002. Using the results of the 2002 HSS, the South African Health Department estimated that 5.3 million South Africans were HIV-positive at the end of 2002, an increase from the comparable 2001 estimate of 4.74 million. The 2002 HSRC national survey estimated that 4.5 million South Africans were living with HIV/AIDS at the end of 2002. Researchers from the University of Cape Town's Center for Actuarial Research put this figure at 6.6 million. 

UNAIDS estimated that there were 5 million South Africans living with HIV/AIDS at the end of 2001 (estimate range: 4 million to 6 million). These estimates suggest that South Africa has more people living with HIV/AIDS than any other country in the world.  UNAIDS underscores that populous countries with fast-growing epidemics may surpass this figure.

During 1982-97, 79 percent of transmission was heterosexual, 13 percent through MTCT, 7 percent through men who have sex with men, and 1 percent through infected blood. 

At least 453,352 South Africans were living with AIDS at the end of 2002. In September 2001, South Africa's Medical Research Council (MRC) estimated that about 40 percent of adult deaths that occurred during 2000 were due to HIV/AIDS and that about 20 percent of all adult deaths in that year were due to AIDS. It went on to estimate that AIDS accounted for about 25 percent of all deaths in 2000 and had become the leading cause of death in South Africa. In March 2003, the MRC released initial estimates from the South African National Burden of Disease Study 2000. It found that HIV/AIDS now accounted for 30 percent of all deaths (34 percent of female deaths and 26 percent of male deaths). AIDS was by far the largest single cause of premature mortality in both males and (particularly) females. 

ANC data currently serve as South Africa's primary sentinel surveillance of HIV/AIDS. Though ANC prevalence is widely used, they are imperfect. Since at least 2000, the South African Government's interpretation of the HSS data has varied greatly from that of many South African and international researchers. The government believes that the epidemic is stabilizing, whereas other researchers voice concern that because more people are dying from HIV/AIDS-related causes, the rate of new HIV infections must be increasing to keep the prevalence rate stable. 

With regard to the 2002 HSS, the government again appears to be focusing solely on declines in prevalence among those under age 20, regardless of whether they are significant, to make the leap to demonstrating slowing incidence. Moreover, the government does not discuss that even if the epidemic is stabilizing (as yet unproven), it is doing so at very high levels. 

Political Economy and Sociobehavioral Context

Many of the factors discussed in this section exist in countries that, unlike South Africa, have low HIV prevalence; these include wide income disparities, history of colonialism and political and economic disenfranchisement, and gender inequality. The relationship between HIV prevalence and socioeconomic markers is highly complex. Risk of HIV infection is related, inter alia, to individual behavior and socioeconomic characteristics as well as to the socioeconomic profile of the community in which one is situated. Moreover, since 1994, the social divisions within South African society have themselves become more complex. This section does not seek to demonstrate causality. Rather, it analyzes key political economy and sociobehavioral contextual elements to highlight the range of sectoral policies and interventions that may affect or be affected by HIV/AIDS. 

Black South Africans have been subject to a long history of systematic social disruption and dislocation. Apartheid disenfranchised black South Africans politically, socially, and economically. Human rights abuses-including those perpetrated within the health sector¾were common. The apartheid government routinely used violence to exert power. Violence remains common in daily life in South Africa.

Even when adjusting for socioeconomic factors, race remains a significant determinant of HIV risk. HIV risk is highest among black South Africans, substantially lower among coloureds and Asians, and lowest among whites. South Africa's 2001 GNI per capita was US$2,820, the second-highest in sub-Saharan Africa, masks wide income disparities.  Thirty-five percent of South Africa's population lives on less than US$2 a day. Postapartheid economic growth in South Africa has been slow, and efforts to increase employment have stalled. Unemployment among women greatly exceeds that among men. There is a high rate of unemployment among unskilled workers, who have the highest HIV infection rate and the highest AIDS-related death rate.

Sixty-one percent of Africans, 38 percent of coloreds, 5 percent of Indians, and 1 percent of whites were poor in 1995. A disproportionate number of the chronically poor are Africans and coloreds living in rural areas; the elderly and female-headed are most likely to be chronically poor. 

Mass resettlements of populations under apartheid, seasonal labor migration, movements along major trade routes, refugees fleeing war in other parts of Africa, and, since 1990, return of political exiles and liberation armies have all contributed to the spread of HIV. There is high mobility among urban, rural, mining, and port areas, much of it dominated by men.   Migrant labor separates men from their families, places them in close proximity to "high-risk" sexual networks, and may result in their having an increased number of sexual contacts.  Migration is an independent risk factor for HIV infection among South African men. Concurrently, it may also lead to women's reliance on sex to supplement their incomes while their male partners are away for long periods.

Men are not allowed to bring their families with them to the mines. Miners live in single-sex hostels or barracks, far from their spouses or regular partners. Commercial sex and access to alcohol are common features of live in hostel compounds. Migrant labor and hazardous physical work¾relieved primarily by alcohol and sex¾create an environment that may be considered conducive to rapid HIV transmission. 

According to the U.N. Office on Drugs and Crime, overall levels of crime began to increase in the mid-1980s and rose throughout the 1990s. Although there are some indications  that the steep increase in crime has abated, South Africa remains among the most crime-ridden and crime-concerned societies in the world. Violent crimes, such as attempted murder, aggravated robbery, serious and common assault, and in particular violence against women and children, has increased since 1994.

Stigma around HIV/AIDS remains strong and is likely to influence personal decisionmaking with regard to HIV testing and disclosure. 

There are one national and nine provincial health departments, with provinces responsible for implementation of AIDS programs. The national government is primarily responsible for collecting and distributing revenue equitably among provinces, formulating broad policy frameworks, and defining norms and standards for service provision. Despite redistributive policies in the early postapartheid period, South Africa's health care infrastructure remains highly inequitable. WHO ranks South Africa a "high TB burden" country, with the world's seventh-highest burden of TB (by number of cases). There is a lack of effective integration between TB and HIV policies and programs. 

The 2002 ANC survey found that an estimated 3.2 percent of ANC attendees had active syphilis. This figure is an increase over the 2001 figure of 2.8 percent in 2001. A study in the mining center Carletonville found that infection with herpes simplex virus type-2 was the most significant factor associated with HIV status for both men and women.[39] 

HIV prevalence among South African women tends to peak between ages 25 and 29, whereas among men, it peaks several years later (usually between ages of 30 and 35) and at lower levels. Women tend to become infected at younger ages than men for both biological and behavioral reasons. High male-to-female transmissibility of HIV is considered likely to play a significant role. Age mixing is another crucial factor.  

Women's subordinate economic status affects their vulnerability to acquiring HIV and, once infected, accessing care and support services. Even among married South African women, there is a high level of economic maltreatment. Women are commonly viewed as "being inferior to men, as possessions, and as needing to be led and controlled." Many women are unable to insist on condom use and negotiate the timing of sex and the conditions under which it occurs. 

Many women also face abuse and/or abandonment if they disclose their HIV-positive status. Lobola, a long-standing tradition whereby men purchase a wife by paying her family a dowry, also renders it difficult for women to leave their husbands, as this would require fathers to repay the dowry. 

In most presentations of police rape statistics, South Africa is near or at the top. Household surveys represent another method of obtaining information on the extent of sexual violence.  The last South African Demographic & Health Survey found a national rape prevalence of 7 percent, a range of 3 to 12 percent across provinces. Both police statistics and household studies reveal that young women¾the demographic group most at risk for HIV/AIDS¾are also at highest risk of being raped.

According to a recent report from the U.S. State Department, South Africa is a destination country for women trafficked from other parts of Africa, Eastern Europe, Asia, and the former Soviet Union for commercial sexual exploitation. South African women and children are also trafficked internally for labor and commercial sexual exploitation. 

Rape, sexual violence, sexual harassment, agressivity toward and physical and verbal degradation of female students by male school teachers and male classmates are widespread and largely normalized and tolerated. Girls who report sexual abuse are often further victimized and stigmatized by teachers and students. School authorities rarely ensure a sense of security at school nor counsel and discipline male perpetrators. 

Several South African researchers underscore that individual risk of HIV infection is determined by individual as well as community factors.  Thus, individual sexual behavior may be less important than the community from which sexual partners are chosen, i.e., social context may be a stronger predictor of disease than individual behavior.

In South Africa, sexual debut is generally early, usually beginning during the mid-teens; for girls, often shortly after menarche. The 2002 HSRC survey found that sexual experience among youth was significantly higher in urban informal areas than in any other types of localities. 

A high number of sexual partners, especially among men, is socially acceptable and encouraged.  Given the country's economic situation and high unemployment, as well as lack of affordable recreational opportunities, sexual relationships provide one of the few opportunities wherein young South Africans may obtain success, respect, and self-esteem.  

Multiple sexual partners, as well as ability to control girlfriends, are key to notions of "masculinity." Masculinity among miners signifies bravery, fearlessness, and the willingness to take risks; "real" men have enormous sex drives that lead them to have sex with an unlimited number of women.  Given this scenario, many miners do not use condoms.

Among 2002 HSRC respondents who had sex in the past 12 months, most indicated that they had a single partner during the past 12 months; the proportion of those with more than one partner was lower for females than for males. A higher proportion of Africans and male or female respondents living in urban informal areas had multiple partners. The 2002 HSRC survey found that youth had significantly higher rates of condom use than adults. Single respondents were considerably more likely to use a condom than those who were married. 

Sex is also often used as a commodity in exchange for money or other forms of payment. Transactional sex involves nonmarital sexual relationships, often with multiple partners, that are a result of men's superior economic position and access to resources, the value placed on men's having multiple sexual partners, and women's desire to access power and resources such as gifts or cash.

Much sex work in South Africa is initiated in shebeens (informal liquor stores or bars), and alcohol consumption is likely to result in inconsistent condom use and other unsafe sex behaviors. Alcohol consumption is more likely to be a risk factor for HIV if associated with an "unsettled lifestyle and migrancy." This is because migrants are less likely to have a regular partner living with them and are thus more likely to acquire sexual partners through visits to shebeens. Data from surveys of young South Africans convey that their drug and alcohol use during sex is a concern. 

Since 2000, heroin use has increased significantly in major urban areas, particularly in Gauteng and Cape Town. Injecting drug use is not common in South Africa, although recent evidence indicates that the injecting of heroin is increasing. 

Some observational studies from sub-Saharan Africa have indicated that male circumcision may reduce the risk of HIV acquisition, though circumcision does not appear to affect transmission from HIV-positive men to their partners. The 2002 HSRC study found that 35 percent of all adult and young males had been circumcised.  

Impact

By 2045-50, South Africa will have the world's 10th-lowest life expectancy at birth. Between 2000 and 2050, life expectancy will be 27 to 41 lower than it would have been in a no-AIDS scenario. Because of AIDS, South Africa's population will be 44 percent smaller in 2050 than it would have been without the epidemic. 

There were 757,000 AIDS deaths in South Africa through 2000, with AIDS increasing mortality by 13 percent.  Between 2000 and 2015, there will be 9.3 million AIDS deaths, representing a 195 percent increase in mortality.

According to a June 2003 report from the World Bank, previous studies have grossly seriously underestimated the economic impact of the AIDS epidemic, failing to factor in the impact of education and parenting on the economy. The authors underscore that by killing primarily young adults, AIDS does more than destroy the human capital embodied in them; it also deprives their children of the requirements to become economically productive adults: their parents' care, knowledge, and capacity to finance education. This weakening of the mechanism through which human capital is transmitted and accumulated across generations becomes apparent only after a long time lag, and it is progressively cumulative in its effects. 
Applying the model to South Africa, they found that in the absence of AIDS, South Africa would have enjoyed modest, though accelerating growth of per capita income, with universal and complete education attained within three generations. With AIDS, however, if no efforts are put forth to combat the epidemic, they project a complete economic collapse within three generations. By 2050, per capita income per family will be half the amount it was in 1990. In about 90 years, South Africa's per capita GDP could experience a 50 percent decline 

South Africans without access to jobs (particularly those that require high skill levels) are likely to bear the brunt of the HIV/AIDS epidemic, whereas relatively skilled workers could benefit from greater employment opportunities (as production becomes more skill- and capital-intensive) and higher wages (as the relative demand for skilled labor increases). And as firms begin to provide these workers with greater access to antiretroviral therapies, they are likely to live longer and more productive lives. Under this scenario, South Africa's socioeconomic disparities will be further exacerbated.

HIV/AIDS has already forced the public health sector to incur significant expenditures. Combined national and provincial expenditures on HIV/AIDS in 2001/2 represented 15 percent of total public health expenditures. In 2000, there were an estimated 628,000 admissions to public hospitals for AIDS-related illnesses, accounting for 24 percent of all public hospital admissions. In 2001/2, the cost of hospitalizing AIDS patients in public facilities equlaed 12.5 percent of the total public health budget.

Approximately 25 percent of miners in South Africa are living with HIV/AIDS; the MRC expects this figure to increase to 30 percent by 2005. Between 1995 and 2020, South Africa will have lost 20 percent of its agricultural labor force because of AIDS. At least one-fifth of the South African National Defence Force is HIV-positive. Among South Africa's 17,5000 inmates, 45.2 percent are HIV-positive.

Traditional extended family and community coping mechanisms in South Africa were weakened by apartheid, which disrupted family and communal life and led to rapid urbanization. As family and community structures became weaker, many South Africans assumed that the state would provide health care and other support. HIV/AIDS has further strained coping mechanisms through its enormous and complex impact on households. By 2010, AIDS may contribute to the chronic impoverishment of 26 to 33 percent more households than would have been the case in the absence of the epidemic.

AIDS-affected households spend an average 34 percent of their monthly income on health care, much higher than that spent on health care by non-AIDS-affected households. The main caregiver in AIDS-affected households is usually a woman, and 73 percent of caregivers are women over 60. 

At the end of 2001, UNAIDS estimated that there were 660,000 AIDS orphans living in South Africa. The number of paternal AIDS orphans under age 18 is expected to peak at 4.7 million in 2015, and the total number of children having lost one or both parents to AIDS will be highest around 2014, at 5.7 million. South Africa's capacity to deal with increased numbers of orphans is limited. Awareness of foster care grants and other forms of assistance is low; moreover, foster care grants are difficult to access. The country's Child Care Act has been criticized as being limited in the placement options it offers for orphaned children. Institutional care is being provided, but to contain costs, there is a shift to models of community-based care, which assume that hard-hit communities have sufficient capacity to care for orphans.

Response

As it was being unbanned, the African National Congress (ANC) played a major role in development of national HIV/AIDS policies. In October 1992, the ANC and the apartheid government's National Department of Health jointly convened a conference on AIDS, which led to creation of the National AIDS Committee of South Africa (NACOSA). 

After a peaceful transition, the ANC won the country's first fully democratic elections. Numerous initiatives aimed at redressing inequalities were launched in the immediate postapartheid period under the Reconstruction and Development Program, the ANC's election platform. The ANC adopted NACOSA's AIDS plan. Along with 20 other social priorities, AIDS was declared a "Presidential Lead Project," giving it special status and early access to resources set aside for reconstruction and development.

The AIDS plan, however, greatly overestimated the implementation capacity of the new government, not least because of the numerous challenges the ANC faced upon assuming office and the enormity of postapartheid reconstruction. In 1994, President Nelson Mandela inherited intact the apartheid administration. The legacy of the apartheid civil service, coupled with the transition period, led to uncoordinated planning within and across government, weak financial and information systems, and lack of managerial skills. Consequently, coordination of a national response was constrained.

Given public sector capacity constraints, multiple sources of special AIDS allocations, and complex disbursement procedures, the national government underspent AIDS funds. Some of the projects on which funds were spent¾and lack of transparency in granting them¾were heavily criticized. As in many countries, the national AIDS program was housed in the Department of Health, thereby impeding a multisectoral response.

In 1997, the Department of Health commissioned the MRC to undertake a review of the 1994 AIDS plan, which led to a reformulation of policy priorities at the national level. In January 2000, the National Department of Health launched the HIV/AIDS and STD Strategic Plan for South Africa 2000-2005. However, the plan has been deemed vague in terms of action and resource prioritization as well as provision of ART. In January 2000, the South African National AIDS Council (SANAC) was formed, bringing together government and civil society, although medical researchers and key were excluded from SANAC.

In the late 1990s, South Africa's Health Minister announced that she would not permit AZT nor NVP to be provided to pregnant, HIV-positive women nor rape survivors in public health facilities; she stated that she had based her decision on ARVs' "cost, toxicity, and efficacy, particularly for the 'African' setting." With regard to AZT, she rejected several reports from the Medicines Controls Council (South Africa's statutory licensing authority for medicines and drugs) in favor of AZT. Her decision also contradicted the international medical consensus that the benefits of AZT outweigh its risks. 

During 2000, President Thabo Mbeki, who had succeeded Nelson Mandela as South Africa's president in 1999, had begun to publicly question the link between HIV and AIDS. In May 2000, he convened a panel of international AIDS experts¾including AIDS dissidents¾charged with reexamining the causes of AIDS and determining African solutions to the pandemic. The panel and its report were met with widespread criticism by South African and international
scientists. Prior to the XIII International AIDS Conference, held in Durban in July 2000, there was growing international discussion of access to ARVs and PMTCT. Data from a South African study of NVP, which highlighted its ease of administration and greater cost-effectiveness were presented at the Durban conference. 

The Durban meeting marked the first time that the international AIDS conference had been held in the South. This, coupled with the increasing international coverage of President Mbeki and Minister Tshabalala-Msimang's HIV/AIDS policies, brought enormous attention to South Africa, much of it highly critical.  The controversies had reached a point such that over 5,000 scientists worldwide signed the Durban Declaration, in which they reaffirmed that HIV was the cause of AIDS.

After Durban, several medical and advocacy groups, such as TAC, petitioned the government to approve and provide NVP in the public health system for PMTCT. In late 2000, the government announced 18 pilot PMTCT sites, which were launched between May and December 2001.

In February 1998, the Pharmaceutical Manufacturers Association and 39 drug makers brought legal action against the South African Medicines and Related Substances Control Amendment Act (90) of 1997, specifically Section 15C allowing for measures (compulsory licenses and parallel imports) that would allow the government to procure essential drugs at cheaper
prices. In April 2001, under national and international pressure, the case against the act was withdrawn. However, the government immediately announced that ARVs were still not a feasible option in the public sector and therefore did not move to issue a compulsory license for generic manufacture of ARVs. 

Minister Tshabalala-Msimang continued to stress South Africa's inability to provide and monitor ARVs, citing toxicity, financial constraints, inadequate health infrastructure, and competing health demands. Many South African researchers acknowledged the major role that poverty plays in HIV transmission and ability to access and provide care, as well as the
high cost (even at subsidized prices) of ARVs. However, they did not believe that these constraints merited rejection of ARVs. 

The South African Government released a statement in April 2002 that appeared to open the door to public provision of ART. However, no concrete actions were taken until mid-2003.

The South African courts have played a major role in HIV policy. Their actions have been underpinned by the South African Constitution, finalized in 1996. The Constitution is the highest law in the land; its Bill of Rights lists protected human rights. For example, the action that TAC and others brought against the government on PMTCT was viewed as a test of the extent to which the Constitution can define social policy for the executive level. 

Apart from the Bill of Rights, numerous other policy and legal instruments protect the rights of persons infected with and affected by HIV/AIDS with regard to education, the workplace, testing and counseling, and patient management. For example, the Labor Relations Act of 1995 protects employees from being dismissed because they are HIV-positive and from being discriminated against with regard to staff training, employee benefits, and other work-related opportunities.

Under the Employment Equity Act of 1998, "no person may unfairly discriminate, directly or indirectly, against an employee, in any employment policy or practice, on one or more grounds, including...HIV status..." The act also prohibited testing of an employee to determine his/her HIV status unless the Labor Court justifies such testing.

However, many of the policies and laws mentioned above have been inadequately implemented and have not had significant impact on the ground. Poverty, stigma, and poor access to legal resources deter many South Africans from seeking redress for human rights violations. Women's low socioeconomic status, coupled with lack of support services and shelters, often prevents them from taking steps to protect themselves from HIV. 

Unlike almost all other sub-Saharan African countries, South Africa is not dependent on donor aid to fund its health and social services. However, the country's national AIDS program has received significant foreign aid and technical assistance.

In the first round of the Global Fund to Fight AIDS, Tuberculosis & Malaria, South Africa submitted two proposals, both of which were funded in April 2002. The federal government was angered that the KZN grant was not submitted through SANAC. After much delay, the South African and KZN governments reached resolution with the GFATM, and in August 2003 they signed agreements for US$41 million over the next two years. Included in this amount was US$27 million for the Enhanced Care Initiative in KZN, a consortium of government, private, and civil society partners to promote continuum of care by implementing key interventions including VCT, ART, and care for patients and their families. SANAC has also signed agreements for:

1. two-year US$12 million grant to enable expansion and acceleration of National Adolescent Friendly Clinic Initiative, formal partnership between loveLife and SA government, to improve access and quality of services to adolescents in public clinics dealing with teen sexuality and reproductive health. 
2. one-year US$2 million grant to support ongoing development and implementation of Soul City and Soul Buddyz, awareness-raising and mobilization tools among youth

For the second round of the GFATM, SANAC submitted three proposals, of which one (HIV/AIDS-TB) was approved to receive US$25 million, pending clarifications. 

Numerous nongovernmental organizations¾including community-based organizations, academic institutes, and trade unions¾have played major, galvanizing roles in initiating and strengthening South Africa's response to HIV/AIDS. 

Health Minister Tshabalala-Msimang had not permitted provision of ARVs in public clinics for postexposure prophylaxis after rape. In a major policy shift, the government announced in April 2002 that it would seek to provide a comprehensive package of care for sexual assault survivors, including counseling and testing for HIV, pregnancy and STIs. This package would also include provision of ARVs, with a related standardized national protocol. However in July 2003, a cabinet decision led to the removal of a clause from the Sexual Offences Bill that would have compelled the government to provide rape survivors with drugs to reduce the risk of HIV infection.

The government launched a VCT program in 2000. Success in implementing VCT varies greatly among provinces. In most provinces, over half of respondents knew where to access VCT services. Mpumalanga and Limpopo have the lowest percentages of respondents who knew where to obtain VCT services. About 40 percent of those ages 15-24,  as well as one-third of those ages 25-49, do not know where to find these services. Urban respondents are more likely to know about VCT services than those in rural areas ones. 

A February 2002 review of the 18 pilot PMTCT sites strongly advocated expansion of them. In 2001, the Treatment Access Campaign brought a lawsuit against the Government of South Africa to compel it to (1) make NVP immediately accessible in the public sector outside pilot sites if medical personnel deemed NVP necessary and (2) institute a comprehensive PMTCT program nationwide. In December 2001, the Pretoria High Court ruled that the South African Government must provide NVP to all HIV-positive pregnant women through its public health facilities. After various government appeals, the Constitutional Court ruled in July 2002 that the government must abide by the High Court's ruling. 

Western Cape was the first province to defy South African government policy by providing NVP to HIV-positive pregnant women in the public health sector. In March 2003, the province announced that all HIV-positive pregnant women could access NVP at their nearest clinic. The province has achieved universal PMTCT coverage of pregnant women. In January 2002, KwaZulu-Natal became the second provincial government to defy government policy by making NVP available to HIV-positive pregnant women in state hospitals.

The Perinatal HIV Research Unit at Chris Hani Baragwanath Hospital provides HAART and monitoring for adults and children. In July 2002, the MTCT Plus Initiative, managed by Columbia University's Mailman School of Public Health, announced grants to several sites in South Africa: clinics operated by Médecins sans Frontières in Khayelitsha, Cape Town, and programs within the universities of the Witwatersrand and Natal. The initiative includes ART, care, and support services for mothers.

In early August 2002, South Africa's MCC announced that it was considering reversing its approval of NVP to prevent mother-to-child transmission of HIV. The MCC stated that it had concerns about NVP's effectiveness and toxicity, despite continued recommendation of NVP by UNAIDS, WHO, NIH, and others.

WHO reported that during 2001, there were no sites in South Africa providing ART.  As of July 2003, about 21,000 South Africans were receiving ART; of them, about 1,500 were receiving treatment in the public sector, the remainder through NGO, university, and private company programs. Apart from postexposure prophylaxis and nevirapine for PMTCT pilot sites, ART is not purchased by the public sector health service. 

In 2003, the South African Cabinet formed a Health/Treasury Task Team to analyze ART roll out. The Task Team recommended the establishment of a "fast track" national price negotiating team and a strategy to obtain drugs at optimal prices. It also recommended encouraging the granting of voluntary licenses by patent holders for local manufacture. The Task Team found that the total cost of providing ART to everyone in need of it would be between US$1 billion and US$1.09 billion by 2005. The Task Team estimated that 1.7 million lives could be saved by 2010 if ART were provided to all in need of it. If ART were not provided, the team projected that 1.8 million more children would be orphaned by 2010. The team estimated that this number would be reduced by 860,000 with 100 percent ART coverage, and by 350,000 with 50 percent ART coverage. In August 2003, the Cabinet approved the provision of AIDS drugs to HIV-positive citizens through the public health system. The Cabinet instructed the Health Department to develop a detailed operational plan for ART rollout and to act "with urgency." The department is now working on a plan, including a procurement strategy, which was due by the end September 2003. 
Over the past four years, South Africa has seen large reductions in the prices of patented ARVs. MSF reports that by importing generic ARVs manufactured by the Brazilian National STD/AIDS Program¾under the South Africa Medicines Control Council "Section 21" permit ¾the prices of triple therapy used in Khayelitsha have fallen by 50 percent, with a triple-therapy regimen provided for R10/day. Aspen Pharmacare was granted a voluntary license by Bristol-Myers Squibb to produce a generic version of Zerit. Under the terms of the agreement, Aspen Pharmacare can sell its version to both public and private patients across Africa. In July 2003, Aspen announced that it is selling one month's supply of Aspen-Stavudine for between US$3 and US$4.50, about 41 percent less expensive than original. In early 2003, 19 projects providing ART established the Generic Antiretroviral Procurement Project (GARPP) to improve access to ART through promotion of cheaper generic drugs. The initiative sources generics approved by the MCC and supplies members throughout the country. In August 2003, GARPP was selling triple-combination therapy at US$40 a month.
In June 2003, South Africa's Medicines Control Council approved the country's first HIV vaccine trial. 

Within South Africa, approximately 12 million people are employed directly, with a further 20 million dependants. Consequently, workplace HIV/AIDS initiatives can have far-reaching impact. Eighty-two percent of large companies have formal HIV/AIDS policies. Among medium and small companies, 51.7 percent and 6.5 percent, respectively, have such policies. Only 6.5 percent of small and 34.5 percent of medium companies have made any HIV/AIDS communication to their employees. Overall, 70.9 percent of companies have not commissioned an HIV/AIDS risk assessment; the majority of companies that have commissioned such an assessment have over 500 employees. Many large South African companies view HIV/AIDS as their main strategic challenge and have formulated and implemented substantial HIV/AIDS policies that address, inter alia, confidentiality and stigma. 

All major mining companies have HIV/AIDS programs, which have been based largely on prevention, condom distribution, treatment of STIs and OIs, and wellness programs for HIV-positive employees. Many utilize peer educators. Several home-based care initiatives for HIV-positive miners are also beginning. Recently, several mining companies in South Africa have been reformulating living arrangements for their male workers as an HIV prevention tool¾permitting miners' families to live with them at the worksite. 

Numerous firms, including mining companies, have announced pilot plans to offer ART. In some cases, ART will also be available to employees' dependents. Most companies are offering cost-sharing arrangements for ART, which may impede uptake. 






Epidemiology

At a Glance Summary Bullets

HIV Sentinel Surveillance

* Since 1990, South Africa's Department of Health has conducted annual HIV sentinel surveys of public sector antenatal clinic attendees.

* In September 2003, the department released the 2002 HSS findings, which indiated that nationally, 26.5 percent of women attending ANCs were HIV-positive in 2002. The department states that although this estimate is higher than the 24.8 percent prevalence recorded in 2001, the increase is not statistically significant; however, the higher confidence interval of in 2002 does suggest a marginal increase in the estimate.

* In 2002, KwaZulu-Natal recorded the highest HIV prevalence among all provinces; the lowest recorded prevalence was in the Western Cape. 

* The 2002 ANC survey found that, as in 2000 and 2001, HIV prevalence peaked among women ages 25 to 29.

First National Study of HIV Prevalence

* Comissioned by the Nelson Mandela Foundation and conducted by South Africa's Human Sciences Research Council (HSRC), the survey found that 11.4 percent of South Africans were living with HIV/AIDS at the end of 2002. 

Number of South Africans Living with HIV/AIDS

* The South African Health Department estimated that 5.3 million South Africans were HIV-positive at the end of 2002, an increase from the comparable 2001 estimate of 4.74 million.

* The 2002 HSRC national survey estimated that 4.5 million South Africans were living with HIV/AIDS at the end of 2002. Researchers from the University of Cape Town's Center for Actuarial Research put this figure at 6.6 million. 

* UNAIDS estimated that there were 5 million South Africans living with HIV/AIDS at the end of 2001 (estimate range: 4 million to 6 million). These estimates suggest that South Africa has more people living with HIV/AIDS than any other country in the world.  UNAIDS underscores that populous countries with fast-growing epidemics may surpass this figure.

Adult Prevalence

* UNAIDS estimated that at the end of 2001, HIV prevalence among adults ages 15 to 49 was 20.1 percent.  

Transmission Patterns

* During 1982-97, 79 percent of transmission was heterosexual, 13 percent through MTCT, 7 percent through men who have sex with men, and 1 percent through infected blood. 

AIDS Cases

* At least 453,352 South Africans were living with AIDS at the end of 2002. 

AIDS Mortality and Disability

* In September 2001, South Africa's Medical Research Council (MRC) estimated that about 40 percent of adult (ages 15-49) deaths that occurred during 2000 were due to HIV/AIDS and that about 20 percent of all adult deaths in that year were due to AIDS. It went on to estimate that AIDS accounted for about 25 percent of all deaths in 2000 and had become the leading cause of death in South Africa. 

* In March 2003, the MRC released initial estimates from the South African National Burden of Disease Study 2000. It found that HIV/AIDS now accounted for 30 percent of all deaths (34 percent of female deaths and 26 percent of male deaths). AIDS was by far the largest single cause of premature mortality in both males and (particularly) females. 

Data Quality Issues

* ANC data currently serve as South Africa's primary sentinel surveillance of HIV/AIDS. Though ANC prevalence is widely used, they are imperfect. Children and the elderly¾who are at substantially lower risk of HIV¾are not captured by antenatal surveys.  Even among adults in sexually active groups, the ANC survey prevalences do not reflect the lower overall risk of men, people who are less sexually active, and those who use private sector health facilities.

* Moreover, ANC data may underestimate HIV prevalence in women of reproductive age as recent studies indicate that fertility among HIV-positive women is substantially lower than among uninfected women.  

* Since at least 2000, the South African Government's interpretation of the HSS data has varied greatly from that of many South African and international researchers. The government believes that the epidemic is stabilizing, whereas other researchers voice concern that because more people are dying from HIV/AIDS-related causes, the rate of new HIV infections must be increasing to keep the prevalence rate stable. 

* With regard to the 2002 HSS, the government again appears to be focusing solely on declines in prevalence among those under age 20, regardless of whether they are significant, to make the leap to demonstrating slowing incidence. Moreover, the government does not discuss that even if the epidemic is stabilizing (as yet unproven), it is doing so at very high levels. And rather than investigate possible provincial dynamics, the government downplayed prevalence increases observed in Western Cape and other provinces.

HIV Sentinel Surveillance

Methodology

Since 1990, South Africa's Department of Health has conducted annual HIV sentinel surveys of public sector antenatal clinic attendees. (In South Africa, 80 percent of all pregnant women, of whom 85.2 percent are African, attend public sector antenatal clinics.[2]). Anonymous, unlinked surveys are carried out during October and involve pregnant women presenting for antenatal care for the first time during the current pregnancy at selected ANC sites in the country's nine provinces.[1]

Latest Findings: 2002

In September 2003, the Department of Health released the 2002 HSS findings. For this round, a total of 16,587 women participated, spanning 396 sentinel sites.[1] (The 2001 HSS involved 421 sentinel sites, from which 16,730 specimens were tested for HIV and 16,701 were tested for syphilis.[2]) 

The survey found that nationally, 26.5 percent of women attending ANCs were HIV-positive in 2002. The department states that although this estimate is higher than the 24.8 percent prevalence recorded in 2001, the increase is not statistically significant; however, the higher confidence interval of 27.6 percent in 2002 (vs. 26.1 percent in 2001) does suggest a marginal increase in the estimate.[1]

In 2002, KwaZulu-Natal recorded the highest HIV prevalence among all provinces: 36.5 percent, an increase over the 33.5 percent recorded in 2001. The lowest recorded prevalence was in the Western Cape: 12.4 percent (vs. 8.6 percent in 2001). According to the South Africa Department of Health, this increase was not statistically significant, nor were increases observed in KwaZulu-Natal, Gauteng, North West, Eastern Cape, and Limpopo. The decreases in Free State, Mpumalanga and Northern Cape were also not statistically significant.[1]


Table 1: Provincial HIV Prevalence Estimates: Public Antenatal Clinic Attendees, South Africa, 1999-2002
Province
HIV pos. 95% CI

1999
2000
2001
2002
KwaZulu-Natal (KZN)
32.5 (30.1 - 35.0)
36.2 (33.4 - 39.0)
33.5 (30.6 - 36.4)
36.5 (33.8-39.2)

Mpumalanga (MP)
27.3 (25.2 - 30.7)
29.7 (25.9 - 33.6)
29.7 (25.9 - 33.6)
28.6 (25.3-31.8)
Gauteng (GP)
23.9 (21.7 - 26.0)
29.4 (27.2 - 31.5)
29.8 (27.5 - 32.1)
31.6 (29.7-33.6)
Free State (FS)
27.9 (24.7 - 29.8)
27.9 (24.6 - 31.3)
30.1 (26.5 - 33.7)
28.8 (26.3-31.2)
North West (NW)
23.0 (19.7 - 26.3)
22.9 (20.1 - 25.7)
25.2 (21.9 - 28.6)
26.2 (23.1-29.4)
Eastern Cape (EC)
18.0 (14.9 - 21.1)
20.2 (17.2 - 23.1)
21.7 (19.0 - 24.4)
23.6 (21.1-26.1)
Limpopo (LP)
11.4 (9.1 - 13.5)
13.2 (11.7 - 14.8)
14.5 (12.2 - 16.9)
15.6 (13.2-17.9)
Northern Cape (NC)
10.1 (6.6 - 13.5)
11.2 (8.5 - 13.8)
15.9(10.1 - 21.6)
15.1 (11.7-18.6)

Western Cape (WC)
7.1 (4.4 - 9.9)
8.7 (6.0 - 11.4)
8.6 (5.8 - 11.5)
12.4 (8.8-15.9)
National 
22.4 (21.3 - 23.6)
24.5 (23.4 - 25.6)
24.8 (23.6 - 26.1)
26.5 (25.5-27.6)
Sources:  South African Department of Health. National HIV and Syphilis Sero-Prevalence Survey of Women Attending Public Antenatal Clinics in South Africa 2001. Pretoria: June 2002; South African Department of Health, National HIV and Syphilis Antenatal Sero-Prevalence Survey in South Africa: 2002. Pretoria: September 2003.

The 2002 ANC survey found that, as in 2000 and 2001, HIV prevalence peaked among women ages 25 to 29, at 34.5 percent in 2002, an increase from 31.4 percent in 2001. The Department of Health states that this increase was statistically significant, as were recorded increases in prevalence among the 30-34 and 40+ age groups.[1]

Table 2: HIV Prevalence by age group among ANC attendees in South Africa: 2000-
2002
Age Group
HIV pos. 95% CI

2000
2001
2002
<20
16.1 (14.5-17.7) 
15.4 (13.8-16.9) 
14.8 (13.4-16.1)
20-24
29.1 (27.4-30.8) 
28.4 (26.5-30.2) 2
29.1 (27.5-30.6)
25-29
30.6 (28.8-32.4) 
31.4 (29.5-33.3) 
34.5 (32.6-36.4)
30-34 
23.3 (21.5-25.1) 
25.6 (23.5-27.7)
29.5 (27.4-31.6)
35-39
15.8 (13.9-17.7) 
19.3 (17.0-21.5) 
19.8 (17.5-22.0)
40+
11.0 (7.9-14.2) 
9.8 (7.0-12.6) 
17.2 (13.5-20.9)
Source:  South African Department of Health, National HIV and Syphilis Antenatal Sero-Prevalence Survey in South Africa: 2002. Pretoria: September 2003.

First National Study of HIV Prevalence

The Nelson Mandela Foundation and the Nelson Mandela Children's Fund commissioned South Africa's first nationally representative study of HIV prevalence. The study was conducted by South Africa's Human Sciences Research Council (HSRC) in collaboration with the Medical Research  Council (MRC) and the Center for AIDS Development, Research, and Evaluation (CADRE). It utilized a national sample of 9,963 people, including anonymous, saliva-based HIV tests from 8,840 participants. The findings, released in December 2002, indicated that 11.4 percent of South Africans¾4.5 million people¾were living with HIV/AIDS at the end of 2002.[3] (HSRC notes that the total sample size was limited by financial constraints. Overall, a total of 14,450 potential participants comprising of 4,001 children, 3,720 youths, and 6,729 adults were selected for the survey; 13,518 (93.6 percent) were actually visited. A small proportion (6.4 percent) of potential respondents could not be approached due to logistic constraints. Among the 13,518 individuals who were selected and contacted for the survey, 9,963 (73.7 percent) agreed to be interviewed, and 8,840 (65.4 percent) also agreed to provide a specimen for an HIV test.[3] ) 

The 2002 HSRC study also found that:

* Among children ages 2-14, HIV prevalence was 5.6 percent (CI: 3.7-7.4%); among girls in this age group, it was 5.2 percent (95% CI=3.2-7.3%) and among boys, 5.9 percent (95% CI-2.8-8.9%). However, given relatively small sample sizes, HSRC noted that prevalence for girls should be interpreted with caution. Among African children in this age group, HIV prevalence was 5.4% (95% CI=3.3-7.6%).[3]

* HSRC notes that the HIV prevalence among children ages 2-14 was unexpected. Once HIV prevalence was identified as high in this group, the authors undertook a record review to determine the number that could have been infected through MTCT. They found that only seven (6.1 percent) of the 86 HIV-positive children ages 2-14 had a biological mother who had died and a similar percentage (7 percent) had a biological father who had died. It remained unclear as to how these children could have been infected. Possible factors for investigation include sexual abuse and unsafe medical practices.[3]

* Prevalence among youth (ages 15-24 ) was 9.3 percent (95% CI=7.3-11.2).  Among young males, it was 6.1 percent (95% CI=3.9-8.3), and among young females, 12.8 percent (95% CI=9.2-14.7). African youth had the highest observed prevalence of HIV infection (10.2 percent [95% CI=7.9-12.5]), followed by coloured youth (6.4 percent [95% CI=4.5-8.4])[3]

* HIV prevalence was higher in urban versus rural areas. Among all locality types, it was highest in urban informal settlements (21.3 percent [95% CI=16.2 -26.5]).[3] [3]

* In contrast to the 2002 HSS findings, Free State, Gauteng, and Mpumalanga had the highest HIV prevalences in South Africa, whereas KwaZulu-Natal ranked fourth (Western Cape and Northwest has similar levels of prevalence). Eastern Cape had the lowest prevalence. HSRC posited several reasons for the observed discrepancies. First, all of KwaZulu-Natal's 36 HSS sites are found along major or main roads, where HIV prevalence is often higher. The HSRC study, in contrast, sampled respondents from rural and urban areas throughout KwaZulu-Natal. A second explanation may lie in locality types. KwaZulu-Natal has the country's second lowest proportion of people living in informal settlements (5 percent), which may account for the province's ranking in the HSRC study. The two provinces with the highest HIV prevalences also had the highest proportion of persons living in urban informal areas: Gauteng (19.9 percent) and Free State (16.9 percent). Further studies are needed to validate HIV prevalence in KwaZulu-Natal. [3]

* The observed HIV prevalence for women age 15-49 years in the Western Cape of 18.5 percent (95% CI=10.9-29.7%) is much higher than that observed in HSS data. The province has a high percentage of its population living in informal settlements (12.8 percent), which may be a factor. This finding also requires further investigation.[3]

A critique of the 2002 HSRC national study by Sarah Bennett, a health care actuary with NMG-LEVY Consultants and Actuaries in South Africa, cautioned that:

"Some of the results of the HSRC survey contradict the results of the annual antenatal survey. In the HSRC survey, prevalence amongst adults in KwaZulu-Natal is estimated to be the fourth highest at 15.7%, compared to the 2001 antenatal survey, which estimates prevalence amongst pregnant women in the province at 33.5% and the highest in South Africa. The findings of the HSRC report also contradict the Actuarial Society of South Africa (ASSA) prevalence projections calibrated primarily on the antenatal survey results. ASSA's estimate of adult prevalence is 24% compared to the HSRC's estimate of 16%."[4]

"When extrapolating the findings of the HSRC report to the entire South African population, we must be convinced that the sample is representative and not biased in any way. The potential for bias arises out of a number of areas:

1. Firstly, as acknowledged by the report, certain potentially high-risk groups such as the military, prisons and hospitals were excluded from the survey.
2. Secondly, only 71% of the valid visiting points were realized. The remaining potential respondents were not at home or not available for the survey. People who are away from home a lot, or keep unconventional hours, may be at higher risk of infection.
3. Thirdly, only 74% of the selected respondents agreed to be interviewed and only 65% agreed also to give a specimen for an HIV test. Those refusing participation could be doing so because they are a higher risk group or know they are positive. An exception to this is the more affluent, who could be low risk, but unwilling to cooperate. 
4. Therefore only 48% (65% of 71%) of potential respondents were tested. With such a low participation rate, there is substantial potential for bias in the results."[4]

"Further sources of bias could be:

* People with no fixed abode, such as truck drivers, who have been proven to have high levels of prevalence, were excluded.
* The interviewers were recently retired nurses, who have a high status in some communities in South Africa. This might have had an impact on how the respondents answered the questionnaire.
* Finally, it is quite possible that children interviewed/tested were those at home who may be there because of illness, which could have resulted in an overstatement of child prevalence."[4]

"Given a sample of 8,428 respondents and ignoring any bias, the estimate of national
prevalence of 11.4% is not statistically significantly different from a true national prevalence as high as, or even higher than, 12.7%. Of course the uncertainty increases as the population sampled gets smaller. Thus although the report suggests that KwaZulu-Natal is no longer the province with the highest prevalence, the confidence interval around the estimate extends up to 15.2%, which means that it is entirely possible that the ordering of the top four provinces is simply a matter of chance. Likewise, again ignoring bias, the prevalence of Whites could be 50% higher or lower than the 6% (i.e. 3% - 9%) estimated by the survey. Thus the estimates from the survey, ignoring any bias, are somewhat uncertain. If 5.6% of the children aged 2-14 are infected, this means around 700 000 children are infected, which would lead, even on very optimistic assumptions about when they got infected and their survival, to around 4 000 deaths per annum due to HIV/AIDS in the 10-14 age group, for example. Extrapolating from the cause of death data captured by Statistics South Africa and adjusting for underreporting of deaths, we only have some 350 to 400 deaths due to AIDS and potentially AIDS related conditions per annum."[4]

HIV Incidence

Dorrington et al. believe that HIV incidence in South Africa peaked around 1998 and has begun to decrease.[5] The prevalence declines observed between 2000 and 2002 in the <20 year age group may be an indication of slowing HIV incidence. Reductions in HIV-1 prevalence, especially those in young adults, may indicate concomitant declines in HIV-1 incidence. However, other factors, such as mortality rates, migration, and survey coverage, also contribute to prevalence trends. Thus, incidence trends cannot be estimated directly from prevalence trends.[6] 

Number of South Africans Living with HIV/AIDS

Using the results of the 2002 HSS, the South African Health Department estimated that 5.3 million South Africans were HIV-positive at the end of 2002, an increase from the comparable 2001 estimate of 4.74 million. The department estimated that in 2002, 2.95 million women and 2.3 million men between ages 15 and 49 years were infected with HIV. An estimated 91,271 babies became infected with HIV through mother-to child transmission route.[1] 

As mentioned above, the 2002 HSRC national survey estimated that 4.5 million South Africans were living with HIV/AIDS at the end of 2002.[3] Dorrington, Bradshaw, and Budlender of the University of Cape Town's Center for Actuarial Research, estimate that at the end of 2002, there were 6.6 million HIV-positive South Africans.[5]

UNAIDS estimated that there were 5 million South Africans living with HIV/AIDS at the end of 2001 (estimate range: 4 million to 6 million), of whom 4.7 million were adults.[4]  These estimates suggest that South Africa has more people living with HIV/AIDS than any other country in the world.  UNAIDS underscores that populous countries with fast-growing epidemics may surpass this figure.

Adult Prevalence

UNAIDS estimated that at the end of 2001, HIV prevalence among adults ages 15 to 49 was 20.1 percent.  Of infected adults, 57.4 percent were women.[4]   

At the end of 2001, UNAIDS estimated that prevalence among South African women ages 15 to 24 ranged from 20.51 to 30.76 percent; the range for men in the same age cohort was 8.53 to 12.79. [4]   

The U.N. Population Division estimates that South Africa's adult HIV prevalence peaked at 21.7 percent in 2002. By 2050, the division estimates that adult prevalence will have fallen to 8.6 percent. (This projection assumes that HIV/AIDS dynamics remain unchanged until 2010. Thereafter, prevalence levels are assumed to decline. By 2050, prevalence levels are lower but still substantial in the most highly affected countries.)[7]

Transmission Patterns

During 1982-97, 79 percent of transmission was heterosexual, 13 percent through mother-to-child transmission (MTCT), 7 percent through men who have sex with men, and 1 percent through infected blood.[17]  (In southern Africa as a whole, 88 percent of new HIV infections are transmitted heterosexually, 10 percent are MTCT, and 2 percent through infected blood transfusions.[18])

A study published in 1998 noted that the HIV epidemic in South Africa represents two separate though simultaneous epidemics: a pattern I epidemic involving primarily white, homosexual or bisexual men, and a pattern II epidemic involving primarily black, heterosexual men and women.[19]

AIDS Cases

Dorrington, Bradshaw, and Budlender of the University of Cape Town's Center for Actuarial Research estimated the number of HIV-positive South Africans in 2002 at 6.6 million; of them, 453,352 were "AIDS sick," i.e., in stage 4 of WHO's staging system, at the end of 2002. Dorrington et al. project that this figure will rise to 1.4 million by the end of 2010.[5] 

A June 2001 report from Abt Associates estimated that by 2010, 1 million South Africans would be living with AIDS.  (NMG-Levy Consultants and Actuaries also puts the number of South Africans with AIDS at 1 million in 2010.[15]  Abt stresses that even then AIDS cases will not have peaked.

AIDS Mortality and Disability

See also the Impact section below.

In September 2001, South Africa's Medical Research Council (MRC) estimated that about 40 percent of adult (ages 15-49) deaths that occurred during 2000 were due to HIV/AIDS and that about 20 percent of all adult deaths in that year were due to AIDS. It went on to estimate that AIDS accounted for about 25 percent of all deaths in 2000 and had become the leading cause of death in South Africa. The MRC's projections indicated that, absent treatment to prevent progression to AIDS, the number of AIDS deaths would grow, within the next 10 years, to over double the number of deaths due to all other causes. Under this scenario, the MRC projected 5 to 7 million cumulative AIDS deaths in South Africa by 2010.[14] 

To rebut the MRC study above, the South African cabinet commissioned Statistics South Africa to undertake a study on AIDS-related mortality. The study examined causes of death in South Africa during 1997-2001 and was based on a 12 percent stratified random sample of deaths occurring during the study period. The findings, released in November 2002, indicated that the five leading underlying causes of death among South Africans between 1997 and 2001 were:

1. unspecified unnatural causes (e.g., suicide, drowning, motor accidents)
2. ill-defined causes
3. TB
4. HIV
5. influenza & pneumonia[8]

According to Statistics South Africa, the proportion of deaths due to HIV nearly doubled, from 4.6 percent in 1997 to 8.7 percent in 2001, whereas the proportion of deaths due to unspecified unnatural causes declined from 15.3 to 8.2 percent during the same period. The study also found:[8] 

* The highest prevalence of HIV deaths was among African females (13.5 percent), females ages 15-29 (24.3 percent), and females ages 30-39 (20.5 percent). The lowest prevalence of HIV deaths was among white females (0.7 percent).[8]

* HIV is the leading cause of death among African females. Males ages 15-39 experienced the highest mortality attributable to unspecified unnatural causes, whereas females in the same age group died primarily as a result of HIV. For both males and females, there was a sharp decline in deaths due to unspecified unnatural causes. By contrast, the proportion dying from TB, HIV, and influenza & pneumonia increased significantly. However, the proportion of deaths due to HIV was about three times higher among females ages 15-29 than among males in the same age group, 22.5 vs. 8.5 percent, respectively. In the age group 40-49, the two leading underlying causes of death among males were unspecified unnatural causes and TB, whereas ill-defined causes and HIV were the two leading causes among females.[8]

* Between 1997 and 2001, the proportion of children dying from HIV and influenza & pneumonia increased, whereas deaths due to unspecified unnatural causes declined. [8]

* The main causes of death among Africans and coloureds were TB, HIV, influenza & pneumonia, and unspecified unnatural causes, whereas whites and Indians tended to die because of diabetes, ischemic heart disease, and cerebrovascular diseases. Cerebrovascular disease was the leading cause of death among coloured females and ischemic heart disease the leading cause among Indian and white females.[8]

In March 2003, the MRC released initial estimates from the South African National Burden of Disease Study 2000. It found that HIV/AIDS was the single leading cause of death in the country, accounting for 30 percent of all deaths, followed by cardiovascular disease (17 percent), infectious and parasitic excluding HIV (10 percent), malignant neoplasms (7 percent), and intentional (7 percent) and unintentional injuries (5 percent). HIV/AIDS accounted for 34 percent of female deaths and 26 percent of male deaths.[9]

The MRC study also examined premature mortality (years of life lost [YLLs], which 
consider not only the number of deaths, but also the age at which death occurred). It found that  HIV/AIDS is by far the largest single cause of YLLs in both males and females (38 percent). Forty-seven percent of all YLLs for females were attributed to HIV/AIDS; the comparable figure for males was 33 percent. Examination of age distribution indicated that it is particularly young female adults who are dying.[9]

Disability adjusted life years (DALYs) include YLLs due to premature mortality as well as "years lived with a disability" (YLDs), weighted according to severity of the disability. The MRC found that in terms of DALYs, HIV/AIDS is the major contributor, followed by other infectious and parasitic diseases, and unintentional and intentional injuries. Without interventions aimed at reducing AIDS mortality, HIV/AIDS will more than double the burden of premature mortality (YLLs) experienced in 2000. By 2010, HIV/AIDS will account for 75 percent of premature mortality, compared to 39 percent in 2000.[9]

Data Quality Issues

See also box 1.

ANC data currently serve as South Africa's primary sentinel surveillance of HIV/AIDS. The South African government is developing new surveillance methods in collaboration with the U.S. Centers for Disease Control and Prevention (CDC).[2]  

Because ANC surveys are the only national source of information on the growth of the epidemic, many assumptions regarding them are based on computer simulation models calibrated to antenatal data.[6, 10]  Though ANC prevalence is widely used, they are imperfect. Children and the elderly¾who are at substantially lower risk of HIV¾are not captured by antenatal surveys.  Even among adults in sexually active groups, the antenatal survey prevalence figures do not reflect the lower overall risk of men, people who are less sexually active, and those who use private sector health facilities.[6][1]

Yet, these antenatal data may underestimate HIV prevalence in women of reproductive age as recent studies indicate that fertility among HIV-positive women is substantially lower than among uninfected women.  Zaba et al. have found 25 to 40 percent lower fertility in women with HIV in high-prevalence African countries; they attribute about half of this "subfertility" directly to HIV infection.[11]

The South African Government's interpretation of the 2000 HSS data varied greatly from that of many South African and international researchers.  The government noted that it was "encouraged to see that the trend observed between 1990 and 1998¾an exponential rise¾has begun to slow down between 1998 and 2000.  As the antenatal survey is a proxy indicator for the development of the HIV epidemic in the general population, the findings for HIV and syphilis in the last three years suggest a slower progression of the pace of epidemic."[9] However, the first sentence of a June 2001 Abt report stated, "During the period 1994 to 2001, there has been an exponential growth of HIV infections in South Africa....Experts agree that South Africa now faces one of the world's most severe HIV/AIDS epidemics."[6]

The South African Government posited that the 2001 HSS data demonstrated that the HIV epidemic was stabilizing, as the government had maintained when the 2000 ANC data were released in 2001. It cited the decline in HIV prevalence among women under age 20 (from 16.1 percent in 2000 to 15.4 percent in 2001), although this was not significant, (Note that from 2000 to 2001, prevalence among women ages 30 to 34 rose from 23.3 to 25.6 percent; for women ages 35 to 39, the comparable increase was 15.8 to 19.3 percent.) The government also cited the decline in syphilis among ANC attendees, from 4.9 percent in 2000 to 2.8 percent in 2001.[1]

Following release of the 2001 ANC data, Prof. Salim Abdool Karim, an epidemiologist who serves as deputy vice chancellor for research at the University of Natal, stressed that because more people are dying from HIV/AIDS-related causes, the rate of new HIV infections must be increasing to keep the prevalence rate stable. He stated that "a lack of change in prevalence data hides the situation where a large number of new infections are taking place."[12]

The Treatment Action Campaign noted that:

In particular we are concerned that although there are signs of declining (but still high) levels of infection among young women under 20, HIV prevalence rises again as women get older. This trend was also noted in the 2000 survey. It suggests that prevention programs that target youth, but are not complemented by equally strident messages targeting older people (and particularly married people), lose their benefits as people enter relationships where they have less sexual autonomy and control....Legitimate questions have been raised about the continued delays in publication of the survey results and denying researchers access to the raw data.[13]

With regard to the 2002 HSS, the government again appears to be focusing solely on declines in prevalence among those under age 20, regardless of whether they are significant, to make the leap to demonstrating slowing incidence. Moreover, the government does not discuss that even if the epidemic is stabilizing (as yet unproven), it is doing so at very high levels:

"When the prevalence rates are examined on a year on year basis, in other words comparing 2001 and 2002 prevalence rates, the observed increase does not raise concern from the perspective of escalation of the epidemic. It is expected during a stabilization phase that there may be minor spiking. Overall, the rate of increase between the two years is very low. It is particularly encouraging to observe what may be the beginnings of a decline in HIV rates among women aged below 20 years. This group is considered the most important to watch with respect to new infections taking place. The increases observed among other age groups need closer examination but may suggest a cohort effect, or less ability/empowerment for women in these age groups to respond to prevention messages."[1]

And rather than investigate possible provincial dynamics, the government downplayed prevalence increases observed in Western Cape and other provinces:

"In terms of provincial comparisons, KwaZulu-Natal is still the province with the highest HIV prevalence rate among pregnant women and has shown an increase between 2001 and 2002. Western Cape province has for the first time since the beginning of the antenatal surveys, recorded a prevalence rate above 10%. Two provinces, namely Free State and Northern Cape have shown slight declines in HIV prevalence between 2001 and 2002, whilst Mpumalanga shows a decline between 2000 and 2002. All other provinces are showing increases in HIV prevalence between 2001 and 2002. The reasons for this may be difficult to decipher as the survey gives an indication of existing infections and not new infections (incidence)."[1]






Political Economy and Sociobehavioral Context

At a Glance Summary Bullets

* Many of the factors discussed in this section exist in countries that, unlike South Africa, have low HIV prevalence; these include wide income disparities, history of colonialism and political and economic disenfranchisement, and gender inequality. 

* The relationship between HIV prevalence and socioeconomic markers is highly complex. Risk of HIV infection is related, inter alia, to individual behavior and socioeconomic characteristics as well as to the socioeconomic profile of the community in which one is situated. Moreover, since 1994, the social divisions within South African society have themselves become more complex. 

* This section does not seek to demonstrate causality. Rather, it analyzes key political economy and sociobehavioral contextual elements to highlight the range of sectoral policies and interventions that may affect or be affected by HIV/AIDS. 

Legacy of Colonialism and Apartheid

* Black South Africans have been subject to a long history of systematic social disruption and dislocation. 

* Apartheid disenfranchised black South Africans politically, socially, and economically. Human rights abuses-including those perpetrated within the health sector¾were common. The apartheid government routinely used violence to exert power.  A study conducted by South Africa's Medical Research Council and the London School of Hygiene and Tropical Medicine found that violence remains common in daily life in South Africa.

Race

* Even when adjusting for socioeconomic factors, race remains a significant determinant of HIV risk. HIV risk is highest among black South Africans, substantially lower among coloureds and Asians, and lowest among whites. 

Socioeconomic Disparities

* South Africa's 2001 GNI per capita was US$2,820, the second-highest in sub-Saharan Africa, masks wide income disparities.  Thirty-five percent of South Africa's population lives on less than US$2 a day. 

* Postapartheid economic growth in South Africa has been slow, and efforts to increase employment have stalled. Unemployment among women greatly exceeds that among men. There is a high rate of unemployment among unskilled workers, who have the highest HIV infection rate and the highest AIDS-related death rate.

Poverty

* Sixty-one percent of Africans, 38 percent of coloreds, 5 percent of Indians, and 1 percent of whites were poor in 1995. A disproportionate number of the chronically poor are Africans and coloreds living in rural areas; the elderly and female-headed are most likely to be chronically poor. 

Population Mobility

* Mass resettlements of populations under apartheid, seasonal labor migration, movements along major trade routes, refugees fleeing war in other parts of Africa, and, since 1990, return of political exiles and liberation armies have all contributed to the spread of HIV.

* There is high mobility among urban, rural, mining, and port areas, much of it dominated by men.   Migrant labor separates men from their families, places them in close proximity to "high-risk" sexual networks, and may result in their having an increased number of sexual contacts.  Migration is an independent risk factor for HIV infection among South African men. Concurrently, it may also lead to women's reliance on sex to supplement their incomes while their male partners are away for long periods.

Mining

* Men are not allowed to bring their families with them to the mines. Miners live in single-sex hostels or barracks, far from their spouses or regular partners. Commercial sex and access to alcohol are common features of live in hostel compounds. Migrant labor and hazardous physical work¾relieved primarily by alcohol and sex¾create an environment that may be considered conducive to rapid HIV transmission. 

Crime

* According to the U.N. Office on Drugs and Crime, overall levels of crime began to increase in the mid-1980s and rose throughout the 1990s. Although there are some indications  that the steep increase in crime has abated, South Africa remains among the most crime-ridden and crime-concerned societies in the world. Violent crimes, such as attempted murder, aggravated robbery, serious and common assault, and in particular violence against women and children, has increased since 1994.

Stigma and Discrimination

* Stigma around HIV/AIDS remains strong and is likely to influence personal decisionmaking with regard to HIV testing and disclosure. 

Health System

* There are one national and nine provincial health departments, with provinces responsible for implementation of AIDS programs. The national government is primarily responsible for collecting and distributing revenue equitably among provinces, formulating broad policy frameworks, and defining norms and standards for service provision.

* Despite redistributive policies in the early postapartheid period, South Africa's health care infrastructure remains highly inequitable.

* WHO ranks South Africa a "high TB burden" country, with the world's seventh-highest burden of TB (by number of cases). There is a lack of effective integration between TB and HIV policies and programs. 

STIs

* The 2002 ANC survey found that an estimated 3.2 percent of ANC attendees had active syphilis. This figure is an increase over the 2001 figure of 2.8 percent in 2001. 

* A study in Carletonville found that infection with herpes simplex virus type-2 was the most significant factor associated with HIV status for both men and women.[39] 

Gender

* HIV prevalence among South African women tends to peak between ages 25 and 29, whereas among men, it peaks several years later (usually between ages of 30 and 35) and at lower levels. Women tend to become infected at younger ages than men for both biological and behavioral reasons. High male-to-female transmissibility of HIV is considered likely to play a significant role. Age mixing is another crucial factor.  

* Women's subordinate economic status affects their vulnerability to acquiring HIV and, once infected, accessing care and support services. Even among married South African women, there is a high level of economic maltreatment.

* Women are commonly viewed as "being inferior to men, as possessions, and as needing to be led and controlled." Many women are unable to insist on condom use and negotiate the timing of sex and the conditions under which it occurs. 

* Many women also face abuse and/or abandonment if they disclose their HIV-positive status. Lobola, a long-standing tradition whereby men purchase a wife by paying her family a dowry, also renders it difficult for women to leave their husbands, as this would require fathers to repay the dowry. 

Sexual Violence

* In most presentations of police rape statistics, South Africa is near or at the top.

* Household surveys represent another method of obtaining information on the extent of sexual violence.  The last South African Demographic & Health Survey found a national rape prevalence of 7 percent, ranging from 3 to 12 percent across provinces.

* Both police statistics and household studies reveal that young women¾the demographic group most at risk for HIV/AIDS¾are also at highest risk of being raped.

* South Africa is a destination country for women trafficked from other parts of Africa, Eastern Europe, Asia, and the former Soviet Union for commercial sexual exploitation. South African women and children are also trafficked internally for labor and commercial sexual exploitation. 

* Rape, sexual violence, sexual harassment, agressivity toward and physical and verbal degradation of female students by male school teachers and male classmates are widespread and largely normalized and tolerated. Girls who report sexual abuse are often further victimized and stigmatized by teachers and students. School authorities rarely ensure a sense of security at school nor counsel and discipline male perpetrators. 

Sexual Behavior

* Several South African researchers underscore that individual risk of HIV infection is determined by individual as well as community factors.  Thus, individual sexual behavior may be less important than the community from which sexual partners are chosen, i.e., social context may be a stronger predictor of disease than individual behavior.

* In South Africa, sexual debut is generally early, usually beginning during the mid-teens; for girls, often shortly after menarche.

* The 2002 HSRC survey found that sexual experience among youth was significantly higher in urban informal areas than in any other types of localities. 

* A high number of sexual partners, especially among men, is socially acceptable and encouraged.  Given the country's economic situation and high unemployment, as well as lack of affordable recreational opportunities, sexual relationships provide one of the few opportunities wherein young South Africans may obtain success, respect, and self-esteem.  

* Multiple sexual partners, as well as ability to control girlfriends, are key to notions of "masculinity." Masculinity among miners signifies bravery, fearlessness, and the willingness to take risks; "real" men have enormous sex drives that lead them to have sex with an unlimited number of women.  Given this scenario, many miners do not use condoms.

* Among 2002 HSRC respondents, a higher proportion of Africans and male or female respondents living in urban informal areas had multiple partners.

* The 2002 HSRC survey found that youth had significantly higher rates of condom use than adults. Single respondents were considerably more likely to use a condom than those who were married. 

Transactional Sex

* Sex is also often used as a commodity in exchange for money or other forms of payment. Transactional sex involves nonmarital sexual relationships, often with multiple partners, that are a result of men's superior economic position and access to resources, the value placed on men's having multiple sexual partners, and women's desire to access power and resources such as gifts or cash.

Awareness and Knowledge of HIV/AIDS

* There are some areas of weak knowledge amnong South Africans. For exampe, knowledge about breastfeeding is poor.

Alcohol and Drug Use

* Much sex work in South Africa is initiated in shebeens (informal liquor stores or bars), and alcohol consumption is likely to result in inconsistent condom use and other unsafe sex behaviors. Alcohol consumption is more likely to be a risk factor for HIV if associated with an "unsettled lifestyle and migrancy." This is because migrants are less likely to have a regular partner living with them and are thus more likely to acquire sexual partners through visits to shebeens.

* Data from surveys of young South Africans convey that their drug and alcohol use during sex is a concern. 

* Since 2000, heroin use has increased significantly in major urban areas, particularly in Gauteng and Cape Town. Injecting drug use is not common in South Africa, although recent evidence indicates that the injecting of heroin is increasing. 

Male Circumcision

* Some observational studies from sub-Saharan Africa have indicated that male circumcision may reduce the risk of HIV acquisition, though circumcision does not appear to affect transmission from HIV-positive men to their partners. 

* The 2002 HSRC study found that 35 percent of all adult and young males had been circumcised.  

In a paper prepared for the WHO Commission on Macroeconomics & Health, David Bloom of Harvard and his colleagues note that:

Existing data provide some indication that the relationship between poverty and HIV is growing stronger over time, both between and within continents. But it is not possible to infer causality from these data. That is, it is difficult to tell whether poverty causes AIDS or vice versa¾or whether another variable, such as war, inadequate health, or poor education, explains the relationship....In sum, the link between economic status and AIDS is complex. While many micro level studies point to a significant link between poverty and HIV prevalence rates, macro data is unconvincing, particularly in terms of the causality of the link. Some risk factors for HIV, such as a high level of disposable income, are more prevalent amongst the rich than the poor. Others, such as lack of education, are more prevalent among the poor than the rich. Both groups exhibit the kind of mobility that appears to be associated with HIV transmission. On balance, it seems plausible that the rich are more at risk in the early stages of an epidemic, and that a combination of factors, including lack of education and other economic exigencies, put the poor at increasing risk as an epidemic progresses. One might therefore expect HIV epidemics to become increasingly embedded in poor communities. Although not proven, this hypothesis is broadly consistent with patterns of HIV transmission seen in Africa and other regions, including wealthy industrial countries such as the US.[10]

Håkan Björkman, senior adviser on HIV/AIDS to UNDP's Bureau for Development Policy, states that:

HIV/AIDS is not strictly speaking a "disease of poverty" as it affects people at all income levels. But evidence from some countries at advanced states of the epidemic shows that new HIV infections disproportionately affect poor people, unskilled workers, and those lacking literacy skills¾esp. young women in each of these categories. The relationship among poverty, gender, and HIV vulnerability has important policy implications.[11]

Many of the factors discussed in this section exist in countries that, unlike South Africa, have low HIV prevalence; these include wide income disparities, history of colonialism and political and economic disenfranchisement, and gender inequality. The relationship between HIV prevalence and socioeconomic markers is highly complex. Risk of HIV infection is related, inter alia, to individual behavior and socioeconomic characteristics as well as to the socioeconomic profile of the community in which one is situated. Moreover, since 1994, the social divisions within South African society have themselves become more complex.[3]

This section does not seek to demonstrate causality. Rather, it analyzes key political economy and sociobehavioral contextual elements to highlight the range of sectoral policies and interventions that may affect or be affected by HIV/AIDS. In addition to the table of key HIV/AIDS and socioeconomic indicators that accompanies this analysis, readers may also want to consult the 2003 indicators related to South Africa's progress on achieving the Millennium Development Goals, which are published by UNDP <http://www.undp.org/hdr2003/indicator/index_indicators.html>.

Legacy of Colonialism and Apartheid

Black South Africans have been subject to a long history of systematic social disruption and dislocation.[20] Through dispossession of land by whites, African farmers were forced to retreat to other areas or to become sharecroppers or farm laborers. In the latter half of the 19th century, the discovery of diamonds and then of gold led to a rapidly growing demand for black mineworkers.[12]During the 19th century, southern African mining industries had a legally enforced migratory black labor system under which many African men were separated from their homes.  The 1913 Native Land Act spurred vast resettlement schemes that dispossessed blacks of their land and sought to ensure a steady supply of male labor to mines and other industries.[20] The act formalized the distinction between African "reserves" and white farming areas, and prohibited Africans from acquiring, owning, or renting land in the latter. This scenario limited their economic options so severely such that many Africans sold their labor to the mines and white farms.[12]

Apartheid disenfranchised black South Africans politically, socially, and economically.[21] Human rights abuses-including those perpetrated within the health sector¾were common.[22]  The apartheid government routinely used violence to exert power.  A study conducted by South Africa's Medical Research Council and the London School of Hygiene and Tropical Medicine found that violence remains common in daily life in South Africa and that beating is perceived as normal way of exacting punishment and exerting control.[23]  A recent study in the mining town of Carletonville found an everyday environment characterized by "chaos and danger," as well as high levels of alcohol consumption, poverty, and gang conflict.[21]   KwaZulu-Natal has been particularly affected by violence and political conflict between African National Congress and Inkatha Freedom Party supporters, which may play some role in the province's high HIV prevalence.[3]  Violence in schools has long been and continues to remain prevalent.[24] (See "Sexual Violence in Schools" box below.)  Sixty-five percent of young South Africans indicate that they are worried about their personal safety and cite crime, violence, and abuse as major concerns.[25]

Race

According to Fassin and Schneider:

"Inequality, mobility, and violence are partly the legacy of centuries of colonial exploitation and racial segregation, culminating in the institution of apartheid in the second half of the 20th century. Epidemiologically this segregation translates as differential HIV seroprevalence between black and white groups and between social classes."[13]

Researchers from the University of Cape Towns' Center for Actuarial Research have found that even when adjusting for socioeconomic factors, race remains a significant determinant of HIV risk. HIV risk is highest among black South Africans, substantially lower among coloureds and Asians, and lowest among whites. The proportion of the population that is black is relatively low in the Western Cape and the Northern Cape, partially explaining why prevalence is relatively low in these provinces.[1, 3] Further, rates of AIDS orphanhood are likely to be highest among black Africans and among poorer socioeconomic groups.[26]

The 2002 HRSC study found that Africans had higher estimated HIV prevalence [12.9% (CI=11.2-14.5%)] than whites [6.2% (CI=3.1-9.2%)] and coloureds [6.1% (CI=4.5-7.8%)]. The interplay of historical inequities, labor migration, mobility, and relocation are likely important factors, as Africans are more likely than any other race to live in informal settlements, where HIV prevalence is highest.[3] (Note caveats to HSRC study above.)

Socioeconomic Disparities

South Africa's 2001 GNI per capita was US$2,820, the second-highest in sub-Saharan Africa (following that of Botswana).[14] Manufacturing, much of it based on mining, is the largest contributor to South Africa's GNI.[28] Yet South Africa's GNI masks wide income disparities.  Thirty-five percent of South Africa's population lives on less than US$2 a day.[27] According to the World Bank, about 13 percent of the population lives in "first world" conditions, whereas 53 percent lives in "third world" conditions.  Among this latter group, 25 percent of households have access to electricity and running water; half have a primary school education; and over one-third of children suffer from chronic malnutrition.[28]

As the accompanying indicator table demonstrates, South Africa's human development and socioeconomic indicators are often higher than those for the sub-Saharan Africa region.  Yet again, these data mask high inequality. One way of measuring such inequality is with the Gini index, which measures the extent to which the distribution of income (or consumption) among individuals or households within a country deviates from a perfectly equal distribution. A value of 0 represents perfect equality, a value of 100 perfect inequality. South Africa's 2001 Gini index of 59.3 connotes a high level of inequality.[15]

Schneider underscores that although poverty is still strongly correlated with race, the social divisions within South African society have become more complex--the result of postapartheid era changes and the opening up of opportunities to historically disadvantaged groups.  She quotes a 2001 paper by Nattrass and Seekings:

"In postapartheid South Africa, inequality is driven by two income gaps: between an increasingly multiracial upper middle class and everyone else; and between a middle class of mostly urban, industrial, or white-collar workers, and a marginalized class of black unemployed and rural poor."[20]

A June 2001 Abt Associates report notes that less than 60 percent of the population lives in formal housing and that 17 percent of households obtain their water supply directly from dams, rivers, streams and boreholes; less 30 percent have telephones; and approximately half have no flush or chemical toilets. A Kaiser Family Foundation survey of young South Africans, undertaken in September 2000, found that one-third live in households with monthly income of less than R1,000 (about US$145).[25]  Schneider also notes that despite redistributive policies in the early post-1994 period, South Africa's health care infrastructure remains highly inequitable.[20] (See Health System section below.)

Postapartheid economic growth in South Africa has been slow, and efforts to increase employment have stalled.[28]  South Africa's unemployment rate is about 34 percent.[6] The 1999 October Household Survey found that 73 percent of those presently unemployed have never had a job.[12]  Unemployment among women greatly exceeds that among men.[16][12]
 
Of those employed, there are large wage differentials: 26 percent earn R500 (US$73) or less each month, and only 11 percent earn over R4,500 (US$653). There are no unemployment benefits for those who have never been formally employed or those who have been unemployed for over one year.[6]  One-half of those unemployed are classified as marginalized, with few prospects of formal sector employment.[28]  There is a high rate of unemployment among unskilled workers, who have the highest HIV infection rate and the highest AIDS-related death rate.[30]

Nattrass of the Center for Social Science Research at the University of Cape Town: Cape Town has found that there appears to be little difference in HIV prevalence between men and women who are employed.  HIV prevalences among those who are unemployed are often 30 to 50 percent higher than among the employed, in part reflecting the large share of young people (and females) among the unemployed.  These data suggest that unemployed women are particularly vulnerable to HIV infection.[31] 

(NB: The 2002 HRSC survey found that there was no significant difference in HIV prevalence between those who reported that they were working (14.2 percent) and those not working (12.1 percent) (p=0.7). See study caveats above.[3])

Employment opportunities for unskilled women with low educational attainment are particularly poor.[21] Sectors in which female employees predominate (e.g., garment industry) have been especially vulnerable to job losses.  Wages in these sectors have fallen and are as low as R260 (US$38) per month.  This scenario weakens women's economic status, thereby exacerbating gender inequalities and thus vulnerability to HIV.[32]  Moreover, the most impoverished women are the least likely to seek out or have access to sexual and reproductive health services.[33]

Poverty

Aliber of the Human Sciences Research Council notes that using a national poverty line of R352 (US$51) per month, 61 percent of Africans, 38 percent of coloreds, 5 percent of Indians, and 1 percent of whites were poor in 1995. Based on the same data set, 72 percent of the poor lived in rural areas. The poorest provinces were those encompassing the most populous former homeland areas, e.g., KwaZulu-Natal, Limpopo, and Eastern Cape. A disproportionate number of the chronically poor are Africans and coloreds living in rural areas; the elderly and female-headed are most likely to be chronically poor. Aliber estimates that at least 18 to 24 percent of households nationwide are in chronic poverty or are highly susceptible to chronic poverty. [12]

The 2002 HRSC survey found that when socioeconomic status of the home is categorized on a
scale ranging from "not having enough money for food and clothes" through "having
disposable income for luxuries," there was a decrease in HIV prevalence moving from poorer to
richer homes when all participants were included. However, this trend disappeared when African-only data were analyzed.[3] (See study caveats above.)

Human Development

One method of tracking human development in South Africa is to analyze trends in its Human Development Index. The HDI was created by UNDP to measures average achievements in life expectancy at birth; adult literacy and combined primary, secondary, and tertiary gross enrollment ratios; and GDP per capita (most UN agencies are now calling this gross national income [GNI]; details on its calculation can be obtained from the World Bank). An HDI of 0.800 or above = high human development; 0.500 - 0.799 = medium human development; less than 0.500 = low human development. In 2001, South Africa's HDI value was 0.684, ranking it 111 out of 175 countries for which UNDP calculated an HDI. [15]
Although South Africa's HDI value is higher than that of the sub-Saharan African region (0.468), it is worrying that it has declined markedly since the mid-1990s, when it stood at 0.741.[15] Part of this decline is likely due to the enormous impact of AIDS mortality (see Impact section), which has drastically reduced the life expectancy component of the HDI value. This phenomenon is also seen in UNDP's data on probability at birth of surviving to age 65: among newborn South Africa females, only 37.4 percent are likely to survive to age 65 (compare the figure for all medium-development countries: 74.4 percent). Among newborn South African males, these figures are 24.9 and 65.3, respectively.[15]

The decline in human development may also be partly attributable to the reduction in public expenditure on education. Public spending on education rose from 6.1 percent of GNP during 1985-87 to 7.6 percent during 1995-97,[16] yet fell to 5.5 percent in 1990.[15] The South African government has increased its spending on health, from 3.1 percent of GDP in 1990 to 3.7 percent in 2000. During the 1990s, military expenditures decreased dramatically, from 4.1 percent of GNI in 1989 to 1.5 percent in 1990.[15]

Population Mobility

Fassin and Schneider discuss how mass resettlements of populations under apartheid, seasonal labor migration, movements along major trade routes, refugees fleeing war in other parts of Africa, and, since 1990, return of political exiles and liberation armies have all contributed to the spread of HIV.[13]

As mentioned above, mobility has been closely intertwined with colonial and apartheid rule. Through most of the 20th century, control of Africans' mobility remained a high priority of the government. Since at least the late-19th century, a pattern emerged wherein Africans and coloreds were relegated to townships adjacent to white towns. The Natives (Urban Areas) Act of 1923 formalized local authorities' power to delineate urban settlements according to race. In 1950, the Urban Labor Preference Policy was introduced, which strengthened the discriminatory system of labor and pass controls. [12]

Currently, there is high mobility among urban, rural, mining, and port areas, within South Africa as well as within the southern Africa subregion.  Much of this movement is dominated by men [3, 34] and has been facilitated by a well-developed transport infrastructure.[18]  Migrant labor separates men from their families, places them in close proximity to "high-risk" sexual networks, and may result in their having an increased number of sexual contacts.  Concurrently, it may also lead to women's reliance on sex to supplement their incomes while their male partners are away for long periods.[3] 

Many of the antiapartheid forces were based north of South Africa's borders, in countries with high HIV prevalence; after 1994, these former revolutionary cadres were incorporated into the country's national defense force.  The return of these cadres from areas of high HIV prevalence to military bases throughout South Africa may be a factor in the country's high HIV prevalence as well as the prevalence levels found in the military[3] (see the "Impact" section below). 

Given the migrant labor system, apartheid-era forced population dislocations, and the transport system, South African rural communities are not as static nor as geographically isolated as those in the rest of sub-Saharan Africa.  These factors have facilitated HIV's rapid spread to rural areas.[3]  Many poor rural households depend on cash transfers through migrant remittances.[20]  The return of HIV-infected migrants to their home areas ends the flow of remittances just as care costs become necessary.  Moreover, a shift of the care burden may result, moving from the relatively better-off areas from which migrants are returning to their poorer home areas.[16]

Lurie of the South African Medical Research Council and his colleagues found that migration is an independent risk factor for HIV infection among South African men. They investigated the association between migration and HIV infection among migrant and nonmigrant men and their rural partners. They used a cross-sectional study of 196 migrant men and 130 of their rural partners, as well as 64 nonmigrant men and 98 rural women whose partners are nonmigrant. Male migrants were recruited at work in two urban centers, 100 km and 700 km from their rural homes. Rural partners were traced and invited to participate. Nonmigrant couples were recruited for comparison. The study involved administration of a detailed questionnaire and blood collection for HIV testing. The researchers found that 25.9 percent of migrant men and 12.7 percent of nonmigrant men were infected with HIV ( P= 0.029; odds ratio = 2.4; 95% CI = 1.1-5.3). In multivariate analysis, main risk factors for male HIV infection were being a migrant, ever having used a condom, and having lived in four or more places during a lifetime. Among women, being the partner of a migrant was not a significant risk factor for HIV infection; significant risk factors for women were reporting more than one current regular partner, being younger than 35 years, and having STI symptoms during the previous four months.[17]

Lurie et al. also examined HIV-1 discordance among migrant and nonmigrant men and their rural partners. Using a cross-sectional behavioral and HIV-1 seroprevalence survey among 168 couples, they found that 70 percent (117 of 168) of couples were negatively concordant for HIV, 9 percent (16 of 168) were positively concordant, and 21 percent (35 of 168) were discordant. Migrant couples were more likely than nonmigrant couples to have one or both partners infected (35 versus 19 percent; P = 0.026; odds ratio (OR) = 2.28) and to be HIV-1 discordant (27 versus 15 percent; P = 0.066; OR = 2.06). In 71.4 percent of discordant couples, the male was the infected partner; this finding did not differ by migration status. In a mathematical model developed by the researchers, migrant men were 26 times more likely to be infected from outside their regular relationships than from inside [relative risk (RR) = 26.3; P = 0.000]; nonmigrant men were 10 times more likely to be infected from outside their regular relationships than inside (RR = 10.5; P = 0.00003).[18]

Numerous studies have been undertaken within mining communities and among truck drivers.  In a study of truckers in KwaZulu-Natal, of whom all traversed more than one province and 67 percent neighboring countries, investigators from South Africa's Medical Research Council found that 37 percent reported always stopping for sex along their route.  Twenty-nine percent reported never using condoms with sex workers, 13 percent used condoms with their wives, 42 percent practiced anal sex, and 66 percent had an STI in the previous six months. The overall HIV prevalence among truck drivers and sex workers located at truck stops surveyed in the study was 56 percent.[35]  (Note that most trucking routes from the north terminate in Durban, which is located in KwaZulu-Natal, the province with the highest HIV prevalence, as per HSS findings.[3] )

In November 1999, Family Health International undertook research in four towns along the Durban-Lusaka highway.  The study found high HIV/STI vulnerability in border towns, whose character has been altered by trucking routes.  Thousands of truckers¾sometimes exceeding the stable adult population of border towns¾pass through each month, and their incomes are far greater than those of local residents.  Acute female poverty and high male and female mobility were found in all sites, as were poor STI treatment facilities and inadequate condom availability.[36]

Mining

The removal of black male labor force from villages to work in mines has been the driving force of the South African economy since the end of the 19th century. Generally, men are not allowed to bring their families with them to the mines. Miners live in single-sex hostels or barracks, far from their spouses or regular partners. Commercial sex and access to alcohol are common features of live in hostel compounds. Migrant labor and hazardous physical work¾relieved primarily by alcohol and sex¾create an environment that may be considered conducive to rapid HIV transmission. Mining areas illustrate how social context can have a greater effect on risk of infection than individual sexual behavior. For example, in the mining town of Carletonville, even adults with a single lifetime sexual partner face an extraordinarily high prevalence of HIV. [37][13]

Mining is South Africa's major source of foreign exchange, and many of the country's rural areas, as well as many parts of southern Africa, depend on mine workers' remittances.[21]  
Carletonville, in Gauteng Province, epitomizes how HIV is spread via population mobility.  The town has a population of about 200,000 people, including 70,000 migrant miners,[38] often hundreds of miles from their families.  The town is a center of sex and recreational drug trades.  A recent study in the Carletonville district found that the prevalence of HIV among women and men ages 14 to 24 was 34.4 and 9.4 percent, respectively.  Among women 24 years of age, HIV prevalence was 66.7 percent.[39]

There has been much research undertaken on sex work in mining communities, where many impoverished women live in informal shack settlements on mine perimeters and work as prostitutes.[21]   Sex workers and their clients are important "bridge" populations in the sexual networks linking sex worker, mobile, and residential communities.[36]

Sex workers in Carletonville have high awareness of HIV/AIDS and prefer to use condoms, but their clients almost always refuse.  Because of poverty and the fear of violence, they usually accede to their clients' demands. Most Carletonville sex workers feel it would be difficult to present a united front against men demanding unprotected sex as there is "fierce competition" for clients.  For many of these women, early life experiences have reduced their confidence in their ability to take control of their lives, rendering them less willing to insist on condom use.[38]

For mine workers, who face high risk of death or injury from their work, the possibility of dying from a slow, chronic infection seems remote.  And studies conducted by South Africa's Council for Scientific and Industrial Research show that many Carletonville miners do not wear condoms or even perceive themselves to be at risk of contracting HIV.[40]

Crime

According to the U.N. Office on Drugs and Crime, overall levels of crime began to increase in the mid-1980s and rose throughout the 1990s. Although there are some indications  that the steep increase in crime has abated, South Africa remains among the most crime-ridden and crime-concerned societies in the world.[19]

The two most developed provinces, Gauteng and Western Cape, with high concentrations of business, public administration, and urban centers (Johannesburg, Pretoria, and Cape Town), are the two most crime-ridden, with the highest rates for violent, property, and commercial crime. Among rural crimes, livestock theft is high in the remaining seven provinces.[19]

Crime does not affect all people uniformly, and the risk of being a crime victim is strongly influenced by gender, ethnicity, age, income, and place of residence. For example, whereas blacks/Africans are at a higher risk for individual violent crimes, nonblacks/Africans are at higher risk for property-related household crimes. Property and violent crimes pose the greatest risk for urban residents.[19]

Violent crimes, such as attempted murder, aggravated robbery, serious and common assault, and in particular violence against women and children, has increased since 1994 (with a slight downturn in 2001-2002). Murder rates, however, have been declining since 1994, by almost 30 percent. Much of the violence is attributed to the proliferation of firearms, both as a cross-border organized crime trafficking problem and as they are illegally appropriated for domestic criminal purposes.[19]

Organized crime has been increasing and comprises a range of criminal activities from trafficking in drugs, firearms, persons and stolen vehicles, to smuggling of precious materials and endangered species. Recently instituted organized crime countermeasures, including a new strategy, laws, asset forfeiture operations, and investigative and prosecutorial structures, have made considerable achievements in dismantling certain organized crime groups and monitoring trends in syndicate activities and targets.[19]

Stigma and Discrimination

Stigma around HIV/AIDS remains strong in South Africa[64] and is likely to influence personal decisionmaking with regard to HIV testing and disclosure. In 2002, Health Systems Trust noted that only 0.5 percent of South Africans believed that there was someone infected with HIV in their families. Up to 92 percent of persons who tested positive for HIV were not able to tell their partners their serostatus.[9]  Given pervasive stigma, many affected South African households face numerous psychosocial difficulties in responding to HIV/AIDS, both within the household and in the community. This can lead to ostracism, loss of social support, and reduced income-generating opportunities. The grief, depression, and stress that result from HIV/AIDS morbidity and mortality can also lead to reduced productivity and risk-taking behavior.[6]

Health System

There are one national and nine provincial health departments, with provinces responsible for implementation of AIDS programs. The national government is primarily responsible for collecting and distributing revenue equitably among provinces, formulating broad policy frameworks, and defining norms and standards for service provision.[76] As mentioned, despite redistributive policies in the early postapartheid period, South Africa's health care infrastructure remains highly inequitable.[20] 

South Africa's health care system comprises:

1. public sector, with government the largest source of health care finance. Government allocates to the health sector a portion of the finances it raises from taxes such as income tax, company tax, and sales tax (VAT); licences; sales of utilities such as electricity and water; and other sources of income. In 1998/99, of the amount raised by government, 94 percent was contributed by central government; provincial and local governments provided only 2.7 and 3.3 percent, respectively, of total government health care finances from their own revenue. Although government as a whole increased its contributions to health care between 1992/93 and 1997/98, there have been signs that government financing began to stagnate in 1997/98. Government financing per capita increased by 4.3 percent between 1996/97 and 1997/98, but declined by 2.5 percent between 1997/98 and 1998/99.[20]
2. households, the second largest source health care expenditures. Households either pay contributions to medical schemes and other forms of private insurance, or pay directly ("out-of-pocket") for services provided by health workers and facilities, as well as for medicines. Households with private insurance make out-of-pocket payments for services that are not covered¾or are not fully covered¾by their benefit packages. In 1998/99, households contributed over one-third of total, national health care expenditures. The increasing burden borne households is mainly the results of increased out-of-pocket expenditures. [20]
3. employers, which include private firms as well as government-owned entities, fund health care for their employees either directly through health services provided at the workplace, or indirectly through contributions to various forms of private insurance on behalf of their employees. The proportion of health care expenditures financed by employers grew at a slightly lower rate than that of households, and represented a smaller percentage (about one-fifth) of total expenditures. Employers' cost of providing health care benefits to their employees appears to be rising rapidly. Concurrently, the value of direct health care services provided by employers to their employees declined at an annual average rate of 5 percent between 1996/97 and 1998/99, likely the results of the rapid contraction over this period in the size of the mining sector, which provided extensive health care services to its employees. (See also the Impact section)
4. donors and NGOs are the fourth source of health care financing. Unlike most countries in Africa, donor contributions represent only a miniscule proportion of overall health care expenditures in South Africa (0.10 percent in 1998/99). This scenario is the result of the self-sufficiency of the South African health care system, as well as the international isolation South Africa experienced under apartheid. However, donor financing of health interventions appears to be growing, with donors interested in the government's policies to extend health care services to the disadvantaged. However, this growth has not diminished the financing burden shouldered by households.[20]

With regard to the private health sector, Health Systems Trust notes:

"Despite the growing dominance of the private sector, it is estimated that less than 20% of the total population made regular use of the full range of services in the private sector in 1998/99. The low coverage of the private sector in South Africa was apparent even in the 1980s. Moreover, private sector coverage declined as a proportion of the total population between 1996/97 and 1998/99,  suggesting that an increasing proportion of the population became reliant on public services even as the public sector received a declining share of health care finances (and even as the HIV/AIDS epidemic began to impact on health care needs). This probably reflected the increasing unaffordability of scheme membership as costs escalated in the private sector. In addition, there was a substantial decline in the number of employees covered by on-site health services, especially in the mining industry. This is attributable to falling levels of employment, most notably on the mines. These trends obviously had implications for equity, as will be discussed in a later section.[20]

Tuberculosis

WHO ranks South Africa a "high TB burden" country, with the world's seventh-highest burden of TB (by number of cases). In 2001, the TB incidence rate was 556 cases per 100,000 population. An estimated 1.5 percent of new cases are multidrug-resistant. An estimated 60 percent of adult (ages 15-49) TB cases are HIV-positive.[21] However, the country's TB control program is poorly equipped to respond.[6]  WHO notes that there is a lack of effective integration between TB and HIV policies and programs. Other constraints include underfunding, high rates of treatment interruption, overcrowding at treatment facilities, inadequate staff training, and managerial and organizational weaknesses. [21] 

Prevalence of Other STIs

In 2003, Health Systems Trust reported that:
"In South Africa, it's estimated that 11 million STI cases occur annually. For example in Hlabisa, a rural area in KwaZulu-Natal, among 321 women attending district antenatal clinics, 52%were found to have at least one STI (gonorrhea, chlamydial infection, trichomoniasis, or syphilis), and 18% had more than one infection. Modeling indicates that around 25%of all women in the reproductive age group residing in that district have at least one STI on any given day, of which about half are asymptomatic. Routine HIV and syphilis surveillance also indicates high rates of these infections countrywide."[20]

* The 2002 ANC survey found that an estimated 3.2 percent of ANC attendees had active syphilis. This figure is an increase over the 2001 figure of 2.8 percent in 2001. In 2002, the province with the highest syphilis prevalence was Gauteng, with an estimated 6.0 percent of ANC attendees testing positive. The Northern Cape and Free State provinces followed, with rates of 5.2 and 5.0 percent,  respectively. KwaZulu-Natal recorded the lowest prevalence, 1.5 percent.[1]

* A study in Carletonville found that infection with herpes simplex virus type-2 was the most significant factor associated with HIV status for both men and women.[39] 

* The 2002 HSRC survey found that 165 participants (out of 7,084 who completed questionnaires), or 2.3 percent reported having been diagnosed with at least one STI during the last three months. When weighted data were used, 2.6 percent of participants had at least one STI during the last three months, with prevalence among men at 3.9 percent (95% CI=2.8-5.4%) and among women, 1.7 percent (95% CI=1.2-2.4%). Despite relatively low reporting levels, there was a strong association between HIV and STIs. STI prevalence was highest among Africans, followed by coloureds and whites (however, the differences were not statistically significant). No major differences were observed in prevalence of self-reported STIs among people living in tribal areas, farms, or urban formal areas; however, there was a significantly higher prevalence of STIs among those living in informal areas.[3]

Gender

See also the Epidemiology section above for gender-disaggregated data on prevalence and mortality.

HIV prevalence among South African women tends to peak between ages 25 and 29, whereas among men, it peaks several years later (usually between ages of 30 and 35) and at lower levels.[3]  Women tend to become infected at younger ages than men for both biological and behavioral reasons. High male-to-female transmissibility of HIV is considered likely to play a significant role.[39]  Age mixing is another crucial factor.  Many young girls have sex with older men, who have been sexually active for many years and are thus more likely to be infected.  The U.S. Census Bureau projects that by 2020 there will be more men of reproductive age than women in the most severely affected countries of sub-Saharan Africa; this imbalance could lead men to seek even younger women.[33]  Also, fear of HIV drives some men to seek very young partners believing that these younger girls are more likely to be uninfected.(88)[41]  Finally, men's sexual "buying power" is low at young ages, but increases as they enter the labor force and acquire greater socioeconomic status; most of this "buying power" is directed at women who are economically vulnerable, and most of these women are relatively young.[3] 

Other factors that may render women vulnerable to HIV infection include:

* sex work
* situations such as food insecurity, in which women may trade sex for food or other necessities
* transactional sex, in which sex may be exchanged for gifts or money (see below)
* asymptomatic infection with other STIs
* coerced sex in dating scenarios, including forced sexual initiation, which occurs frequently[42]
* lack of/inadequate female-controlled preventive methods
* a resulting sense of fatalism that may reduce women's motivation to protect their sexual health[38]

(With regard to polygyny, the 2002 HSRC survey found that only 3.4 percent of married respondents (both male and female) (n=3,594) reported that they were in a polygynous union. [3])

Women's subordinate economic status affects their vulnerability to acquiring HIV and, once infected, accessing care and support services. A recent study found that even among married South African women, there is a high level of economic maltreatment: the partners of one in five married women regularly withheld money for essential living expenses, such as food or rent.[16]

Women are commonly viewed as "being inferior to men, as possessions, and as needing to be led and controlled.[43]  "Some men view women as sexually "out of control."[44]  Many women are unable to insist on condom use and negotiate the timing of sex and the conditions under which it occurs.[45, 46]  Even when women know that their husbands are at high risk of HIV, many do not raise the issue of condoms as to do so might be perceived as accusing their husbands of infidelity or depriving them of sexual pleasure. Women who do suggest condom use may be at increased risk of physical violence and/or economic abandonment. One study, for example, found that 57 percent of women living in the Eastern Cape believed that they could not refuse sex with their partner.[47]  The same study notes that in South Africa, a common form of spousal emotional abuse involves a husband's boasting about his other sex partners and/or bringing them home for sex in the marital bed; 10 percent of women in one province reported that their spouse had done this in the previous year. The study also found that HIV prevention was discussed significantly less often in relationships with physical violence.

Many women also face abuse and/or abandonment if they disclose their HIV-positive status.[16] Lobola, a long-standing tradition whereby men purchase a wife by paying her family a dowry, also renders it difficult for women to leave their husbands, as this would require fathers to repay the dowry. The 2002 HRSC study found that 50.2 percent of married respondents (both male and female) (n=3,374) reported that lobola or dowry had been paid at the time of their marriage.[3]

Sexual Violence

Rape Statistics

Watts and Zimmerman note that cross-country and cross-study comparisons of sexual violence are difficult, given differences in study populations and context-specific variations in respondents' willingness to disclose experiences of violence.[48]  The South Africa figures presented below, therefore, should be viewed with this caveat in mind.

In 1996, there were 44,222 reported rape cases in South Africa, equivalent to 210 incidents per 100,000 women. In comparison, in 1990, there were 102,555 reported rape cases in the U.S., an incidence of 80 per 100,000 women. In most presentations of police rape statistics, South Africa is near or at the top.[41]  Household surveys represent another method of obtaining information on the extent of sexual violence.  The last South African Demographic & Health Survey found a national rape prevalence of 7 percent, ranging from 3 to 12 percent across provinces.[41]  Gang rape is common.[48]  

Between 20 and 33 percent of al1 rapes are reported to the police.[49]  Reasons for low reporting of rape include women's reluctance to report rapes, lack of access to police stations (particularly in rural areas), police resistance to filing a report, inefficiency, red tape, or corruption.  Police turn only a small proportion of reported rapes into cases. Few cases are referred to court, and of these, a tiny fraction end in convictions.[50] (Julia Kim of Wits notes a paucity of data concerning rape committed against men, probably because of the related stigma.[41])

Both police statistics and household studies reveal that young women¾the demographic group most at risk for HIV/AIDS(108)[6]¾are also at highest risk of being raped.[41]  For example, using a nationally representative sample of 11,735 women ages 15 to 49, the Gender and Health Research Unit of South Africa's Medical Research Council found that 1.6 percent of these women had been raped (forced or persuaded to have sex against their will) before the age of 15.  They found that younger women were significantly more likely to report rape than older women.  The largest group of perpetrators (33 percent) were school teachers, followed by relatives (21 percent), strangers or recent acquaintances (21 percent), and boyfriends (10 percent).  Educational status and type of residence were not associated with child rape, but ethnic origin (based on apartheid-defined population categories), province, and age-cohort were.  Recently, there has been increased attention on infant and child rape.[42, 43, 51]


Trafficking

According to a recent report from the U.S. State Department, South Africa is a destination country for women trafficked from other parts of Africa, Eastern Europe, Asia, and the former Soviet Union for commercial sexual exploitation. South African women and children are also trafficked internally for labor and commercial sexual exploitation. Powerful trafficking syndicates from Russia, Thailand, China, and Nigeria control much of the sex trade. Sex tourism is also increasing. South Africa is a country of transit for trafficking operations between developing countries and Europe, the United States, and Canada. [22]

Sexual Behavior

Several South African researchers underscore that individual risk of HIV infection is determined by individual as well as community factors.  Thus, individual sexual behavior may be less important than the community from which sexual partners are chosen, i.e., social context may be a stronger predictor of disease than individual behavior.[3, 20]  Thus, the data below should be viewed against this backdrop.

Age at First Sexual Intercourse

In South Africa, sexual debut is generally early.[9, 16]  It usually begins during the mid-teens; for girls, often shortly after menarche.[52]  The 2002 HSRC survey found that the median age at first sex for respondents 25 years and older was 18 years. However, earlier median ages at first sex were noted among younger age groups. The median age of sexual début among 25- to 34-year-olds was 17 years; among 35- to 44-year-olds, it was 18 years. Among sexually active
15- to 24-year-olds, the median age was 16 years ( but this figure applies only to the 56.8 percent of respondents in this age group who were sexually active). Analysis found a trend toward earlier sexual début among younger respondents.[3]

Sexual Experience

The HSRC survey found that sexual experience among youth was significantly higher in urban informal areas than in any other types of localities. [3]

Multiple Partners

A high number of sexual partners, especially among men, is socially acceptable and encouraged.[6]  Given the country's economic situation and high unemployment, as well as lack of affordable recreational opportunities, Jewkes et al. posit that sexual relationships provide one of the few opportunities wherein young South Africans may obtain success, respect, and self-esteem.  Thus, they spend much time and effort on acquiring and keeping the "right" sexual partners.[52]

Multiple sexual partners, as well as ability to control girlfriends, are key to notions of "masculinity."[23]  Masculinity among miners signifies bravery, fearlessness, and the willingness to take risks; "real" men have enormous sex drives that lead them to have sex with an unlimited number of women.  Given this scenario, many miners do not use condoms.[21]

Among 2002 HSRC respondents who had sex in the past 12 months, most indicated that they had a single partner during the past 12 months; the proportion of those with more than one partner was lower for females (3.9 percent) than for males (13.5 percent) (p<0.001). For both sexes, youth were more likely to have had more than one partner in the past year, whereas most older respondents had only one partner. A higher proportion of Africans and male or female respondents living in urban informal areas had multiple partners.[3]

Self-reported Behavior Change

Participants in the 2002 HSRC study were asked whether they had changed their behavior in the last few years and how they had done so. Altogether, 40.2 percent of adults and youth 
indicated that they had changed their behavior. Significantly more males reported that they had changed their behavior than did females (p<0.001). When asked to specify in what way they had changed their behavior, a similar majority of both sexes indicated that they had only one partner and were faithful to their partner. The second most frequent behavioral strategy reported was that they al