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South Africa: New AIDS Statistics

AfricaFocus Bulletin
Feb 16, 2006 (060216)
(Reposted from sources cited below)

Editor's Note

A new study released this month estimates that 4.8 million people, or approximately 10.8 percent of South Africans over the age of 2, are now living with HIV/AIDS. The nation-wide survey, carried out by the Human Sciences Research Council (HSRC), was close to the estimates produced by the latest Actuarial Society of South Africa (ASSA) computer model, released in December. Both studies provide new detailed breakdowns of data, with the HSRC survey showing, for example, rates of AIDS prevalence as high as 17.6 percent in informal (slum) residential areas.

The full HSRC report is available for download from http://www.hsrcpress.co.za. The ASSA computer models and data are available from http://www.assa.org.za. The ASSA study focuses on numerical estimates, but the HSRC report also provides extensive analysis and detailed policy recommendations. It notes, for example, a rate of infection among children 2-14 too large to be accounted for by mother-to-child transmission, and recommends further investigation both of child abuse and possible transmission through the healthcare system. It also notes still widespread levels of misinformation and ignorance about HIV/AIDS, particularly among those aged over 50 and in the 12 to 14 age bracket.

This AfricaFocus Bulletin contains brief excerpts from the press release from ASSA and from the recommendations in the HSRC report.

Another AfricaFocus Bulletin sent out today contains excerpts from a speech by Paul Farmer on grounds for optimism on AIDS treatment worldwide and in Africa despite the limitations of current efforts. For earlier AfricaFocus Bulletins on health issues, visit http://www.africafocus.org/healthexp.php

++++++++++++++++++++++end editor's note+++++++++++++++++++++++

New South African Aids Model Released

Actuarial Society of South Africa

Press Release November 28, 2005

[Excerpted from the full press release on http://www.assa.org.za The full models are also available for download with a free login to the site.]

The Actuarial Society of South Africa ('ASSA') has released the new version of its local AIDS and Demographic model that provides insight into the state of the HIV epidemic in each province in South Africa. ASSA2003 is the first AIDS and Demographic model to take the government's Comprehensive Plan for HIV and AIDS into account at a provincial level. The model has been designed by South African demographers and actuaries based on detailed South African data. Using these data, the model projects the numbers of South Africans living with HIV, new infections, AIDS deaths, AIDS sickness and many more statistics into the future. According to Dominic Liber, convenor of the ASSA AIDS Committee, "this is the most accurate model that ASSA has developed to date, that allows for differing rates of HIV spread and differing levels of intervention by province."

...

Profile of the epidemic in 2005 at a national level

The total number of people living with HIV in South Africa is estimated to be 5.2 million in 2005. It is estimated that there were around 530,000 new HIV infections between the middle of 2004 and the middle of 2005 and around 340,000 AIDS deaths over the same period. As the number of new HIV infections currently exceeds the number of AIDS deaths, the HIV prevalence is still slowly growing in South Africa. The current massive number of HIV positive individuals has resulted in an estimated 520,000 untreated South Africans who are sick with AIDS and in need of antiretroviral treatment. As at the middle of 2005, the model estimates that just over 120,000 South Africans were receiving antiretroviral treatment. ASSA2003 also estimates that around 1.5 million South Africans have died from AIDS-related illnesses since the start of the epidemic. The ASSA2003 model predicts that the total number of HIV infections in South Africa will increase slightly, from 5.2 million currently to 5.8 million by 2010. The annual number of new HIV infections is likely to remain at close to half a million over the next few years, in spite of the significant interventions that have already been introduced to limit the spread of HIV.

Profile of the epidemic in 2005 at a provincial level

... KwaZulu-Natal is clearly the province worst affected by the HIV/AIDS epidemic, with the highest rates of HIV prevalence, and the lowest life expectancy. Other severely affected provinces are Gauteng, Free State, Mpumalanga and North West. Differences in life expectancies between the provinces are partly due to differences in the socio-economic profiles of the populations in the different provinces, but are also largely a reflection of the differences in rates of HIV prevalence and consequent AIDS mortality.

Access to antiretroviral treatment in the provinces

The ASSA2003 AIDS model will become a valuable tool for the provincial health departments in the implementation of the national Comprehensive HIV and AIDS plan. The model provides estimates of the expected numbers of South Africans who are entering the AIDS sick phase and who will be requiring antiretroviral treatment in the future. As at mid-2005, the proportion of AIDS cases on antiretroviral treatment ranged from 15% in KwaZulu-Natal to 50% in the Western Cape. According to Leigh Johnson, actuary and member of the AIDS Committee, these differences are in part due to differences between provinces in terms of the proportion of the population using private facilities, but are also largely a reflection of inequality in access to treatment within the public health sector.

For more information

ASSA2003 is freely available for download from the Actuarial Society of South Africa's website: http://www.assa.org.za ...


South African National HIV Prevalence, HIV Incidence, Behaviour and Communication Survey, 2005

4.2 Recommendations

[Excerpts only. For full set of recommendations see pages 139-145 in the full report available at http://www.hsrcpress.co.za]

The HIV prevalence in South Africa among persons aged 2 years and older at 10.8% translates to 4.8 million (95% CI: 4.2-5.3 million) people living with HIV/AIDS in 2005.

False sense of security

Factors underpinning continued high HIV prevalence are partly illustrated by the finding that half of the respondents in this study who were found to be HIV positive did not think they were at risk of HIV infection. Put another way, over two million people who are HIV positive in South Africa do not think they are at risk. This means they may be unaware of their risk of potentially infecting others. For this reason it is also recommended that HIV/AIDS campaigns and programmes address this false sense of security in the general population, with a particular emphasis on finding out one's HIV status. Counselling and other services need to be expanded to provide additional support to persons who find out that they are HIV positive.

Stigmatising attitudes are decreasing

The survey showed that nearly half of South Africans aged 15 years and older think it is acceptable to marry a person with HIV and also that a similar proportion would not have a problem having protected sex with an HIV-positive person. These results suggest that South Africans are accepting HIV/AIDS as a reality in South Africa. It is critical that service providers capitalise on this window of opportunity to encourage disclosure of HIV status.

Integration of family planning and HIV/AIDS services is vital

In view of the high prevalence and incidence of HIV amongst pregnant women and women in the child-bearing age group, it is critical that the government targets this group and strengthens family planning programmes. This is important, given that one in five South African women of reproductive age are not using any contraceptive method. For those who use injectable contraceptives and contraceptive pills, it is important to emphasise consistent use of condoms with regular and non-regular partners as long as they are not certain of their own, or their sexual partner's HIV status.

The high risks of HIV transmission from mother to baby before, during and after pregnancy, and including the risk of becoming HIV positive late in pregnancy or during the period of breastfeeding, need to be noted as important areas of risk. Teenage females have been underemphasised as a target group, although pregnancy levels are high in this age group. We recommend that urgent action on a national scale be taken to make women aware of the risks of HIV infection during pregnancy so they can make informed choices about how best to protect themselves and their offspring, from becoming infected. HIV/AIDS campaigns should also target would-be parents to encourage them to: (a) plan the pregnancy; (b) each get tested for HIV before trying to conceive and disclose the results to each other. Prospective parents should also be informed that women run a greater risk of being infected with HIV towards the end of pregnancy.

Periodic HIV testing is crucial

South Africa appears to have a well-established VCT (voluntary counselling and testing) system, and most respondents know of a place to get tested. However, many respondents found to be HIV positive in this survey had not been tested. Knowledge of HIV status is a critical aspect of prevention as it is linked to motivation to address HIV prevention risk to others. It also serves as an entr‚e into seeking treatment for opportunistic infections and ARV (in the case of advanced HIV infection). ...

The extremely high HIV incidence in females aged 15 24 years (six times higher than males of the same age) is a source of concern. Since half of those who are HIV positive do not know their HIV status, we recommend that HIV/AIDS campaigns and programmes should sensitise this young female group to the fact that the risk of HIV is real. They should be strongly encouraged to know their HIV status through the VCT sites that are available and accessible. Annual testing, particularly amongst young females, is recommended.

It is also recommended that VCT services continue to be promoted, but that routine testing also be considered for persons seeking healthcare for other reasons particularly, as recommended by UNAIDS/WHO, STI patients and patients with diseases associated with HIV infection.

Young people should be encouraged to delay sexual debut

Data from this study shows clearly that the more sex one has, the greater the chances of acquiring HIV. Sexually active persons had an HIV prevalence that was four times higher than that of those who said they had not had sex and 75% higher than that of those who had abstained from sex in the past 12 months. When controlling for age of the participant, the relationship remained strong for the youth. For this reason, it is critical that young people be encouraged to delay sexual debut.

Avoid high partner turnover and concurrent sexual partnerships

Frequent partner turnover and concurrent sexual partnerships partly contribute to high HIV prevalence among single men and women. Clearly there is a need for prevention campaigns and programmes to emphasise this aspect of risk. To reduce HIV risk, it is recommended that sexually active persons should: (a) avoid engaging in unprotected sex with any person whose HIV status they do not know; (b) access and consistently use condoms from the government or other sources to protect themselves in every sexual encounter; and (c) avoid frequent partner turnover and concurrent sexual partnerships.

Sexual partners amongst youth should be within a five-year age range

What distinguishes HIV risk between young females and young males is the age group with which each has sex. The study found that young females are more likely to have male partners who are five years older than themselves (females: 15-19 = 18.5% and 20-24 = 28.4%) versus (males: 15-19 = 2% and 20-24 = 1%). Older male sexual partners have a higher HIV prevalence than younger male partners. ...

Inform women that they are more at risk and encourage self-protection

Women are biologically susceptible to HIV infection and men are more efficient at transmitting HIV. In addition to social factors that increase vulnerability to HIV, biological factors increase susceptibility to HIV among women. While men are more efficient at transmitting HIV, females are more susceptible to HIV infection. It is recommended that women ensure that they use condoms to prevent themselves from becoming infected.

Get treated for STIs and abstain from sex when one has STIs

Sexually transmitted infections increase susceptibility to HIV infection. This study found a strong association between having a history of STI and being HIV positive. For this reason, we recommend that the risks of HIV infection with concurrent STI infection need to continue to be emphasised in prevention programmes. Those who have signs or symptoms of STIs should immediately seek treatment and also not have sex when symptoms are present.

Warn older South Africans that they too are at risk of HIV

The high HIV prevalence among South Africans aged 50 years and older calls for development of targeted interventions for this age group. Persons aged 50 years and older are considerably less aware of national HIV/AIDS campaigns and programmes and have generally poorer knowledge of key aspects of HIV prevention and other aspects of HIV/AIDS. ...

HIV infection among children needs emphasis

The high HIV prevalence among South African children is a major cause of concern. When the 2002 results were released there was a tendency not to acknowledge that so many South African children were infected with HIV. The estimated 129,621 children aged 2-4 years and 214,102 children aged 5-9 currently living with HIV/AIDS are significant numbers. In view of these findings we recommend that the government reviews the 'baby friendly' breastfeeding policy and encourage HIV-positive women not to breastfeed their children and to supply them with a breastmilk substitute instead. It is feasible for the state to establish a not- for-profit enterprise that can produce a breastmilk substitute specifically to support women who cannot breastfeed because of HIV and other conditions.

The PMTCT programme needs to be strengthened. In addition, there is a need to examine other modes of HIV transmission in children. Given that 6% of new infections occurred within 180 days prior to testing of children in this survey, and the observation that these children were no longer being breastfed, the chances of them being infected through mother-to-child transmission seems unlikely. There is thus a likelihood that they were infected horizontally through other means. The source of infection in these children needs to be investigated, including the potential of child sexual abuse. ,,,

Safe male circumcision is vital to prevent HIV in South Africa

In view of the high HIV prevalence among adult men in South Africa, although lower than that of women, it is crucial that South Africa adds to the evidenced-based prevention effort. In a study in Orange Farm in South Africa, Auvert and Puren (2004) concluded that safe circumcision can offer at least 60% protection from infection among males. For this reason, we recommend that healthcare providers, as part of routine healthcare, encourage young men to be safely circumcised before becoming sexually active. ... However, care needs to be taken in communicating this intervention, so that an impression is not created that male circumcision completely prevents HIV acquisition. Clearly not all men who are circumcised will escape HIV infection and it is still important for circumcised men to practice safe sex.

Positive prevention is an important tool for HIV prevention

Although there was an improvement in the proportions of people who are aware of their HIV status who were using condoms during the last sex act in this study when compared to the 2002 survey, there is still some concern that many of the people who have tested for HIV and know their status are still engaging in risky behaviour. It is important that everyone who knows their status takes the appropriate steps to both reduce the chances of infection (in the case of those who are HIV negative), and avoid infection of uninfected partners or those who are unaware of their status (in the case of those who are HIV positive). ...

Refocus communication strategy

With regard to HIV/AIDS communication campaigns and programmes, there needs to be a systematic and co-ordinated approach to addressing key knowledge areas of prevention, treatment, care, support and rights. Clearly there is a need for accountability of programmes to an overarching communication strategy that is related to the National Comprehensive Plan. This study found that there is an urban bias in the reach of HIV/AIDS campaigns and programmes and emphasis on the use of radio in all languages is recommended to increase non-urban reach.

Most national campaigns and programmes see youth as a primary target audience. The notion that a focus on youth under 20 will have a knock-on effect on HIV prevalence amongst young adults, or adults in general, does not appear to be the case. ... Emphasis therefore urgently needs to be placed on non-youth audiences. ,,,

Partner reduction and avoidance of partner concurrency as strategies for HIV prevention do not appear to have been sufficiently emphasised by campaigns. These strategies are recognised as having potential as efficient mechanisms to reduce HIV incidence, and should be prioritised in HIV/AIDS campaigns and programmes directed at all age groups and localities. This is particularly important for the young adult and adult age groups who are exposed to sexual networks where HIV prevalence is high.

Attention should be given to conveying knowledge of the basic science of HIV including its relation to causing AIDS, the fact that it is incurable, and that ARV treatment exists as a means to prolong life. ...

Investigate a dedicated tax for HIV/AIDS

This study indicates that between 4.8 million and 5.3 million South Africans aged 2 years and older are living with HIV/AIDS in 2005; many already need ARV therapy as seen from the study of a national probability sample of South African educators, where 22% of those infected with HIV had CD4 cell counts < 200 cells/mm3 blood (Rehle et al. 2005). Currently the government is providing ARV therapy to many, but not all. The cost is likely to escalate. This survey showed that although South Africans believe the government is committed to controlling HIV/AIDS and is not in denial about HIV/AIDS, they are of the view that the government is not providing sufficient funding for HIV/AIDS. Because the resources are not limitless, it is crucial to explore sources of additional funding. When employed study participants were asked whether they are prepared to pay tax for HIV/ AIDS, 47% of males and 44.2% said they were willing to pay and a small proportion of 29.3% males and 27.1% females were unwilling to do so. The remainder did not express an opinion. It is recommended that the government explores this option to ensure sustainability of the ARV therapy programme. This could take the form of establishing a committee to explore the issues around financing of HIV/AIDS programmes.


AfricaFocus Bulletin is an independent electronic publication providing reposted commentary and analysis on African issues, with a particular focus on U.S. and international policies. AfricaFocus Bulletin is edited by William Minter.

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