HIV Around the World - Southafrica

HIV Around the World - SouthAfrica

Political Turmoil and Denial Feeds a RagingEpidemic

From Mark Cichocki, R.N., former About.com Guide

Updated February 11, 2011

About.com Health's Disease and Condition content is reviewed by the Medical Review Board

Nowhere in the world is the HIV/AIDS epidemic more prevalent than the continent of Africa. For South Africa, political turmoil, apartheid, and government denial has fed an epidemic that has reached disastrous proportions. As the number of infected and dead continue to rise, the impact on the people of South Africa and the entire world is growing. This edition of HIV Around the World takes us to Africa, a country with an unparalleled HIV crisis.

South Africa - Demographics

First some facts about South Africa:

• located at the southern-most tip of the African continent
• a country of 46.6 million people (about one sixth as many as the US) spread over 1.2 million square miles (about one fourth the size of Texas)
• eleven official languages including English
• religiously diverse but predominantly Christian
• a 1991 law created four officially recognized races: "Africans," "Whites," "Coloreds" and "Asians." While the law has been abolished, people still view themselves and others in these four categories.
• racial make-up is 79 percent African (black) and 10 percent white; there are several ethnicities within the African segment of the population.
• ruled by a parliamentary democracy that has seen a history of significant political unrest, violence and racial discrimination (apartheid).
• while apartheid related violence has decreased significantly, violent crime and organized crime is occurring at increasing frequency.

The Status of HIV in South Africa

Here are some facts about HIV and AIDS in South Africa:

• the most current estimate is that 5.5 million people are living with HIV, which represents about 12 percent of the population
• one in four people age 15 to 49 years is infected with HIV
• over 1,700 AIDS related deaths each day
• currently it is estimated that there are 600,000 orphaned children as a result of AIDS
• a survey done in 2004 reported that South African citizens spend more time at funerals than weddings, haircuts, or grocery shopping

The History of HIV in South Africa

The HIV/AIDS epidemic emerged in South African around 1982. However, the country was in the midst of the racial horrors of apartheid, so the HIV problem was for the most part ignored. Silently, while political unrest dominated the media, HIV began to take hold, primarily in the gay community.

Quickly, the disease spread outside of the gay population and by 1991 the heterosexual transmission rate equaled the rate of new infections among men who have sex with men (MSM). By the mid-1990s, HIV rates had increased by 60 percent, yet the government was still slow in its response to what was becoming a public health disaster.

Finally, in 2000 the South African Department of Health outlined a five-year HIV/AIDS plan, but got little support from South African President Thabo Mbeki. After consulting a group of HIV denialists headed by Dr. Peter Duesberg, Mbeki rejected conventional HIV science and instead blamed the growing AIDS epidemic on poverty.

Without government support, the five-year plan did not get off the ground. In the meantime, HIV among pregnant South African women soared from eight-tenths of one percent in 1990 to 30 percent 10 years later.

It was obvious that without political support, prevention efforts had a difficult time gaining a foothold. Even when the South African government gave in to worldwide pressure and established a plan that would make HIV medications publicly available, the government response was slow and inadequate.

By 2005, the extent of publicly available HIV medications were drastically behind goals set forth in 2003. Today, HIV experts around the world believe that a combination of political unrest, poor government support and political denial has fueled the public health disaster in South Africa.

The New Apartheid

From 1948 to 1992, South Africa's white minority government sanctioned discrimination based on race and economic status. This policy, known as apartheid, still exists today, but not as the world has come to know it.

For the vast majority of HIV-infected people, poverty is a cruel reality. Their only resort for health care is the government-sponsored public health sector. Unfortunately, public health care resources are scarce. There is little or no access to quality medical care, HIV testing, or, most importantly, HIV medications.

The rich and those who are better educated get the best medical care including HIV medications they need to stay healthy. So while political apartheid has officially ended, an AIDS apartheid remains and the poor are paying the price.

Who is Infected?

For decades, the prevailing thought among South Africans was that HIV/AIDS was a disease of the poor. Today, HIV is found everywhere, even among the country's rich. Still, there are groups that have been hit by the epidemic harder than others. Let's look at those populations.

• Young People - Young people ages 15 to 24 years make up the largest proportion of HIV infected people in South Africa. Of the thousands of new HIV infections each year, 58 percent of those are people younger that the age of 24. So why is this the case? Most believe the most probable causes include:
• profound poverty that limits access to education, good paying jobs, and health care
• young people orphaned by AIDS have no access to HIV education and are powerless to protect themselves from the disease

• Women - Females account for 55 percent of all new infections. Of all the infections in people 15 to 24 years old, 77 percent are women. There are many factors that account for this disproportional infection rate among women:
• South Africa is a patriarchal society, meaning men have social and economic power, making them the decision makers. Sexism against women is a common practice. Because men have the social, political and economic power, women are less able to make decisions that impact their lives, including the use of safer sex methods.
• Women are economically dependent on men. Because men are their only source of income, women feel they must obey their husband's wishes in order to maintain the relationship. It is difficult for a woman to insist on safer sex and condoms when they fear doing so will cause them to lose their only means of providing for their children. For those who have no source of income at all, prostitution is their means of making a living. And again, because of the male-dominated school of thought, these women have little or no choice regarding safer sex and condom use.
• Gender-based violence is a spin-off of the male-dominated societal norm. Sexual abuse, rape, and domestic violence are common. One study showed that over 1,000 rapes occurred each day. Fear of violence makes women hesitant to insist on condoms. It's common for men to believe women have been unfaithful if they ask for condoms. Asking for a condom can lead to rape, gang rape, or physical violence as a form of punishment for the woman's infidelity. And because women are looked upon as "less worthy people," these practices are common and seldom frowned upon. In fact, 30 percent of South African women say their first sexual experience was forced sex. Economic dependency, sexism, and gender-based oppression has become a deadly combination for the women of South Africa.
• Mother-to-Child Transmission - With the advent of HIV medications, HIV transmission from mother to child has decreased to less than three percent in countries like the U.S. Yet, in South Africa, this mode of HIV transmission is very common. By 2005, over 30 percent of all pregnant women were HIV infected. With limited access to medical care before, during and after delivery, mother-to-child transmission occurs in 25 to 30 percent of all pregnancies. After childbirth, breastfeeding contributes to the mother-to-child transmission problem. The lack of commercial formulas and clean water leaves breastfeeding as the only choice for mothers of newborns. Unfortunately, the rate of HIV infection by breastfeeding can be as high as 30 percent.
• Men Who Have Sex with Men (MSM) - Heterosexual transmission is the most common transmission type in South African. However, transmission among MSMs is gaining ground. Estimates place the infection rate among gay men at 33 percent. Since apartheid ended, homosexuality has become more accepted yet many still consider it a taboo. As such, gay men are subject to significant discrimination and stigma. National prevention agencies have been accused by the South African government of omitting gay men from their HIV education targets. The agencies in turn blame the omission on a lack of support from the South African government. The result is that condom use is at best erratic, and for the most part non-existent among gay men.
• Migration - South African men often have to go to where the work is. These men migrate to rural areas to work in mines, farms, and factories. They return home two or three times each year to see their families. Unfortunately, while they are away from home, unsafe sex outside their marriages is quite common. Young men with disposable income far away from home is a recipe for something South African officials call "migration-induced unsafe sex." Since the end of apartheid, this migration problem has gotten worse because travel restrictions have been lifted.

HIV Prevention

The prevention group LoveLife launched South Africa's largest prevention campaign in 1999. Targeting young people, the goal was to decrease HIV, sexually transmitted diseases, and teen pregnancies. The group launched support hotlines, HIV clinics, youth centers and health clinics. For those hard-to-reach populations in rural areas or outside the education system, LoveLife traveled to them to deliver their HIV message.

Yet, LoveLife has been criticized for poor implementation of education programs, poor choices of who to target with their education, and failing to address identified weaknesses in their programs. In fact, their largest funding source, The Global Fund, pulled its funding from the program in 2005.

Like many countries with an out-of-control HIV problem, South Africa's economic, racial, and ethnic diversity makes prevention and HIV education very difficult. With limited resources, both financial and professional, choosing which populations to target and how exactly to get the prevention message across is a daunting task. But there are some programs in place:

• Voluntary HIV testing sites have gone up all over South Africa. Unfortunately, perceptions among South African citizens has made widespread testing difficult. For example, many more women than men are accessing the testing sites. Men feel that learning their HIV status is a burden that has no real benefit. That, combined with concerns of confidentiality and HIV stigma, keeps them away from the testing sites.
• As mentioned earlier, homosexuality is more acceptable now than at any other time in South African history. Yet, significant discrimination and stigma remains at an individual and institutional level. A counseling and medical service called the Triangle Project sets up shop in gay bars and clubs in hopes of providing a safe haven for gay men; allowing them to access the educational and medical services they need. Yet the lack of consistent education and prevention efforts is evident, fueling a rising infection rate among gay men.
• Prevention, testing, and education requires financial and human resources. Unfortunately, there is a shortage of both. Health-care workers, testing professionals, and HIV educators are lacking. Ironically, the shortage of these professionals is due in large part to high death rates from the hands of the very disease they are trying to stop.

HIV Treatment and Care

The sad fact is that most infected South Africans do not get the HIV care they need. For most, their only chance at care is through publicly funded. Only 20 percent of South Africans have private insurance or access to privately funded care. As a result, the public clinics are short-staffed, have long lines, are poorly equipped and maintained, and sadly there is little government initiative to address the problem.

Among the lucky few who get publicly funded care, it is inconsistent, most often without access to even the most basic services and HIV medications. Among the 80 percent that rely on public health care, the feeling is that society doesn't care and has alienated them from the rest of South Africa because of their disease.

The Treatment Action Campaign (TAC) was started by ZackieAchmat, an HIV positive man who recognized the importance of regular HIV care and medications. His organization has put tremendous pressure on the South African government in hopes of persuading them to provide basic HIV medications and HIV care to those in need.

In what was thought to be a huge positive step, South Africa's High Court agreed with him and ordered the government to make the HIV medication Nevirapine available in all state hospitals and clinics. The benefits of Nevirapine and its success in lowering the risk of mother-to-child transmission has been proven by scientists around the world. Yet, the government has been slow to follow the Court's order, citing concerns over the safety and effectiveness of Nevirapine. They went as far as making the distribution of Nevirapine a crime, punishable by jail time and dismissal from the medical community.

Sadly, many feel that with the right political commitment, HIV medications like Nevirapine could be universally available in as little as five years. But the reality is that while the government drags its feet, babies continue to be infected by their mothers and South Africans continue to die.