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Combating HIV Infection in Soweto, South Africa

By Glenda Gray, MD
Originally published in HIV/AIDS: Annual Update 2001

Background

Even though South Africa has more HIV-infected people than any other country in the world, it is still a country in denial. It is estimated that over 4.7 million South Africans are currently HIV-infected. This number is projected to more than double during the next decade. In 2005 there could be around 5.3-6.1 million infected individuals, rising to 6.0-7.5 million by 2010.

Approximately 13% of all South African adults aged 20-64 are currently infected with HIV; this percentage could rise to 20% to 23% by 2005 and 22% to 27% by 2010.

HIV is a disease that affects young people; approximately half of all adults who acquire HIV become infected before they turn 25. These young people typically die of AIDS before their 35th birthday.

Sex differences are also quite pronounced: The infection rate among women is highest between the ages of 15 and 20, whereas the highest incidence in men is observed at older ages. Infection levels among teenagers are still increasing at alarming rates. A total of 53% of the South African population is aged under 25, emphasizing the enormous impact that infection in young people will have on the population as a whole.

The number of AIDS deaths is expected to rise rapidly in South Africa from 90,000 in 2000 to between 354,000 and 390,000 in 2005, to over half a million in 2010. AIDS deaths will soon outstrip non-AIDS deaths in adults in the economically active age groups. By 2010, life expectancy is predicted to be 43 years—17 years less than it would have been without AIDS—and the infant mortality rate will have doubled.

HIV prevention requires sustained efforts of social mobilization toward healthier and safer sexual behavior. Data from the South Africa Demographic and Health Survey in 1998 indicate early onset of sexual activity and poor condom use. The survey reported that only 22% of women have ever used condoms, and only 8% had used a condom in their last sexual encounter. This survey shows that although people have good knowledge of HIV/AIDS, its mode of transmission, and how it can be prevented, they often fail to act on their knowledge.

Women and HIV/AIDS

HIV seroprevalence continues to increase in pregnant women. The country has seen an increase from 4% in 1993 to 24% in 2000. Women are particularly heavily affected by the epidemic. They are at greatest risk of infection due to biologic, social, and economic factors, and are also more vulnerable to the impact of HIV for many reasons:

• South African households headed by women tend to be poorer than those headed by men, and therefore have fewer reserves.
• Unemployment is higher among women.
• Even among married women there is a high level of economic maltreatment. A recent survey indicated that partners of 1 in 5 women regularly withheld money for essential living expenses.
• Violence against women is high, with 13% of women reporting being beaten by a partner. Many women face risk of abandonment and abuse following disclosure of HIV-positive status.
• Women traditionally provide care to the terminally ill, and female children in particular may be expected to provide care when 1 or both parents have died of AIDS.

Adolescents and HIV/AIDS

Like young people everywhere, young South Africans face challenging situations and choices about sexual relationships. Due to South Africa's high rate of HIV infection, however, these choices can have severe consequences. Overall, 31% of South African youth are sexually active, with the majority having their first sexual experience when aged between 12 and 15. Young people express a great deal of concern about HIV infection: no fewer than 66% feel that they could die of AIDS. But despite this, many engage in risky sexual behavior and do not protect themselves against pregnancy or infection: 35% report that they avoid sex with condoms.

For some young people, sex is used as a commodity in exchange for money, drinks, food, or gifts. A total of 43% of sexually active South Africans indicate they know someone their own age who has sex for gifts, while 16% of sexually experienced girls say they themselves have had sex for gifts. While in some situations this exchange of sex for gifts may involve older men, even young boys report that they have given a girlfriend pocket money, or bought her drinks or food, in return for sex.

Not all young people are sexually active by choice; a number of young people deal with sexual coercion and a concerning number have experienced sex by force. A total of 33% of sexually experienced girls are afraid of saying no to sex. Over half of sexually experienced girls agree with the statement "There are times when I don't want to have sex, but I do because my boyfriend insists on having sex." Young people are both the perpetrators and victims of sexual coercion. More than 1 in 3 sexually active boys disagree with the statement "If my girlfriend says no to sex, I do not insist on having sex with her."

Sadly, the majority of South African youth name HIV/AIDS as one of the 5 greatest concerns for young people today. Many believe that they or one of their family members might die of AIDS in the future.

Children and HIV/AIDS

HIV can be prevented by providing HIV-infected pregnant women with appropriate antiretroviral therapy during pregnancy and delivery. The higher the seroprevalence of HIV, the more cost-effective are intervention programs addressing mother-to-child HIV transmission. It is estimated that 70,000 children are infected with HIV each year in South Africa because there are no programs in place to avert these infections. In Soweto, 50% of pediatric admissions and two thirds of deaths in children are attributable to HIV.

Orphans

Orphans are perhaps the most tragic and enduring legacy of the HIV/AIDS epidemic. Caring for them is one of the greatest challenges facing South Africa. It is expected that by 2005 there will be around 800,000 orphans under the age of 15, rising to almost 2 million in 2010. Many orphans will grow up as street children or will form child-headed households to avoid being separated from siblings. All will have been traumatized by the illness and death of parents, and often by separation from their siblings. Trauma will be exacerbated by stigma and secrecy around HIV/AIDS which hampers the bereavement process and exposes children to discrimination in their community or extended family.

Orphans will probably be more susceptible to becoming HIV-infected themselves through abuse, sex work, or emotional instability leading to high-risk relationships.

As children grow up in these pressurized circumstances without adequate parenting, support and opportunities, they are at high risk of developing antisocial behavior and becoming less productive members of society. The consequences for affected children—and society as a whole—will be profound.

HIV Care in South Africa

It is anticipated that HIV-infected individuals will experience a greater degree of rationing of hospital care than other health service users. There are already anecdotal reports of public hospitals refusing to admit patients at all if they have a positive HIV test. Rationing of access to hospital care for children ill with AIDS may become commonplace as levels of infection increase. There will be increasing temptation to blame the victims of the epidemic for the strain caused to health services and deny them access to basic care. Clearly the challenge is to adopt more cost-effective models of healthcare rather than to resort to irrational or discriminatory exclusion from services.

Government and Industry Responses

In the face of the AIDS catastrophe, the response of the South African government has been highly inadequate. Instead of implementing effective public health policies such as the use of short-course antiretroviral therapy to prevent mother-to-child HIV transmission, or exploring all possible avenues to supply treatment drugs to infected patients, official pronouncements have toyed with 'AIDS dissident' beliefs that HIV does not cause AIDS, and have blocked the use of affordable therapies. Only very recently was it made legal to prescribe nevirapine, a cheap and highly effective intervention to reduce mother-to-child transmission.

This situation has been exacerbated by the refusal of the pharmaceutical industry to waive patent rights and allow the manufacture of generic versions of antiretroviral agents. In April 2001, the collapse of the case brought against the South African government by 39 pharmaceutical companies raised the hope that countries in the developing world may be able to pass laws to allow them to develop affordable drugs, although the South African government quickly made clear that it has no intention to use this opportunity to accelerate access to antiretroviral medications.

Conclusion

With the recent focus on affordable drugs for people in developing countries and programs to implement mother-to-child HIV prevention interventions, hopefully the tide is turning in South Africa. Nevertheless, over the course of many years, hundreds of thousands of South Africans who might have lived long and productive lives will have died because of the inertia of and lack of adequate response by the South African government.

Suggested Reading and Related Resources

Glenda Gray, MD, is the Director of the Perinatal HIV Research Unit at the Chris Hani Baragwanath Hospital in Soweto, South Africa.

Copyright © 2001 by iMedOptions, LLC.