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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
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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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