A frequently asked question is: 'Why is South Africa, a comparatively wealthy and developed country in Africa, so badly affected by RN/AIDS?' Reinecken (2003) stated that the reasons for the spread of the epidemic in Southern Africa overall are complex but offered this explanation for South Africa:
The main factors spreading the epidemic are the breakdown of the social fabric of society as a consequence of apartheid, the migrant labor system, the good transport infrastructure leading to high population mobility, the large disparities in income, and the low level of education. Other factors include high levels of prostitution and sexually transmitted disease, resistance to condom use, and social norms permitting high numbers of sexual partners. (p. 283)
There has been growing recognition among researchers over the past decade of the importance of acknowledging and understanding the "contextual backdrop" of RN/AIDS in South Africa (Bernstein & van Rooyen, 1994; lames, 2002). Campbell (2003) indicated that "the forces shaping sexual behavior and sexual health are far more complex than individual rational decisions based on simple factual knowledge about
health risks, and the availability of medical services" (p. 7). She stressed the importance of understanding both micro-level factors (e.g. attitudes, cognitive processes, perceived vulnerability) and macro-level factors (e.g. poverty, gender inequalities) and she asserted that "each of these perspectives forms an essential frame in the kaleidoscope of factors that are implicated in the development and persistence of the HIV epidemic... " (p. 7).
However, we are only just beginning to understand how historical, social, political, and cultural factors interact to shape the epidemic in South Africa (Delius & Walker, 2002). According to Campbell (2003), inadequate attention has been paid to how micro and macro factors interact at the community level. I will briefly review some of the main factors that appear to have contributed to the extent and severity of the HIV/AIDS epidemic in South Africa from the micro to the macro level.
Sexual Knowledge, Attitudes and Behavior ofAdults
A significant body of research has developed focusing on HIV/AIDS awareness and sexual risk behaviors among adults and youth in South Africa. But the problem is that many studies report contradictory findings, making it confusing where we stand in terms of HIV prevention needs. For example, Dorrington and Johnson (2002) asserted that a significant proportion of South Africans lacked basic knowledge about HIV/AIDS. In contrast, the 2002 national HIV/AIDS Household survey found that overall South Africans had "good knowledge of key aspects of HIV/AIDS information" (Nelson MandelalHuman Sciences Research Council Study of HIVIAlDS, 2002, p.15).
A significant weakness of recent studies of risk behaviors among South Africans (Nelson Mandelal Human Sciences Research Council Study of HIV/AIDS, 2002;
Simbayi, Chauveau, & Shisana, 2004) is that few have included any items relating to specific sexual behaviors (e.g. receptive oral sex, insertive anal sex, mutual masturbation, kissing etc). This is troublesome since there are varying degrees of associated risk along the continuum of sexual behaviors. According to Brody and Potterat (2003), health warnings in Sub-Saharan Africa tend to avoid mentioning anal sex, and it is believed that a significant proportion of both women and men engage in receptive anal intercourse.
The glaring omission of questions relating to specific types of sexual behavior is also evident in recent surveys of risk attitudes and behaviour of youth (Peltzer, 2003; Taylor,
Dlamini, Kagoro, Jinabhai & de Vries, 2003). This needs to be addressed in future surveys.
Inaddition, a subject that has been virtually ignored by researchers and those involved in HIV prevention efforts in South Africa concerns male-male sex. Inhis case study of same-sex sexuality in Dakar, Senegal, Teunis (2001) asserted that "male same-sex sexuality is more prevalent on the African continent than the literature on African sexuality suggests" (p. 180). More specific to the local context, Niehaus (2002) conducted interviews with former mineworkers and prisoners in Impalahoek, a village in the Bushbuckridge area of the South African lowveld, and indicated that "contrary to popular assumptions, male-male sex is extremely pervasive in both institutions and frequently takes the form of anal intercourse" (p. 94).
In Southern Africa, several politicians have made homophobic remarks, notably Robert Mugabe, the President of Zimbabwe and his Namibian counterpart, Sam Nujoma, as well as Kenneth Meshoe, the leader ofthe African Christian Democratic Party (Teunis, 2001; Niehaus, 2002). This hardly helps prevention efforts targeting men who engage in same sex behavior. There are such limited data available on risk behaviours among men who have sex with other men in Africa but evidence provided by both Teunis (2001) and Niehaus (2002) indicates that these men have inadequate knowledge about AIDS and a large proportion of them do not use condoms when engaging in anal intercourse. Both authors urged that we need to be more open about same sex sexuality and that we need to recognize that male-male sex is a high risk activity for the transmission ofHIV.
Too few surveys have inquired about sexual behaviours with partners of the same sex;
at best there may be a single question asking whether or not the respondent ever engaged in homosexual intercourse (Simbayi, Chauveau, & Shisana, 2004). The percentage of respondents who indicated in these surveys that they engaged in homosexual intercourse has been extremely (and suspiciously) low. For example, in the national HN/AIDS Household Survey, 1.1 % of youths 15-24 years of age indicated that they had at least one sexual experience with a member of the same gender in the past 12 months (Simbayi, Chauveau, & Shisana, 2004). Similarly, in the survey by Peltzer (2003) of a rural adult population, only two respondents out of a total of 398 adults (155 males and 243 females) reported having had a same sex partner (and they had not engaged in penetrative anal
intercourse in the past 12 months). The social desirability bias inherent in these self- report surveys requires that we view these kinds of figures with caution.
Despite these flaws, recent research suggests that adult South Africans continue to put themselves at risk. For example, a study of female sex workers in the Limpopo Province, Peltzer, Seoka, and Raphala (2004) showed that although three quarters had been exposed to HIV interventions, most of them demonstrated inadequate knowledge of HIV prevention methods, some incorrect beliefs about HIV transmission, inconsistent condom use with paying partners, and poor condom use with regular partners. Olley, Seedat, Gxamza, Reuter and Stein (2005) examined the prevalence of unprotected sex in a sample of men and women in Cape Town who were recently diagnosed with HIV. Two thirds had been sexually active in the six months before the study and over half (54.5%) had not used a condom the last time they had sex. Individuals who had a shorter duration of HIV infection and who were more likely to engage in denial tended to have unprotected sex.
What seems to be evident from a range of studies with diverse population groups (e.g., school age youth, university students, adults, sex workers, teachers, mineworkers) (Taylor et aI., 2003; Peltzer, 2003; Wojcicki & Malala, 2001; Varga, 2001; Maharaj, 2001; Macheke & Campbell, 1998; Smith, Visser & Akande, 1998; Mwamwenda &
Jadezweni, 2000; MacPahil & Campbell, 2001; Peltzer& Promtussananon, 2003) is that while AIDS awareness seems to have increased over the past decade, condom use is still far too low given the pervasive and lethal nature of the epidemic in South Africa. In their review of HIV prevention programmes in South Africa, Harrison, Smit, and Myer (2000) concluded that "currently there is a substantial gap between high levels of knowledge and low levels of preventive practice" (p. 283).
Sexual Knowledge, AUitudes and Behavior of Children and Youths
Eaton, Flisher and Aaro (2003) reviewed a total of 75 research papers on sexual behavior among South African youth and they concluded from this review that although the majority of youth knew that AIDS was a fatal, sexually transmitted disease, there were serious gaps in their knowledge about the nature of HIV, the modes of transmission and ways to prevent infection (including proper use of condoms). A survey by Strydom
(2003) of high school students throughout the North West Province confinned this trend.
When asked how they regarded their knowledge of AIDS, 70% of respondents said
"uncertain" and "inadequate." Macintyre, Rutenberg, Brown, and Karim (2004) surveyed 2,716 adolescents aged 14-22 in Durban Metro and Mtunzuni in KwaZulu- Natal to explore factors that influenced their perception of HIV risk. Twenty percent of respondents with high risk behaviors did not perceive that they were at risk for HIV infection. Factors predicting increased perception of risk among adolescents who reported current risky behavior were: less confidence to use a condom for males, older age for females, living in a household with a chronically sick member for females, and willingness to be a friend with a person with AIDS for males. Among male and females not engaged in current risky behavior, perception of risk was higher when it was perceived that adults in the community thought the youth were at risk. Based on their findings, Macintyre et al. suggested that future HIV prevention efforts focus on involving parents and other adults in helping adolescents identify risk behavior and to encourage them to protect themselves. Bernardi (2002) similarly stressed the important role the social network can play in influencing HIV risk perception in her study of adults in Western Kenya.
In their review, Eaton et al. also found that while most youth were not promiscuous, more than half of those who were sexually active reported not using condoms at all.
Taylor, Dlamini, Kagoro, Jinabhai, and de Vries (2003) reported a similar finding in their survey of high school students in rural high schools in KwaZulu-Natal. Thirty percent of students were sexually active and only 53% had used a condom inthe past month. This is consistent with the national HIVIAIDS Household Survey which reported that 57% of males and 46% of females aged 15-24 had used condoms at last sexual intercourse (Nelson Mandela/Human Sciences Research Council Study of HIV/AIDS, 2002). The authors of the latter report prefaced this finding with the comment that condom use among this group was "high" (p. 15). Itseems odd that anyone would consider condom use to be high when only about one half of youth are using condoms while living in a country where their chances of becoming infected are extremely high.
A recent study by Anderson et al. (2004) painted a deeply worrisome picture of views about HIV risk among South African school pupils. The researchers conducted a huge,
cross-sectional study of 269,705 pupils across 1,418 South African schools and findings included the following:
• 59.6% believed that condoms could help prevent HIV infection.
• 15.7% of males and 14.4% of females said they would not tell their family if they were HN-positive.
• 15% said they would have unprotected sex and 15.7% said they would spread the virus intentionally.
• 12.7% believed that sex with a virgin could cure HIV or AIDS.
Simbayi, Chauveau, and Shisana (2004) presented a more optimistic picture of the HN/AIDS crisis among youth, however. In a recent report using data collected as part of the national HN/AIDS Household Survey, they asserted that South African youths are
"making positive behavioral responses to the HIV/AIDS epidemic" (p. 613), especially when compared to the findings reported by Eaton et al. (2003). Simbayi, Chauveau, and Shisana argued that Eaton et al.' s review of studies on sexual risk behavior among South African youth did not provide an accurate picture of the current status of the behavioural responses of South African youth. They asserted that most of the studies that were reviewed by Eaton et al. were small in scale, focusing on particular groups known to engage in high-risk sex, and furthermore many of the studies predated the implementation of major prevention programmes in South Africa. Simbayi, Chauveau, and Shisana proceeded to offer recent data on sexual behavior among 2,430 youths aged 15-24. To summarize, their main findings for both males and females were:
• The average age of first sexual experience was 16.5 years.
• The majority (86.4%) had been sexually active over the past 12 months.
• Over two-thirds (66.6%) had used a condom during their lifetime.
• Just over half (52.8%) had used a condom at last intercourse.
• Over two-thirds (68.9%) reported ever discussing HIV prevention with their sexual partner.
• The majority (81.6%) had never done an HN test.
• The majority (84.4%) did not know their HIV status.
Simbayi, Chauveau, and Shisana may have interpreted their findings in a more positive light than was truly warranted. For example, they made the sweeping and not totally accurate statement that "the majority of both male and female youths in the present study reported that they were using condoms and that they also had discussed HIV/AIDS with their partners ... " (p. 617). No data were provided that would lead one to conclude that youths were consistently using condoms or that they discussed HIV prevention with every partner. There is a big difference between reporting to use condoms in one's lifetime (or even in the past 12 months) and using them every time one has sex. Again, the fact that only one half of respondents used a condom at last intercourse is hardly reassuring in a country with an extremely high HIV prevalence rate.
Furthermore, not nearly enough attention was paid in their discussion to the implications that the majority of youths had not been tested and that they were not aware of their HIV status. The authors also neglected to discuss what I consider to be an important finding - that females from poorer household economic situations had more sexual experience.
The implications of this in terms of HIV risk and prevention deserved further comment.
Simbayi, Chauveau, and Shisana concluded by asserting that "it is nonetheless still critical to intensify prevention campaigns for current youth" (p. 617). While I wholeheartedly agree with this statement, it does appear somewhat inconsistent with the way they interpreted their data.
Another report using data collected from the 2002 national Household Survey was recently published by Brookes, Shisana, and Richter (2004) and it focused on HIV prevalence, HIV knowledge and risk factors for HIV infection among youth under 18 years of age. Data were analyzed for 3,988 children and here are some of the more important findings:
• 5.4% of children 2-18 years of age were HIV-infected.
• Among children 12 to 14 years of age, only half agreed that HIV could be transmitted through unprotected vaginal sex.
• Just over two-thirds of children said that condoms protect against contracting HIY.
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Two fifths of children reported that boys sexually harass girls.
15% of children reported that male teachers proposed relationships with students.
The authors of the report concluded that correct knowledge about HIVIAIDS was deficient and communication about sexual matters was inadequate, particularly for boys and by fathers. The most recent review of research on sexual behaviour among adolescents in South Africa by Hartell (2005) draws this bleak conclusion: " ... despite the efforts of researchers, there has been no significant change in the rate of infection among adolescents in South Africa" (p. 180).
Sexually Transmitted Infections (STIs)
A significant correlation between STIs and HIV prevalence was confirmed in the 2002 national HIV/AIDS Household Survey (Nelson MandelalHuman Sciences Research Council Study of HIVIAIDS, 2002). Among those who had been diagnosed with an STI within the past three months, 38.9% were found to be HIV-positive compared to 13.2%
who did not have an STI in the past three months. The high levels of STI infection in South Africa are indeed worrisome. In 1996, there were as many as 15,000 cases of syphilis per 100,000 in South Africa, compared to 15 cases per 100,000 in the United States and the United Kingdom (Pham-Kanter, Steinberg & Ballard, 1996). Other shocking data were: 12% of men had an STI within the past three months (Department of Health, 1999), and 25% of women living in rural areas of KwaZulu-Natal reported having had at least one STI (Wilkinson et a1., 1999).
The Status of Women
Women are not only more biologically vulnerable to HIV infection but their status in society raises their risk further. Despite South Africa's progressive constitution, the balance of power remains weighted heavily toward men. According to Walker, Reid, and Comell (2004):
Young African women are the poorest, most economically marginalized and least educated sector of the South African population. This places them at the bottom of the health pile and renders them particularly vulnerable to HIV/AIDS. (p. 40)
The widespread oppressIOn, violence and rape of women in South Africa are troublesome. There is a strong correlation between sexual and other types of abuse and women's chances of becoming HIV-infected (Garcia-Moreno & Watts, 2000). For many men, sex is a means to exert control over women. Itis very difficult for women to insist on condom use because of the threat of violence (Walker & Gilbert, 2002; van Niekerk, 2001; Walker, Reid, & Cornell, 2004). The statistics on sexual abuse of women are alarming. South Africa is reported to have the highest per capita reported rape rate in the world with approximately one million rapes occurring each year (Rape Crisis Cape Town, 2001). Ithas been estimated that one third of all women in South Africa will be sexually assaulted or raped in their lifetime (Cook, 1994). The victimization of women begins at an early age; a number of studies have shown that females are coerced into sexual activity at an early age against their wishes (Vundule, Maforah, Jewkes& Jordaan, 2001; Ntlabati, Kelly, & Mankayi, 2001). According to a recent national survey, 28% of young women reported that their first sexual experience was unwanted and 10% said they had been forced to have sex (Reproductive Health Research Unit, Medical Research Council, 2004).
The brutalization of women is compounded by the added risk of being infected by the perpetrators. Among women attending antenatal clinics in Soweto, HIV infection was discovered to be more prevalent among women who had been physically abused by their partners than those who had not (Dunkle et aI., 2004a). According to Kalichman and Simbayi (2004a), there is a close association between sexual assault and risk for HIV infection. In a street survey of women living in an African township in the Western Cape, they reported that 44% of respondents had a history of sexual assault. Respondents who had been sexually assaulted were more likely to have unprotected vaginal intercourse, lower levels of protected anal intercourse, more likely to fear asking their partners to use condoms, more sexual contacts involving blood, and more STIs and genital ulcers.
South Africa's risky sexual culture poses an immense challenge for HIV prevention efforts. For example, Leclerc-Madlala (2001) characterized Zulu sexual culture as consisting of the following:
... gender inequity, transactional sex ... multiple sexual partnerships, lack of discussion on matters of sexuality in the home and between sexual partners, the conditioning of both men and women to accept sexual violence as 'normal' masculine behavior along with the 'right' of men to control sexual encounters, and the existence of increasingly discordant and contested gender scripts. (p. 41)
A recent survey of HIV prevalence among young South Africans provided disturbing data on the vulnerability of young women. In the age group 20-24 years, 24.5% of women surveyed were HIV-infected, compared to 7.6% of men (Reproductive Health Research Unit, Medical Research Council, 2004). Overall, women made up 77% of South Africans under 30 years of age who were living with HIV (Reproductive Health Research Unit, Medical Research Council, 2004). Karim (1998) acknowledged that there are no immediate solutions to reducing women's vulnerability to HIV infection.
Furthermore, he asserted that "any attempt to reduce women's vulnerability and risk has to focus on structural changes, development and the power imbalances in society" (p. 24).
Other researchers have also stressed the importance of changing the power imbalances between men and women in South African society to fight HIV/AIDS (Ackermann & de Klerk, 2002). The important question is how do we make these types of recommendations a reality? Structural changes do not occur overnight and recommendations of this sort seem rather abstract for those on the frontlines of HIV prevention. Albertyn (2003) analyzed gender inequality in South Africa through the lens of HIV/AIDS, and offered preliminary suggestions for translating theoretical insights about gender inequality into political strategies in the local context. Jewkes, Levin, and Penn-Kekana (2003) adopted a more cautious approach to the issue of gender inequality and HIVIAIDS and recommended that we first need to do more research "to explore more critically the relationship between gender inequalities and HIV prevention" (p.
132).