2.3 HIV and AIDS in South Africa
2.3.3 Situation of HIV and AIDS
Following this overview of the emergence of HIV and AIDS in South Africa, it is appropriate to ask the question: what has been covered by discourses with regard to HIV and AIDS in this country? The response to this question is divided into four sections. The first section includes an overview on HIV and AIDS prevalence. According to Gouws and Karim (2010) there have been three key research programmes on the spread of HIV prevalence in South Africa. The first is that of ANC surveys. This programme comprises anonymous national annual ANC surveys initiated by the Department of National Health and Population Development in 1990 which involved women attending ANCs for their first pregnancy visit. It also includes annual anonymous ANC surveys in the rural Hlabisa Health District, KZN, conducted between 1992 and 2002 by the South African Medical Research Council in the same months as the national ANC surveys (October and November), to provide consistent comparative data from rural areas (:58-59). The second programme consists of population-based surveys. These were the three population-based surveys conducted in conjunction with the Malaria Control Programme between 1990 and 1992 in rural KZN; the national population-based household surveys undertaken by the Human Sciences Research Council (HSRC) in conjunction with other partners in 2002, 2005, and 2008; and the Carletonville/urban population baseline survey in 1998 and follow-up surveys in 1999 and 2000 (:59-60). The third programme mentioned by these authors
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is the research conducted over several years by the HSRC with sex workers at truck-stops in the KZN Midlands and the 1998 cross-section HIV sero-prevalence study with their clients (:60).
Whiteside and Sunter (2000) have also acknowledged the role played by surveys with ANC attendees and commercial sex workers in providing HIV and AIDS prevalence data in South Africa. In addition, they mention that surveys also included blood donors, and people with sexually transmitted infections (hereafter STIs) and Tuberculosis (hereafter TB) (:33). They further recognize the role of the UNAIDS‘ yearly estimates available on the UNAIDS website, www.unaids.org, and the projections done in 1998 by Metropolitan Life (:54; 69). Those projections also analysed by Love Life during the same year (Love Life, 2000), provide the situation on cross-sectional HIV prevalence in South Africa, including prevalence per sex, race, and provinces as well as AIDS-related mortality and orphan rates.
In addition, there are sporadic researches on HIV prevalence in selective communities such as those conducted by Myers (2010:6) in higher education, as well as by Lane et al. (2011:626), Rispel et al. (2011:69), and Baral et al. (2011:1) with male homosexuals respectively in Soweto, Johannesburg and Durban, and Cape Town. However, Gouws and Karim (2010:55, 59) note that the most extensive data are those provided by ANCs although these data are subject to bias as they exclude males and females who do not use ANCs (see also Love Life, 2000:2; Stats SA, 2011:4). It therefore appears that there exists a gap in the systematic knowledge about HIV and AIDS prevalence in groups other than ANC attendees that research needs to fill. This gap is likely to have a negative impact on responsive strategies.
The second section of the response concerns factors determining the spread of HIV and AIDS.
Authors such as Barnett and Whiteside (2006), Echenberg (2006), and Kocheleff (2006), identify South African economic and political systems as key role-players in the spread of HIV and AIDS, especially among black people. They show that the apartheid system prevented black people from having sufficient access to healthcare and other resources (:149) and had created a migrant labour system under which black workers could not be accompanied by their spouses, which encouraged prostitution (Echenberg, 2006:89). Kocheleff (2006:150) also points out that under the de Klerk government, the structure established to diffuse information on STIs and HIV and AIDS was stopped and media messages changed into English and Afrikaans languages that many black people could not use. This government was also said to have hired HIV positive men to infect sex workers in Hillbrow, Johannesburg (Barnett and Whiteside (2006:165-166).
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However, no study has been able to provide conclusive researched estimates determining the apartheid system‘s role in the spread of HIV and AIDS among Black communities.
As regards the South African National HIV and AIDS Survey (2008), Gouws and Karim (2010), and Fröhlich (2011), age is another important factor in the spread of HIV and AIDS, with the youth being the most vulnerable. At this point, Fröhlich (2011:17) demonstrates that from 2001 up to 2010, age groups 25-29 and 30-34 always registered the peak in HIV prevalence among the Vulindlela ANC attendees. According to the HSRC (2002:69) and Harrison (2010:307), this high HIV prevalence among young people is due to bodily changes brought on by puberty and curiosity about sex whilst sexually inexperienced and unable to negotiate safe sex. For Warren and Hajiyiannis (2008:8), it is due to the shortage of financial means among the youth which adults take advantage of to impose unprotected sex on them. One may ask, what makes the prevalence of HIV and AIDS lower among adults that engage in unprotected sex with these youngsters? One can argue that some infected young people die of AIDS-related diseases before reaching adulthood and that the current adult population are those who have survived. However, more clarification is still needed in this regard.
Discourses also identify the kinds of sexuality practiced as factors in the spread of HIV and AIDS. Phiri (2003a), Denis (2006), and Buvé (2006) include here the practice of dry sex.
According to their research, the HIV infection risk resides in the tearing of the vaginal mucous membrane that provides entry for viruses (Phiri, 200a3:10-11; Buvé, 2006:47-48). Denis (2006:24) also observes that dry sex contributes to the high prevalence of HIV in the KZN Province. Moreover, authors such as Love Life (2000), Kenyon et al. (2010) and Karim (2010) suggest concurrent sexual partnerships, arguing that one man can infect many women. But Mcetywa (2000) and Denis (2003) reject this factor if the traditional rules of the practice of polygamy are respected. In responding to them, Phiri (2003a:12) rejects their suggestion, stating that African culture encourages men to have sex with limitless partners, even when one is already in polygamous relationships. Furthermore, Makhubele and Parker (n.d: 2, 6) also mention anal sex as increasing the vulnerability to HIV infection. However, with all these authors, no statistical evidences were provided to show the actual role played by the kind of sex practiced in HIV infection. It is therefore argued that the risk of HIV infection does not lie in the kind of sexuality practiced but in the practice of unsafe sex itself.
Moreover, Gouws and Karim (2010) suggest population density as another factor in the spread of HIV and AIDS in South Africa, the most vulnerable being areas of high population density.
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Hence, they find high rates of HIV in Durban and Hlabisa in KZN, Port Elisabeth in the Eastern Cape, Johannesburg in Gauteng, Cape Town in the Western Cape, and Welkom in the Free State (:53-65). Here, they share some views with Denis (2010:134) who suggests that the KZN Province is greatly affected because of its strategic location through which the N3 national highway runs. However, their mapping leaves several unanswered questions. Does this imply that in southern Africa where HIV prevalence is estimated the highest globally, the population density is also the highest? Is it in KZN, the province known as the most affected by HIV in South Africa that the population density is the highest? Data on population density displays negative responses to these questions (Population Density per Square Mile of Countries, 2007; The Nine Provinces of South Africa (n.d.)).15 In the same vein, Kleinschmidt et al.
(2007:1165) observe that population density is not sufficient to determine HIV prevalence because other factors such as race and socio-economic aspects also play a decisive role here. As a result, research has yet to clearly show the exact role that population density plays in HIV and AIDS prevalence in South Africa.
Barnett and Whiteside (2006) suggest that social cohesion combined with financial wealth also constitute a contributing factor (See also Manning, 2002:24). They argue that HIV infection is high in communities with low social cohesion and low wealth as well as in low social cohesion and high wealth communities. They therefore classify South Africa in the latter category (Barnett and Whiteside, 2006:96). They elaborate that South Africa is the third wealthiest country in Africa after Gabon and Botswana (high wealth) but with institutionalized inequality characterized by racial discrimination after 1948, a mobile population, breakdown in social structure, wealth and lifestyle inequality, crime, violence, and rape (low social cohesion) (:131-132; 159-167). This analysis has similarities with the socio-political factors as described earlier, especially concerning inequality in wealth and limited access to health facilities. This indicates that addressing the problem of inequality and low social cohesion in South Africa would have a positive impact on the response to HIV and AIDS.
Furthermore, De Waal and Whiteside (2006) regard HIV and AIDS in South Africa as a Darwinian event. They demonstrate that some people, especially those who habitually think or act in the short term, are not sufficiently equipped to profitably respond to the natural selection
15 Data of 2007 show that Southern African countries do not appear among countries with high population density globally (See Population Density per Square Mile of Coun tries, 2007). Likewise, data on population density in South Africa show that though KwaZulu-Natal Province is the second in high density after Gauteng, it is far from being considered the first in HIV prevalence if only the population density is considered. This is because the density in Gauteng is 5.5 times higher than in KwaZulu-Natal (See, The Nine Provinces of South Africa (n.d.)
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in which only the fittest survives, and thus are at high risk of infection (:62). They conclude that demographically, the HIV and AIDS pandemic is a Darwinian event but they recognise the existence of other economic and social consequences (:72). This shows that much effort is needed to help people to successfully survive during this natural selection. But viewing this factor as well as all other factors described above, no author was able to statistically evidence the role of any factor in HIV prevalence. Therefore, further research is required to clarify this issue.
The third section concerns the impact of HIV and AIDS. Gray et al. (2010) locate the impact of HIV and AIDS in physical life. For them, in the absence of treatment, HIV and AIDS weakens the immune system of the body leaving the infected person open to many diseases and associated sufferings thus exposing them to premature death (:127). Similarly, Stats SA (2009:11) demonstrates that since 2001 up to 2011, the KZN province, as the most affected by HIV and AIDS in South Africa, has had the lowest life expectancy at birth, estimated at 50.6 from 2001 to 2005 and at 51.0 from 2006 to 2011 in females. The highest life expectancy at birth was estimated at 66.5 between 2001 and 2005 and 67.9 between 2006 and 2011 in the female population of the Western Province known to be the less affected of HIV and AIDS. In the same vein, Dubula (2011) compares South Africa with Brazil, highlighting that from 1991 to 2011, the life expectancy at birth in South Africa has fallen from 63 years to 52 years while it was 71 years in Brazil. Dubula attributes this decline to the HIV and AIDS pandemic.
The impact of HIV and AIDS on social structures and relations is also discussed by Skinner and Mfecane (2004), Peltzer (2008), Fröhlich (2010), and Du Preez and Niehof (2010). Flöhlich (2010: 374) observes that HIV and AIDS undermines the fundamental social fabric by changing roles initially played by particular categories of people. Here, she refers to the dropout rate of scholars in order to take care of adults suffering from AIDS related diseases; the education of children by single mothers or widows instead of both parents and by grandparents instead of parents because the adults are no longer able or have died (Flöhlich, 2010: 374. See also Stats SA, 2006:16, Teljeur, 2002:59). Regarding social relations, Parker and Aggleton (2003:14-17), Parker and Birdsall (2005:5), Gill (2007:19-20), and Wittenberg (2007:152) focus on HIV and AIDS related psychological disturbances, stigma and discrimination against people infected and their relatives.16 Likewise Haber et al. (2011:545) point to the stigma by association experienced by healthcare providers who offer services to HIV positive people. However, although these
16 As an example, Skinner and Mfecane (2004:160) recall people threatened because they are HIV positive, including Gugu Dlamini murdered in 1998 in Durban when she disclosed and Lorna Mlofane murdered in 2004 by her three rapists when they learnt that she was HIV-positive.
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authors confirm the existence of a HIV and AIDS-related stigma and discrimination, Lamula (2011) underlines that the discriminative behaviour is declining.
According to Booysen et al. (2003), Whiteside (2010), Seeley et al. (2010), and Du Preez and Niehof (2010), the HIV and AIDS impact is observed at both micro- and macro-economic levels where the number and capacity of producers and providers decreases while the expenditure increases. As an example of the effects on the micro-economy, du Perez and Niehof (2010:47, 49) cite a case from KZN in which, Bongi, a 47 year old HIV-positive woman lived with eight dependents. She was initially employed in a small shop and used to sew and grow vegetables. As she gradually lost the capacity to work, she stopped these income-generating activities to depend only on one child‘s support grant. In this household, some dependents were also HIV positive and needed special attention. As to the effects on the macro-economy, Whiteside (2010) quotes ING Baring‘s predictions as follow, ―AIDS will cause the economy to grow more slowly. GDP [Gross Domestic Product] growth in 2001 will be 0.3% lower because of AIDS, and for the period 2006 to 2010 it will be 0.4% lower each year‖ (:421). It is therefore clear that the pandemic affects the South African economy at every level.
Discourses indicate the HIV impact on many other sectors. The Department of Health (2002), Metropolitan Holdings Limited (MHL) (2006), Ministry of Health (2008), and Colvin (2010) highlight the impact on the health system (see also Healthcare in South Africa, n.d.). Myers (2010) underlines its impact on education, Strand and Chirambo (2005) and Barnett and Whiteside (2006) on governance, and Singh (2010) on ethics. The overall observation in these discourses is that HIV and AIDS has negatively impacted on almost all aspects of life. Hence, a concerted response is required in order to preserve the wellness of the people.
The last section of the response to the question pertains to the reaction to HIV and AIDS in South Africa. Van Houtain (2006) conducted research on the behaviour of South Africans in reaction to HIV and AIDS. Using the model developed by the Business Exchange on AIDS and Development Group (hereafter, BEAD), he found four gradual stages in the population‘s acceptance of the disease. In the ‗invisible epidemic‘ stage, the population was denying the disease and the need for practicing safe sex. During the ‗awareness‘ stage, they recognised the disease‘s existence but thought it affected ‗others‘ only. During the ‗acceptance‘ stage, they accepted it as threat and began caring for the sick but did not change their sexual behaviour. In the last stage of ‗behavioural change,‘ they fully understood that any sexually active person is at risk of being infected (:167-168). This description is unfortunately not distributed according to a
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timeline. However, it can assist in locating phenomena identified by other authors on a timeline.
Therefore, the second period of ‗awareness‘ mixed with denial may correspond with the murder in 1998 of Gugu Dlamini in the KZN Province after the disclosure of her HIV positive status (Fröhlich, 2010:377). As with this event, one can also confirm the suggestion by Denis (2006:2) that the spread of AIDS occurred later in South Africa than in East and Central Africa, because by that time, a broad and collective response to the pandemic had already been initiated at international level (Carael, 2006:20-37).
In addition to the population‘s gradual acceptance of the pandemic, authors such as Hickey (2002), Kocheleff (2006:150), Heywood (2010), and Gouws and Karim (2010:61-62) point out similar attitudes among the country‘s leadership. They underline reluctance, opposition and the negligence of apartheid leaders to effectively respond to HIV and AIDS, as well as their active participation in infecting the population (Barnett and Whiteside, 2006:165-166). Karim and Baxter (2010a) inform that because of this attitude, the African National Congress‘s members in exile and within the country as well as other anti-apartheid organizations, expressed through the Maputo Statement (Maputo Statement, 1990) the need to prioritize HIV prevention. As a result, the National AIDS Convention of South Africa (hereafter, NACOSA) was created in 1993 with joint coordination of apartheid and anti-apartheid AIDS activist representatives (Karim and Baxter, 2010a:41).
However, as Karim and Baxter (2010a:41, 42) remark, the democratically elected government in 1994 did not significantly support the NACOSA plan of addressing the pandemic, although it had adopted it as credible for the country‘s reconstruction and development. In 1998, the African National Congress-led government also failed to fund the provision of the zidovuzine, antiretroviral used to prevent mother-to-child transmission (:41). As to the second government instituted in 1999, Van Houten (2006:166-167) and Karim and Baxter (2010a:42-43) recall former president Thabo Mbeki and health minister Dr. Manto Tshabalala-Msimang‘s denial of HIV being the cause of AIDS. However, because of the Treatment Action Campaign (hereafter, TAC) and its supporters, antiretroviral therapy (hereafter, ART) has been available since the 2000s (Echenberg, 2006:95; Karim and Baxter, 2010a:42). According to Karim and Baxter (2010a:43), the Jacob Zuma-led government elected in 2009 was an improvement on the previous dispensations, especially in promoting ART. In 2003 a decision was made to provide ART free of charge in public services (Karim and Baxter, 2010a, 42-43) but the treatment only began to expand in mid-2005 (Fröhlich , 2011:7). In August 2011 under the Zuma government, ART was extended to all patients with a CD4 count of 350 (:7). It is therefore evident that there
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has been an improvement in the attitudes of the South African population and the Government towards the pandemic.
In addition to the attitude towards HIV and AIDS in South Africa, various discourses also inform about effective responses, especially with regards to prevention and treatment.
Concerning prevention, authors such as Myer (2010) and Kalichman and Lurie (2010) conducted research on behavioural strategies including sexual Abstinence, Being faithful to a sexual partner and use of (male and female) Condoms (hereafter ABC). Heath (2009:71) criticises this strategy of feeding stigma by focusing on sex and sustaining a false belief of total safety once faithful.
However, according to UNAIDS (2010b:64, 70) and Gouws and Karim (2010:66), the use of condoms has contributed significantly to stabilising the HIV prevalence in ANC attendees since 2005. Within behavioural strategies, Kalichman and Lurie (2010) also include the ‗Behavioural Positive Prevention‘ consisting of working with PLWHA, but noting that this can be effective only if implemented as part of a broad HIV and AIDS prevention plan rather than in an isolated fashion (:265).
Nattrass (2004) and Coovadia (2010) have also discoursed on bio-medical-based preventive strategies that comprise of mother-to-child transmission prevention (hereafter, MTCTP), pre- exposure prophylaxis (hereafter, PreP) and post-exposure prophylaxis (hereafter, PeP). At this point, UNAIDS (2010b:10) appreciates that in 2010, South Africa covered almost 90% of MTCTP. However, studies on PreP and PeP remain scarce in South Africa (Aidsbuzz, 2012;
Whiteside, 2012; Hallett et al. 2011; Cohen et al. 2011; and Kim et al. 2007).
Prevention strategies appearing in discourses also include those mainly applied to sexual matters, namely, the control of STIs, microbicides, and male circumcision. For Coetzee and Johnson (2010:216), studies have not yet conclusively determined the level of effect of the control of STIs on HIV prevalence. As to microbicides, Karim et al. (2010:1168), estimate their capacity to reduce HIV infection by 39% overall and by 54% in women with high adherence. Karim and Boxter (2010:268) observe that microbicides fill the gap for female-controlled prevention methods and are likely to be available before the effective vaccine. However, this strategy is still on trial in order to definitely determine its effect at national and international levels (Joint summary, 2007; The Lancet papers for the year 2010, 2011; Whiteside, 2012). Concerning male circumcision, Auvert et al. (2005:112) suggest that it can play a definitive role in the protection against HIV infection. Whiteside (2012) estimates this protection at 64%. However, the