Nelson Mandela Foundation

JOHANNESBURG – The HIV infection rate in persons aged two years and older is estimated to be 10.8%, with a higher rate in females (13.3%) than in males (8.2%). HIV prevalence among young adults in the 15 to 49 age group increased slightly from 15.6% in 2002 to 16.2% in 2005, which may be an indication that the epidemic in the general population of South Africa has entered a phase of levelling off.

Of great concern is the finding that young women in the 15 to 24 age group are up to four times more likely to be HIV positive than young men in the same group.

These are some of the results from the 2005 South African National Household Survey on HIV Prevalence, Incidence, Behaviour and Communication, commissioned by the Nelson Mandela Foundation (NMF) and conducted by the Human Sciences Research Council (HSRC) of South Africa, in partnership with the Medical Research Council (MRC) and the Centre for AIDS Development Research and Evaluation (CADRE).

The 2005 survey is a repeat of the 2002 survey, and allows for generating estimates of HIV and associated factors in a representative sample of the total South African population. It excludes children under two years of age and adults who live in university dormitories, boarding schools, and army barracks, and hospital patients.

Dr Olive Shisana, principal investigator and CEO of the HSRC, emphasised that the sample size in the 2005 survey was larger than that in 2002 and the estimates are therefore more robust. In 2005, 23 275 people took part in the survey and 15 851 respondents agreed to be tested for HIV, compared to 2002, when 9 963 people took part in the survey and 8 428 agreed to be tested.

Mr John Samuel, Chief Executive of the Foundation, said today that the organisation commissioned the repeat survey as part of its continuing effort to promote understanding, dialogue and action on the central challenges South Africa is tackling.

“While the Foundation is not primarily a research body, we occasionally commission research to broaden scientific and social knowledge of HIV/AIDS.  This is the first time a repeat study of HIV prevalence has been done in South Africa, and the first time incidence has been investigated. We believe the findings can make a meaningful contribution to policy. It is also important that the vital information produced by the study be used to focus practice in the field of HIV/AIDS,” said Mr Samuel.

The Foundation’s support for a repeat study was also informed by positive responses to the usefulness of the first, which was ground-breaking and, for the first time, demonstrated levels of infection in South Africa by age, gender, location and race.

Since then, the Foundation has participated with the HSRC in providing technical assistance in Botswana, Swaziland, Mozambique and Lesotho in conducting similar household studies. The first study also received international acclaim and influenced government policy on treatment. A second study to assess risk exposure of HIV in the age group 2 to 9 provided an evidence base for AIDS Service Organisations.

“The second study has allowed us to assess trends in infection and knowledge of HIV between 2002 and 2005.  It enables us to probe behaviour, communication and perceptions around treatment, mental health, and vaccine development.  It also provides critical insights into contextual, structural and political factors for HIV,” said Mr Samuel.

“It is the intention of the Foundation to discuss these figures with government to help to inform the national Comprehensive Plan for Prevention, Treatment, Care and Management of HIV/AIDS.”

Professor Thomas Rehle, a co-principal investigator of the report, explained that technological developments have allowed new biological tests to be conducted on samples gathered in the survey. One of the hallmarks of the 2005 survey is the availability of nationally representative estimates of annual new infections, or incidence rates.

“The addition of HIV incidence testing into the survey protocol allows a simultaneous analysis of HIV prevalence and incidence that will significantly improve our understanding of the current dynamics of HIV transmission in South Africa. Such information is vital to informing interventions and systems of support”, Rehle said. The analysis will also contribute to improvements in models for projecting existing and future trends in relation to HIV and AIDS.

Comparing the 2002 household survey with the 2005 survey, the study found increased HIV prevalence among young people aged 15 to 24 (10.3% vs 9.3%) and a similar prevalence in adults 25 years and older (15.6% vs 15.5%). In the broader age group of people 15 to 49, the study found an HIV prevalence of 16.2% in 2005 and 15.6% in 2002. Among children aged 2 to 14, however, a substantially lower HIV prevalence was recorded – 3.3% in 2005, compared to 5.6% in 2002.  A further breakdown for ages 2 to 4 (5.1%) and 5 to 9 (4.4%) indicates that the HIV problem is significant among children.

The study found an overall estimate of 10.8% HIV in the population in 2005, similar to the 11.4% estimated in 2002. Using the 2005 mid-year population estimates, this translates to 4.8 (4.2 to 5.3) million people, aged two years and older, living with HIV/AIDS. As in 2002, women are more likely to be living with HIV, and this proportion has increased over time. The largest increase in prevalence was found among females aged 15 to 24 – 16.9% in 2005 compared to 12.0% in 2002. The prevalence in females is almost 4 times that of males – 16.9% vs 4.4%.  The results confirm the findings of the RHRU Youth Survey (“Lovelife survey”) conducted in 2003, which found similar HIV prevalence in males and females, 4.8% and 15.5%.

The results of the 2005 survey also suggest that the HIV profile among women aged 15 to 49 years compared well with the findings of the 2004 antenatal survey, especially for African women.

HIV prevalence by province shows that among people aged two years and older KwaZulu-Natal (16.5%), Mpumalanga (15.2%) and Free State (12.6) have the most people living with HIV.  Among those aged 15 to 49 years, the HIV prevalence is highest in Mpumalanga (23.1%) and KwaZulu-Natal (21.9%).

Race remains an important factor in South Africa as it reflects the socio-economic inequalities that increase vulnerability to many illnesses, and HIV is no exception. The overall HIV prevalence among African respondents increased slightly from 12.9% in 2002 to 13.3% in 2005. In African adults aged 15 to 49 years the corresponding figures are much higher, namely 18.4% in 2002 and 19.9% in 2005. The HIV figure for African women in the same age group is 24.4% in 2005.

People living in informal settlements have by far the highest HIV prevalence. In the 15 to 49 age group, HIV prevalence is 25.8%, followed by rural informal areas at 17.3%, and urban formal and rural formal areas, at 13.9%. In the study population of two years and older, rural areas saw an increase in HIV prevalence while urban areas saw a decrease between the 2002 and 2005 surveys.

One of the notable differences from the previous survey was the significantly lower HIV rates recorded for whites and coloureds in 2005. The investigators stressed that the findings for the Western Cape must be interpreted with caution and further analysis of the data will be undertaken to clarify the situation with regard to HIV prevalence in this province. The uncertainties in the Western Cape prevalence rates also lead to uncertainties with regard to coloured and white national HIV statistics, because of the large proportion of these populations in the Western Cape.

The current HIV transmission dynamics in South Africa are best reflected by the HIV incidence figures observed in the different sub-populations. Especially alarming are the incidence rates among young females in their prime childbearing age. Females aged 15 to 24 years have an eight times higher HIV incidence than males, 6.5% compared to 0.8%, and account for 87% of the recent HIV infections in this age group.

Key findings and recommendations

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 in 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.

The study recommends that HIV/AIDS campaigns and programmes address this false sense of security in the general population, with a particular emphasis on encouraging people to go for voluntary testing and counselling and 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.

Attitudes that stigmatise are less
The survey showed that an overwhelming majority of people are willing to care for an AIDS patient. Nearly half of South Africans of 15 years and older do not think it is wrong to marry a person with HIV and 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, and that stigmatisation in society is becoming less of a factor, especially in urban areas, although in some rural areas this is still a problem.

The study recommends that service providers capitalise on this window of opportunity by encouraging people to undergo counselling and testing, and to disclose their HIV status to their partners.

Integration of family planning and HIV/AIDS services is vital
The HIV incidence analysis confirmed recent findings from other studies that suggest an increased risk of HIV acquisition during pregnancy. African females aged 15 to 49 years who reported having been pregnant in the last 24 months were estimated to have an HIV incidence of 7.9%, the highest incidence rate of all analysed sub-populations in the survey.

HIV transmission from mother to baby before, during and after pregnancy, and the risk of becoming HIV positive late in pregnancy, or during breastfeeding, are important periods of HIV transmission. Teenage women have been under-emphasised as a target group, although pregnancy levels are high in this age group.

The study recommends that awareness campaigns of the risks of HIV infection during pregnancy, aimed at pregnant women, should be undertaken on a national scale. HIV/AIDS campaigns should also target would-be parents to inform them that women run a greater risk of becoming infected with HIV during pregnancy, and to encourage couples to:

  • plan the pregnancy;
  • get tested for HIV before trying to conceive and to disclose their results to each other.

Periodic HIV testing is crucial
South Africa appears to have a well-established voluntary counselling and testing (VCT) service, and most respondents know of a place to be tested. But 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 prevent HIV infection of others. It also serves as an entrée into seeking treatment for opportunistic infections and receiving anti-retrovirals in the case of advanced HIV infection.

The study recommends that periodic HIV testing for men and women in stable partnerships should be encouraged, especially when planning to have a child. Should one of the partners be HIV positive, he/she should be counselled to discuss the advisability of conception. This is important because the couple needs to be aware that the HIV-negative partner is at risk of becoming infected with HIV.

The extremely high HIV incidence in females aged 15 to 24 years 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.

HIV in children is high
The estimated 129 621 children aged 2 to 4 years and 214 102 children aged 5 to 9 with HIV/AIDS are significant numbers. Most of the HIV-positive children aged 2 to 4 years are likely to have been infected through mother-to-child transmission, or during prolonged breastfeeding.

Analysis of incidence data shows that 6% of all recent HIV infections in South Africa occurred in children aged 2 to 14 years. A further breakdown shows that 3.3% occurred in children 5 to 9 years old. These infections cannot be clearly linked to mother-to-child transmission, and could include child sexual abuse or infection through the healthcare system.

Other findings suggest that many children are left unsupervised for much of the time including going to and from school and being sent on errands alone. Such practices may expose children to sexual abuse.

The report further recommends that:
• HIV prevention campaigns should include messages on increasing supervision of children.
• The government should review the ‘baby friendly’ breastfeeding policy and encourage HIV positive women not to breastfeed their children and to supply them with a breast milk substitute instead.
• The prevention of mother-to-child transmission programme needs to be strengthened, and other modes of HIV transmission in children should be investigated.

Sex at a young age, high partner turnover and concurrent sexual partnerships
A high number of sexual partners, regular turnover of sexual partners, and concurrent sexual partnerships pose significant risks for HIV infection. Over a quarter of males in the 15 to 24 age group have had more than one partner in the past 12 months.

The study indicates that the use of condoms at last sexual intercourse has increased over time, as has the number of people who went for HIV tests.

It also found that young women are more likely to have male partners who are at least five years older. Older men have a higher HIV prevalence than younger men and therefore young women with older male partners increase their chances of getting HIV.

The study recommends that prevention campaigns and programmes should emphasise these aspects of risk, and that sexually active people should:

  • avoid engaging in unprotected sex with anyone whose HIV status they do not know;
  • access and consistently use condoms to protect themselves in every sexual encounter with non-regular partners;
  • avoid frequent partner turnover and concurrent sexual partnerships.

Older people are also at risk of HIV
The high HIV prevalence among South Africans aged 50 years and older (5.8%) calls for development of targeted interventions for this age group, as they 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.

Safe male circumcision is vital to prevention
A study in Orange Farm in South Africa by Bertran Auvert and Adrian Puren concluded that safe circumcision can offer at least 60% protection from infection among males.

This study recommends that safe male circumcision must be encouraged by the public health sector, medical insurance schemes and women as one effective way of reducing and preventing the spread of HIV infection. But the study warns that an impression should not be created that male circumcision completely prevents HIV acquisition, as not all men who are circumcised will escape HIV infection. It is important that circumcised men still practise safer sex.

Refocus communication strategy
The study measured knowledge and awareness of communication campaigns and programmes and found that awareness of the government’s Khomanani Campaign is the lowest in all age groups. Awareness of campaigns in general is highest amongst the 15 to 24 year age group. Although LoveLife’s primary target group is 12 to 17 year-old youth, Soul City, Soul Buddyz and Takalani Sesame achieve higher awareness in the 12 to 14 year age group, and awareness of Soul City is highest in all age groups. Although Takalani Sesame is primarily a children’s programme, it achieves high awareness across all age groups.

The study recommends the need to have a systematic and co-ordinated approach in addressing key knowledge areas of prevention, treatment, care, support and rights. There should be accountability of programmes to an overarching communication strategy that is related to the national comprehensive plan.

Issues of risk and vulnerability should be addressed directly, particularly issues relating to:

  • gender vulnerability and rights (the vulnerabilities of girls and women);
  • age-related vulnerability (eg high age differences between youth and their sexual partners);
  • legal rights (eg the illegality of statutory rape); and
  • vulnerability as a product of migration and mobility.

Implications of anti-retroviral therapies (ARVs)
The study also included questions on ARV therapy. The majority of the respondents (60%) surveyed had heard about ARV therapy. Awareness was highest among respondents aged 25 to 49 years (67.6%). Whites (83.6%) and Indians (79.8%) had a higher awareness than coloureds (56.8%) and Africans (58.2%).

The study recommends that ways should be investigated in which interventions, such as the government ARV programme, might change attitudes to people with HIV/AIDS. It should also look at the extent to which such attitude changes impact on the uptake of services.

Investigate a dedicated tax for HIV/AIDS
The survey showed that although South Africans believe the government is committed to controlling HIV/AIDS and is not in denial about HIV/AIDS, 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% of females 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 want to pay tax or did not express an opinion.

The study recommends that the government explores the possibility of introducing a dedicated health tax 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.