Rethinking HIV/AIDS Prevention Strategies for South Africa: searching for appropriate responses for the South African Epidemic

The 2010 Report on the Global AIDS Epidemic released by the United Nations in November 2010 reaffirms what most AIDS researchers have long recognized: that Sub-Saharan Africa bears an incredibly inordinate share of the global HIV burden. The report notes that while the epidemics[1] in Sub-Saharan Africa differ considerably, southern Africa is still the most affected area with an estimated 11.3 million 1 people in 2009 living with HIV found solely in southern Africa.

Globally, this means that just over 34% of the people living with HIV in the year 2009 could be found in 10 countries of Southern Africa. Moreover that 31% of the new infections which occurred in 2009 occurred in these 10 countries including 34% of all global AIDS related deaths. And, to top this, it is estimated that just over 40% of all the adult women living with HIV reside in Southern Africa[2].

South Africa’s HIV epidemic remains the largest in the world with an estimated 5.6 million 2 living with HIV in 2009 residing in South Africa. After his first official visit to Africa in 2009, Pope Benedict XVI is quoted to have described AIDS as “a tragedy that cannot be overcome by money alone, and that cannot be overcome through the distribution of condoms, which even aggravates the problems.

This piece, in the same light with Pope Benedict aims to rethink the current prevention strategies employed by the South African government to combat HIV/AIDS, and argues that while the provision of condoms as a means of combating HIV/AIDS is important, I argue that this is not enough. Taking cue from leading South African AIDS Academic, Dr Kevin Kelly I posit that the South African HIV epidemic is driven largely by new infections and that for proper and effective preventative strategies, we need to ask” “where are the next 1000 infections going to come from.”[3]

This approach is in line with the UNAIDS famous “Know your Epidemic and your Current Response” approach.[4] The quest here is to understand the different HIV epidemics we have as there is no one single homogenous HIV epidemic, but rather multitudes and diverse epidemics. This means that no single prescription can be tailored for countries in a standardized manner as if they are the same.

It is useful therefore to make a distinction between concentrated and generalized epidemics. In situations where there are concentrated epidemics, this usually means that transmission of the HIV virus occurs mainly in certain defined vulnerable groups, most commonly sex workers, men who have sex with men (MSM), injecting drug users and their sexual partners[5]. Generalised epidemics conversely are “generalized if the transmission is sustained by sexual behavior in the general population and would persist despite programmes for vulnerable groups.”[6]

It is noted therefore that “those in Latin America, the Middle East, Europe and Asia—i.e., most of the world—are and undoubtedly will remain concentrated, while most of the Southern and parts of eastern Africa are generalised.”[7] South Africa is therefore pained primarily with a generalised HIV epidemic.

The response carved by the Government of South Africa has largely been channelled towards the provision of condoms as the key HIV preventative strategy. This strategy has for the most part been effective in raising national consciousness around HIV/AIDS and condoms but has not been able to penetrate through mindsets to ensure the necessary behavioural change to adapt safe sexual practices.

The continental incidence of HIV is said to “have peaked in the mid-1990’s and there is evidence of declines in incidence in several countries in Sub-Saharan Africa. In Zimbabwe [for instance], the main behavioural change appears to have been a reduction in the proportion of men with casual partners, while condom use with non-regular partners has remained high since the late 1990’s.”[8] Furthermore “new indicators show a slowing of HIV incidence amid some signs of a shift towards safer sex among young people. The annual HIV incidence among 18-year-olds in South Africa declined sharply from 1.8% in 2005 to 0.8% in 2008.”[9]

A 2011 study by Brown University[10] researchers on sexual risk behaviors within long term couples in South Africa recently found that HIV positive people in long term sexual relationships take as much risk in their sexual behaviour when they are aware that their partner is HIV negative or do not know the partners HIV status.[11] Similar research on married couples further supports this research to show that married couples and people in long term relationships are in greater risk of HIV transmission and account for a large number of the new infections in South Africa.

These researchers consequently contend that fighting HIV in South Africa should focus on couples, remembering that the South African HIV epidemic is driven by the new infections. If we ask ‘where are the next 1000 infections going come from’, recent research would show that young people are taking safe sex precautions as the UNAIDS report demonstrates, but that to tackle and prevent new infections, there is a strong call to focus on long term relationships where couples often relax condom usage often based on trust, or sometimes structural issues such a fear/threat of violence or removal of economic subsistence by the partner should a condom be suggested for use.

Some suggested (and yet untapped) HIV prevention strategies include medical male circumcision which has been shown to greatly reduce the risk the risk of HIV contraction[12], prolonging sexual debut, and no multiple concurrent partners. This piece has therefore tried to show that if the South African government is to have any effective HIV preventative strategy, it needs to rethink condom prevention as the primary HIV prevention strategy. The government needs to carefully review where the next infections are going to come from. Here I have made a case that married/long term relationships drive the South African epidemic, and for circumstances stated above, condoms are not the effective strategy.


[1] An ‘epidemic’ is defined as “A widespread occurrence of an infectious disease in a community at a particular time”: http://www.google.co.za/m/search?site=universal&safe=active&q=epidemic+definition

[2] For more information/statistics on the Southern Africa/Sub-Saharan Africa HIV situation, Please see the University of California’s designated ‘HIV InSite’ at: http://hivinsite.ucsf.edu/global?page=cr09-00-00

[3] Dr Kevin Kelly is the Director and founder of the Centre for AIDS Development Research and Evaluation (CADRE) in South Africa. Please see the NGO’s website at: http://www.cadre.org. The information is gathered from his speech delivered at the 2011 Conference on Leadership in Africa (CoLiA) at Rhodes University (July 21-22, 2011). Please see: http://www.conferenceonleadershipinafrica.webs.com

[5] Please see: David Wilson, 2008. “Know your Epidemic, Know your Response”: a useful approach, if we : http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(08)60883-1/fulltext

[7] Ibid

[8] Please see the University of California’s designated ‘HIV InSite’ at: http://hivinsite.ucsf.edu/global?page=cr09-00-00

[9] Ibid

[12] This strategy has been greatly criticised however, because it only protects the male and does not ensure that the man’s partner also won’t contract HIV.

Gcobani Qambela

Gcobani Qambela is a Graduate Student in South Africa with an interest in African masculinities, HIV/AIDS research and public health in general.

  1. 6 million -11.9 million
  2. 4 million – 5.8 million

6 Responses to Rethinking HIV/AIDS Prevention Strategies for South Africa: searching for appropriate responses for the South African Epidemic

  1. Interesting piece GQ. Interesting how you contend that infections are primarily fueled by long tern relationships that tend to fall into the comfort zone on sex. Kenyan case is however slightly different. It had been shown that the epidemic was spread, at an alarming rate by the way, by young people who tend to indulge in risky sexual behavior. Emphasis was put on awareness among this group, on BCE, Condom use and generally one partner relationship. This worked incredibly. However, a new paradigm arose, that which you have touched on. The CSWs and MSMs. Currently, studies have shown that the epidemic spreads fast among married couples who indulge in extra marital affairs. The issue of male circumcision is also true. A lot of emphasis and money have been put by the government to have all males get circumcised and the response has been amazing. Currently, our infection rate is a little over 3% compared to 9% in 1990.

    • Thanks Siphokazi and Thembani.I’m glad you guys found the article insightful as that was the aim. Often this information remains reserved for the ‘educated’ in peer reviewed journals and does not reach the people who are supposed to read it, and I’m glad that the Bokamoso Africa blog allows us to democratise this information and make it available for everyone in an easily accessible manner.

      @Ediie: Interesting and powerful intervention and I agree with you. That’s why in the article I state that “no single prescription can be tailored for countries in a standardized manner as if they are the same.” The piece is restricted only to recent research on South Africa with people who are in heterosexual relationships (as I state the epidemic is not concentrated but rather generalised in South Africa).

      But in essence we both agree that each countries epidemics differ and consequently the different responses have to be tailored to suit thoseparticular epidemics.

      Interesting to read your country’s information as I have not researched it. We are reading – lets all share this information now with people. Thanks for the comment again!

  2. Thank you for the article, very insightful! But don’t you think the stigma associated with HIV/AIDS is another contributing factor that needs to be addressed? Shouldn’t educational campaigns be structured in a manner that parents are directly invovled in talking about sex with their children? It would be interesting to have the minister of health read this piece. It will serve as an insightful guide to their approach to curbing the spread of HIV in South Africa.

  3. Thanks for the comment Nomfundo.

    The issue of the HIV/AIDS stigma is an important one and is also often underplayed in academe, but the way I see it is that it actually plays two roles, one is as you correctly state a controbutory role in perpertuating the virus (for most people would want to be assumed HIV negative and hence go around sleeping without protection as they do not want to arouse doubt about their status). The other role that the stigma plays is that it can also act as a detterent for people NOT to contract the virus for maybe they will be too scared of victimisation/getting sick should they contract the virus.

    I agree with you, educational programmes are very important, and what I tried to show with the piece is that for the most part these have been relatively successful in raising national consciousness about HIV — this is demonstrated by the fact that recent statistics actually demonstrate a decrease in HIV risk behavior amongst young people as they are practicing safe sex but the problem lies in the long term relationships.

    Look, I don’t want to simply things as this is a largely behaviorist issue that is NOT homogenous at large, but again I have to agree with you: research demonstares that youngsters do actually want to hear information from their parents as they regard this with more authority than their peers… a key approach that researchers have recently pointed to is that kids should be encouraged to as far as possible prolong their sexual debut into their mid/early twenties where they are able to understand the risk associated with sex, and those that are in long term partnerships should maintain one partner and at no point should be involved in multiple concurrent partners.

    I too then have to agree then that perhaps educational programmes should be expanded to encompass this (although worth noting that a lot of NGO’s have already started doing amazing work in communication programmes along these lines).

    Thanks for the comment again, and for taking time to think through the article.

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