AIDS IN SOUTH AFRICA

SUBMITTED TO : B R M RAO SIR SUBMITTED BY : MEHUL RAVAL

AHMEDABAD MANAGEMENT ASSOCIATION

PGDIBM – 2007 2009

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South Africa is currently experiencing one of the most severe AIDS epidemics in the world. At the end of 2007, there were approximately 5.7 million people living with HIV in South Africa, and almost 1,000 AIDS deaths occurring every day.1 A number of factors have been blamed for the increasing severity of South Africa’s AIDS epidemic, and debate has raged about whether the government’s response has been sufficient. This page looks at the impact that AIDS has had on South Africa, the historical context of the epidemic, and the major issues surrounding the crisis.
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Percent of Adults Estimated to Be Living with HIV/AIDS (end 2003)

Number of People Estimated to be Living with HIV/AIDS (end 2003)

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Introduction During the last two decades, the HIV pandemic has entered the consciousness as an incomprehensible calamity. HIV/AIDS has already taken a terrible human toll, laying claim to millions of lives, inflicting pain and grief, causing fear and uncertainty and threatening economic devastation. According to the Joint United Nations Programme on HIV/AIDS (UNAIDS) and the World Health Organisation (WHO), the number of people living with HIV by the end of 1998 was estimated to be 33.4 million, a 100% increase compared to 1997. In Sub-Saharan Africa, more than a quarter of young adults are infected with HIV. Assuming that no cure is found, it is estimated that more than 50 million people globally will be living with HIV by 2010. The impact of the epidemic on the economy is already being felt in most countries. Life expectancy has been significantly reduced as many people in the 15-49 year age group are now dying of AIDS. Many countries both in Africa and Asia have taken urgent steps to curb the epidemic with varying degrees of success. In South Africa, despite the efforts, the HIV infection rate has increased significantly over the past 5 years. This increase in the infection rate calls for a renewed commitment from all South Africans. HIV/AIDS in South Africa

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The scale of South Africa’s AIDS crisis It is difficult to overstate the suffering that HIV has caused in South Africa. With statistics showing that almost one in five adults are infected, HIV is widespread in a sense that can be difficult to imagine for those living in less-affected countries. For each person living with HIV, in South Africa and elsewhere, not only does it impact on their lives, but also those of their families, friends and wider communities. With antiretroviral drug treatment, HIV-positive people can maintain their health and often lead relatively normal lives. Sadly, few people in South Africa have access to this treatment. This means that AIDS deaths are alarmingly common throughout the country. It is thought that almost half of all deaths in South Africa, and a staggering 71% of deaths among those aged between 15 and 49, are caused by AIDS. So many people are dying from AIDS that in some parts of the country, cemeteries are running out of space for the dead. Recent estimates suggest that of all people living with HIV in the world, 6 out of every 10 men, 8 out of every 10 women, and 9 out of every 10 children are in Sub-Saharan Africa. These figures provide sufficient evidence to make HIV/AIDS both a regional and a national priority. Data from the DOH’s annual National HIV Seroprevalence Surveys of Women attending Antenatal Clinics for the past 9 years provides a good estimate of HIV prevalence and trends over time in South Africa. Fig. National HIV survey of women attending antenatal clinics of the public health services in South Africa, 1990 – 1999

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A recent survey found that South Africans spent more time at funerals than they did having their hair cut, shopping or having barbecues. It also found that more than twice as many people had been to a funeral in the past month than had been to a wedding.

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As well as the death and suffering that HIV has caused on an individual and community level, South Africa’s AIDS epidemic has also had a substantial impact on the country’s overall social and economic progress: • • Average life expectancy in South Africa is now 54 years – without AIDS, it is estimated that it would be 64. Over half of 15 year olds are not expected to reach the age of 60. Between 1990 and 2003 – a period during which HIV prevalence in South Africa increased dramatically – the country fell by 35 places in the Human Development Index, a global directory that ranks countries by how developed they are. • Hospitals are struggling to cope with the number of HIV-related patients that they have to care for. In 2006 a leading researcher estimated that HIV-positive patients would soon account for 60-70% of medical expenditure in South African hospitals.

Schools have fewer teachers because of the AIDS epidemic. In 2006 it was estimated that 21% of teachers in South Africa were living with HIV.

It is clear that AIDS is having a devastating impact on South Africa. There are many possible reasons why South Africa has been so badly affected by AIDS, including poverty, social instability and a lack of government action. One way to gain a better insight into the situation is to look back on the history of AIDS in South Africa.

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The history of AIDS in South Africa South Africa has had a turbulent past, and this history is relevant to the explosive spread of HIV in the country. 1980s - In 1985, a State of Emergency was declared in South Africa that would last for five years. This was a result of riots and unrest that had arisen in response to Apartheid, the system of racial segregation that had been in place since the 1950s. Apartheid prohibited mixed-race marriages and sex between different ethnic groups, and categorized separate areas in which different races lived. In the same year, the government set up the country’s first AIDS Advisory Group in response to the increasingly apparent presence of HIV amongst South Africans. The first recorded case of AIDS in South Africa was diagnosed in 1982, and although initially HIV infections seemed mainly to be occurring amongst gay men, by 1985 it was clear that other sectors of society were also affected. Towards the end of the decade, as the abolition of Apartheid began, an increasing amount of attention was paid to the AIDS crisis. 1990 - The first national antenatal survey to test for HIV found that 0.8% of pregnant women were HIV-positive.9 It was estimated that there were between 74,000 and 120,000 people in South Africa living with HIV. Antenatal surveys have subsequently been carried out annually. 1991 - The number of diagnosed heterosexually transmitted HIV infections equaled the number transmitted through sex between men. Since this point, heterosexually acquired infections have dominated the epidemic. Several AIDS information, training and counseling centers were established during the year. 1992 - The government’s first significant response to AIDS came when Nelson Mandela addressed the newly formed National AIDS Convention of South Africa (NACOSA). The purpose of NACOSA was to begin developing a national strategy to cope with AIDS. The free National AIDS Helpline was founded. 1993 - The National Health Department reported that the number of recorded HIV infections had increased by 60% in the previous two years and the number was expected to double in 1993. The HIV prevalence rate among pregnant women was 4.3%.
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1994 - The Minister for Health accepted the basis of the NACOSA strategy as the foundation of the government's AIDS plan. There was criticism that the plan, however well intended, was poorly thought-out and disorganized. The South African organization Soul City was formed, with the aim of developing media productions to educate people about health issues, including HIV/AIDS. 1995 - The International Conference for People Living with HIV and AIDS was held in South Africa, the first time that the annual conference had been held in Africa. The then Deputy President Thabo Mbeki, acknowledged the seriousness of the epidemic, and the South African Ministry of Health announced that some 850,000 people - 2.1% of the total population - were believed to be HIV-positive.10 1996 - The HIV prevalence rate among pregnant women was 12.2%. 1997 - The HIV prevalence rate among pregnant women was 17.0%. A national review of South Africa's AIDS response to the epidemic found that there was a lack of political leadership. 1998 - The pressure group Treatment Action Campaign (TAC) was founded, to campaign for the rights of people living with HIV, and to demand access to HIV treatment in South Africa for all those who were in need of it. Deputy President Thabo Mbeki launched the Partnership Against AIDS, admitting that 1,500 HIV infections were occurring every day. 1999 - The HIV prevalence rate among pregnant women was 22.4%. 2000 - The Department of Health outlined a five-year plan to combat AIDS, HIV and STIs.11 A National AIDS Council was set up to oversee these developments. At the International AIDS Conference in Durban, the new South African President Thabo Mbeki made a speech that avoided reference to HIV and instead focused on the problem of poverty, fuelling suspicions that he saw poverty, rather than HIV, as the main cause of AIDS. President Mbeki consulted a number of ‘dissident’ scientists who rejected the link between HIV and AIDS. 2001 - The HIV prevalence rate among pregnant women was 24.8%. 2002 - South Africa's High Court ordered the government to make the drug nevirapine available to pregnant women to help prevent mother to child transmission of HIV. Despite international drug companies offering free or cheap antiretroviral drugs,12 the Health Ministry, led by Manto Tshabalala-Msimang, remained hesitant about providing treatment for people living with HIV.
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2003 - In November, the government finally approved a plan to make antiretroviral treatment publicly available. The HIV prevalence rate among pregnant women was 27.9%. 2004 - The South African government’s treatment program began to take effect in Gauteng in March, followed shortly afterwards by other provinces. 2005 - At least one service point for AIDS related care and treatment had been established in all of the 53 districts in the country by March, meeting the government’s 2003 target. However, it was clear that the number of people receiving antiretroviral drugs was well behind initial targets. The HIV prevalence rate among pregnant women was 30.2%. 2006 – Jacob Zuma, the Former South African Deputy-President, went on trial for allegedly raping an HIV-positive woman. He argued that she had consented to sex and was eventually found not guilty, but attracted controversy when he stated that he had showered after sex in the belief that this would reduce his chances of becoming infected with HIV. Criticism of the government’s response to AIDS heightened, with UN special envoy Stephen Lewis attacking the government as ‘obtuse and negligent’ at the International AIDS Conference in Toronto. At the end of the year, the government announced a draft framework to tackle AIDS and pledged to improve antiretroviral drug access. Civil society groups claimed that this marked a turning point in the government’s response. 2008 – President Mbeki resigned in September 2008 after losing the support of his party. Kgalema Motlanthe took over as interim president and appointed Barbara Hogan as health minister in place of Manto Tshabalala-Msimang. AIDS activists welcomed the changes, anticipating greater government commitment to the AIDS response.

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Why did South Africa’s AIDS epidemic go unchecked for so long? The most rapid increase in South Africa’s HIV prevalence took place between 1993 and 2000, during which time the country was distracted by major political changes. While the attention of the South African people and the world's media was focused on the country's transition from apartheid, HIV was rapidly becoming more widespread. Although the results of these political changes were positive, the spread of the virus was not given the attention that it deserved, and the impact of the epidemic was not acknowledged. It is likely that the severity of the epidemic could have been lessened by prompt action at this time Major causes and determinants of the epidemic in South Africa The immediate determinants of the epidemic include behavioural factors such as unprotected sexual intercourse and multiple sexual partners, and biological factors such as the high prevalence of sexually transmitted diseases. The underlying causes include socio-economic factors such as poverty, migrant labour, commercial sex workers, the low status of women, illiteracy, the lack of formal education, stigma and discrimination. The national HIV/AIDS & STD Strategic Plan must address all these immediate determinants and underlying causes. Tuberculosis and HIV/AIDS Closely linked to the HIV/AIDS epidemic, is a Tuberculosis (TB) epidemic which is fuelled by HIV infection and which is also the most frequent cause of death in people living with HIV. In South Africa, approximately 40-50% of TB patients are infected with HIV. In some hospitals in South Africa, the HIV prevalence in TB patients has been recorded as over 70%. Sexually Transmitted Diseases There is compelling evidence of the importance of STDs as a major determinant of HIV transmission. There are approximately 11 million STD episodes treated annually in South Africa,
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with approximately 5 million of these managed by private general practitioners. Even without the HIV epidemic, STDs pose an important public health problem. HIV treatment in South Africa South Africa’s national HIV treatment programme has been the topic of much debate. The South African government was initially hesitant about providing antiretroviral treatment to HIV-positive people, and only started to supply the drugs in 2004 – years after many other nations had begun to do so – following pressure from activists. Even since 2004, the distribution of antiretroviral drugs has been relatively slow, with only around 28% of people in need receiving treatment at the end of 2007.13 The government was also initially reluctant to provide drugs that could prevent HIV-positive mothers from passing HIV on to their babies, and has been accused of not making enough effort to get these drugs to women that need them. The slow provision of treatment has been linked to unconventional views about HIV and AIDS amongst the government. Alongside President Mbeki’s questioning of whether HIV really causes AIDS, his health minister Manto Tshabalala-Msimang caused controversy by promoting nutrition rather than antiretroviral drugs as a means of treating HIV. These views attracted widespread criticism, both within South Africa and amongst the international community.

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HIV testing in South Africa HIV voluntary counselling and testing (VCT) should be an important part of any country’s response to AIDS. The number of VCT sites in South Africa has increased significantly in recent years, with 4,172 operational by November 2006. Despite this progress, there are concerns about the quality of VCT services in some areas. Reports suggest that counsellors are not always adequately trained, may lack medical knowledge about HIV, and are often overworked. Another problem is that women seem to be accessing testing more readily than men in South Africa. Researchers believe that this is due to fears amongst men that their HIV-positive status will be disclosed through testing, and that stigmatisation will follow. Surveys have also suggested that some men see no value in knowing their HIV status, viewing such knowledge as a burden

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STRUCTURES IN SOUTH AFRICA TO ADDRESS HIV/AIDS The expanded national response will be managed by different structures at all levels. It is envisaged that each government ministry will have a focal person and team whose responsibility will be to plan, budget, implement and monitor HIV/AIDS interventions. It is also recommended that all other sectors including parastatals, NGOs, the private sector, faith-based organisations, youth, and women will also have dedicated HIV/AIDS focal persons. The following presents a brief overview of important structures at national and provincial levels and their specific role and functions relating to HIV/AIDS. - Cabinet The Cabinet is the highest political authority in the country. The Cabinet meets weekly, but HIV/AIDS issues are not regularly discussed at this level, as all Cabinet members plus all Deputy Ministers and members of the Department of Health meet monthly in the Inter-Ministerial Committee on AIDS. - National AIDS Council The National AIDS Council is the highest body that advises government on all matters relating to HIV/AIDS. Its major functions are to: (a) advise government on HIV/AIDS/STD policy, (b) advocate for the effective involvement of sectors and organisations in implementing programmes and strategies, (c) monitor the implementation of the Strategic Plan in all sectors of society, (d) create and strengthen partnerships for an expanded national response among all sectors, (e) mobilise resources for the implementation of the AIDS programmes, and (f) recommend appropriate research. This body is chaired by the Deputy President, and consists of 15 government representatives and 16 civil society representatives

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Relevant National and Provincial Structures

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Government Ministers of Health; Education; Welfare and Population Development; Agriculture; Arts, Culture, Science and Technology; Transport; Labour; Finance; Provincial and Local Government; Defence; Minerals and Energy; Correctional Services; the Deputy CEO of the Government Communication and Information Systems; the Chairperson of the Portfolio Committee on Health; and the Chairperson of the Select Committee on Social Services. Sectors to be represented One representative each from Business; People living with HIV/AIDS; Non-government organisations; Faith-based organisations; Trade Unions; Women; Youth; Traditional healers; Traditional leaders; Legal and Human Rights; Disabled People; Celebrities; Sport; Media; Hospitality Industry; and Local government. Technical Task Teams The NAC will be assisted in its deliberations and decisions by technical task teams to be established by the Ministry of Health, and comprising experts in the following five areas: a) Prevention; b) Care and Support, c) IEC and Social Mobilisation, d) Research, Monitoring, Surveillance and Evaluation; and e) Legal Issues and Human Rights. Inter-Ministerial Committee on AIDS (IMC) In 1997, the South African Cabinet formed the IMC. The IMC consists of all Ministers and Deputy Ministers and is chaired by the Deputy President. This committee meets on a monthly basis to review the country’s response to the HIV/AIDS epidemic. Issues of strategic importance are discussed and political guidance is given to the HIV/AIDS and STD Directorate and the IDC. Interdepartmental Committee on AIDS (IDC)

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This committee consists of representatives from all government Departments who co-ordinate HIV/AIDS activities. The IDC meets monthly to review government programs and to fulfil requests from the IMC. Goals of the IDC include facilitating the development of HIV/AIDS workplace policies in all Government Departments, ensuring that all Government Departments allocate financial resources to HIV/AIDS; and developing minimum HIV/AIDS programs for all Government Departments. MinMEC The MinMEC consists of all Provincial Health MECs and the national Minister of Health. The MinMEC meets every six weeks, and is the body that approves national policies and guidelines. HIV/AIDS is a standing item where reports on national and provincial programmes are discussed. Provincial Health Restructuring Committee (PHRC) This committee consists of all Provincial Heads of Health and meets on a monthly basis to discuss the strategic issues of national and provincial importance. HIV/AIDS is a standing agenda item where reports from the IMC, National HIV/AIDS/STD Directorate and Provincial HIV/AIDS Coordinators are discussed. Once the PHRC has discussed and approved documentation, it is referred to the MinMEC for the political approval. Director-Generals Forum This forum consists of Director Generals from all the National Government Departments and meets regularly. HIV/AIDS is a standing agenda item where reports from the IMC are discussed. HIV/AIDS and STD Directorate, Department of Health HIV/AIDS issues are brought to the attention of the above national bodies by the Department of Health’s Directorate of HIV/AIDS and STDs. This Directorate prepares briefing documents for these national forums, and attends meetings to provide further information to aid decision-making in these national committees and bodies.
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HIV prevention campaigns in South Africa The issue of HIV prevention in South Africa has attracted less controversy and debate than other aspects of the country’s response to AIDS. There have been some notable national efforts, including: • • • ‘The Soul City Project’, which was started in 1994 and educated people about AIDS through radio, print, and television, using dramas and soap operas to promote its message. The ‘Beyond Awareness’ campaign, which ran between 1998 and 2000 and concentrated on informing young people about AIDS through the media. The 'Khomanani' (‘caring together’) campaign, run by the Aids Communication Team (ACT), a group that was set up by the government in 2001. The Khomanani campaign has used the mass media and celebrity endorsement to get across HIV prevention messages, with a particular emphasis on encouraging HIV testing. • loveLife, the most prominent HIV prevention campaign to be carried out in South Africa, which specifically targets young people and attempts to integrate HIV prevention messages into their culture. It was launched in 1999, with the aim of reducing rates of teenage pregnancy, HIV and sexually transmitted infections amongst young South Africans. The campaign attempts to market sexual responsibility through the media as if it were a brand. It also operates a network of telephone lines, clinics and youth centres that provide sexual health facilities, as well as an outreach service that travels to remote rural areas, to reach young people who are not in the educational system. Although these campaigns have probably saved many lives, the actual difference they have made in reducing the number of new HIV infections is very difficult to measure. The prevailing high rates of HIV found across South Africa suggest that either the message isn’t getting through to many people, or that people are receiving information but not acting upon it.

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A LOVELIFE BILLBOARD ADVERTISING PROTECTION AGAINST HIV In some cases the problem may lie with the campaigns themselves. Some AIDS activists have criticised the ongoing loveLife campaign, arguing that it is poorly targeted and ineffective. 16 In December 2005, loveLife suffered a major set back when the Global Fund, one of its main financial backers, withdrew funding, stating that the campaign ‘was deemed to not have sufficiently addressed weaknesses in its implementation’.17 However, the seeming lack of progress made by HIV prevention campaigns does not necessarily reflect a lack of effort. Various social factors make it difficult to carry out effective HIV prevention campaigns in South Africa, as the population is highly diverse and divided by deeply rooted social inequalities. South Africans have a mixture of ethnic backgrounds: black people account for 75% of the population, whites make up around 13%, Asians make up about 3%, and other people of mixed racial heritages account for about 9%. There are 11 official languages and many dialects; around 86% of the population is literate.18 Some live in large, crowded cities, while others live in sparsely populated rural areas, many of which are isolated, underdeveloped and lacking infrastructure. This diversity has made it very difficult to carry out AIDS awareness campaigns that actually influence people’s behaviour.

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STIGMA AND DISCRIMINATION IN SOUTH AFRICA The prevalence of misinformation about AIDS in South Africa has not only hampered efforts to increase access to treatment, but has also created a climate of confusion in which prejudice towards people living with HIV thrives. HIV is sometimes seen as being a disease of the poor. In South Africa, there is some correlation between extreme poverty and high HIV prevalence, although HIV is prevalent across all sectors of society.19 By 1998, although people from more affluent, largely white society were starting to come out as being HIV-positive, stigmatization of the condition remained still deeply rooted in township areas. In October 1998, the then Deputy President Thabo Mbeki made the Declaration of Partnership Against AIDS, in which he called for an end to discrimination against people living with HIV. However, it was clear that there was a long way to go before this goal could be achieved; less than two months later, Gugu Dlamini, an AIDS activist in Durban, was beaten to death by her neighbors after declaring that she was HIV-positive on World AIDS Day. In 2000, Justice Edwin Cameron of the South African court announced in a speech that he was HIVpositive. The public response to this declaration was, on the face of it, largely supportive. However, coming out as HIV-positive can in many cases have a negative effect on employment and housing opportunities, as well as social relationships. A study in 2002 revealed that only one third of respondents who had revealed their HIV-positive status were met with a positive response in their communities. One in ten said that they had been met with outright hostility and rejection.21 When his son died of AIDS in 2005, Nelson Mandela publicized the cause of his death in an effort to challenge the stigma that surrounds HIV infection: "Let us give publicity to HIV/AIDS and not hide it, because [that is] the only way to make it appear like a normal illness."

Gender inequality and sexual abuse in South Africa
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Although HIV prevention campaigns usually encourage people to use condoms and have fewer sexual partners, women and girls in South Africa are often unable to negotiate safer sex and are frequently involved with men who have several sexual partners. They are also particularly vulnerable to sexual abuse and rape, and are economically and socially subordinate to men. Police reports suggest that in 2004-2005 there were at least 55,114 cases of rape in South Africa
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although the actual figure is undoubtedly higher than this since the majority of cases go unreported. In a 2006 study of 1,370 South African men, nearly one fifth revealed that they had raped a woman.24 Rape plays a significant role in the high prevalence of HIV among women in South Africa. Women often face more severe discrimination than men if they are known to be HIV-positive. This can lead to physical abuse and the loss of economic stability if their partners leave them. Since antenatal testing gives them a greater chance of being identified as HIV-positive, women are sometimes branded as ‘spreaders’ of infection. The government has acknowledged that many women face ‘triple oppression’ in South African society – oppression on the grounds of race, class and gender – and has been making efforts to address this problem, through education and skills development schemes.25 In September 2007 rape laws were strengthened to stop judges and magistrates taking into account factors such as a rape victim's sexual history, their apparent lack of physical injury, or the relationship between the victim and the perpetrator, when deciding on the length of the perpetrator's sentence. Children, HIV and AIDS in South Africa With many women who are HIV-positive still not receiving drugs that could prevent them passing HIV to their babies, HIV infections are alarmingly common amongst children in South Africa. According to UNAIDS, there were around 280,000 children aged below 15 living with HIV in South Africa in 2007. Children who are living with HIV are highly vulnerable to illness and death unless they are provided with pediatric antiretroviral treatment. Unfortunately there is still a shortage of such treatment in South Africa. The AIDS Law Project, an NGO based in Johannesburg, estimated that 50,000 children in South Africa were in need of antiretroviral drugs at the beginning of 2006, but that only
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around 10,000 were receiving them.28 UNAIDS estimates that at the end of 2005, children accounted for 8% of those receiving antiretroviral drugs in South Africa.29 As well as many children being infected with HIV in South Africa, many more are suffering from the loss of their parents and family members from AIDS. UNAIDS estimated that there were 1.4 million South African children orphaned by AIDS in 2007, compared to 780,000 in 2003.30 Once orphaned, these children are more likely to face poverty, poor health and a lack of access to education. YOUTH AS A TARGET GROUP Youth is a specific focus area in the fight against HIV/AIDS as people between the ages of 14 –35 the most vulnerable to HIV infection. In addition, the youth are an important target group to protect against future HIV infection as they represent both the present and future economic powerhouse of the country. Promote improved health seeking behaviour and adoption of safe sex practices - Produce and disseminate IEC material and messages to different stakeholders - Implement life skills education in all primary and secondary schools Broaden responsibility for the prevention of HIV to all sectors of government and civil society - Develop sector-specific policies and plans for the prevention of HIV/AIDS/STDs, focussing specially on the following sectors: … youth … Improve access to and use of male and female condoms, especially amongst 15 – 25 year olds - Expand condom distribution through non-traditional outlets - Improve access to condoms in high transmission areas (e.g. truck stops, borders, mines and brothels) - Increase acceptance, attitudes, perceptions, efficacy and use of condoms as a form of contraception among the youth Increase access to youth friendly reproductive health services – including STD management, VTC and rapid HIV testing facilities - Make clinics and HCWs “youth friendly”
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- Make schools places where youth can access friendly and supportive counselling services Increase the number of persons seeking voluntary HIV testing and counseling services - Promote access to VTC services, especially for the youth Develop and implement programmes to support the health and social needs of children affected by HIV/AIDS - Promote advocacy of all relevant issues that affect children - MoBilise financial and material resources for orphans and child-headed households - Investigate the legal protection of child-headed households - Provide social welfare, legal and human rights support to protect educational and constitutional rights Implement measures to facilitate adoption of AIDS orphans - Investigate the use of welfare benefits to assist children and families living with HIV/AIDS - Subsidize adoption of AIDS orphans Conduct National Surveillance on HIV and STD risk behaviours, especially among youth - Conduct behavioural sentinel surveys, with a focus on youth - Conduct national HIV infections surveillance in selected populations and groups, including youth

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The way forward for South Africa In recent years, antenatal survey results have led the South African government to claim that the HIV epidemic is beginning to stabilise. The Democratic Alliance (the main opposition party in South Africa) argues that such claims detract from the seriousness of the country’s AIDS crisis. Even if the epidemic is stabilising, it is doing so at a very high level. Following the antenatal survey in 2004, Democratic Alliance health spokesman Ryan Coetzee stated: “The figures continue to increase, and that is not 'stabilising'. The report proves the government's prevention campaign is not succeeding”31 The high level of new HIV infections occurring in South Africa reflects the difficulties that have been faced by AIDS education and prevention campaigns. In addition, the high number of AIDS deaths occurring in the country reflects the continuing lack of antiretroviral treatment available. The future of the epidemic at least partly depends on the direction of the government’s HIV and AIDS policies. Thabo Mbeki and his health minister were widely criticised for failing to effectively address the epidemic. Following a change in leadership, and the adoption of an ambitious national plan, many are hopeful that the government’s response will improve. However, given the scale of the crisis, any change is likely to be gradual. In the face of such a terrible epidemic, there is a tendency for some people to adopt a fatalistic attitude. But, as Justice Cameron once said, "We don't accept 'sad realities' in South Africa. If we accepted sad realities, we would still have a racist oligarchy here."

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