Article: The Challenge of HIV/AIDS in South Africa

19 October 2001

Article: The Challenge of HIV/AIDS in South Africa

Research and prevention in KwaZulu-Natal

By David Pitts
Washington File Staff Writer

Durban, KwaZulu-Natal, South Africa -- At King Edward, the province's main public hospital located on the outskirts of this city, HIV/AIDS is all but overwhelming the doctors and nurses who work here. In the outpatient area, scores of adults wait for hours for drugs to treat both minor and serious infections, but there are no drugs to treat HIV itself. In the pediatric unit, babies, some of them orphaned as a result of their parents dying of AIDS, cry helplessly -- tormented by a variety of ailments including HIV. Just last week, the administrator of the hospital, Sibusiso Mhlambi, resigned, warning that the institution could collapse under the burden of HIV/AIDS.

"This is the face of HIV/AIDS in KwaZulu-Natal," says a researcher at the nearby Nelson Mandela Medical School, established in the 1950s as the first medical school for blacks and where Steve Biko, leader of the black consciousness movement, once studied. "We have the highest infection rate in the country -- an estimated one in three persons," she adds. The school is conducting a research project into risk behaviors, focused on the rural areas in an attempt to forge strategies that will better prevent infection. A report from the country's Medical Research Council (MRC) produced earlier this month named AIDS the number one killer in South Africa -- accounting for one in four deaths in the country -- and provincial ANC-led governments in Gauteng and Free State provinces echoed the finding, saying AIDS is the number one killer in their jurisdictions. The MRC report says that between five and seven million South Africans out of a total population of about 40 million could die from AIDS by 2010. In South Africa, HIV/AIDS is mainly transmitted through heterosexual relations.

HIV/AIDS is so pervasive that it is not just a medical story. Researchers and civil society advocates interviewed for this article say that the scale of the problem could impair the economy, social cohesion and thereby the future of South African democracy. That is a view held by Alan Whiteside, the director of the health economics and HIV/AIDS research division of the University of Natal. "HIV infection has risen dramatically here during the 1990s. Behind the HIV epidemic will be an even larger rise in AIDS cases," he says. "Families are being impoverished by the epidemic as young wage earners get sick or die." One recent study concluded the infection rate at selected clinics is approaching 40 percent. The death rate among South African men 35-39 is now 50 percent higher than it was just three years ago, the study added.

Whiteside's research has documented the effect in specific areas of South African life -- for example, education. "There has been a dramatic decline in grade one enrollment in schools here. We're not sure of the causes of this right now. It could be because of children getting sick themselves or they could be staying away from schools because of the impact of the disease on their parents." The results of his research into the effects of HIV/AIDS on schools were widely reported in the South African press earlier this month. The headline in the Sunday Independent said, "Pupil Enrollment Plummets as AIDS Bites in KwaZulu-Natal." The Cape Times highlighted Whiteside's prediction that there will be "an estimated two million AIDS orphans in South Africa by 2010; 500,000 of them in KwaZulu-Natal." A separate report concluded that social grant spending on the poor "will be seriously affected by the need to provide grants to HIV/AIDS orphans." "HIV/AIDS is ravaging South Africa," says Whiteside, who last year wrote a book, "AIDS: The Challenge for South Africa," about the scale of the problem.

However, Whiteside says the picture is not all bleak. The South African government has negotiated cheaper drugs that will allow HIV positive employees to work longer. In addition, the government has started to provide anti-retroviral drugs to HIV positive pregnant women. He also notes that the upward curve of AIDS cases in South Africa can be reduced if prevention efforts prove effective. "We can change the future if we impact prevention, if we get the right information out there. Also, we still have time to plan for impact in terms of the HIV cases in process now that will materialize into AIDS," he says. "But we must move fast." Research projects also underway at the university are examining the impact of HIV/AIDS on democratic governance and on children orphaned by the disease. The U.S. Agency for International Development (USAID) and UNICEF are providing major support.

A key problem, as far as HIV/AIDS in South Africa is concerned, is getting good information, particularly about the black majority and especially in rural areas. Health Systems Trust (HST) is an organization funded by the Henry J. Kaiser Family Foundation, among other sources, that has been working to fill the gap. "We are currently conducting a survey to understand the impact of HIV on families, including its impact on finances," says executive director David Mametja "We also are examining the services that are being provided to those who are infected -- to identify problems and deficiencies," he adds. At the sub-district level, HST is assessing the quality of care and working with local clinics to improve it. Nurse practitioners are at work in a number of provinces in addition to KwaZulu-Natal. A major focus is to prevent mother-to-child HIV infection.

"A big issue is the marginalization of women," says Grace Mufamadi, HST's facilitator for the program. "Rural women are often powerless and cannot for example, insist on the use of condoms. In addition, the distance to the clinics -- where drugs are available to treat sexually transmitted infections -- can be very far and the women often don't have the knowledge to understand that information and treatment is available." And "you always have to keep in mind that South Africa is a developing country where income is limited and resources are scarce," says Fatima Suleman, an HST researcher. "Even if the full range of drugs were available for treatment of HIV/AIDS," she says, "there are insufficient resources for delivery and testing," -- for example, measuring T-cell counts -- necessary to determine appropriate drug therapy. An intergovernmental fiscal review, released October 9, predicts that even real growth in the health budget will not be adequate to deal with the increase in demand for services as a result of AIDS. It notes that patients admitted to public hospitals like King Edward's with HIV/AIDS related problems have grown substantially.

The good news, say the researchers, is that South Africans are increasingly aware of the danger that HIV/AIDS poses to themselves and their young democracy. Newspapers are aggressively covering the disease and organizations like Lovelife have mounted an ambitious nationwide prevention campaign aimed directly at young people. The organization uses an upbeat multi-media approach to promoting safe sex. Earlier this month, the media and Lovelife formed an alliance. Independent newspapers signed a five-year contract with the organization valued at about six million Rand annually. The main product of the partnership will be a newsletter called Thetha Nathi (Speak to Us) targeted at teenagers. It is expected to be launched November 5 in the Western Cape and November 8 here in KwaZulu-Natal. It will be available as a supplement in The Star, Pretoria News, Daily News and Cape Argos -- among other newspapers -- assuring a higher readership. It also will be distributed to schools nationally and public clinics that are part of the Lovelife program.

Beginning in October, the KwaZulu Department of Health, together with the AIDS Action Unit, launched a project to distribute condoms in taverns. The question is whether these and other efforts to fight HIV/AIDS in South Africa -- by government and NGOs -- will be sufficient to contain the damage inflicted not only on individuals and families -- and babies not yet born -- but also on the country's economy and new democratic infrastructure. Adding to the complexity of the issue is the fact that South Africa is a developing country with a high level of poverty. Many political leaders, as well as researchers and civil society advocates, stress that combating HIV/AIDS cannot be undertaken in a vacuum, but must be part of an overall strategy to reduce poverty and improve education.