HIV Prevalence Continues to Rise: Government Must Urgently Improve Prevention and Treatment Response

24 September 2004

Approximately 5.6 million South Africans lived with HIV in 2003 according to the Department of Health's latest National HIV and Syphilis Antenatal Sero-Prevalence Survey in South Africa, released yesterday. This, the 14th antenatal survey since 1990, demonstrates yet again the need for all sectors of South African society, including government, business, labour, faith organisations and civil society, to improve HIV prevention and treatment efforts. The growth in the number of HIV cases continues and there is no evidence that the number of infections has stabilised, or that the level of new HIV infections is dropping among youth. HIV/AIDS is a national disaster and emergency measures for alleviating the epidemic are needed urgently.

This year's antenatal study is much more detailed than in previous years, containing a breakdown of the number of women tested by age group and province. The Treatment Action Campaign (TAC) welcomes this improvement. However,
we continue to insist on the need to publish results on a district by district basis, which would greatly help localised prevention and treatment efforts.

The report can be downloaded from the Department of Health's website:

Key Findings

The Survey found that 27.9% of pregnant women attending public antenatal clinic surveys in South Africa were HIV-positive in 2003. This is up from 26.5% in 2002. The first antenatal survey conducted in 1990 found a prevalence of 0.7%.

Among pregnant women younger than 20, the prevalence was 15.8%, up from 14.8% in 2002, but almost the same as the 2001 survey. Kwazulu-Natal Province continues to have the highest prevalence rate at 37.5%. Mpumalanga Province has become the province with the second-highest number of antenatal infections at 32.6%.

The Department of Health uses a model based on the antenatal results to estimate that the number of South Africans with HIV in 2003 was 5.6 million. The majority of HIV-positive people, between 2.8 and 3.4 million, are women. Between 90 and 103 thousand infants are also infected emphasizing the need for a more effective mother-to-child transmission prevention rollout.

The projections made by the Department of Health are similar to those of the Actuarial Society of South Africa's ASSA2002 model and the findings of the Human Science Research Council in a 2002 community survey. Our knowledge of the HIV epidemic in South Africa is growing due to increased collection of primary data, such as the antenatal surveys, and there has been convergence of a number of different population prevalence estimates.

Here are key statistics published in the Survey:

Number of women surveyed: 16, 643
Antenatal HIV prevalence by province (95% Confidence intervals in parenthesis)
KwaZulu-Natal 37.5 (35.2 - 39.8)
Mpumalanga 32.6 (28.5 - 36.6)
Free State 30.1 (26.9 - 33.3)
North West 29.9 (26.8 - 33.1)
Gauteng 29.6 (27.8 - 31.5)
Eastern Cape 27.1 (24.6 - 29.7)
Limpopo 17.5 (14.9 - 20.0)
Northern Cape 16.7 (11.9 - 21.5)
Western Cape 13.1 (8.5 - 17.7)

South Africa antenatal prevalence in:
2001: 24.8 (23.6 - 26.1)
2002: 26.5 (25.5 - 27.6)
2003: 27.9 (26.8 - 28.9)
Antenatal HIV prevalence by age group for 2003
< 20 15.8 (14.3 - 17.2)
20 - 24 30.3 (28.8 - 31.8)
25 - 29 35.4 (33.6 - 37.2)
30 - 34 30.9 (28.9 - 32.9)
35 - 39 23.4 (20.9 - 25.9)
40+ 9.8 15.8 (12.3 -19.3)

One promising result is that syphilis rates have stabilized for the last few years at approximately 3%.

Timely Access to Information

The TAC is concerned that the publication of the antenatal survey has become progressively later each year. The antenatal results used to come out in April of each year; there is no explanation as to why its release is delayed until  September as has been the case for at least the last two  years. This report is essential for informing public debate and forming public policy. We are also disturbed that the report was released on the internet without a press conference. This is nationally important information that should be known and understood by all who live in South Africa.

After the antenatal survey of 2002 was released in September 2003 the TAC stated

"The Department of Health encourages over-optimism in suggesting that the observed increase does not raise concern from the perspective of the escalation of the epidemic. The Department's press release sends the wrong message to the public with the argument that these findings support the view that although the HIV infection rate is high in South Africa, there has been a significant slowing down in the spread of the epidemic and South Africa can be considered to have a slow developing epidemic.' (TAC Statement, 14 September 2003)

This was written primarily in response to the following statement in last year's report:

"When the prevalence rates are examined on a year on year basis, in other words comparing 2001 and 2002 prevalence rates, the observed increase does not raise concern from the perspective of escalation of the epidemic. It is expected during a stabilisation phase that there may be minor spiking. Overall, the rate of increase between the two years is very low. It is particularly encouraging to observe what may be the beginnings of a decline in HIV rates among women aged below 20 years." (Department of Health, 2003)

We are forced to express the same reservation about the tone of this year's report which states

"The findings of the 2003 antenatal survey show that HIV prevalence rates remain high in South Africa. The findings estimate a prevalence rate of 27.9% in 2003. When compared to the estimate of the previous year (2002) there is an apparent increase, however it is not statistically significant. Similarly the provincial estimates suggest that although there appears to be some slight increases in the prevalence between 2002 and 2003 in provinces, these increases are not statistically significant. The findings in general seem to suggest that the epidemic is slowly stabilizing. This stabilization is also evident from comparisons made between estimates of national prevalence in 2000 and 2003 which show marginal increases which are statistically significant." (Department of Health, 2004)

These comments suggest complacency . While the rate of infection might be slowing, which is to be expected when the prevalence is as high as it is in South Africa, this is not evidence that the epidemic will stabilise any time soon. The survey shows unequivocally that prevention interventions between 2001 and 2003 have been insufficient.

The 2002 survey also emphasised a reduction in prevalence among women under 20, a suggestion that was premature given the statistical insignificance of the result. The 2003 survey finds a prevalence rate among women under 20 equal to 2001 demonstrating that there is unfortunately no evidence for this reduction in prevalence among young people. This too is a matter of grave concern and calls for a close evaluation of existing prevention efforts.

Improve Treatment and Prevention Interventions

To stem the rise in HIV infections, a new approach is needed that must be lead by the South African Government, especially the President and the Cabinet. Every school, church, mosque, synagogue and community meeting place should make condoms easily available. Every school needs to introduce life-skills education programmes with an emphasis on sex-education and the prevention, treatment and destigmatisation of HIV/AIDS. These programmes must encourage delayed sex in youth in a non-judgmental environment but they must also teach that if youth have sex (as many do), they must use condoms so as not to harm themselves and their partners. The values of safer sex and not doing harm to one another must become ingrained into South African society. Every radio and television station and every newspaper, especially
community ones, should devote prime-time to conveying scientifically accurate information on HIV/AIDS. Euphemistic and simplified prevention messages must be complemented by frank, detailed, public discussions about sex and HIV. The ABC campaign is not enough.

Mother-to-child transmission prevention must also be improved. Wherever possible, better regimens than the current single-dose nevirapine one should be introduced. Every Maternity Obstetric Unit in the country should have a mother-to-child transmission prevention programme and adverts need to be placed on radio and television by the Department of Health encouraging pregnant women to get tested so they can enroll in this programme where necessary. Provinces such as the Western Cape have demonstrated that this can reduce mother-to-child transmission dramatically.

Government has the tools and policies to control this epidemic, but it seems not to want to use them. A treatment plan has been approved by Cabinet but is being throttled by political disinterest in its success. Health workers are battling and doing their best to implement treatment, but are not getting either resources or recognition for their efforts. Treatment is the vehicle to improve prevention: it should be used to encourage take-up of voluntary counselling and testing and mother-to-child transmission prevention.

It is vital that our government's leaders publicly demonstrate the political will to fight this epidemic. President Mbeki ,
Deputy-President Zuma and Minister Tshabalala-Msimang must begin ceaselessly to state in every forum that the HIV epidemic is an emergency. They must encourage people to have safer sex and to get counseled, tested and treated. The rollout of antiretroviral treatment must be sped up in all provinces. This is the only way to save the lives of millions of South Africans.


We reprint our statement in response to last year's antenatal survey below.

600 000 New Infections - Redouble Prevention Efforts and Implement a Treatment Plan

14 September 2003

The results of the latest ante-natal survey was released on 9 September
2003, five months later than expected.  In October 2002, the Department
of Health
conducted the 13th national HIV sero-prevalence study among pregnant
women in the public sector.  Despite the unnecessary delay in publishing
the results, the government must be commended for maintaining this
prevalence study as a measurement tool in the epidemic.

What does the survey show?

This survey demonstrates conclusively that the HIV epidemic remains the
most serious health challenge in our country with more than 600 000 new
in 2002. 16 587 women in 396 public sector facilities across the country
participated in this study by the Department of Health.  Of all those
tested, 4 395 women or 26.5% of all pregnant women tested positive for
HIV.  The Department of Health says that last year, there were about 600
000 new infections. On average, this means more than 1 500 new
infections every day. 4.7 million people living with HIV/AIDS in South
Africa, this number increased to 5.3 million.


Pregnant women tested:      16 587
Pregnant women positive:   4 395 or 26.5% [2001= 24.8%)

Projected 95% confidence intervals for the entire public sector antental
2002: 25.5% to 27.6%
2001: 23.6% to 26.1%

The following statistics given by the Department of Health are  
estimated using their demographic modelling utility
New infections:                      600 000 / +1 500 every day
People With HIV                    5.3 million (2001 = 4.7 million)
Women with HIV (15-49)   2.95 million
Men with HIV (15-49)         2.30 million
Estimated MTCT:                  91 271 infants

Source: Department of Health: 2003

What is happening in the provinces?

The survey demonstrates that the most affected province remains
KwaZulu-Natal with more than 36.5%.  Western Cape remained the province
with the lowest infection rate but it has increased to more than 10% for
the first time. Regrettably, the published report does not give the
number of women who were tested by province.   This renders the apparent
reduction in provinces such as Mpumalanga, Northern Cape and Free State

How are different age groups affected?

The Department of Health suggests that the appearance of a decline among
women under 20 years of age from 15.4%(2001) to 14.8% (2002).  Again,
the survey suffers from over-generalisation.  The total number of
pregnant women under 20 is not given in the survey results. The
statistic is a total for the whole country.  Everyone would benefit from
a provincial age breakdown of the statistics because this will mean
better prevention planning and resource allocation by civil society,
government and the private sector.

The most serious news from the survey suggests that new infections occur
mostly among women over 20 and particularly those who are married.  The
most significant age-group increase was seen in pregnant women over 40
years of age from 9.8% (2001) to 17.2% (2002).  Once again, here it
would have been useful to see the provincial breakdown and the total
number of women tested.

The Department of Health encourages over-optimism in suggesting that
"the observed increase [600 000 new infections] does not raise concern
from the perspective of the escalation of the epidemic." The
Department's press release sends the wrong message to the public with
the argument that these findings support the view that although the HIV
infection rate is high in South Africa, there has been a significant
slowing down in the spread of the epidemic and South Africa can be
considered to have a slow developing epidemic.

Based on this report, the Treatment Action Campaign and its allies want
to hear the following message from the Department of Health.

.        The number of new infections in 2002 was more than the total
number of people of people living with HIV/AIDS in Botswana.

.        No society can countenance such a high number of new
infections. Every effort must be made to reduce new infections.

.        A national treatment and prevention plan is essential to
encourage openness. Every person must learn her or his HIV status.

.        Condoms will be made available in every public facility.
Schools, colleges, universities and technikons will be required to make
condoms and sexuality education available to all learners.

.        Fullest media attention will be given to target all age groups
on safer sex practices and behaviour change.

.        Every effort will be made to assist people living with HIV/AIDS
to live healthy and productive lives.

TAC appeals to the Department of Health to release the full report
immediately to allow the fullest academic and scientific discussion of
the implications of the report.  TAC also appeals to our allies and
government to join us in convening a national HIV prevention summit.

The hope given to the country by the Cabinet instruction to develop an
ARV operational plan by the end of this month will only be strengthened
by decisive
action along these lines.