On the eve of World AIDS Day 2011, 5.6 million South Africans (roughly 10% of the country’s population) are living with HIV. In sheer numerical terms, this is the biggest epidemic in the world, accounting for an estimated 17% of people living with HIV globally, despite constituting only 0.7% of the world’s population. All is not doom and gloom, however, and the annual incidence of HIV in South Africa dropped by a third (from 2.4% to 1.5%) between 2001 and 2009. Explanations vary as to why this is the case.
Some attribute positive epidemiological trends to concerted political will and leadership, as evidenced by changes in policy direction wrought by President Jacob Zuma and Minister of Health Aaron Motsoaledi. In his World AIDS Day address on December 1, 2009 President Zuma announced a new direction in the country’s approach to HIV and AIDS prevention and treatment. And so April 2010 saw the launch of a massive HCT (HIV Counselling and Testing) drive, which aimed to test fifteen million people of twelve years and older by June 2011.
During the same address, President Zuma announced that pregnant women with CD4 counts of 350 or below (or present symptoms of advanced HIV infection, regardless of CD4 count) would receive antiretroviral treatment; that all pregnant women with CD4 counts above 350 would start PMTCT at 14 instead of 28 weeks; that all TB and HIV co-infected people would start treatment at CD4 counts of 350 or below; and that HIV positive infants would be put on treatment regardless of CD4 count.
Calls by international organisations such as the WHO and UNAIDS to step up the provision of medical male circumcision (MMC) have also been heeded. MMC has been integrated into fixed settings such as district hospitals and linked to HCT, where available. By the end of 2010, 145 475 MMCs were performed at 143 sites in SA for HIV prevention (over 130 000 during 2010). These efforts were generally lauded at the fifth South African AIDS Conference, held in Durban in July of 2010, where interventions such as testing, treatment and MMC received wide support.
In contrast, participants attending the first bi-annual International HIV Social Science and Humanities Conference in Durban (held directly after the SA AIDS Conference) expressed a profound sense of unease with regards to these bold biomedical steps. Those who critiqued mass testing pointed out that testing takes place in complex personal, social and health environments, that good support services are a prerequisite to testing and that people must have the right to refuse an HIV test. They also argued that a negative test result very seldom changes sexual behaviour and that any major testing initiative therefore needs to be fully cognisant of the social constraints to testing, treatments and personal agency.
Others questioned the mass rollout of MMC and argued that support for this ‘prevention technology’ is based on scientific studies that show efficacy in more controlled research conditions but not effectiveness in real-life contexts. In addition, the implementation of such a strategy, it was argued, could undercut hard-won changes in sexual cultures and shifts toward safer sexual practices.
Yet others warned that an already heavily burdened health system would not be able to cope with the vast amounts of extra people qualifying for antiretroviral treatment; and that a catastrophe looms with regards to the ability of people on ART to adhere to their lifelong treatment regimens, leading to the development of drug resistant strains of HIV.
To compound matters, international funding is getting harder to access due to South Africa’s recent classification as a middle-income-country, and the country joining BRICS. This is sure to put a spotlight on political leadership as South Africa and the world awaits President Zuma’s 2011 World AIDS Day speech.
Will we see yet more biomedicalization of approaches to HIV or will social science, and its more nuanced understandings of human behaviour around research, sex, testing and treatment, influence health policy as it applies to HIV? We will know tomorrow.
