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THE HIV EPIDEMIC IN South Africa has evolved over the last 25 years and is now characterised by a levelling off of prevalence rates, amidst persistently high HIV incidence rates. The national incidence rate of HIV infection in antenatal clinic attendees is estimated to have peaked at 6.5% in 1997 and HIV transmission models have suggested that incidence has continued to hover at this level for the past five years. South Africa is now dealing with the full impact of the clinical burden of AIDS and the concomitant deaths that result. The introduction of free antiretroviral therapy in the public sector is a turning point that enables South Africa to purposefully and deliberately choose the future path of the HIV epidemic in this country. Choosing to implement treatment programmes without concomitant prevention interventions will result in an upward trend in the epidemic curve and an evergrowing unsustainable level of demand for antiretroviral therapy. However, South Africa has an opportunity to choose a better future; a future including the integration of HIV treatment and prevention programmes, which will result in a downward trend in the epidemic and our best hope for a bright future for South Africa.
It is well established in many industrialised countries that antiretroviral therapy can transform the natural course of hiv infection by reducing morbidity and mortality. Antiretroviral therapy also symbolises hope for many communities.
CROSS-SECTIONAL DATA ON HIV prevalence in South Africa is widely available, the most extensive being based on the annual surveillance set up by the National Department of Health in 1990 to monitor the prevalence of HIV infection in women attending public antenatal clinics. Many additional surveys, including three national population-based surveys, have since been conducted in South Africa, providing crucial information on epidemic trends, patterns of infection and factors that contribute to the spread of the epidemic.
South Africa experienced one of the fastest growing hiv epidemics in the world and is currently the country with the largest number of people living with hiv, contributing to about 17% of the global burden of hiv infection. The epidemic, predominantly of subtype C, is characterised by high hiv prevalence and high rates of new infections among young women. The prevalence varies by age, gender and geographic area. Data collected over recent years indicate that the epidemic is levelling off, an effect that is unlikely to be due to interventions, but simply reflects the natural saturation of the epidemic.
This chapter provides a summary of the hiv epidemic in time and space and gives an introduction to factors that influence the transmission of hiv. Our understanding of the hiv epidemic in South Africa depends largely on a range of sero-prevalence surveys that have been conducted in a variety of settings and populations; a brief description of some of these sources of hiv data is provided.
AT PRESENT, AFRICA BEARS the brunt of the HIV epidemic. And it is southern Africa that has the highest burden of disease on the continent. In South Africa alone, by the end of 2007 around five million adults were living with HIV. That figure is growing. Every day several thousand people are estimated to become infected with the virus. The disease has rightly been likened to a whirlwind, sweeping everything before it as millions become infected, fall ill and die.
hiv is a particularly fascinating virus. As a retrovirus it inserts itself into the dna of its host, becoming a Trojan horse in the immune system and systematically weakening the host until the body can no longer efficiently fight infection. What is particularly devious is the way in which the body's initial response to the infection is incorporated into hiv's attack strategy. The very immune cells produced in defence allow the virus to penetrate further and further into the host's tissues, ensuring a lifetime of infection. It is probably the infinitely fascinating science of the virus that initially stimulated researchers around the world to spend so much time elucidating the cause of the mysterious syndrome that first appeared in the medical literature in 1981.
Since then it has become clear that hiv affects all aspects of our lives – even those who are not infected with the virus; from the molecular level, to the level of the immune system, to the way in which the virus causes disease – to the community level.
THIS CHAPTER PROVIDES A brief overview of the global burden of heterosexually transmitted HIV, the role of age, gender, migration and sexually transmitted infections as key factors driving the epidemiology of HIV transmission and some of the underlying biological mechanisms for the heterosexual transmission of HIV. Specific societal and economic factors that shape masculine and feminine identities, and contribute to differences in the risk of acquiring infection heterosexually between men and women, are presented. Within this context the limitations of the current paradigm of HIV prevention, namely abstinence, behaviour modification and use of male condoms are also considered. These data show that acquisition and prevention of sexual transmission of HIV is a multi-factorial and complex social and biological challenge. If we are to make an impact on the current trajectory of this epidemic we will need to adopt more gender-sensitive approaches in all aspects of our response to the HIV epidemic. In conclusion, the approaches for achieving this are highlighted.
Heterosexual transmission of HIV
Some indication of the importance of the heterosexual component of the global burden of hiv infection is shown by the unaids estimates at the end of 2007. Of the estimated 33 million prevalent infections, about 84% were acquired through heterosexual transmission. Further, of the 2.7 million new infections and 2.0 million aids deaths in 2007, over 85% were in people who acquired hiv infection heterosexually.
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