In 2002, the Nelson Mandela Foundation (NMF) commissioned a national, household sero-prevalence survey of HIV/AIDS in South Africa. According to the Human Sciences Research Council (HSRC), significant shifts have occurred since 2002: South Africa developed a comprehensive programme for the care and treatment of HIV-infected individuals and has invested in mass media campaigns aimed at preventing new infections. The NMF realised that it was important assess the extent to which these policies and practices had changed the shape of the epidemic in South Africa by following up on the first survey. As part of its continuing effort to promote understanding, dialogue and action on the central challenges South Africa is tackling, NMF commissioned a repeat survey, which was carried out by the HSRC in partnership with the Centre for AIDS Development Research and Evaluation (CADRE) and the Medical Research Council of South Africa (MRC).

This 200-page document shares the results from the follow-up South African national household survey on HIV prevalence, incidence, behaviour and communication. It is designed to facilitate the generation of estimates of HIV and associated factors in a representative sample of the total South African population; hallmarks of the 2005 survey include the availability of nationally representative estimates of annual new infections, or incidence rates, as well as technological developments that have allowed new biological tests to be conducted on samples gathered in the survey. Furthermore, in 2005, 23,275 people took part in the survey and 15,851 respondents agreed to be tested for HIV, compared to 2002, when 9,963 people took part in the survey and 8,428 agreed to be tested.

Centrally, the study brings home the reality that HIV prevalence in South Africa among persons aged 2 years and older at 10.8% translates to 4.8 million people living with HIV/AIDS in 2005.

Some "positive" results:

• HIV prevalence among young adults in the 15-49 age group increased only slightly from 15.6% in 2002 to 16.2% in 2005, which may be an indication that the epidemic in the general population of South Africa has entered a phase of levelling off;
• South Africans are increasingly being tested to find out their HIV status;
• Most males (78.6%) and females (79.0%) were aware of a place nearby where they could obtain voluntary counselling and testing (VCT) services.
• More people, including older South Africans, are using condoms at higher rates than before;
• More care and support is being provided to people living with and affected by HIV/AIDS; and
• Among children aged 2-14, a substantially lower HIV prevalence was recorded: 3.3% in 2005, compared to 5.6% in 2002



Some reasons to worry:


• A further breakdown for ages 2-4 (5.1%) and 5-9 (4.4%) - which amounts to an estimated 129,621 children aged 2-4 years and 214,102 children aged 5-9 with HIV/AIDS - indicates that the HIV problem is significant among children.
• Females aged 15-24 years have an 8 times higher HIV incidence than males, 6.5% compared to 0.8%, and account for 87% of the recent HIV infections in this age group.
• People living in informal settlements have by far the highest HIV prevalence. In the 15-49 age-group, HIV prevalence is 25.8%, followed by rural informal areas at 17.3%, and urban formal and rural formal areas, at 13.9%.
• The overall HIV prevalence among African respondents increased slightly from 12.9% in 2002 to 13.3% in 2005. In African adults aged 15-49 years the corresponding figures are much higher (18.4% in 2002 and 19.9% in 2005). The HIV figure for African women in the same age group is 24.4% in 2005.
• About two-thirds of the adult and youth participants indicated that they believed they would not get infected with HIV. Half of the respondents who were found to be HIV positive in the survey did not think they were at risk of HIV infection.
• Over two-thirds of respondents (69.7%) had not had an HIV test.
• Only a small proportion (9.7%) have been exposed to information about HIV vaccine research and development.
• Around one-third of respondents in all age categories disagreed or were unsure when asked if the risk of HIV infection could be reduced by having fewer sexual partners. There was some confusion documented about whether HIV causes AIDS, whether there is a cure for AIDS, and anti-retrovirals (ARVs).
• While the overwhelming majority of respondents would be willing to care for a family member with AIDS, less than half would consider marrying a person with HIV/AIDS and nearly half said they would have a problem having protected sex with a partner who has HIV/AIDS.

After sharing these and other statistics, the report explores existing HIV/AIDS communication campaigns - Soul City, Soul Buddyz, Khomanani, Love Life, Gazlam, Tsha Tsha, and Takalani Sesame. They stress that these campaigns are "not the only sources of information about HIV/AIDS, nor the only stimulus to communication and behavioural response in relation to disease. HIV/AIDS communication is broad-based in a society where the disease is advanced..." That is to say, beyond campaigns, key sources for HIV/AIDS information include politicial and social communication that includes talk shows, dramas, feature articles, and entertainment programmes. People also learn about HIV/AIDS through forms of direct exposure, such as knowing someone with the disease or school programming: An overwhelming majority (91.2%) aged 12-14 years said that schools were a useful source of information. Furthermore, there are challenges associated with measuring communication impacts and responses due to an overlap between campaigns, as well as influence from sources of information beyond campaigns.

Despite these caveats, some HIV/AIDS communication campaigns have been successful in reaching audiences. For instance, the evaluators noted that, "Although Takalani Sesame is primarily a children's programme, it achieves high awareness across all age groups." The researchers further note that, "[While] Takalani Sesame [is] most likely to be known by English and Afrikaans language speakers... Venda and Tsonga home-language speakers do not appear to be unduly marginalized...." The report shows that a majority of respondents (in this case they were aged 15 years and older) whose home language was Nguni, Sotho, Venda, or Tsonga were aware of the programme. The researchers conclude that "Takalani Sesame has a wide awareness across age groups and contexts, which is surprising given its emphasis on children..." As a comparison: awareness of the Government's Khomanani campaign is the lowest in all age groups. Although LoveLife’s primarily addresses 12-17 year-old youth, Soul City, Soul Buddyz and Takalani Sesame achieve higher awareness in the 12-14 year age group, and awareness of Soul City is highest in all age groups.

The authors conclude with key findings and recommendations, including:

• HIV/AIDS campaigns and programmes should address the false sense of security about AIDS, such as by encouraging people to go for VCT. Counselling and other services need to be expanded to provide additional support to persons who find out that they are HIV positive.
• Service providers should capitalise on the "window of opportunity" presented by the finding that South Africans are accepting HIV/AIDS as a reality in South Africa, such as by encouraging people to disclose their HIV status to their partners.
• Awareness campaigns focusing on the risks of HIV infection during pregnancy, aimed at pregnant women, should be undertaken on a national scale. HIV/AIDS campaigns should also address would-be parents to inform them that women run a greater risk of becoming infected with HIV during pregnancy, and to encourage couples to plan the pregnancy; get tested for HIV before trying to conceive; and disclose their results to each other. The authors suggest that the government should review the "baby friendly" breastfeeding policy and encourage HIV-positive women not to breastfeed their children and to supply them with a breast milk substitute instead. The prevention of mother-to-child transmission programme needs to be strengthened, they urge, and other modes of HIV transmission in children should be investigated.
• In light of findings suggesting that many children are left unsupervised, which may expose them to sexual abuse (and, in some cases, HIV/AIDS), HIV prevention campaigns should include messages on increasing supervision of children.
• Prevention campaigns should emphasise certain elements of risk highlighted in the study - e.g., young women are more likely to have male partners who are at least five years older, and older men have a higher HIV prevalence than younger men - and should encourage sexually active people to: avoid engaging in unprotected sex with anyone whose HIV status they do not know; access and consistently use condoms to protect themselves in every sexual encounter with non-regular partners; and avoid frequent partner turnover and concurrent sexual partnerships.
• In light of the high prevalence of HIV among South Africans aged 50 years and older (5.8%), targeted interventions are needed for this age group, as they are considerably less aware of national HIV/AIDS campaigns and programmes and have generally poorer knowledge of key aspects of HIV prevention and other aspects of HIV/AIDS.
• The communication strategy needs to be refocused through a systematic and coordinated approach in addressing key knowledge areas of prevention, treatment, care, support and rights. There should be accountability of programmes to an overarching communication strategy that is related to the national comprehensive plan. Issues of risk and vulnerability should be addressed directly, particularly issues relating to: the vulnerabilities of girls and women; high age differences between female youth and their sexual partners; legal rights; and vulnerability as a product of migration and mobility.

Emails from June H. Lee and Olive Shisana to The Communication Initiative on February 8 and July 13 2006, respectively; Nelson Mandela Foundation website; and HSRC website.