The Storm Clouds are Gathering

HIV / AIDS A South African Overview

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This Book Is Dedicated To:

My family To Linda, my beloved wife and Editor in Chief. Words cannot express my love for you. To Simon, my eldest son You have shown me what it is to face death and overcome as you fought Leukaemia To Michael, my youngest son Your comments always make me think through an issue from as many sides as possible. To Michelle, my beautiful artistic daughter. As you convert your thoughts to images, you have taught me that its all right just to be me.

My wider family In Johannesburg and America You dont know how much you mean to me.

My Christian family, especially Pastors Len and Dagmar You have given me liberty to listen for Gods voice in every situation. Pastors Derick and Anne Thank you for caring enough to get involved. My dear friends, Dr Sylvester Mathenjwa and his wife, Joyce Every day, you are there in the midst of the battle against HIV / AIDS. Dr Arnau Van Wyngaard A good friend and neighbor who authored the article Why are we losing the battle against AIDS1 and graciously critiqued this overview. Lindiwe2 AIDS took you from us, but we will always remember you. My fellow elders and good friends. My work colleagues. Those of you in the midst of a life and death struggle with HIV / AIDS. We care. The Church Together we will overcome.

The Reformed Ecumenical Council 4_1_7 - Why are we losing the battle against AIDS? Dr Arnau Van Wyngaard Lindiwe, whose picture appears on the cover, was one of the first orphans to come to Uzwelo Home. She was with us for two and a half years until she died aged six.
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Neville I Curle 16th June 2005

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THE STORM CLOUDS ARE GATHERING HIV / AIDS A South African Overview

INDEX
1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. HIV / AIDS - The New Leprosy What Is HIV / AIDS? A Backdrop To The HIV AIDS Pandemic In Southern Africa The Current Treatment Of HIV / AIDS Prevention is better than cure The Current Situation In South Africa How Will AIDS Affect Us? What is the South African Government doing? A vision of the future The scenarios open to us. What can we do practically? The Role Of The Church In Closing Essential Reading 1 3 6 11 17 20 30 36 39 43 48 56 61 64

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HIV / AIDS THE NEW LEPROSY

Foreword In drawing up this overview of the epidemic in South and Southern Africa I take little credit for myself, apart from being able to research the Internet and compile a summary of where we currently stand. The section on The Current Treatment of HIV / AIDS has been gleaned from my friend and fellow elder, Dr Sylvester Mathenjwa. The sections on "A Vision of the Future" and "The role of the Church" come from a warning3 from God given to me. From the message and my own research, I drew my own conclusions. I am a layman (an Elder in the Church and a Financial Manager of a medium sized Timber Group). This overview is designed to give other lay people an understanding of the enormity of the challenge that we, as a nation, face. During my research, I came to grips with the underlying causes behind the fact that the epidemic in Southern Africa is far worse than anywhere else in the world. I was able to do this from the detached position of an observer, clinically dissecting between fact, fable and feeling. Then, on 28th September 2004, I was awakened at about 3.40 in the morning by a deep conviction of my spirit. The gist of it was as follows: You, and many like you, are judging My people because of their HIV/AIDS status. I called you to love and forgiveness. They are no more sinful than you are. In many ways, your sin is greater than theirs. Your sin comes from pride. Their sin comes from their social and economic position, over which they have no control. By your judgment, you bind them to secrecy. As long as this happens, they will live in fear and the problem will multiply. Right now, there are people in your congregation who are dying from this disease. Repent of your sin.

The scriptures bombarded my brain: "Two men went up into the temple to pray; one was a Pharisee, and the other was a tax collector (AIDS sufferer)4. The Pharisee stood and prayed to himself like this: 'God, I thank you, that I am not like the rest of men, extortionists, (drug addicts), unrighteous, adulterers, or even like this tax collector (AIDS sufferer ). I fast twice a week. I give tithes of all that I get.' But the tax collector (AIDS sufferer) , standing far away, wouldn't even lift up his eyes to heaven, but beat his breast, saying, 'God, be merciful to me, a sinner!' I tell you, this man went down to his house justified rather than the other; for everyone who exalts himself will be humbled, but he who humbles himself will be exalted."
8 7 5 6

Behold, a leper came to him and worshiped him, saying, "Lord, if you want to, you can make me clean." Jesus stretched out his hand, and touched him, saying, "I want to. Be made clean." Immediately his leprosy was cleansed. 9

In Scripture, a revelation from God; an appearance or exhibition of something supernaturally presented to the minds of the prophets, by which they were informed of future events. Inserted by the author for context. Ibid Ibid Ibid Luke 18 v 10 14 : The Web Bible (Downloaded from E-Sword) Mathew 8 v 2-3 : The Web Bible (Downloaded from E-Sword)
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4 5 6 7 8 9

But when they continued asking him, he looked up and said to them, "He who is without sin among you, let him throw the first stone at her." Again he stooped down, and with his finger wrote on the ground. They, when they heard it, being convicted by their conscience, went out one by one, beginning from the oldest, even to the last. Jesus was left alone with the woman where she was, in the middle. Jesus, standing up, saw her and said, "Woman, where are your accusers? Did no one condemn you?" She said, "No one, Lord." Jesus said, "Neither do I condemn you. Go your way. From now on, sin no more."
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If my people, who are called by my name, shall humble themselves, and pray, and seek my face, and turn from their wicked ways; then will I hear from heaven, and will forgive their sin, and will heal their land.
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As the truth struck home, tears welled up in my eyes. From all the research I had done, God was telling me like it is. As a Christian leader, I stood condemned for elevating myself above those that are suffering. Many of them: Live in homes that consist of one room. Have no food to eat and must sell their bodies to survive. Were raped just because they were unable to protect themselves.

How dare I judge them! Father, forgive me for my arrogance and pride. Replace my self-righteousness with the righteousness of Christ Jesus and give me the compassion that You feel for Your people. If you are suffering from HIV / AIDS please forgive me and all those in the Church who have treated you like a leper because of their fear of the silent, deadly weapon that satan is using in his war against you and me. Join me, as I try to convey: Where we have come from. Where we are now. Where we will land if we do not take some decisive steps. What we, as a Nation and as The Church, can do to prevent us from landing deeper in the quagmire.

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John 8 v 7 11 : The Web Bible (Downloaded from E-Sword) 2 Chronicles 7 v 14 : The Web Bible (Downloaded from E-Sword)
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WHAT IS HIV / AIDS?

The scientists seem to agree that HIV is a descendant of an Immuno-deficiency virus derived from a monkey. How it was transferred - from the original host (possibly a green monkey) through an intermediate host (possibly a chimpanzee) to finally find its home in humans - only the Lord knows. What we are fairly sure about is that its origin was in West Africa. The earliest recorded cases of infections of HIV are believed to be12: 1. 2. 3. A plasma sample taken in 1959 from an adult male living in what is now the Democratic Republic of Congo. HIV found in tissue samples from an American teenager who died in St. Louis in 1969. HIV found in tissue samples from a Norwegian sailor who died around 1976.

The escalation of the disease from those early days to its current extreme geometric progression13 reveals how effective the virus is. Before briefly discussing the virus, its important to understand where its efficiency comes from. What is HIV? HIV stands for the Human Immuno-deficiency Virus. A virus is a miniscule thing that, though not technically alive, can reproduce and spread. Like a parasite, HIV cant exist by itself it needs a host to live in. In order to replicate, HIV must invade a cell, hide its own DNA within the DNA of the cell, and then, using the bodys own generative systems, whilst the cell tries to make new proteins, it automatically replicates the HIV as well. The main target of the Human Immuno-deficiency Virus is the T4-lymphocyte (also called the "T-helper cell"), a kind of white blood cell that has lots of CD4 receptors (where the HIV attaches itself). The T4-cell is responsible for warning the immune system that the aliens have landed. Without these, the immune systems ability to fight off the virus is compromised, and HIV spreads throughout the body. The problem with the Human Immuno-deficiency Virus is that it regenerates slowly and secretively. A blood test will only detect the virus between one and six months after the infection first occurred. The person will probably look and feel perfectly well for many years and may not even know that he is infected. Its only as the immune system fails that he will become increasingly vulnerable to illness.

The victim will become ill more and more often until, usually several years after infection, he: gets chronic diarrhea develops shingles contracts a severe illness such as tuberculoses or pneumonia.

Acquired Immuno-deficiency Syndrome (AIDS) is an extremely serious condition, and by the time it reaches this stage, the body has very little resistance against opportunistic diseases.

Annabel Kanabus & Sarah Allen. September 2, 2004. The Origin of AIDS & HIV, and the First Cases of AIDS. Avert.org http://www.avert.org/origins.htm
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Geometric progression 2, 4, 8, 16, 32, 64, 128, 256, 512, 1 024, 2 048, 4 096, 8 192, 16 384, 32 768, 65 536 .
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What causes infection with HIV? Sexually

Having sexual intercourse with a person who is already infected. Sexual intercourse without a condom has a high risk because the virus, present in an infected person's fluids, can pass directly into the body of their partner. Anal sex, because of the lacerations that occur which allow blood/semen to pass from one partner to the other. Oral sex carries a lower risk, but if one partner has bleeding gums or an open cut in his/her mouth, the virus can be transmitted from one partner to the other via the fluids.

Mother to child

During the birth process. Whilst in the womb, the baby is protected from infection. Unfortunately, once the waters break and the baby passes through the birth canal, both mother and baby experience lacerations and the virus can be passed from mother to child.

Breastfeeding (The virus can only be contracted if received in large amounts.) There is very little HIV present in the breast milk of women, but because the baby drinks a lot of milk, the virus is carried over to the baby. If the baby does not have any scars or injuries to the stomach lining, the virus will be destroyed. If there are any lacerations in the stomach lining, then the virus will be given to the baby. The recommended practice for mothers with HIV is only to breastfeed their babies for the first six months. After six months, breast-feeding should be discontinued abruptly. The rationale behind this is that mothers milk does no damage at all to the lining, whilst the use of formula can. Thus the change from breast milk to other products has to be radically abrupt. This has its own emotional trauma.
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One other aspect that is often overlooked by theorists is the practical problem of shopping and traveling in a rural environment. It costs at least R20 to travel to town to buy formula - R20.00 that the mother does not have. Consider this article by good friend and neighbour Dr Arnau Van Wyngaard15: Milk formula is also too expensive for the majority of people living in the rural areas. Even if they are able to afford it, then it has to be mixed with water. Where there is no pure water in the rural areas, it means that water from the rivers have to be used.

I have made it a point NEVER to drink water from a river in Swaziland, knowing that cattle are walking in the rivers, but worse, people use the rivers as toilets. Bilharzia is also common in virtually all rivers in sub-Saharan Africa. On one occasion some un-boiled river water was accidentally mixed with cool-drink that was offered to me, and I became seriously ill through gastro. Therefore, if milk formula is given to a baby, and the water has not been purified or boiled for a very long time, the baby will become ill and can even die.

A second problem is the cleaning of bottles. In the Western culture all kinds of methods are used to ensure that feeding bottles are clean. This is a whole training course which needs to be undertaken in Africa if mothers want to ensure that they feed their children with sterilized bottles. To simply propagate that milk formula should be used (even if it is offered free of charge), is not the final answer to this problem.

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Breast-Plus-Bottle Risky for Babies with HIV+ Moms - Reuters Report http://www.hivnet.ch:8000/africa/af-aids/view?973

Dr Arnau Van Wyngaard. Re Formula for Disaster - UNICEF vs. Baby-Formula Industry. http://www.hivnet.ch:8000/africa/afaids/view?891
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Directly through blood

Use of infected blood-products Many people in the past have been infected with HIV by the use of contaminated blood.

Contact with an infected persons blood If infected blood passes from an infected person into an uninfected person, the virus can be passed on to them.

Injecting drugs People who inject themselves with contaminated needles are vulnerable to HIV infection. There is a high level of contamination amongst drug users who share equipment. If blood is contaminated, even the tiniest amount injected directly into the bloodstream can transmit HIV.

What does not cause infection with HIV? Shaking hands Coughing, sneezing Kissing on the cheek Hugging Using a telephone or drinking from a fountain Using a toilet Mosquito or any other insect bite Eating or drinking from same glass or plate as an HIV-infected person Swimming or bathing Sharing a crowded bus Looking after pets or animals Wearing someone elses clothes

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A BACKDROP AGAINST WHICH TO VIEW THE HIV/AIDS PANDEMIC IN SOUTHERN AFRICA

Historic From the time of the San, each of the dominant powers at first the Nguni, then the Dutch, the English, the Afrikaner and currently the ANC - have sought to gain the very best for their own people. For example, 1. 2. On hearing that gold had been discovered on the Rand, the English decided to annex it from the Boers16. The Boers, or Afrikaners, on gaining political power, sought to empower their kind by: denying jobs, other than menial labour, to the Blacks17. withholding specialized education from them. (Verwoerd introduced a bill in 1953 to remove Black education from missionary control to that of the Native Affairs Department. As he put it: 'I will reform it [Black education] so that Natives will be taught from childhood to realize that equality with Europeans is not for them .) The graph alongside reveals the unfortunate truth that, when considering statistics in South Africa, race played a major part and the effect of this racial bias is now being felt. Over and above this, the Blacks had been ring-fenced into Homelands, without the right to move about freely and own land in so-called White areas. This had the following effects: The men worked on the mines in the White areas, whilst the women stayed at home in the rural areas. To keep their women faithful, the men ensured that they were constantly pregnant .
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SOUTH AFRICAN EDUCATION

35.00% 30.00% 25.00% 20.00% 15.00% 10.00% 5.00% 0.00% Tertiary Grade 12 Completed primary Some primary Some secondary No schooling White Asian Coloured Black

Up until the 70s when the Government introduced family planning clinics in the Homeland20, the Black population grew at an exponential rate, impoverishing themselves and the country as a whole. The men were kept in hostels according to ethnic classification and treated more as animals than humans . They formed hostel gangs. These ethnic divisions reinforced the hostility, and this led to tribal warfare . Because they were forced to spend long
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16 17 18

South African Information; Gold and War. http://www.southafrica.info/ess_info/sa_glance/history/919547.htm Wallace G. Mills; Poor Whites History Lecture 322. http://husky1.stmarys.ca/~wmills/welcome.html

Neil Parsons, A New History of South Africa, London (Macmillan Education Ltd.) 1982, p. 291-293. http://www.socsci.kun.nl/ped/whp/histeduc/apartheid.html In the authors opinion, this policy was responsible for a large portion of our present HIV / AIDS pandemic. It reduced the level of education available to the vast majority of our population. This directly impacted the number of children born in an impoverished state, which began the cycle of extreme poverty. Add promiscuity to poverty and the result is HIV / AIDS. The results of a survey, carried out in 1980 by Linda Curle, as part of a Social Studies Assignment, amongst the Black Women of Vryheid, KwaZulu Natal indicated that the men of the mines did not want their wives to use contraceptives as this kept them from getting pregnant.
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Mark Schoofs. All that Glitters: How HIV caught Fire in South Africa Part One Sex and the Migrant Miner The Village Voice April 28 May 4, 1999; http://www.aegis.com/news/vv/1999/VV990401.html

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James Motlatsi, President - National Union Of Mineworkers for The National Executive Committee Meeting. The History of Violence In The Mining Industry Of South Africa http://www.num.org.za/News/misc/violence.html Mark Schoofs. All that Glitters: How HIV caught Fire in South Africa Part One: Sex and the Migrant Miner The Village Voice April 28 May 4, 1999; http://www.aegis.com/news/vv/1999/VV990401.html
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periods away from home (up to a year), the men sought sexual gratification where they could find it whether by rape or prostitution . It is not hard to see how migrant labour played a major role in the spread of the HIV/STI epidemic in southern Africa. Take millions of young men, remove them from their rural homes, house them in single-sex hostels, give them easy access to sex workers and alcohol and little or no access to condoms, and pretty soon one will have a major HIV / STI epidemic. Send those men back to visit their rural partners every once in a while and the epidemic will take hold in rural areas as well. This situation roughly describes the conditions for more than 2.5 million official - and many more unofficial - migrants in southern Africa, and explains, at least in part, why the HIV prevalence in southern Africa has reached epidemic proportions. In addition, the Black leaders saw that their only hope of achieving equality was to overthrow the Government. One of the strategies that they used to accomplish this was to make South Africa ungovernable, which encouraged their followers to commit violent crimes . Cultural Whether it comes as a result of decades of oppression under the Apartheid system or out of generations of male domination, many men in our country
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see themselves as Baas van die Plaas, Lord of the Manor or uNdlovu ayiphendulwa . (In essence male chauvinist pigs.) link the concept of masculinity to roughness, male chauvinism and dominance.
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believe that violence is an acceptable means of interpersonal conflict resolution. see women more as a possession rather than an equal.

Even though the legal status of women changed with the 1996 Constitution, and with a range of other Acts passed since then the economic and social conditions under which most South African women still live effectively renders them citizens without rights. Because of this, women are economically dependent and have limited access to employment, education, training, money and credit.
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The effect of our Historical and Cultural Background.

In South Africa, we live in a society where the majority of the people are under-educated and poor have little regard for anyone in authority, are exposed to HIV/AIDS because of the economics of migrant labour, and have little regard for the rights of women. Here is a testimony of the harsh South African realities McGregor, Nomvula Nhlapo fell in love at the age of 16 and, to the fury of her father, left home to live with her boyfriend. Four years later, she returned, terminally ill with Aids. Her father refused to allow her into the house. She collapsed under a tree and stayed there for the last few weeks of her life. Neighbours washed
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together with some thoughts by Liz

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James Motlatsi, President - National Union Of Mineworkers for The National Executive Committee Meeting. The History of Violence In The Mining Industry Of South Africa http://www.num.org.za/News/misc/violence.html 24. Take the struggle to the White Areas; Make South Africa ungovernable This leaflet was distributed inside South Africa in the latter half of 1985 www.anc.org.za/ancdocs/history/ug/pam8500.html

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If one translates the Zulu directly it means, Dont talk back to the elephant.

26. Migration and AIDS in southern Africa: Challenging common assumptions; Mark Lurie Brown University Medical School, USA www.aidsmobility.org/lurie.html 27 Susan Fox. Gender based violence and HIV/AIDS in South Africa. An organizational response. Page 17 http://hivaidsclearinghouse.unesco.org/ev_en.php?ID=2348_201&ID2=DO_TOPIC 28 Susan Fox. Gender based violence and HIV/AIDS in South Africa. An organizational response. Page 17 http://hivaidsclearinghouse.unesco.org/ev_en.php?ID=2348_201&ID2=DO_TOPIC
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Liz McGregor. Women bear brunt of AIDS toll. www.globalpolicy.org/socecon/ develop/aids/2003/0323women.htm

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and fed her and moved her out of the sun when it got too hot, but her father never relented. She died three weeks ago - in the open, a short distance from her family home. Nomvula's lonely death sums up the course of the epidemic here. Compared with Aids in the developed world, in South Africa the disease is primarily one affecting women: more women than men carry the virus, they are infected at a younger age, and they die earlier. It is the mothers, wives, sisters and daughters who are giving up jobs and dropping out of school to care for dying relatives. Two-thirds of those caring for Aids patients in their last year of life are female relatives. One reason for the higher rate of infection in women is biological; the virus does not survive long outside the body but it does stay alive in the vagina long enough to be able to enter the bloodstream through little tears. But probably the primary underlying reason for the higher rate is cultural, resting with the patriarchal nature of much of African society, as illustrated by Nomvula's intransigent father The status of women is low, and rape and domestic violence are common. In 1998 alone, 49,286 rape cases were reported to police, 41 per cent of which were to do with people under the age of 17. Professor Isak Niehaus, of the University of Pretoria, who has extensively researched African masculinity, believes the solution lies in focusing on the men. He talks of the 'wound in the psyche of the oppressor in the male dominated society', citing suicide figures which show that men, compared with women, are four and a half times as likely to kill themselves. He sees the rape epidemic as masculine domination in a section of society that has suffered successive assaults. Apartheid turned black men into servants and destroyed the family structure through removals of communities from land reserved for whites. Migrant labour in mines caused further havoc. The arrival of democracy in 1994 brought further stress. Then, unrealistic expectations of life turned to bitterness as thousands of jobs vanished through market liberalisation. Privatisation and the decamping of corporate giants hit employment figures. And the foreign investment that was expected to follow the opening of markets largely failed to materialise. Forty two per cent of black people are unemployed. Men's response to this insecurity has been to cling to traditional roles. Women are more likely to embrace modernity. They tend to be better informed about Aids as they are counseled and offered tests at antenatal clinics before being offered anti-retroviral drugs to prevent passing the virus to their babies. And, while both sexes tune into the media, often it is the women who favour soap operas - several of which have HIV-positive characters and actively promote women's rights. Men are more likely to discover they are HIV-positive when they become ill.
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In the Swazi Observer, Khosi Khoza writes that In Swazi Society, males are brought up or socialized to adopt the attitude of machoismo. In machoismo, males rate themselves as superior. That position is made even worse by Swazi tradition, which relegates the position and status of a woman to that of a minor. For example, a woman is not allowed to own property, and she is barred from taking meaningful decisions without consulting a male member of the family Boys are taught from a young age to be aggressive and assertive. They are taught to get what they want, no matter what. On the other hand, girls are taught to be submissive and subservient. Customary rules of

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Khosi Khoza The Swazi Observer, 26th January 2005. Child sex abuse in Swaziland
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courtship state, that a woman is supposed to repel the mans advance even though she is attracted to him, that is why no is still confused as yes Girls are taught that the way to earn approval from men (who are very powerful in girls lives) is to be pretty and pleasing. The way to please is to make themselves sexually accessible to men that is to allow men to touch, talk about and enjoy their bodies and their sexuality, and once they have accepted this, they are perfectly prepared for their future roles as wives, mothers and sex objects. To some men her consent is not an issue, but only the satisfaction of his lust. To understand the truth of the above, one should consider some of the traditions in Swazi culture, such as kwendzisa1, kuganwa2, kulamuta3 and taking a female relative as an inhlanti4, all practiced without the females consent to sex. In short, in the eyes of society, a female is just a sex object, a medium of exchange, and someone who is not expected to say No!, even if the circumstances compromise her life, security and happiness and, or health. Note: 1. Kwendzisa : When a rich man approaches the father of a girl and influences that father to coerce his daughter to marry the rich man. 2. Kuganwa : If a man dies, a younger brother takes on the dead brothers wife as his own. 3. Kulamuta : If a man is married to a woman, he can sleep with his wifes younger sisters. 4. Inhlanti : If the older sister is barren, the man can choose a second sister as a second wife. This also happens when an aunt is barren. In this case, one of the aunts nieces will be sent to bear the uncles child. Sometimes if the man has indulged in kulamuta, he may choose to take the woman as a second wife. 5.Kukeka : (Another practice not listed in the article : This practice allows a man to have as many wives as he wants. Dealing with the effect of our historical and cultural background is not a simple matter. Consider the following statement from an Empilisweni Woodlands AIDS Centre worker Abstinence Be faithful Condomise It was like I was a faithful apostle and I would tell the women ABC. Then I began to realize that we were actually talking about something that wasnt possible for women. Its totally inappropriate to go around saying ABC is what you are going to have to do to prevent AIDS. We have to look at all these things from a different perspective because that message is gender insensitive. 1. 2. Women are not able to abstain because they dont have that choice. Women are not able to be faithful because the word is mutually faithful. Now if my partner or ones partner is not faithful as long as it is not a mutual commitment then it is no use. So that message also loses its meaning for women. 3. And the same thing for condomising all women know how difficult it is to persuade a male partner to use a condom.
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When I started this work I was very happy to go around preaching the ABC.

31: Susan Fox. Gender based violence and HIV/AIDS in South Africa. An organizational response Page 21 http://hivaidsclearinghouse.unesco.org/ev_en.php?ID=2348_201&ID2=DO_TOPIC
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So we should be doing something else and its not quite clear in my mind yet how we can change these messages so that they are more gender appropriate. Similar thoughts are echoed in Dr Arnau Van Wyngaards article
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coming from his experiences in Swaziland:

Officially, people are told that the ABC method should be followed in order to prevent AIDS In Africa I have found that only the last method is seriously propagated, more commonly known as "safe sex." In spite of huge promotional campaigns to convince people to use condoms, even to the extent where billboards were erected in South Africa with the national flag on it in the shape of a condom, the number of people contracting AIDS is still growing exponentially. There are many reasons why this method is not working. The main reason is probably a cultural one: In Africa the use of a condom is often compared to bathing with your socks on. It is just not part of Africas culture to use condoms during sexual intercourse. In articles and comic strips in which the use of condoms is promoted to address the AIDS problem in Africa, women are encouraged to deny sex to men if the men are not willing to use a condom. In the African culture, women are taught from a young age that they have to respect men. Where they are traditionally considered to be inferior to men, it is extremely difficult for them to apply this in practice. In extensive studies done among people in Africa, it has been found that a woman has very little say about her sex life - even before marriage. Violence against women within marriage relationships is common. Where countries are in a state of war, rape is also much more common, as this is often used as a method of intimidating the enemy. Even in countries not ravaged by war, rape, including the rape of children under the age of sixteen, has increased tremendously over the past few years. Child abuse is also occurring much more commonly. This cycle of being under-educated, poor and violent feeds on itself. Add to this the migrant labour problem and one must acknowledge that our President, Thabo Mbeki, is correct when he declares that AIDS needs to be treated as a social disease rather than simply focusing on the medical reality that it is caused by sexual intercourse. When people are so poor that families of eight or nine people are forced to sleep under one roof, how does one prevent an early onset of sexual activity? incest between siblings, especially when younger sisters surround older brothers encountering their sexuality? rape?

Dr Van Wyngaard is a respected Dutch Reformed Minister who has devoted his life to serving the people of Swaziland. He has a first hand knowledge of the realities of HIV / AIDS. In February 2004, an article of his was published in The Reformed Ecumenical Councils Focus magazine entitled Why are we losing the battle against AIDS. http://community.gospelcom.net/Brix?pageID=7870
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THE CURRENT TREATMENT FOR HIV/AIDS

There is no cure known to man for the Human Immuno-deficiency Virus as it advances, and certainly not once it has reached Acquired Immune Deficiency Syndrome status. Many people think that the Anti-retroviral medications are a cure for Acquired Immuno-deficiency Syndrome. Unfortunately, the Anti-retroviral medication only slows the progression from Human Immuno-deficiency Virus to Acquired Immuno-deficiency Syndrome. Whilst the Anti-retroviral medication does, in fact, slow down the progression, in some cases it seems to become ineffectual after a number of years. In other cases, people recover and live with HIV for decades, provided they scrupulously take powerful medication every day of their lives, sometimes with very unpleasant side effects. Until a cure is found, what can I do? If one has been exposed to the virus within the past 72 hours, then: a) b) c) A blood test is taken. An immediate one-month course of Anti-retrovirals is mandatory. After three months, a further blood test is taken.

This often happens within the medical fraternity, where a surgeon may cut or prick himself during an operation. It is also available after rape or, in special circumstances, after unprotected sexual intercourse. The benefit obtained by doing this is that the bodys DNA acquires a protective barrier surrounding it, shielding it from the Human Immuno-deficiency Virus trying to penetrate the T or other immunity cells.

If, on the other hand, the infection took place some time ago, the problem is far greater. Before anything else, one needs to establish the root cause of the aliens invasion. What caused the problem? Was it from unprotected sex? contact with an infected persons blood? use of infected blood products? use of an infected needle? contact with body fluids?

After establishing the root cause, one needs to reconsider ones lifestyle. This is not only about sexual habits, but encompasses a wide range of issues to do with health and the risks that are taken as part of ones lifestyle. Consider the following examples: A nurse dealing with infected patients needs to wear gloves when exposed to patients blood. When sanitation workers come into contact with linen soaked in blood or body fluids, they need to take preventative precautions. A good way to look at it is to view the body as a battleground where the troops need to be given the very best possible fighting chance.
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The review of ones life habits should include such things as: Make sure that one has the very best diet that can be afforded. (From the moment a person becomes infected, HIV starts to negatively impact nutrition. Even if there are no symptoms present, the immune system is using up the bodys energy in an attempt to fight the virus. As a result, the protein, energy and vitamin/mineral needs of a person with HIV are much higher than those of people without HIV.33) The body needs to be fit so exercise! The body needs to be clean so wash! Remember, the immune system is not functioning at peak capacity, so other germs will be lying in wait, just anticipating an opportunity to ambush the person. Thats why the doctors call them opportunistic diseases. Washing ones hands becomes of the utmost importance to keep germs at bay. Make certain that when one has sex, a new, unperished condom is used. This is not only important for the partner but, because the virus mutates differently in each person, one should try not to get re-infected with a new strain of the virus. Anti-retroviral treatment Should one, in consultation with the medics, decide to use this treatment, it is important to understand that the decision has to be for life. It is no good taking the treatment for a month and then stopping when there appears to be a breakthrough. If one doesnt continue, the enemy will regroup and attack with renewed vigour. In addition, for this treatment to be effective, it has been found that one needs to take more than one Anti-retroviral drug at a time. The general recommendation is to use a minimum of three different types. If only one drug is taken, over a period of time the drug stops working because HIV mutates and adapts itself to the drug in the persons body. This is known as the virus becoming resistant to the drug. If two or more Anti-retrovirals are taken together, the virus has been found to have less chance of becoming resistant. The Groups of Anti-retroviral Drugs
34

There are three main groups of anti-HIV drugs. Each of these groups attacks HIV in a different way. 1. Reverse Transcriptase Inhibitors

HIV needs an enzyme called reverse transcriptase in order to infect healthy cells and reproduce itself in a persons body. As the name says, reverse transcriptase inhibitors slow down the production of the reverse transcriptase enzyme and make HIV unable to infect cells and duplicate itself. 2. Protease Inhibitors

The second type of Anti-retroviral is the Protease Inhibitor (PI) group. Protease is a digestive enzyme that breaks down protein. It is also one of the many enzymes that HIV uses to reproduce itself. The protease in HIV attacks the long healthy chains of enzymes and proteins in the bodys cells and cuts them into smaller pieces. These infected smaller pieces continue to infect new cells. The protease inhibitors act against the HIV before the protease in HIV has the chance to attack the protein and enzymes. This way the protease inhibitors slow down the duplication of the virus and thus prevent the infection of new cells. 3. Fusion or Entry Inhibitors

The third group of Anti-retrovirals is called Fusion or Entry Inhibitors. The surface of HIV carries proteins called gp41 and gp120. These are the proteins that allow HIV to attach itself to and enter into cells. By blocking one of these proteins, fusion inhibitors slow down the reproduction of the virus.

33 34

Nutrition in HIV / AIDS A guide to deal with common HIV associated nutritional problems C Rijkenberg HIV/AIDS treatment & care www.avert.org/hivtreatment.htm
Page 16

Tests 1. The Elisa Test The initial test to screen whether or not patients have HIV is an Elisa Test. This is a simple test costing approximately R50. The test takes approximately 15 minutes and consists of a drop of blood from a finger prick being dropped on a simple device, which has antibodies, which react to the blood if it is positive. 2. The Western Blot Test If The Elisa Test is positive, a further test is taken to ensure that the blood is HIV positive. A blood specimen is drawn and sent to a laboratory where it is tested. 3. If both the Elisa and the Western Blot Tests are positive, then three further samples of the blood are taken, to be used as follows: a) b) c) CD4 count Viral Load Count Blood tests as follows: i. ii. iii. 4. Full Blood Count A liver function test A kidney function test

The CD4 Test The main cell that HIV attacks is called a T-helper cell or CD4 cell. The T-helper cell not only warns the other cells of an impending attack, but also acts like a General, co-coordinating the cell troops to fight illnesses. If the T-helper cells (The Generals) are taken out, it can have a serious effect on the immune system. The Achilles heel of the T-helper cell is the protein CD4 on its surface. HIV uses the CD4 as a gateway to the cells it targets to infect. The CD4 test measures the number of CD4 or T-helper cells in ones blood. The more CD4 cells in ones blood per millilitre, the stronger is ones immune system. The stronger the immune system, the better the body can fight illnesses.

5.

The Viral Load Test The viral load refers to the amount of HIV in ones blood. The result of a viral load test indicates how much virus there is in the bloodstream that can harm the immune system. The higher the level of HIV in ones blood, the faster ones CD4 cells are being destroyed by HIV. The lower the viral load, the stronger is ones immune system. The result of the viral load test is normally described as the amount of HIV RNA copies per millilitre of blood. A viral load higher than 100,000 copies is considered to be high, and below 10,000 is considered low in people who are HIV positive. Sometimes the viral load is so low (less than 50) that it cannot be measured. This is called an undetectable viral load. It does not mean that the person does not have any HIV in the blood or is not infected with HIV any more. An undetectable viral load indicates that the level of HIV is too low to be measured by the viral load test. The advantages of having undetectable viral load are that the person has lower risk of developing AIDS and also a low risk of developing resistance to the drugs if taking anti-HIV drugs.

6.

The Full Blood Test, Liver Function Test and Kidney Function Test These tests are taken to ensure that the patient will be able to cope with the onslaught of the HIV drugs.

Page 17

In South Africa, when a patient is first diagnosed, the CD4 count and the viral load count are measured. If the CD4 count is still above 350, (a normal count exceeds 500), the patient is counseled to come back in 6 months for a further set of tests. If the count is below 350, the patient is counseled to start the treatment. Practically, where the patient does not have a medical aid, the treatment is only started when the counts are below 250. If the State has to pay, then the count has to be lower than 200 before treatment begins, in terms of the roll out. If the hemoglobin (red blood cells) count is lower than 8 the patient is first given an iron supplement to boost the hemoglobin count. If the Anti-retroviral drugs were given when the hemoglobin count was too low, the patient could not take the onslaught. Once the above criteria have been met, decisions need to be taken: 1. 2. Is the patient prepared to suffer the side effects? Which line of treatment will be used? a) First Line Treatment - (Small round ammunition) Minimal side effects. This is a combination of the following drugs, where up to 4 tablets are taken daily: i) ii) iii) Zidovudine . Lamivudine Efavirenz
35

This treatment is given for 6 weeks, after which a second set of blood tests is taken to ascertain the efficacy of the treatment. If there is no change in the CD4 and viral load counts, then: i) ii) The patient is not adhering to the treatment or The medicine is not effective.

The patient is encouraged by counseling to adhere to the treatment and asked to come back in 18 weeks time for a Viral Load count test. This must be less than 50; otherwise the Second Line Treatment must be adopted. b) Second Line combination (Heavy artillery) Severe side effects. This is prescribed if the First Line Treatment is not working. This is a combination of the following drugs where up to 7 tablets are taken daily: i) Didanosine ii) Abacavir iii)Lopinavir-ritonavir c) If the patient has responded well, and wants a break from the side-effects, then a one month break may be considered after serious counseling. d) Over and above the Anti-retrovirals, a further two sets of drugs are prescribed. These are to counter opportunistic infections: i) Bactrim - 1 tablet daily against pneumonia until the CD4 count reaches 300 ii) Isoniazid 300mg daily against TB for 6 months (This protects against TB for 18 months where after the course is given again.)

Rollout: The South African Government has introduced a programme where it will roll out the introduction of Anti Retrovirals across the country over an unspecified period of time.
Page 18

35

Side-effects Drugs often have unpleasant side affects causing the body to do things that were not intended. Most of the antiHIV drugs have such side effects. Some people only experience mild side effects36. For others, the side effects are so severe that they have to consider other alternative drugs. The most common of these side effects are: 1. 2. 3. 4. Nausea Feeling tired Pins and needles in the legs A skin rash

Sticking to the plan (Adherence) Adherence means taking the drugs exactly as prescribed: 1. 2. 3. On time The right amount Under the right dietary course of treatment

Adherence can be difficult, especially when there are severe side affects. Sometimes there is a need to make changes to ones lifestyle to adjust to the treatment. The doctor may also prescribe some other medicines to help counter the side affects. Starting Treatment There is no right time to start HIV treatment. The timing of starting the treatment depends on the person involved and his particular needs: 1. 2. 3. 4. The patients symptoms, What he can cope with physically and emotionally, Whether he will be able to continue the life long course of treatment and The side effects that he may experience.

The person must realize that commitment to the treatment is as important as the drugs themselves. Mother to Child Transmission & Pregnancy A woman can minimize the risk of HIV being passed to her child by certain interventions. These include: 1. 2. 3. 4. 5. Taking Anti-retrovirals during pregnancy (excluding the first 3-4 months of pregnancy), Taking Anti-retroviral drugs during labour Choosing caesarean section as the method of delivery Giving the baby a short course of Anti-retroviral therapy after birth Abstaining from breast-feeding

36

Note: It is considered a mild side effect if a person has 2-3 vomiting episodes a day.
Page 19

Consider this extract from an article written by Dr Arnau Van Wyngaard / AIDS and the nutrition of orphans.

37

who has an extensive understanding of HIV

Another tremendous problem in the whole of Africa is that it has now become clear that HIV can also be spread through breast-feeding. It has been found that 36% of the children with HIV were infected with the disease through breast milk from their HIV+ mothers. The obvious solution is for mothers who are HIV+ not to breast-feed their babies any longer. But things are not quite that simple. For women staying in rural areas there is no other option than to breast-feed their children. The choice is: lose your child through HIV or lose your child (perhaps even earlier!) through malnutrition, typhoid, cholera or similar diseases. Milk formula is also too expensive for the majority of people living in the rural areas. Even if the milk formula should be given to HIV+ mothers free of charge, it still has to be mixed with water. Where there is no pure water in the rural areas, it means that water from the rivers have to be used. However, upstream one will find cattle walking in the river and often humans also use these rivers as toilets. Bilharzia is also common in virtually all rivers in sub-Saharan Africa. Therefore, if milk formula is given to a baby, and the water has not been purified or boiled for a very long time, the baby will become ill and can even die. A second problem is the cleaning of bottles. In the Western culture all kinds of methods are used to ensure that feeding bottles are clean. A whole training course will need to be undertaken in Africa if mothers want to ensure that they feed their children with sterilized bottles. Researchers now recommend that African women with HIV breast-feed exclusively for six months, using techniques that minimize cracked nipples, and then abruptly wean. Doing so could reduce the HIV transmission risk to as low as 6 percent. Anything else given to an infant - water, bits of porridge or cooking oil (often given to combat constipation) irritate the lining of the gut, increasing the possibility that the babys body will absorb the HIV virus through the milk. So researchers are now proposing that women practise exclusive breast feeding and abrupt weaning. That is, nothing at all except breast milk for six months, and then an abrupt cutoff. Medically, this method has been proved to be effective in reducing the risk of mother-to-child transmission of HIV. However, especially in the rural areas, it is highly unlikely that this method will be implemented. In most, if not all sub-Saharan African countries, breast-feeding is as normal as having a cup of tea. When a baby is unhappy, the mother breast-feeds the child. This happens publicly, in church, on the bus or wherever they are. To change this custom will not be easy. A total paradigm shift will have to take place in most cultures, which may be possible in the long term, but definitely not in the short term. The only other possible solution at this point, other than convincing a mother not to breast-feed at all or to practise exclusive breast-feeding for six months and then weaning abruptly, is to supply an anti-retroviral drug to both mother and child. At present nevirapene seems to be one of the most effective drugs used for this purpose. A single dose is given to the mother at the onset of labour and a single dose is given to the baby 48 to 72 hours after birth. Tests have shown that there is a substantial decrease in the chance of a baby getting HIV from the mother if nevirapene is administered in this way. Unfortunately a new problem has now arisen. In a medical research paper published in February 2003, it was reported that the most important resistance mutation to nevirapene has been detected in the breast milk of at least 70% of women forming part of a test group in Zimbabwe. This means that nevirapene may not be effective for much longer to prevent mother-to-child transmission of HIV. Breast-feeding, central in the raising of a baby in most African countries, has now become one of the major problems in these countries, where AIDS is slowly but surely wiping out large parts of the population.

37

The Reformed Ecumenical Council 4_1_7 - Why are we losing the battle against AIDS? Dr Arnau Van Wyngaard

http://community.gospelcom.net/Brix?pageID=7870
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PREVENTION IS BETTER THAN CURE

Before reviewing the subject of prevention, consider the story that is told of how, many years ago in Holland, there lived a young boy who became an urban legend. To understand the story, it is important to know that a large part of Holland is below sea level. The sea is kept from flooding the land by means of strong dam walls called dikes. Even the children know that every one must be on a careful lookout to make sure that the sea never floods over the land. One day, when the boy was about eight years old, he asked his parents if he could take some cakes to a blind man who lived some way away. He faithfully delivered the cakes, spent some time with the dear old man, and started to walk home. On the way home, he noticed that the sun was setting and it was growing dark. He was still some distance from home. He heard the sound of trickling water. He looked up and saw a small hole in the dike through which a tiny stream was flowing. That little hole would soon be a large one. Eventually the water would break through and the dyke would fail and the people in the village drowned. The boy climbed up until he reached the trickle of water. His pushed his finger in to the hole and the water stopped! It got darker. He shouted loudly, 'Come here! come here!' but no one heard. It got colder and colder and his finger became numb. He shouted again, 'Will no one come? "Mom, Dad!" Nothing happened. The boy began to pray. The only thought that came to him was that "I must stay here 'till morning." The night grew colder as the hours passed. Loneliness set in. He lost all feeling in his finger and it seemed as though the night would never end. Eventually the first grey light of dawn broke through the darkness. The boy, tired, lonely and now racked with pain, continued his vigil. Finally, as the sun rose, a Dominee returning home from visiting a sick person thought he heard groans as he walked along the top of the dike. Looking down, he saw a small boy, obviously in pain. He called out, "'what are you doing?' 'I am stopping the water from coming through,' was the answer. 'Tell them to come quick.' The Dominee ran off and told the mayor. Soon the dyke was fixed and the crisis averted. A strange story to be found in the middle of an overview on HIV Aids. Not so, for there is another story of a country in East Africa where people saw the risk of HIV Aids when it first started took action and was able to lessen the effect. This is the story of Uganda. Uganda is almost unique because of the extent that HIV /AIDS have declined
38

HIV AIDS dates back to the late 70s, where it became known as the slim disease. 1982 The first AIDS case in Uganda was diagnosed on the Eastern Shores of Lake Victoria. From there it to spread to the surrounding villages. 1986 President Yoweri Museveni took ownership of the burgeoning HIV crisis. He embarked on a nationwide tour telling people that: avoiding AIDS was their duty to the country, they should adopt the ABC Lifestyle and in so doing: o o o
38

should Abstain from sex before marriage should Be always faithful to their spouses should use Condoms.

The Impact of HIV/AIDS on Children: Lights and Shadows in the "Successful Case" of Uganda* Robert Basaza and Darlison Kaija http://www.unicef-icdc.org/research/ESP/aids/aids_index.html
Page 21

The Health Minister announced to the World Health Assembly that there was HIV in Uganda, and the first AIDS control program in Uganda was established. It focused on providing safe blood products, and educating people about risks. 1987 16 volunteers who had been personally affected by HIV/AIDS came together to found the community organisation TASO. A program was established to control the spread of HIV in the military. 1988 The first national survey to assess the extent of the epidemic was conducted and found the average prevalence in the population to be 9% 1990 The AIDS Information Centre was formed to provide voluntary counselling and testing. In the late 80s and early 90s, condom use rose steeply among unmarried sexually active men and women, and since the mid 1990s, condom promotion and distribution in Uganda has increased dramatically. It is thought that this has helped to keep down the number of new infections in recent years. 1991 Prevalence among pregnant women aged 15-24 peaked in this year at 21%. UNAIDS estimated data indicates that national prevalence peaked at 15% in 1991. 1992 The government adopted a multisectoral approach to addressing the epidemic and coordinating the response to it. HIV prevalence in young pregnant women in Uganda began to decrease between 1991 and 1993. It is probable that the number of new infections peaked in the late 1980s, and then fell sharply until the mid 1990s. This is generally thought to have been due to: 1994 the result of behaviour change. Increased abstinence, a rise in the average age of first sex, a reduction in the average number of sexual partners and more frequent use of condoms is all likely to have contributed.

Various governmental departments - for example, Agriculture, Internal Affairs, Justice, etc established individual AIDS control Program Units. The government borrowed $50million from the World Bank to fight the epidemic, with the Ugandan government and other donors making this up to a total of $75million to set up the Sexually Transmitted Infections Project.

1995

Uganda announced that it had observed what appeared to be declining trends in HIV prevalence.

1997

Ugandans participated in a study of using anti-retroviral drugs to prevent mother-to-child transmission of HIV.

1998

Prevalence among pregnant women aged 15-24 had fallen to 9.7%. The Drug Access Initiative was established to lobby for reduced prices for antiretroviral (ARV) medication which can improve the health of an infected person, and the establishment of the infrastructure necessary to allow these drugs to be generally accessible.

Compare the table below which reflects the actions of Uganda as well as those of South Africa. Then consider the graphs39 below.

Uganda's Prevalence figures : The Impact of HIV/AIDS on Children: Lights and Shadows in the "Successful Case" of Uganda* Robert Basaza and Darlison Kaija http://www.unicef-icdc.org/research/ESP/aids/aids_index.html
Page 22

39

REACTION Presidents reaction

UGANDA Immediate personal ownership and involvement of the problem by the State President.

SOUTH AFRICA Delaying tactics by both Nationalist and ANC parties before finally appointing Vice President Zuma to head up the committee

Solution

Promotion of Abstinence, Faithfulness and, where neither is possible, the use of a condom,

Be wise, condomise!

Approach to notifiability

Family, close contacts and health workers of the infected person to be immediately advised in terms of law.

Only if specific permission is given, may any one be advised.

South Africa's prevalence figures: Avert : Aids in South Africa http://www.avert.org/aidssouthafrica.htm

Returning to the story of the young Dutch boy, in Uganda it appears that his cries would have been heard whilst in South Africa and Swaziland, it seems that many are lining up to drill even more holes in the dyke causing a deluge of death and misery.

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THE CURRENT SITUATION IN SOUTHERN AFRICA

It's against this backdrop of poverty, crime and illiteracy that we find the modern South Africa - a mixture of first world (predominantly white) and third world (predominantly black). There is an age old saying that one gets "lies, damn lies and then statistics." Statistics never tell the full truth as their basis is often flawed. In addition, statistics take time to collate and by the time that they are collated, are already out of date. This is especially true of AIDS, but the Statistics do give an indication of the trends. With that in mind, consider the following statistics about South Africa. HIV / AIDS in Africa, south of the Sahara 1. 71% of all people with HIV in the world live in Sub-Saharan Africa. Currently 25 million Africans are infected with HIV. South of the Sahara, around 26.6 million people - in a range of 25 million to 28.2 million were predicted to be infected with HIV out of an estimated global tally of 40 million
40.

40

U N AIDS Report 2004. http://www.unaids.org/wad2004/EPI_1204.pdf_en/ EpiUpdate2004_en.pdf

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2.

Sub-Saharan Africa has just over 10% of the worlds population, but is home to more than 60% of all people living with HIVsome 25.4 million.
41

3.

Adult HIV prevalence has been roughly stable in recent years. But stabilization does not necessarily mean the epidemic is slowing. On the contrary, it can disguise the worst phases of an epidemicwhen roughly equally large numbers of people are being newly infected with HIV and are dying of AIDS.42

4.

While a birds-eye view might discern overall stabilizing trends in HIV prevalence, the AIDS epidemics coursing through this region are highly variedboth between and within sub-regions. It is therefore inaccurate to speak of a single, African epidemic and misleading to apply insights about the epidemic gleaned from specific parts or sub regions, to the entire sub-Saharan Africa region.43

5.

Newly published study findings show southern Africa to be firmly in the grip of the AIDS epidemic, as more people succumb to HIV-related illnesses and die. Life expectancy at birth has dropped below 40 years in nine African countriesBotswana, Central African Republic, Lesotho, Malawi, Mozambique, Rwanda, Swaziland, Zambia and Zimbabwe. All are severely affected by AIDS (UNDP, 2004).44

HIV / AIDS in South Africa 1. South Africa continues to have the highest number of people living with HIV in the world. An estimated 5.3 million [4.5 million6.2 million] . 2. Whilst five million South Africans are infected only 10% of them know it 3.
46. 45

Percentage H I V Prevelance in South Africa

30 25 20 15 10 5 0
1990 2001 1991 2002 1992 1993 1994
1

South Africa's adult death rate has jumped by almost 50% over the past six years and the

1995

1996

1997

1998

1999

2000

country's devastating AIDS epidemic is probably the primary cause47.

41 42 43 44 45

UN AIDS Update December 2004 http://www.unaids.org/wad2004/EPI_1204.pdf_en/ EpiUpdate2004_en.pdf Ibid. Ibid. Ibid. Ibid.

46 In Denial About A Deadly Future South Africas AIDS Apartheid. http://mondediplo.com/2002/08/04aids

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4. 5.

In KwaZulu Natal the death rate due to AIDS is now higher than the birth rate

48.

In 1990 only 1% of pregnant women in KwaZulu-Natal were HIV positive," says Dr Paul Kocheleff, who runs the HIV clinics at Pietermaritzburgs city and township hospitals. "Today its 36%. About half the hospital beds are occupied by people with AIDS." After passing through the fertile fields of the big white farms of Natal, the road winds through the Valley of a Thousand Hills to the coast. Not one of the households living in the small family shacks that dot the landscape is untouched by AIDS. Probably 80% of young adults are infected. Here the South Africans say, "People are dying like flies". But the death rate, which lags five to 10 years behind the rate of infection, is still rising.
49

Impact on Women 1. The Graph showing the percentages of those with HIV/AIDS in South Africa indicates that men aged 2529 appear to be infecting young girls between 15-19 years.
25.00 30.00 Ages of HIV / AIDS Sufferers

2.

About 25% of women aged 15-19 are HIV positive. Compare this with the prevalence of young men 7.6% This has been attributed to a number of factors including: Sexual abuse by older men The Sugar Daddy syndrome
Number of men and women living with HIV / AIDS in Sub Saharan Africa
16.00

20.00 15.00 10.00 5.00 0.00

0-4 4-9 1014 1519 2024 2529 3034 3539 3044 4549 5054

Women living with HIV

Men living with HIV

Female

Male

1985

1986

1987

1988

1989

1990

1991

1992

1993

1994

1995

1996

1997

1998

1999

2000

2001

2002

2003

2004

M I L L I O N S
47 48 50 51

14.00

3.

The number of women being infected is growing at a much faster rate than their male counterparts, indicating that men are having multiple partners.50 This phenomenon has put pressure on the scientists to develop a microbicide for use by women.

12.00

10.00

8.00

6.00

4.

In South Africa, 28% of sexually active young women state that their first sexual experience was unwanted, whilst 10% reported that they had been forced to have sex, according to a survey done by the Reproductive Health Research Unit and Medical Research Council (2003) .
51

4.00

2.00

0.00

Health Systems Trust http://www.hst.org.za/news/20040307 Lean on me http://www.wecare4africa.com/about.html http://mondediplo.com/2002/08/04aids

49 In Denial About A Deadly Future South Africas AIDS Apartheid

UN AIDS 2004 update report http://www.unaids.org/wad2004/EPI_1204.pdf_en/ EpiUpdate2004_en.pdf Ibid

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Impact on young children 1. 2. Almost 25% of all South African children under age 15 have lost at least one parent to AIDS . In South Africa, an estimated 26.5% of pregnant women were HIV positive in 2002. An estimated 91,271 infants were born with HIV infection in 200253. 3. Orphans are perhaps the most tragic and enduring legacy of the HIV/AIDS epidemic. Caring for them is one of the greatest challenges facing South Africa. By 2005 there are expected to be around 800 000 orphans under the age of 15, rising to 1.95 million in 2010. 4.
54
2010 2007 2004 2001 1998
0 0.2 0.4 0.6 0.8 1 1.2 1.4 1.6 1.8 2

52

Number of Orphans in Millions

Southern Africa is in serious crisis as females head up many homes. One must consider that women are currently more susceptible to HIV / AIDS and their deaths will cause a major impact on the region.

Projected number of orphans in millions

5.

Many orphans will grow up as street children or will form child-headed households to avoid being separated from siblings.

6.

Grandparents will bring others up. These Grandparents are often illiterate and have a limited capacity to take on parenting responsibilities. In all probability, these orphans will be destined to a similar illiterate fate.

7. 8.

All will have been traumatized by the illness and death of parents, and often by separation from siblings. Trauma will be exacerbated by stigma and secrecy around HIV/AIDS that hampers the bereavement process and exposes children to discrimination in their community and even extended family. Orphans will probably be more susceptible to becoming HIV-infected through abuse, sex work or emotional instability leading to high-risk relationships.55

Young South Africans 1. Young men are more likely to have multiple partners than young women.
56

Percentage of young men between the age of 19-24 and the number of people with whom they have had sex.

Percentage of young women between the age of 19-24 and the number of people with whom they have had sex.

1 2 3-5 6-10 >10

1 2 3-5 6-10 >10

Pangaea Global AIDS Foundation Applauds South Africas Plan to Provide HIV Antiretroviral Drugs as Part of National HIV/AIDS Response http://www.pgaf.org/pressreleases/south_africa.html Pangaea Global AIDS Foundation Applauds South Africas Plan to Provide HIV Antiretroviral Drugs as Part of National HIV/AIDS Response http://www.pgaf.org/pressreleases/south_africa.html
54 55 56 53

52

Facts, figures and the future; Chapter 15 South African Health Review 2000 http://www.hst.org.za/sahr/2000/chapter15.htm Facts, figures and the future; Chapter 15 South African Health Review 2000 http://www.hst.org.za/sahr/2000/chapter15.htm HIV and Sexual Behaviour Among Young South Africans: A national survey of 15-24 year olds 2003 http://www.lovelife.org.za/
Page 27

2.

In a recent Study about HIV and Sexual Behaviour Among Young South Africans : a About ten percent (10.2%) of all young people age 15-24 years are infected with HIV in South Africa. By the age of sixteen, 2% of boys and 4% of girls are already infected with HIV, emphasizing the need to target youth before they become sexually active. b The majority of youth (87%) felt that they were able to access condoms when they needed them. Among sexually experienced youth, only 52% reported using a condom the last time they had sex. Condom use was almost identical among sexually experienced men and women aged 15-19 years but, among sexually experienced 20-24 year olds, females were significantly less likely to report condom use at last sex than men (44% vs. 57%). c d There were no differences by gender or age. Youth living in rural areas were more likely to agree that using a condom is a sign of not trusting your partner than youth living in urban formal areas; i. ii. iii. 43% of youth living in rural formal areas, 19% of youth living in urban formal areas and 36% of youth living in urban informal areas
Less than half the time 12% Half the time 11% More than half the time 12% Never 31% Alw ays 34% Condom Use Consistency w ith Most Recent Sexual Partner
A m o n g t ho se who r e p or t e d h a v i n g h a d se x i n t he pa st 12 m on t h s. . .

57

Agreed that using a condom was a sign of not trusting your partner. e Overall, 67% of young people age 15-24 years reported having ever had sexual intercourse (this includes either vaginal or anal sex); f 48% of those age 15-19 years reported that they had ever had sex. Compare this to the 89% of those aged between 20-24 years. There was no major difference in sexual experience by gender (67% of males vs. 68% of females). g Of the Youth aged 15-24 i. ii. iii. iv. h 71% of the African youth reported that they had had sex before. 58% of the Coloured youth reported that they had had sex before. 43% of the White youth reported that they had had sex before. 43% of the Indian youth reported that they had had sex before.

When asked about their risk for HIV infection i. ii. iii. iv. 36% stated that they were at no risk; 35% of all youth indicated that they were at small risk; 12% indicated moderate risk; and 14% stated that they were at high risk for HIV infection. (Females were more likely than males to see themselves at high risk for HIV infection (18% vs. 11%).)

Among Youth there is no increase in perceived risk of HIV infection as risk behaviours increase. (62% of HIV positive youth stated that they had thought they had no chance or only a small chance of contracting HIV.)

j
57

Among young people who have had sexual intercourse in the past 12 months,

HIV and Sexual Behaviour Among Young South Africans: A national survey of 15-24 year olds 2003 http://www.lovelife.org.za/
Page 28

27% reported that they had more than one sexual partner in the past 12 months. Males who had sex in the past 12 months were significantly more likely to report having had more than one sexual partner in the past year compared to females (44% vs. 12%). Thus among youth who reported having had sex in the past 12 months, 56% of males and 88% of females reported only having one sexual partner in the past 12 months.

The results of one of the more disturbing surveys are found in the paper entitled Bus Fare, please: The economics of sex and gifts among adolescents. (aged 14 19) in Urban South Africa 58 The survey was carried out in Durban, Kwa-Zulu Natal and set out to investigate the economic context of gift-giving or receiving and its relationship to patterns of risky sexual behavior such as reports of sexual coercion or force. The findings of the survey are that: Gift giving amongst young people is common and designed to curry sexual favor from the partner. Only township males of 14-15 and white males did not accept this aspect of gift giving. The gift giving is seen by both genders as an important part of their relationship. The giving of cash is associated with prostitution. Whilst money is associated with prostitution, young people find it acceptable for a woman to have a minister of transport, a minister of tourism and a minister of education. These ministers provide, transport, vacations and school or college fees in return for sexual favours. In addition to these ministers, there is a straight minister who is considered to be their true love. Apart from gifts, alcohol and drugs played a major part in encouraging sexual favours. There was a lack of use of condoms. White men would only use a condom as a last resort to get it in. Young black women felt that if they wanted to see the man again or to prevent her from being slapped around, the issue of condoms should not be raised. Certainly, if a gift had been offered and accepted, then the woman had no right to expect the man to use a condom. Only young adolescents saw the use of condoms as essential. Economic impact 1. 2. Consider what impact the following diagram59 will have on your business: Approximately 25% of South Africas economically active individuals are HIV positive.60 3. The overall impact of HIV and AIDS on the health infrastructure and access to care has been significant. The percentage of hospital beds occupied due to AIDS ranges from 26% to 70% among adults in some areas, and from 26% to 30% for children.61

Carol E Kaufman & Stavros E Stavrou. Bus Fare Please. The economics of Sex and Gifts amongst Adolescents in Urban South Africa http://hivinsite.ucsf.edu/global?page=cr09-sf-00 Mark Heyward. (AIDS Law Project, Centre for Applied Legal Studies, P Bag 3, University of the Witwatersrand), A human rights approach to AIDS prevention at work: The Southern African Development Communitys Code on HIV/AIDS and Employment. www.hst.org.za/publications/371 - 25k - 26 Dec 2004 Pangaea Global AIDS Foundation Applauds South Africas Plan to Provide HIV Antiretroviral Drugs as Part of National HIV/AIDS Response http://www.pgaf.org/pressreleases/south_africa.html
61 60 59

58

Ibid
Page 29

4.

The HIV/AIDS pandemic primarily affects working age adults and far outweighs any other threat to the health and well being of South African employees. AIDS deaths will soon exceed all other causes of death put together amongst employees in South African workforces. Over the next 10 years, the number of employees lost to AIDS is expected to be the equivalent of 40-50% of the current workforce in many South African firms.
62

5.

The most significant costs for most companies are likely to be indirect. These include costs of absenteeism due to illness or funeral attendance, lost skills, training and recruitment costs, and reduced work performance and lower productivity. Obviously, these costs are most striking for skilled workers, where instant substitution is more difficult. By 2010 it is estimated that approximately 15% of highly skilled employees will have contracted HIV.

6.

Gold mine employees suffer most from the HIV epidemic, but because there is relatively little task specialization, production has not been seriously affected. Coal mining, on the other hand, employs small numbers of machine operators each performing specialized tasks, and loss of a few operators can lead to substantial production losses.

7. 8.

There is a definite reverse correlation between HIV infection, education and earnings. A report commissioned by the loveLife programme, published in 2000, asserts that it would cost R70 billion per annum by 2010 to provide HAART63 on a wide scale without savings being made to the public sector.64

9.

In their cabinet statement, the SA Government estimates that it would cost R7 billion to treat one million people with ARVs. However the time period over which this happens is not stated.
65

10. Anti-retrovirals (ARVs) to treat the most seriously HIV-compromised individuals could save between 500,000 to 700 000 lives over a 5-year period, according to a recent government report.
66

11. Now consider the following conclusion in a paper entitled The Long-run Economic Costs of AIDS: Theory and an Application to South Africa : The argument establishing how AIDS can severely retard economic growth, even to the point of leading to an economic collapse, is made in three steps. 1 AIDS destroys existing human capital in a selective way. It is primarily a disease of young adults. A few years after they become infected, it reduces their productivity by making them sick and weak, and then it kills them in their prime, thereby destroying the human capital progressively built up in them through child-rearing, formal education, and learning on the job. 2 AIDS weakens or even wrecks the mechanisms that generate human capital formation. In the household, the quality of child rearing depends heavily on the parents human capital, as broadly defined above. If one or, worse, both parents die while their offspring are still children, the transmission of knowledge and potential productive capacity across the two generations will be weakened.
67

62 63 64 65 66

Facts, figures and the future; Chapter 15 South African Health Review 2000 http://www.hst.org.za/uploads/files/chapter15.pdf HAAT = Highly Active Antiretrovirals Therapy Antiretrovirals Chapter 13 - South African Health Review 2002 http://www.hst.org.za/uploads/files/chapter13.pdf Ibid.

Pangaea Global AIDS Foundation Applauds South Africas Plan to Provide HIV Antiretroviral Drugs as Part of National HIV/AIDS Response http://www.pgaf.org/pressreleases/south_africa.html Clive Bell, Shantayanan Devarajan and Hans Gersbach. The Long-run Economic Costs of AIDS: Theory and an Application to South Africa - http://www1.worldbank.org/hiv_aids/docs/BeDeGe_BP_total2.pdf
Page 30
67

At the same time, the loss of income due to disability and early death reduces the lifetime resources available to the family, which may well result in the children spending much less time (if any at all) at school. The outcome can be quite pathological. 3 The chance that the children themselves will contract the disease in adulthood makes investment in their education less attractive, even when both parents themselves remain uninfected. The weakening of these transmission processes is insidious; for its effects are felt only over the longer run, as the poor education of children today translates into low productivity of adults a generation hence. As the children of AIDS victims become adults with little education and limited knowledge received from their parents, they are in turn less able to raise their own children and to invest in their education. A vicious cycle ensues. If nothing is done, the outbreak of the disease will eventually precipitate a collapse of economic productivity. In the early phases of the epidemic, the damage may appear to be slight. But as the transmission of capacities and potential from one generation to the next is progressively weakened and the failure to accumulate human capital becomes more pronounced, the economy will begin to slow down, with the growing threat of a collapse to follow. This is the essence of the argument. It has two particularly important implications for economic policy. 1. The first is fiscal in nature. By killing off mainly young adults, AIDS also seriously weakens the tax base, and so reduces the resources available to meet the demands for public expenditures, including those aimed at accumulating human capital, such as education and health services not related to AIDS. Thus, for any given level of fiscal effort, the deleterious effects of the disease on economic growth over the longer run are intensified through this channel. As a result, the states finances will come under increasing pressure. Slower growth of the economy means slower growth of the tax base, an effect that will be reinforced if there are growing expenditures on treating the sick and caring for orphans. 2. The other effect is to exacerbate inequality. If the children left orphaned are not given the care and education enjoyed by those whose parents remain uninfected, the weakening of the intergenerational transmission mechanism will express itself in increasing inequality among the next generation of adults and the families they form. Social customs of adoption and fostering, however well established, may not be able to cope with the scale of the problem generated by a sharp increase in adult mortality, thereby shifting the onus onto the government. As just argued, however, the government itself is likely to experience increasing fiscal difficulties, and so lack the resources to assume this additional burden in full. Where to now? 1. Projections in 1999 show that the country was likely to be in the throes of the AIDS epidemic by 2004, women in the age group 15 - 19 and men in the age group 20 - 25 years having the highest rates of incidence 2.
68.

According to a worst-case scenario (as projected in 200069) there will be approximately 7.5 million people infected with HIV by the year 2010. At that time, it was projected that 932 000 will have reached the AIDS70 stage. If the 2004 UNAIDS report is superimposed on this, a frightening fact becomes apparent - the predictions in 2000 are seriously understated. In the year 2000, it was estimated that there would be 5.1 million AIDS-

68 69 70

Facts, figures and the future; Chapter 15 South African Health Review 2000 http://www.hst.org.za/uploads/files/chapter15.pdf Facts, figures and the future; Chapter 15 South African Health Review 2000 http://www.hst.org.za/uploads/files/chapter15.pdf Ibid.
Page 31

sufferers in the year 2003. In 2004, they revised the Worst Expected to be 6.2 million factor of 20% per year.

71.

This indicates a growth

SOUTH AFRICAN HIV/AIDS EXPECTATIONS

8.00 7.00
M I L L I O N S

6.00 5.00 4.00 3.00 2.00 1.00 0.00 1999 2001 2003 2005 2007 2009

2000 Best Expected Worst Expected in the 2000 projection Worst Expected in the 2003 projection

3.

Extrapolate (mathematically estimate) the 6.2 million at 20% until the year 2010 and the warning that is detailed in Chapter 8 takes on a frightening reality. If the 2003 expectation, which reflects a 20% growth, is extrapolated through to 2010, then there is a possibility that more than 50% of the population may be affected.

SOUTH AFRICA HIV / AIDS EXTRAPOLATED AT A GROWTH RATE OF 20% PER ANNUM
M I L L I O N S

25.00 20.00 15.00 10.00 5.00 0.00 1999 2001 2003 2005 2007 2009 Worst Expected in the 2000 projection Extrapolated at 20% per annum Worst Expected in the 2003 projection

E s t im a t e d a n d p r o je c t e d d e a t h s 1 5 - 3 4 , w it h a n d w it h o u t A ID S in S o u t h A fr ic a : 1 9 8 0 - 2 0 2 5
2 ,0 0 0 Deaths (thousands) 1 ,6 0 0 1 ,2 0 0 800 400 0
1 9 9 5 -2 0 0 0 2 0 1 0 -2 0 1 5 1 9 8 0 -1 9 8 5 2015-2020 1 9 8 5 -1 9 9 0 2000-2005 2 0 0 5 -2 0 1 0 2 0 2 0 -2 0 2 5 1 9 9 0 -1 9 9 5

W ith o u t A ID S

W it h A ID S

S o u r c e : U N D e p a r t m e n t o f E c o n o m ic a n d S o c ia l A ff a ir s ( 2 0 0 2 ) W o r ld P o p u la t io n P r o sp e c t s , t h e 2 0 0 0 R e v isi o n

71

Page 190 - UNaids report 2004 http://www.unaids.org/bangkok2004/GAR2004_pdf/UNAIDSGlobalReport2004_en.pdf

Page 32

4.

The expected deaths for 2010 are already shocking, without even considering all the other various problems caused by the extrapolation of the numbers.

Consider this: According to the UN AIDS Report 2004, it is possible that 520 000 eventuates, this figure could easily quadruple. Consider the following table:

72

South Africans will die of AIDS this

year. This equates to 1 425 every day or one in every minute. In the year 2010, if the worst expected scenario

rate used by the

Worst Expected

Extrapolated by

Extrapolation

Extrapolation

Deaths 2003

per UNAIDS

AIDS Cases

AIDS Cases

2000 Worst

One Death 4m 3m 2m 1m 1m
Page 33

the Author

2000 Best

Expected

Expected

Report

Author

2000

Year

rate

1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010

80,498 115,366 159,300 212,483 274,452 344,004 419,038 496,687 573,430 645,456 709,438 763,093 805,473

81,003 117,028 163,085 219,626 286,391 362,460 446,100 534,761 625,115 713,375 795,812 869,403 932,193 44.47% 39.36% 34.67% 30.40% 26.56% 23.08% 19.87% 16.90% 14.12% 11.56% 9.25% 7.22%

81,000 119,880 175,624 254,655 365,430 518,911 718,691 959,453 1,232,897 1,522,628 1,804,314 2,047,896 2,221,967 48.00% 46.50% 45.00% 43.50% 42.00% 38.50% 33.50% 28.50% 23.50% 18.50% 13.50% 8.50%

6m 29s 23s 00s 04s 26s 01s 44s 33s 26s 21s 17s 15s 14s

520,000.00

The above table and the accompanying graph are presented in the hope that we will realize the seriousness of the pandemic that we are facing.

EXTRAPOLATED DEATHS FROM AIDS

2500000 2000000 Deaths per annum 1500000 1000000 500000 0
19 98 20 00 20 02 20 04 20 06 20 08 20 10

Revised Estimate 2003 Aids Cases 2000 Best Expected Aids Cases 2000 Worst Expected Extrapolated by the Author

Most of us in South Africa see HIV / AIDS through the eyes of the proverbial ostrich - head buried deep in the sand to prevent our seeing its harsh reality.

72

UNAids Report 2004 Page 193

per

HOW WILL AIDS AFFECT US73?

Before analyzing the effect of HIV / AIDS, consider this testimony from Lavumisa, a small town in Swaziland, close to the South African border.
74

The average life expectancy here is 34 years, but there are fewer and fewer 34 year-olds - just the very young and the old, struggling to do a 34-year-old's job. Today, Lavumisa's schools are collapsing. Crime is climbing. Medical clinics are jammed. Family assets are sold to fend off hunger. The sick are dying, sometimes alone, because they are too many and the caretakers are too few. Much of this is occurring because adults, whose labors once fed children, paid school fees and sustained families, are dead. Lavumisa's lost generation of adults has reached beyond the grave, robbing survivors of their aspirations, reducing promising lives to struggles for existence. Lavumisa is just one of many towns like it in Swaziland, which is said to have the worst pandemic in the World. However, the people in Lavumisa are not different from those in Pongola, a South African town close by. HIV / AIDS is a reality. Consider now how it will impact you, your family, your school and your business. 1 Effect on Households Poor households in South Africa carry the greatest burden of disease. experience the greatest negative impacts. have the least reserves available to cope with the disease.

Many households in South Africa have to provide care in cramped housing. with limited or no access to basic amenities such as water and sanitation.

Impact on household economies In most poor households, all the members are expected to contribute to the common cause. When one of the members suffers from AIDS, not only the infected member stops work, but one of the others will need to care for him/her. In many households, the entire family will come to depend on the grandmothers old age pension after they have sold of all their assets. The cost of caring for the infected person will impact negatively on the ability of the family to pay for food, clothing and education. One of the cultural realties of South Africa is that burials cost money big money75 as the family seeks to honour the dead person. The impact of a household without income causes other members to move into prostitution, where the cycle will probably begin again.

73 74

Facts, figures and the future; chapter 15 South African health review 2000 http://www.hst.org.za/uploads/files/chapter15.pdf

Hollowed generation | plunge in life expectancy hut by hut, AIDS steals life in a Southern African town by Michael Wines and Sharon LaFraniere, New York Times on November 28, 2004 http://stephenlewisfoundation.org/articles/2004-11-28NewYorkTimes.htm Part of the African culture is to honour the dead by an all night vigil followed by a feast. Central to the feast is the slaughtering of an ox that will cost in excess of R2 000 or over three months of a poor persons wages. Apart from the ox, there is the cost of all the other food provided, such as maize meal. This cost is normally borne by the spouse / parent and the entire village is invited to the feast. Because it is a community event, people from outside the village often join in. To refuse them entry to the feast is considered to be dishonouring the dead.
Page 34
75

Education limited

Caring for the terminally ill

Unemployment

HIV / AIDS

Poverty

Pre Marital Sex / Rape/ Prostitution

Crime & Violence

Imprisonment

Impact on Women Women have a greater risk of infection for many reasons, including: Male dominance (Infected males ordering women to submit to sex without consent or a condom) Rape Economics (Women cannot escape from an abusive situation because she is not educated and has no money to live.) The reality that the male fluids stay within the female body for far longer than the other way round.

Women are the ones who care for the terminally ill. It is the wife or the grandmother who cares for the terminally ill. If the husband dies, the wife has to take over the role of breadwinner. If the wife dies, her daughters will take over the role of caregiver. o o o o 3 She must become the provider. She has to run the household. She must care for the younger siblings. She nurses any terminally ill people in the home.

Impact on Orphans With the high birth rate prevailing in South Africa, orphans are the natural result of AIDS. Unfortunately many of these orphans are left without any parent/grandparent/foster parent and have no source of income. Because of this, they are forced to fend for themselves. Without adults to assist them, they are unaware of the grants that are available to them and turn to theft or prostitution to survive. This has the effect of exacerbating the pandemic.

Economic Impact Background: The South African Economy Manufacturing is the largest contributor to GDP76 in South Africa, followed by community, social and personal services. The greatest percentage of workers is employed in these sectors. Industries like mining are changing

76

GDP = Gross Domestic Product = Total earnings for the country.

Page 35

from labour-intensive to mechanized production methods. Government is trying to spur economic growth by holding back on public spending and encouraging international investment. Businesses will be at risk because their key suppliers (e.g. water and electricity, telecommunications and basic government service suppliers) have not reacted to the HIV threat timeously. This is relevant in all industries, including the timber industry where I am employed. If the Swaziland Electricity Board were unable to meet our electricity needs because of manpower shortages, we would be unable to saw logs, which are used in the mining industry to prop up the mineshafts. Cost of treatment Total AIDS treatment & care costs by scenario (target year 2008, in billions of Rand per year) Scenario No ARV 20% cover 50% cover 100% cover 2003 5.4 5.5 5.5 5.6 5.7 2005 6.3 6.6 7.0 7.9 8.3 2008 6.7 7.8 8.1 9.6 10.5 13.4 15.7
77

2010 6.7 8.2 9.0 10.8 12.9 16.9 21.4

Today is the 1st January 2005. Our present costs are estimated to be R6.5 billion. The Government has allocated R3.5 billion (See chapter 7). Where the difference will come from is unknown. Some are counting on the Global Aids Fund to meet the shortfall. Unfortunately, they are not receiving the funds that they budgeted on. Some are looking to America to foot the bill. America is giving a grant to pay for the Antiretrovirals. Regrettably the goalposts for receiving the grant are such that only drugs made by the Multi-National Conglomerate drug companies meet the criteria required79. The effect of this is that America will give a grant to South Africa to buy American drugs extremely understandable if you are an American. Unfortunately American drugs are far more expensive than generic equivalents. Consider the following comment of Drug costs in South Africa:
80 78.

South African prices for AIDS drugs are already well below those in the United States and other developed

countries. For example, while U. S. consumers pay $10.12 for AZT, South Africans pay $2.16. (Authors note: South Africa has more HIV victims than any other country. The United States, on the other hand, has one of the lowest incidences of HIV AIDS. Because of this, South Africans are entitled to a large quantity discount) About 80 percent of South Africa's population relies on (mostly free) care through the public sector, while the remaining 20 percent relies on a private sector system much like that of the United States. Here too, the price discrimination between these sectors works to the advantage of low-income patients. Prices are higher in the

South African HIV treatment costs, scope of plan, begin to emerge AIDSMAP news 9th August 2003 http://www.aidsmap.com/en/news/B224E392-EBA2-4E39-A94F-701896D82AF2.asp
78

77

The UN Aids Global Fund

For those who believe that the UN Aids Global Fund will foot the bill, consider the following extract from a Christian Aid News 78 briefing entitled: Fighting HIV/AIDS with peanuts - a year in the life of the Global Fund for AIDS, TB and Malaria /07.02 Aid for HIV/AIDS - what is needed? Promise: The war on AIDS will not be won without a war chest At a minimum, we need to be able to spend an additional $7-10 billion (5-7 billion) a year on the struggle against HIV/AIDS. Kofi Annan, speech to OAU Conference, April 2001. Reality: The Fund has around $2.1 billion (1.4 billion) over five years 5 per cent of the money called for by Kofi Annan. Add to this the drain of available funds that have been caused by the Iraqi war and the Tsunami on 26 December 2004, and one must realize that, to a large degree, we will have to paddle our own canoe.
79 80 th

The Treatment Era: ART in Africa http://www.irinnews.org/webspecials/ARV/afrmon.asp Duncan Reekie. South Africa's Battle with AIDS and Drug Prices http://www.ncpa.org/ba/ba334/ba334.html
Page 36

low-volume private sector and lower in the high-volume public sector. Government purchases account for 70 percent of industry volume but only 30 percent of revenues, while the private sector generates 70 percent of turnover on only 30 percent of volume. Although drug manufacturer prices in South Africa are among the lowest in the world, its retailers' markups in the private sector are among the highest. Just over half (55 percent) of the price of drugs (net of tax) in South Africa goes to the manufacturer, while wholesalers' margins add about 11 percent and retailers about 34 percent. By comparison, the manufacturer's price is 65 percent in Germany and 88 percent in Sweden. Retail margins are high due to cartel-like distribution in a noncompetitive retail market. Small retail pharmacies have successfully lobbied against corporately owned retail chain pharmacies as well as managed-care-type contracting with selected retailers. The government proposes to reduce the cost of medicines by controlling manufacturers' prices and imposing a fixed dispensing fee on retail prices. A 1997 act, currently under court challenge, requires the substitution of generic drugs for brand-name drugs (unless overridden by the doctor or patient) and authorizes the Minister of Health to allow parallel imports by third parties of cheaper generic equivalents of patent-protected medicines. Drug research companies argue that generics violate their patents and are of lower quality. The pharmaceutical industry is also challenging the provision of the act that requires them to post list prices and forbids any deviation. This so-called single-exit price would be monitored and controlled by a proposed governmental pricing commission. By making it illegal for manufacturers to negotiate discounts on prescription medicines with retailers, such laws keep prices for consumers high. Anglo American has conducted a comprehensive cost and cost benefit study of expanded treatment for all employees that would include HAART. Although the company announced in May 2001 the intention to treat all employees, it has since decided that only 14,000 senior staff (those who can afford health insurance). would be eligible for ARVs. It decided that Antiretroviral Treatment for all employees would be unaffordable based on the cost of R1,500 ($166) a month. Impact on Markets HIV/AIDS will impact on the growth of many markets for goods and services. Households will be forced to change the way in which their income is distributed. Expenditure on HIV/AIDS-related needs, such as health care and funeral expenses, will increase. "Luxury", non-essential goods will suffer, as households are forced to spend their money on HIV related needs. Poor households will be pushed further into poverty. Many middle-income households will fall back into poverty.
81

Impact on Health Care82 Increasing demand for care and support is emerging and will continue to grow for at least eight to ten years. This demand manifests itself currently in presentation to primary care and admission to hospital. To date, this demand has been accommodated by three main mechanisms: Crowding out of care for persons with non-HIV related needs Provision of inadequate quality of care for many of those presenting with HIV related needs Not providing any meaningful care for a proportion of those sick with HIV/AIDS, especially in areas with generally poor access to health care

The cost of treating HIV/AIDS with ARVs in South Africa. Who knows? Who cares? http://www.iaen.org/files.cgi/6929_connelly2.pdf
82

81

An Enhanced Response to HIV/AIDS and Tuberculosis in the Public Health Sector www.doh.gov.za/aids/docs/response.html
Page 37

The current coping mechanisms are likely to become increasingly unsustainable as absolute numbers of people sick with AIDS grow rapidly over the next few years. In particular: The sheer rate of growth in demand for care by people with AIDS will mean that crowding out of non-AIDS care will rapidly reach unacceptable proportions. This will become unsustainable politically and will result in major inefficiencies in health provision. (As AIDS cases start to encroach onto surgical wards, operating lists will be disrupted leading to inefficient use of theatre, surgical and anesthetist time will cause falling surgical output and resultant rising unit costs). Continuing to provide low quality care becomes self-defeating, as it results in re-admission and revolving door patients. For example, better drug availability could ensure that a patient will not require repeat hospitalization as part of the same care episode. Numbers of acutely sick people will continue to grow and will continue to present at health facilities. This presents a real risk that delivery systems and staff morale will buckle unless concomitant increases in essential drugs and supplies are made available. Failing to provide care for population sub-groups (primarily the rural poor with poor access to health care) will become increasingly politically dangerous as the absolute number of people sick with AIDS rises among poor and vulnerable groups. Increasing inequality in access to very basic care will result if investment in key services does not occur in resource-poor areas. Providing sub-standard care or failing to provide basic care is clearly also unacceptable from a human rights perspective. In the current environment, it is likely to lead increasingly to legal challenge. Effective interventions are available which provide cheap, cost-effective and flexible means of providing basic symptomatic and palliative care for people with AIDS. Foremost amongst these are home-based care (HBC) and step-down care. These provide a mechanism to achieve the following objectives: Diverting increased demand for care away from acute hospitals and into a lower-cost environment, allowing acute hospitals to focus on more patients requiring more complex care. A low-cost and flexible option for expanding service provision in areas that is currently underserved. Both HBC and step-down care require little or no medical input and can be led by nurses with most activity undertaken by nursing assistants or community workers with basic training only. Over and above the issues raised by the government, one needs to consider the reluctance of surgeons to operate on HIV / AIDS victims due to personal risk, as well as the reduced life expectancy of the patient. the resistance of patients to continue to take all their medication correctly. Tuberculosis has a similar problem and patients are hospitalized to ensure that they complete the course of treatment. Consider the problem with HIV / AIDS where the patient: o o o feels that the treatment has been successful and is no longer necessary. does not wish to continue the treatment because of the side effects. has to travel long distances at a high cost to get to the clinic83.

Impact on essential governmental services South African Defense Force

84

On October 7, 2003, Minister Lekota announced that at least one-fifth of the SANDF was infected with HIV. During this press conference, he downplayed the impact of HIV/AIDS within the SANDF as well as the country as

83 84

This problem was told to Dr Arnau Van Wyngaard by a welfare worker at a Manzini (Swaziland) hospital.

HIV/AIDS in South Africa - AIDS Policy Research Center at the University of California San Francisco. http://ari.ucsf.edu/policy/profiles/SouthAfrica.pdf
Page 38

a whole. Some researchers have estimated that although overall HIV infection rates in the SANDF appear to be comparable to those of the general public, HIV prevalence among 23- to 29-year-old soldiers may be as high as 50 percent. Illness and turnover among the ranks of the SANDF will lead to a loss of skills and break in the continuity of command, with implications for morale, discipline, and cohesion. The epidemic also poses challenges for recruitment and for dealing with personnel who are no longer able to participate in active duty. It also raises issues regarding peacekeeper and other special deployments. Prisons 85 Among South Africa's 175,000 inmates, 45.2 percent are HIV-positive. Severe overcrowding, among other factors, may be facilitating rape and transmission of HIV/STIs, as well as TB spread. Many South Africans consider a sentence in one of these jails as a death sentence because of the probability of contracting HIV / AIDS. Health Care Workers86 South Africa has been contending with an exodus of doctors for some time. The IMF estimates that if the current number of doctors and nurses remains constant--and assuming that HIV prevalence among health sector staff is similar to those of the general population-training of doctors and nurses will have to increase by 25 to 40 percent to meet demand for health services. Education 87 In seeking to redress the many inequities of the apartheid educational system, South Africa was already contending with numerous challenges, including a shortage of teachers, limited budgets, and under-funded teacher training colleges HIV/AIDS has exacerbated the situation88. Educators may be particularly vulnerable to HIV infection given their comparatively high incomes, sometimesremote postings, and geographic and social mobility - all of which may increase their number of sexual partners and contacts with different sexual networks. Long Range Impact It is probable that the long-term effect of AIDS will be far more severe than previously anticipated. The basis of this is that not only does AIDS destroy existing human capital but, by killing mostly young adults, it also weakens the mechanism through which knowledge and abilities are transmitted from one generation to the next. The children of AIDS victims will be left without one or both parents to love, raise and educate them. Teachers, who are the secondary transmitters of knowledge, skills and values to our children, are also succumbing in large numbers to HIV / AIDS. Finally there is the effect that this will have on the Fiscus. By 2045-50, South Africa will have the world's 10th-lowest life expectancy at birth. Between 2000 and 2050, life expectancy will be 27 to 41 years lower than it would have been in a no-AIDS scenario.
89.

85 86

Ibid

HIV/AIDS in South Africa AIDS Policy Research Center at the University of California San Francisco. http://ari.ucsf.edu/policy/profiles/SouthAfrica.pdf
87 88

Ibid

Some 12 percent of the country's teachers are infected with HIV, according to the World Bank and in KwaZulu Natal, South Africa's largest and mostly rural province on the country's east coast where one in four people carry the virus, 70,000 new teachers will be needed by 2010 to replace sick and dying instructors. HIV/AIDS in South Africa AIDS Policy Research Center at the University of California San Francisco. Htt\p://ari.ucsf.edu/policy/profiles/SouthAfrica.pdf
Page 39
89

WHAT IS THE SOUTH AFRICAN GOVERNMENT DOING?

With an unemployment factor equal to 28%90 of the Economically Active Population, the Government's ability to raise funds is substantially restricted. It must walk a tight line between taxing
Population in 000's 7,000 6,000 5,000 4,000 3,000 2,000 1,000 0 Male employed Male unemployed Female employed Female unemployed Coloured Asian White Black

South African Employment Statistics of economically able persons

those that earn large incomes so heavily that they leave the country and not taxing them sufficiently so as to provide for the growing financial needs. Added to this is corruption, which dissipates the ability to utilize the funds efficiently. With its policy of granting free housing, low cost water and electricity, as well as considerable.

increasing health care and social benefits, the constraints to increase any other field of expenditure are

Much of the funding that has been used up to now in the AIDS campaign has been directed towards educating the nation about AIDS and to promote the use of condoms. Neither appears to be having any significant effect on the rate of infection. The more recent thrust of the advertising, targeting teenagers, has met with more positive results as can be seen from the graph below, where there has been a marked decline in the prevalence among pregnant women under twenty (<20)

In developing the country's AIDS policies, the Health Ministry has largely ignored the nation's many AIDS activists and health workers, and has sometimes aggressively disparaged them. Some opponents of the government have accused it of having a hidden agenda in not providing the drugs. The worst of these suggest that the government is actually "culling" the population. The government is faced with a number of conflicting needs. In the 2004 budget91, the funds were distributed as follows: Out of a total budgeted expenditure of R319 billion,92,Health was allocated R42.586 billion93. (2003 :R39.667 billion). According to Idasas calculations , the national government has set aside R1.952 billion for HIV/AIDS in 2003/4.
94

South African Budgetted Expenditure - 2004 / 2005

Education Health Welfare Housing Police Defence Economic services Admin

90 91 92 93 94

Labour Force Survey 2004 website: www.statssa.gov.za Absa Group Limited Economic Perspective Special Edition, March 2004. www.finforum.co.za/econanal/ep2004budget.pdf Ibid Ibid IDASA - Budget Information Service www.idasa.org.za/gbOutputFiles. asp?WriteContent=Y&RID=573
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Source IDASA - Budget Information Service

95

Whilst the commitment seems impressive, one should consider the following: Assuming the government wished to provide anti-retroviral drugs to everyone who needed them, this would impact the budget by R8 billion and reduce its ability to provide services to other areas. Not an easy decision. No wonder the cabinet is dragging its heels on drugs that cannot cure but can only extend the lifetimes of those who take it. Added to this is the debacle about the costs of the drugs. On the 8th August 2003, Cabinet requested the Ministry of Health to develop as a matter of urgency a detailed operational plan on an Anti-retroviral treatment Programme by the end of September 2003.97 In November 2003 Cabinet approved a national plan on HIV/AIDS prevention, care and treatment. The Plan estimated that 53 000 people would be placed on anti-retroviral (ARV) treatment by the end of March 2004. In May 2004 the President shifted this target to the end of March 2005 signaling a one year delay in reaching patient targets, and many lives that will now not be saved.98 According to Trevor Manuel, the Government has allocated R12bn over three years for the treatment of AIDS. He did not indicate where it would be coming from or how it would be spent99.
96

Added to this is the problem that many of those that should know better - the teachers and the health care workers are themselves falling prey to HIV/AIDS. Those that are not falling prey are leaving the country in droves as their skills are desired in other lands where they are paid more, have better working conditions and the level of crime is far less.

Professor Ruben Sher, the Head of Research Unit at the South African Institute for Medical Research (SAIMR) had the following to say100:

95 96

IDASA - Budget Information Service www.idasa.org.za/gbOutputFiles. asp?WriteContent=Y&RID=573

Special Report on AIDS treatment programme; Southern African Regional HIV/AIDS Information Network www.irinnews.org/S_report.asp?ReportID=36063
97 98 99

GOVZA Antiretroviral Treatment Programme Task Team www.cptech.org/ip/health/sa/sa-moh082003.html National Union of Mineworkers of South Africa Where is the ARV Rollout? http://www.numsa.org.za/article.php?cat=&id=749

SA budgets R12bn to fight AIDS South Africa. Info www.safrica.info/doing_business/ economy/fiscal_policies/minibudget03aids.htm

100

Professor Ruben Sher on his resigning for personal reasons from the AIDS FOUNDATION was quoted in his tribute. The site is no longer available on the Web.
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I think the Government is doing very little in terms of contributing. It is not just about wearing a red ribbon. It is about: o action, o mass education o medical professional training o destigmatization and o service provision

Never mind a State of Emergency, the Government should declare a State of War against AIDS. They are rejecting pharmaceutical companies heavily cut-priced Anti-retrovirals, e.g. the Boehringer and GlaxoSmithKline offer. There are 1 600 new infections a day! To complicate the matters, the disease has attracted too many inappropriate opportunists hell-bent on empire building, with no desire to put something back into the community?

In another interview in 2001, Professor Sher

101

was even more blunt:

Ive got another slide that talks about the three major disasters of the 20th Century: o o o The Holocaust under Nazi Germany The Atomic Bomb and AIDS

Now I have one for the 21st Century The attitude of the government towards AIDS We know that 50 60% of admissions to medical wards are HIV related. Absolute numbers arent important. Its the trend thats important and its going up and up.

We have been messing around too long. Everyone who needs anti retroviral should get it, not only because it will improve quality of life and improve the economy but it CAN REDUCE THE NATIONAL VIRAL LOAD and break the backbone of the epidemic.

101

Remembering the Beginning Professor Ruben Sher http://www.suntimes.co.za/2001/11/25/insight/in12.as

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A VISION OF THE FUTURE

The following warning was given to me during August 2004. I believe God allows us to look at satan's blueprints through such warnings so that we can thwart his plans. "Most South Africans do not realize the impact that AIDS will have. If we do not severely curtail the impact of the pandemic, within 10 years the number of persons with HIV/AIDS will outnumber those without. The epidemic in India will follow and emulate that in Africa - south of the Sahara. The resultant poverty will widen the divide between the haves and the have nots. The division between the rich and the poor will form along National lines. (Rich America will get richer and poor South Africa will get poorer.) The poverty will bring immense pressure on governments as they attempt to provide for the poor, the sick and the dying. Class, racial and religious tensions will rise. This pressure and tension will encourage many nations to adopt authoritarian political positions to control the unrest amongst the poor. There will be a rise in the countries governed by dictators. There will also be a rise in the level of international terrorism. The area encompassing the Ancient Roman Empire will become a cauldron of political upheaval.

This was the warning message the Lord gave to me and, using my research, I analyzed the data from a rational perspective. This is my analysis:
Practical Implications In South Africa

1.

Economics a) The majority of the normal working population of persons between 15 and 25 will die off within the next 10 to 15 years, unless there is a radical intervention. b) Key areas within the economy will face major manpower shortages. These areas will include the Civil Service. This will include the health care and education fields that are heavily dependent on persons aged from 25 to 35. c) d) Other areas of the economy that will be affected include industries such as mining, transport, electricity, etc. There will be major disruptions in these fields as workers fall sick, regain health and then fall sick again and possibly die. e) The productivity levels in all companies will reduce as people fall ill with the effects of HIV/AIDS and their related opportunist diseases. f) g) h) i) Companies will be forced to supply their staff with Anti-retrovirals to protect their levels of production. The problems in e) and f) above will cause many companies to drop in profitability, with a number failing. Turnovers and profits will drop, which will result in reduced taxes for the Fiscus. At a time when the government needs increased levels of income to fund health care, its resources will be hamstrung. j) k) This will bring about increased levels of taxation for the wealthy. The brain drain will escalate as families seek countries where they are not so heavily taxed.

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l)

What has been accepted as a reasonable retirement age will no longer apply. Older men and women will, of necessity, be required to work long past their current retirement ages.

2.

Families Because those persons aged between 15 and 25 will be dying at an abnormal rate, there will be: a) b) c) d) many, many, orphans many families with single parents - because one of the parents has died of AIDS related diseases. grandparents caring for their grandchildren, because their children have died, many families where the oldest child will head up the family - having no parents, grandparents or other relations to care for them. e) low disposable income because: i. ii. the bread winner has died. the available income is being used to pay for health care or funerals. f g h increased child prostitution to provide funds for the family to survive. increased child pregnancies. increased child mortalities because of AIDS.

Because of their inability to meet the crisis, many men and women will turn to violence to deal with their frustrations. This will result in the abuse of women and children escalating at a horrific rate. As a matter of course, there will be an increased need for living in extended families. 3. Government funded health care a) Currently, Health Care is budgeted at R43 billion. Persons suffering with HIV/AIDS are estimated at 5.3 million. It is anticipated that, at the end of the 5-year roll out programme, the budgeted expenditure on Antiretrovirals will increase to R4.5 billion and be given to approximately 1 million sufferers. (Based on experience gained in other nations providing ARVs, 15-20% of HIV+ persons are clinically in need of antiretroviral therapies.) b) The above figures are based on the current percentage of sufferers that approximates 12% of the population. c) Because the HIV victims do not take their medication properly, the H I Virus will have the opportunity to mutate. As individuals continue to be sexually active in an unprotected state, the different strains of the virus will mix and continue to mutate, making the drugs ineffective. d) e) It is probable that the current care relating to blood transfusions will reduce, with resultant infections. The funds that will be necessary to meet the situation where more than 50% of the population has HIV/AIDS (based on 20% of HIV+ persons clinically in need of anti-retroviral therapies) is extrapolated as R18.75 billion or approximately half of the current total Health Care budget. Whatever the level, it is improbable that the country will try to meet the challenge. f) Between 20 and 60% of available hospital beds are already being used to accommodate patients with AIDSrelated diseases. As the crisis deepens, this percentage will increase. g) h) i) At the same time, numbers of health care workers will be decreasing themselves victims of the epidemic. Government funding, because of decreased taxes, will be reduced. The result of all this will be a decrease in the care available to patients.

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Education a) One of the by-products of a school-leaving certificate at the end of Grade 9 will be an increase in the level of under-educated job seekers. b) c) The cost of advanced education will be extreme and few school leavers will be able to afford it. The resultant number of under-educated persons will bring about an increased level of unprotected sexual activity. d) e) This will exacerbate the HIV/AIDS problem. An additional element to consider is the current high learner/teacher ratio. With an increase in the number of educators not being able to teach because of HIV/AIDS, this ratio will escalate. f) The reduced ability of the government to fund expenditure on education will further aggravate the problem.

5.

Law and order a) Most of the law enforcement officers are aged in that critical age group from 18 35. Many, if not most of these, will fall prey to HIV/AIDS. b) c) The resultant loss of active manpower will result in increased lawlessness. Added to this will be the need for poverty stricken families to obtain food to eat at any cost.

6.

The Church a) b) c) d) e) f) In the midst of this unfolding crisis will be the Church. Our first function, according to James, is to care for widows and orphans. There will a plethora of these. Many local churches will find that their funding dries up, as people strive to eke out a meager living. Those churches that have not preached tithing in the past will not be able to do so in the midst of the crisis. Priorities such as evangelistic crusade outreach will need to take second place to evangelistic social outreach. g) h) i) j) k) Orphanages, education and health care must become priorities. The Church, as a whole, must enter into dialogue with Government to ease the pain that is coming. Christians need to adopt a holy lifestyle or perish with the rest. For most of the population, marriage between two non-HIV/AIDS sufferers will be rare. Our young people will need to be taught survival tactics. How does one cope when ones marriage partner is infected? l) Time is not on our side. As a nation, we need to develop strategies to deal with the crisis.

Outside of South Africa

1. a) b) c) d) e) f) g)

Economics The West encourages freedom of choice as a human right. This is a two-sided coin because, whilst it brings about civil liberties, it also encourages promiscuity. Where promiscuity and poverty meet, HIV/AIDS normally follows. This will result in HIV/AIDS spreading rapidly throughout those regions where poverty abounds. This is spelt out in the 2003 HIV/AIDS statistics where Africa South of the Sahara - and India are in crisis. The warning indicates that this crisis will extend to the poorer nations in what was The Roman Empire. Much of the Roman Empire is now part of the European Union.
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h) i) 2. a) b)

How the Union will embrace the resultant poverty that flows from the HIV/AIDS crisis is yet to be seen. What is likely is that the tension within Asia Minor and the Middle East will increase. Politics Increased tension will bring about non-democratic regimes. History tells us that abject poverty will encourage dictators to emerge.

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THE SCENARIOS OPEN TO US

What then can we do? What avenues are available to us? Consider the following scenarios as envisaged by UN Aids: 102
The scenarios were created by a team of about 50, mainly African, men and women. Most of them live and work in Africa, dealing daily with the effects of the epidemic. They brought a wide range of experience and expertise, and were anxious to look beyond, and below the surface of, everyday events, sharing and building on their wide range of understanding Each of the three scenarios describes a different, plausible way in which the AIDS epidemic could play out across the whole of the African continent. They are rigorously constructed accounts of the future that use the power of story-telling as a means of going beyond the assumptions and understandings of any one interest group, in order to create a shared basis for dialogue and action about critical and difficult issues. The epidemiological descriptions are explicitly not projections of what will happen. Rather, each scenario is illustrated by a model, based on one of three assumptions: 1. Traps and legacies extrapolates current trends until 2025. Traps and legacies is a story in which Africa as a whole fails to escape from its more negative legacies, and AIDS deepens the traps of poverty, underdevelopment, and marginalization in a globalizing world. Despite the good intentions of leaders and substantial aid from international donors, a series of seven traps prevent all but a few nations or privileged segments of the population from being able to escape continuing poverty and continued high HIV prevalence. The scenario identifies seven traps that preclude effective, long-term, or widespread development in Africa.
1. The legacy of Africas history (post-colonialism has been unable to overcome deep divisions).

How African leaders left office

19601969 Overthrown in a coup, war or invasion Died of natural or accidental causes Assassination (not part of a coup) Retired Lost election Other interim or caretaker regimes
Percentage non democratic assumption of rule

19701979 68.18 6.82 2.27 4.55 0.00 18.18 88.64

19901989 61.11 11.11 2.78 11.11 2.78 11.11 75.00

19901999 35.48 4.84 3.23 14.52 19.35 22.58 61.29

20002003 40.00 0.00 0.00 13.33 40.00 6.67 46.67

Total 55.44% 6.22% 2.59% 9.33% 9.84% 16.58% 74.61%

75.00 5.56 2.78 2.78 0.00 13.89 91.67

Source: Risk, rule and reason in Africa. African Economic Research Policy Discussion Paper No. 46. Washington D.C., USAID.

1 UNAIDS/04.52E (English original, January 2005 scenarios-2025_report_en.pdf

http://www.unaids.org/unaids_resources/images/AIDSScenarios/AIDS-

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2. 3. 4.

The cycle of poverty, inequality, and disease (rising populations put pressure on inadequate social sector infrastructure, and AIDS further depletes capacity). The divisions rupturing society (scarcity promotes division, and AIDS and stigma feed off division). The quest for swift dividends (African leaders and their donor partners want to show quick results, so are unable to invest in long-term change).

5. The challenges of globalization: integration and marginalization (trade rounds and reducing foreign

investment fail to benefit Africa, whose formal economy is left to rely on a narrow primary export base).
6.

Aid dependency and the quest for global security (aid donors fail to live up to the rhetoric of harmonization and the so-called global war on terrorism spills over into Africa, determining donor funding patterns).

7.

Responding to the AIDS epidemic: shortcuts and magic bullets (the scramble to roll out antiretroviral therapy leaves few lasting benefits and prevents the much needed scale-up of prevention). Traps and legacies describes how AIDS does catalyse people and institutions into a response, but they cannot make sufficient headway with depleted capacities and infrastructure. The additional burden of responding to the AIDS epidemic detracts from other development effortscontinuing underdevelopment in turn undermines the ability of many countries to get ahead of the epidemic. The scenario shows growing disunity and disintegration, diminishing capacity, ongoing ethnic and religious tensions, and wasted resources, with (initially) abundant funding supporting a growing so-called AIDS industry alongside a discourse of blame and punishment around the epidemic. It shows how, despite good intentions, the epidemic will simply continue across many countries and populations in the continent as: HIV is seen in isolation from its root social, economic, and political context, is medicalized, and is treated primarily as an issue of individual behavioural change or personal treatment; Resource provision is as inconsistent and unpredictable over the next 20 years as it has been over the past 20; African countries fail to translate aspirations of pan-African unity into effective reality; Donors do not harmonize their responses; Aid is volatile and of poor quality, and AIDS funding continues but in the absence of deeper investments in social and economic development; It is easier to get antiretroviral drugs than adequate nutrition and clean water; The realities of human behaviour are denied; and The root causes of poverty are not addressed.

In this scenario, across the continent by 2025, HIV prevalence remains similar to today, at around 5% of the adult population, with some countries above, or below this level. The high prevalence rate translates into continuing reduced life expectancy across many countries, and an increase in the number of people living with HIV and AIDS of more than 50%. Prevention efforts are not effectively scaled up - although the level of services achieved in 2004 is maintained and expanded, it only grows at the same rate as the population. Efforts to roll out antiretroviral therapy continue, but are impeded by a combination of underdeveloped and overwhelmed systems, and overall cost. By 2015 a little over 20% of people who need antiretroviral therapy have access to it and this figure stubbornly refuses to budge for the rest of the scenario. Care and treatment for a minority still costs an average of US$ 1.3 billion per year over the 23 years of the scenario. By 2025 this scenario is still costing US$ 4 billion per year in HIV- and AIDS-specific programme costs just to keep service provision at the level that it is today. Because there is a failure to get ahead of the epidemic in terms of prevention, the costs continue to rise, and this rise continues into the foreseeable future.

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Traps and legacies offers a disturbing window on the future death toll across the continent, with the cumulative number of people dying from AIDS increasing more than fourfold, and the number of children orphaned by the epidemic continuing to rise beyond 2025.

2. 'Tough choices applies the trajectory of the most successful response to date (Uganda), adjusted for respective national levels of the epidemic. Tough choices tells a story in which African leaders choose to take tough measures that reduce the spread of HIV in the long term, even if it means difficulties in the short term. This scenario shows that, even with fluctuating aid, economic uncertainty, and governance challenges, collectively, Africa can lay the foundation for future growth and development, and reduce the incidence of HIV.

In this scenario, governments insist that HIV and AIDS are tackled as part of an overall, coherent strategy for national medium-term and long-term development. They impose discipline on themselves, each other, and their external partners (if they refuse to take this on themselves) and demand that action match rhetoric.

The scenario identifies a series of tough choices and careful balancing acts.
1. 2. 3.

The interests of the state as a whole versus those of individual communities, and individual rights versus the collective good. Inevitably, this includes managing dissent. Immediate economic growth versus longer term investment in human capital. Choosing how to target resourcesshould the priority be to rapidly develop the skills and capacity of a minority essential for building and maintaining the functions of the state, or should most resources be spent on services for all and alleviating general poverty.

4. 5. 6.

Navigating between helpful and risk-enhancing cultural traditions. Balancing nation building with strong regional and pan-African alliances; and freedom from external control with the benefits of external resources. Protecting women versus increasing womens freedom.

3. Times of transition illustrates what might occur if a comprehensive prevention and treatment response were rolled out across Africa as quickly as possible. Times of transition is the story of what might happen if all of todays good intentions were translated into the coherent and integrated development response necessary to tackle HIV and AIDS in Africa. This scenario is about the transitions and transformations that must take place in the way in which the world and Africa tackle health, development, trade, security, and international relations, in order to achieve the goals of halving the numbers of people living with HIV and AIDS and ensuring that the majority of those who need antiretroviral therapy have access it by 2025. A set of six interlocking transformations reshaping Africas future, and its place in the world, is identified in the scenario:
1. 2.

Back from the brink describes changes in how HIV and AIDS are dealt with, with a rapid roll-out of treatment and effective prevention strategies, supported by a very active civil society. Setting the house in order focuses on national policy responses to reduce poverty and spur development, crucial for limiting the spread of HIV.

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3.

Working together for development investigates the improved collaboration between African governments and their external partners over the first quarter of the century, as resources are increasingly owned, directed, and coordinated by African governments and their people.

4. 5.

Trading on strengths details the key changes that have taken place in global trade. Human hearts and human rights describes the people at the core of the scenario and the ways in which they have changedincluding powerful changes in the ways women and men relate to one another and to their communities.

6.

Planting peace describes how the prevention of conflict and promotion of peace and security, both within and between countries, has been a vital part of the new African agenda for the twenty-first century.

These transitions begin with a growing perception of crisis: the AIDS epidemic acts as an overarching symbol of many other problems facing Africa and the world in this scenario, including the potential collapse of the regulation of world trade; the failure to meet the Millennium Development Goals; continuing global inequality; the undermining of the multilateral order; the growth of terrorism; and urgent evidence of continuing climate change. The prospect of another century of conflict and impoverishment drives changes in attitudes, values, and behaviour - catalysed by civil society as much as by state leadership. The three scenarios are not mutually exclusive. They just focus on the issues from three different perspectives. Hopefully, we will not maintain the status quo. Hopefully, as a Nation we will take tough decisions. Hopefully we (towns, cities, nations, continents and the whole of mankind) will all involved to rescue this world from a pandemic that threatens us all. Unfortunately there are many, many people with and without influence who do not see the dangers of the pandemic. Consider this report from the Australian
103

WASHINGTON: James Wolfensohn has used his final appearance as head of the World Bank to rebuke his organisation and world leaders for their failure to confront the AIDS crisis. Mr Wolfensohn, who hands over to Deputy US Defence Secretary Paul Wolfowitz at the end of the month, said he was disappointed in his failure to convince world leaders to act faster against AIDS. "I think we were late. I knew about AIDS a long time ago," Mr Wolfensohn said. The World Bank warned this week that young women and girls, often powerless to refuse sex, are increasingly falling victim to the global AIDS pandemic. Girls aged 15-19 are often either forced into sexual relationships or coerced through money, gifts and favours, a World Bank HIV-AIDS Program of Action report says. "For many young women, marriage does not provide protection either, as young brides often lack the power to negotiate safe sex practices," the report says. The report seeks to answer why, despite scientific advances and billions of dollars of aid programs, more people will be infected with HIV and die of AIDS in 2005 than in any previous year. The bank says a new plan is needed because the pandemic has reached a new stage, moving from an emergency health threat to an issue that threatens global development. The bank also concludes that, despite new and more widely available retro-virus drugs to fight the disease, "preventing new infections should still remain the highest priority for all countries".

103

- Wolfensohn's AIDS regret AFP19may05 www.theaustralian.news.com.au/common/ story_page/0,5744,15332666%255E2703,00.html

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The report coincides with a new study from South Africa's Medical Research Council which says HIV-AIDS now kills one in three people in South Africa. The study bases its findings on statistics drawn from the year 2000 that show 30per cent of South Africans died of AIDS. South Africa has the world's highest AIDS caseload, with 5.3million people -- or an estimated one out of five adults - living with HIV and AIDS, according to UN figures. The study, the first to give provincial breakdowns of AIDS deaths, places the eastern KwaZuluNatal province at the top of the list, with 41.5per cent of deaths caused by AIDS. KwaZulu-Natal is followed by Mpumalanga, with 40.7 per cent, while Gauteng ranks third with 33 per cent. Mr Wolfensohn, 71, said that during the early years of his first five-year mandate, world leaders had failed to foresee the implications of AIDS. "Somehow the penny hadn't dropped, that this was something that was at the whole core of human development ... this was a human tragedy and it could be averted and it could be treated," he said. The development bank boss blamed himself for being "late" to highlight the terrible potential of AIDS, even as he was lauded for smashing global silence on the disease. Added to the blindness of the World at large, there are already signs that we will not be able to rely on the promises made by grand standing politicians. Consider this report
104

UNAIDS Executive Director Peter Piot said that it is "no longer realistic to hope" that the world can meet the MDG target of reversing the spread of the virus by 2015, the AP/Globe reports. He added that although some countries will be able to control the disease, the pandemic is still spreading "far ahead" of efforts to curb it in "crucial" regions of the world, including Eastern Europe, Africa and Central America, the AP/Globe reports. "What we are faced with is multiple epidemics and that the epidemic is still expanding. We are actually still moving into the globalization of the AIDS epidemic," Piot also called for a "quantum leap" in financial commitments from meeting delegates, saying that for universal access to treatment and other HIV/AIDS-related services to "become a reality, we must close huge funding gaps." Piot said between $14 billion and $16 billion should be spent on HIV/AIDS each year, compared with the $8 billion pledged to combat the pandemic in 2005 (Lederer, Associated Press, 6/2). Piot added that national efforts and financing for children who have lost one or both parents to the disease also are insufficient, although political commitments to address the pandemic have "increased significantly" since the 2001 meeting, according to the Times. However, in some countries where the pandemic is beginning to emerge, political commitments still are deficient, he added (New York Times, 6/3). Global Fund Executive Director Richard Feachem, who also attended the meeting, said the fund aims to attain "absolutely rock-solid, predictable and sustained" financing but added that funding gaps still exist. Feachem said that the fund needs $2.33 billion in 2005, $3.5 billion in 2006 and $3.6 billion in 2007, although pledges for those years fall "far short" of what is needed, according to Washington File (Aita, Washington File, 6/2).

104

Washington File http://usinfo.state.gov/xarchives/display.html?p=washfileenglish&y=2005&m=June&x=20050602173331eaifas0.3984491&t=livefeeds/wf-latest.html

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WHAT CAN WE DO PRACTICALLY?

With a prevalence that is currently standing above 27%, what can be done? Consider the following South African graph.
105

A number of realities are blatantly clear: 1. That, whilst the total number of men with HIV appears to equal that of women, there are large discrepancies in the various age groups. 2. 3. 4. 5. Girls aged 15-24 appear to be contracting HIV from men who are much older. The group of men aged 25-39 appear to be so set in their ways that little will change them. The group of women aged 20-39 are similarly predisposed to contracting HIV AIDS. There is a group of young people aged 10-14 who have, as yet, not contracted HIV as well as a large number of teenagers who are HIV free. 6. Because of this, there is a window of opportunity to reach those children and stem the flow of misery.
What can be done to address the problem?

To re-iterate the words of Professor Ruben Sher: WE NEED TO REDUCE THE NATIONAL VIRAL LOAD AND BREAK THE BACKBONE OF THIS EPIDEMIC
106

The scientists tell us that there is currently no hope of an AIDS vaccine. It is therefore vital that, as a Nation, we come to terms with the reality that we must change.

105 106

The Demographic Impact of HIV/AIDS in South Africa URL http://www.mrc.ac.za/bod/demographic.pdf Remembering the Beginning Professor Ruben Sher http://www.suntimes.co.za/2001/11/25/insight/in12.as
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Dr Arnau Van Wyngaard

107

writing for The Reformed Ecumenical Council considers the following as some of the

main reasons why we are losing the battle against HIV/AIDS in Africa: Denial o o o by those not directly affected by HIV / AIDS by Countries affected by HIV / AIDS by Individuals affected by HIV / AIDS

The typical attitude towards sex. (Whilst the subject is officially taboo, young children play sexual games with each other, which stems from a situation where there is no sense of privacy and youth often see each other naked.)

Migrant labour Prostitution Breast feeding Useless methods to prevent HIV / AIDS The myth of Safe Sex

How does one begin to address the issues of HIV / AIDS?

Consider the following far-reaching proposals that are included amongst many others in an article written by Dr Robert Shell, Director, Population Research Unit, Rhodes University, East London108: Consideration should be given to the re-imposition of the death penalty for rape while knowing that one is HIV positive. Both HIV and AIDS must be made notifiable
109

The practice of shared confidentiality, as practiced in Uganda, must be implemented. People who are tested positive must be notified in the presence of their spouse, parent or next of kin.

All drivers or pilots of all vehicles must be routinely tested. Suspected rapists must be immediately and mandatory tested for all STIs for the victims sake. Stricter controls on what is known as hard core pornography i.e. any material which degrades the natural dignity of men, women, children and animals, e.g. snuff and grunt movies.

HIV testing must be made mandatory for marriages, drivers licenses and at release of all state prisoners. HIV counselling for all people planning to get married must be mandatory Universal male circumcision110 at birth in hospitals and clinics Bachelor migrant labour must be slowly eradicated from South African society. Residential stability must be encouraged throughout all sectors.

107

Dr Van Wyngaard is a respected Dutch Reformed Minister who has devoted his life to serving the people of Swaziland. He has a first hand knowledge of the realities of HIV / AIDS. In February 2004, an article of his was published in The Reformed Ecumenical Councils Focus magazine entitled Why are we losing the battle against AIDS. http://community.gospelcom.net/Brix?pageID=7870 Dr Robert Shell, Director, Population Research Unit, Rhodes University, East London. Halfway to the Holocaust: The Economic; Demographic and Social implications of the AIDS Pandemic to the Year 2010 in the Southern African Region. http://www.science.uwc.ac.za/stats/research/21_holoc.pdf The Notification System In A Nutshell http://www.doh.gov.za/docs/misc/epi_comment/notify.html

108

109 110

It has been conjectured that males who are circumcised are less likely to contract HIV than those who have not. http://www.cirp.org/library/disease/HIV/nicoll/
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Phased abolition of all forms of polygamy and the reduction and discouragement of all cultural norms condoning multiple sexual partners, e.g. free love and the sexual revolution.

Rape while HIV positive must become a special offence.111

There are already epidemiologists who are arguing that this generation is lost to the possibility of significant behaviour modification, which might save them. For the next generation, a new HIV-safe society must be created through various cradle-to-grave measures and the inculcation of a new set of values.
The country needs a cultural revolution!

What could the first steps towards changing the mind-set of a nation be?
I believe that the only practical way of doing this is:

As a Nation, starting with the State President and his entire cabinet, we need to acknowledge and own the reality that:

HIV AIDS will affect me.

We need to understand that preaching a policy that encourages sex whilst helping to prevent HIV is short sighted - it might deal with the immediate problem but eventually many more will succumb to HIV AIDS. To practically address the issues of HIV AIDS is complex. There is no simple answer. Firstly, because HIV is contracted sexually, different solutions need to be found for the different generations. Men and women from 15 - 39

Apart from a miracle cure being found, or God intervening in an unprecedented manner, I see little hope for most of this generation. Many are already suffering from HIV / AIDS or have a mindset regarding sex that will ultimately take them down the road where they will succumb to the Virus. However we can reduce the extent of the problem: We need to adopt the Ugandan approach where: o o Abstinence and faithfulness are accepted as the best method of prevention. HIV / AIDS is discussed openly and honestly

We need to emancipate our women o Our men need to understand that masculinity is reflected in our ability to defend those whom we love and are called on to love. o o Our women need to be placed in a position where they can be economically independent of an abuser. Our law enforcement authorities need to understand that the abuse of women and children is not something to be condoned or swept under the carpet, but aggressively attacked and the proponents thereof taught the error of their ways.

Next, comes the question of disclosure. The Ugandan approach should be the minimum standard adopted by the country. It is vital that people living or dealing with people who have HIV be given at least an understanding of the risks that they personally face. o As a Nation we need to emulate our beloved Madiba
112

and be honest

111

A special offense is one where the courts see the action of the perpetrator in the far more serious light where the act is deemed to be premeditated and the courts discretion as to length of sentence is removed. http://www.jregrassroots.org/forums/lofiversion/index.php/t11929.html
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o o

We need to accept that HIV/AIDS is a reality that we must deal with openly and honestly. If we become HIV positive, we need to be honest with ourselves, our partners and those around us so that together we can all deal with the problem.

Our people need housing Our husbands and wives need to be able to live together. Because money is scarce we also need to adopt simpler lifestyles. When our people die, we need to conserve the money that we have for those that are left behind and not waste it on lavish funerals with expensive coffins. We do not honour the dead by spending large amounts on celebrating their death. We honour them by taking care of their loved ones.

We need to understand that to stigmatise people because they have contracted HIV only serves to undermine our ability to face the problem.

We need to reduce the Nations viral load through the use of Ante Retroviral drugs for those that are currently suffering.

Children aged 5 - 15

If we are pragmatic, our hope lies with this generation. We must save them! Our children need a decent education. Within that education our children need to have a good knowledge of HIV/AIDS, its mode of transmission, and how it can be prevented. The principles adopted by Focus on the Family in its No compromise113 programme are amongst the best that I have seen. The programme encourages the following approach:
Abstain until marriage Be Faithful to the one person that you marry

To do this, you need Character

Whilst the Provincial departments approve the principles in the programme, I believe that they need to make them mandatory for all schools.
Other Principles

Apart from the principles outlined above, the education policy should include the following principles
Curriculum and the role of the teacher
114

HIV/AIDS education should never be presented in isolation. Children may acquire an irrational fear of the disease. Such a distorted emphasis may interfere with the childs healthy sexual development because the child may become accustomed to equating sex with disease and death.

HIV/AIDS education should preferably form part of a life skills education programme, which includes sexuality education, as well as information on HIV and AIDS.

112

Nelson Mandela, on the death of his son, declared to the world that his son had died of an AIDS related illness and encouraged other South Africans to follow his lead.

113

Teens get the facts about sex and the importance of purity in this exciting release from Focus on the Family Films. Highlighting abstinence as the only true "safe sex," it's a powerful, hope-filled expose that delivers an unforgettable message about strength, courage and character, revealing the importance of waiting until marriage to have sex and uncovering what happens when teens don't.http://www.family.org/resources/itempg.cfm?itemid=384&refcd=OL04XPRRC&tvar=n Risky Sexual Behaviour Amongst South African Teenagers And The Role Of HIV / AIDS Educational Programs: A Critical Literature Survey http://etd.rau.ac.za/theses/available/etd-09142004-130613/restricted/MastersResearchMiniThesis.pdf
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114

HIV/AIDS information can also be integrated into the existing school curriculum, either as part of other health-related subjects, or with one or more subject areas such as biology, science, social science and religious studies.

HIV/AIDS education should begin as early as the junior primary school phase. At this early age, the childs behaviour patterns have not yet been formed and they are very receptive to the principles that govern healthy behaviour.

HIV/AIDS education should be an ongoing process. A single lesson or video is insufficient, because it is necessary to begin instilling the life skills one needs to prevent HIV infection at a young age.

It is important to include parents, community leaders and spiritual leaders so they make an active contribution to all stages of programme development. The full support of all community stakeholders needs to be sought, to reflect the whole spectrum of religious, cultural and moral values found in any particular community.

The CDC (1988) recommends that the class-teacher should teach HIV/AIDS education, especially in the lower grades, because of the familiarity they share with children. Teachers are also best equipped to use teaching strategies that are appropriate to the childrens age group. It is preferable for specially trained guidance or life skills teachers, to present HIV/AIDS education and life skills training in the more senior or secondary grades.

The teacher should feel comfortable with the content of the HIV/AIDS curriculum and should be a role model with whom learners can easily identify.

HIV/AIDS education that focuses on problems, while ignoring sexuality as a normal aspect of all human life, may well impede the normal sexual development of the child. Children must be made aware that sexual feelings and impulses (which are presented from birth) are both pleasant and normal. However, they must be informed that although sexual feelings are normal, the active expression of sexuality is not appropriate behaviour for young children (Quackenbush et al, 1988).

Sexuality and HIV/AIDS education should always be tailored so that it is appropriate to a child or teenagers particular developmental stage. It is therefore important to have a clear understanding of the degree of cognitive, emotional, social, moral and sexual development in children in specific age groups so that the sexual education will be appropriate and suited to the developmental stage of the child. Teachers should always remain sensitive to individual and cultural development needs and differences and adjust their education programmes accordingly.

Within that education, there need value systems which enforce: o o The need for boys to understand that girls are equal to them in position if not strength. The need to engender an understanding that, because girls are physically weaker, they need to be protected from abuse - not subjugated into sexual slavery. o The understanding that our young girls value to us as a Nation, is to be found more in their minds than in their ability to relieve the sexual stresses of a man. o An understanding that sex is a gift from God - and as such needs to be treated with respect not used as a term of barter.

All of the above will require more money put into education, job creation, health and infrastructure - vast amounts of money - money that the Government just does not have. As previously stated, the Global Fund does not have sufficient resources and we must therefore look to our selves. The R12 billion that has been set aside for anti retroviral drugs will need to come from the sale of the Governments interest in Quasi state companies.

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The final reality is that time is limited. The longer that we delay changing our ways, the more money it will cost because the effect of AIDS is exponential.
Practical Programmes to consider Community based HIV/AIDS care and support models in South Africa 115 General models Type of activity

1. Funding, technical assistance and support programmes 2. Advocacy and community mobilization

Umbrella structures channelling funds, providing technical assistance and monitoring and evaluation functions. Community structures to protect the rights of individuals and facilitate access to health and welfare services and schooling.

3.

Drop-in centres/support groups

Physical facility that provides space to run support groups and income-generating activities.

4.

Home visiting programmes

Home visiting, assistance with chores and psychological support.

5.

Comprehensive home-based care

Package involving palliative care and well-developed referral network to health facilities and welfare agencies.

Women

116

The Global Coalition on Women and AIDS was launched by UNAIDS in early 2004 to highlight the effects of AIDS on women and girls and to stimulate effective action to reduce that impact. The Global Coalition on Women and AIDS is not a new organization but a movement of people, networks and organizations supported by activists, leaders, government representatives, community workers and celebrities. Its work is focused on seven areas: 1. 2. 3. 4. 5. 6. 7. Preventing HIV infection among adolescent girls; Reducing violence against women; Protecting the property and inheritance rights of women and girls; Ensuring equal access by women and girls to care and treatment; Supporting improved community-based care, with a special focus on women and girls; Promoting access to new prevention options, including female condoms and microbicides; and Supporting on-going efforts towards universal education for girls.

115 116

Models of community based care; Chapter 16 South African Health Review 2000 http://www.hst.org.za/sahr/2000/chapter16.htm UN AIDS Update 2004 http://www.unaids.org/wad2004/EPI_1204.pdf_en/ EpiUpdate2004_en.pdf
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Models for placement of orphans

117

1.

The extended family approach A family member is identified to care for orphans after the death of parents. Often the family member is a grandmother.

2.

Child headed households When parents die and there is a sibling fifteen years or older, social services may work with that child to keep the family together. The younger siblings remain in their home with the older sibling acting as a parent. They may receive support from volunteers who will visit the household to ensure that they are coping and to resolve problems.

3. Create a Family or Cluster Foster Care This intervention, adopted by SOS Villages in Swaziland as well as Wellspring Ministries involves identifying a surrogate mother, who is hired to care for six orphans in the community. She is provided with a home, in which they all live, and she raises the children as though they were her own. With the assistance of the Wellspring Ministries, foster care grants were accessed to pay for school fees and uniforms, and the foster parent received a stipend. This model serves as a job creation opportunity for women. Wellspring Ministries is currently negotiating with the Department of welfare to become a recognized orphanage 4. Placing adults (usually older women) in the homes of orphaned children This approach has worked successfully in the Masoyi Project (Mpumalanga). This approach benefits both the children and the adult, as often the latter live in the poorest of housing (mud shacks) while the children tend to live in better quality (brick) houses.

Businesses

Businesses need to seriously review their positions and plan ahead for the future, as there are severe implications for many industries within the economy. Consider the following table:
118

Sector

Heavy

Agri business

Small Mining Companies

Large Mining Retail ManuCompanies facturing

Workforce size (number of employees) Estimated HIV prevalence 2002 (%)

>25 000

5 000 10 <1 000 000

>1 000

<1 000

9.9

24.4

33.6

24.1

11.2

117 118

Models of community based care; Chapter 16 South African Health Review 2000 http://www.hst.org.za/sahr/2000/chapter16.htm AIDS and The Private Sector Chapter 12 - South African Health Review 2002 ftp://ftp.hst.org.za/pubs/sahr/2002/chapter12.pdf
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Cost per infection by job level (present value, 2001 US$)

Unskilled/semi-skilled Technician/artisan Supervisor/manager

32 393 50 075 83 789

4 439 6 772 18 956 1.1

10 732 17 972 63 271 5.1

9 474 14 097 45 515 2.9

4 518 11 422 24 149 0.9

Average cost per infection (multiple 4.3 of median salary) Liability acquired in 2002 (future cost of incident infections)(% of payroll) Undisclosed cost of prevalent infections in 2006 (% of payroll) 5.0

2.4

9.4

5.9

5.9

4.8

18.1

12.2

1.8

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THE ROLE OF THE CHURCH

Above all, the country needs revival. It needs the Gospel of the Kingdom to be preached and lived from every pulpit in the land. If revival in Wales can empty the prisons, then revival in South Africa will bring healing to us as a nation. As a country we are reaping what we have sown. What is it that we have sown? During the Apartheid era, we denied the vast majority of our people a decent education. o o o Because of this, they are inadequately equipped to provide for themselves or their children. The result of this is that they have been stripped of the economic freedom to feed, house, clothe and educate themselves. Economically, we have taken away their freedom of choice.

Through the policy of Apartheid, we have encouraged promiscuity by separating men from their wives for extended periods of time.

We have wasted our resources on civil war. We have encouraged our people to reject the authority of the law. We have preached a Gospel that differentiates between the "haves" and the "have-nots" to the point that Christianity is irrelevant to many of the people in our land.

We have largely ignored the impact of male dominance and abuse. Even within the church, we encounter the imposition of authority through the use of power, instead of love. (The picture to the right, taken during a mission trip to Mozambique, clearly depicts the difference between the young missionarys authority with love and local church elders wielding of a big stick.)

Perhaps the worst effect of the AIDS epidemic is that our people are losing hope. And it is this element that so desperately needs to be restored in the land.

If James were writing to the Church in South Africa, what would he write?

To the poor he would bring the same words of comfort. (James 1: 9) To the rich, he might confirm that their riches would diminish. (James 1: 10) He would call for abstinence not condoms. (James 1: 21) The words about faith and actions would still be there. (James 2: 18) Especially to men and boys as they relate to the other gender.

The bit about Orphans and Widows would be addressed especially to men. (James 1: 27) The next part of the verse, about keeping oneself unstained by the World, would be to each one of us. (James 1: 27)
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To the church leaders, he would call them to preach a Gospel that o o does not distinguish between haves and have-nots. promotes the equality of the sexes.

Perhaps James would go further The Government is losing the battle in the fields of healthcare, and, if it is honest, education. o o The Nationalist Government took healthcare and education away from the church. Maybe he would be calling the Church to take back those roles. (James 2: 14)

Above all, I believe he would call the church to repentance for the way that we judge those who are HIV/AIDS positive. (James 4: 11)

What can we do practically?

I am a pragmatist. What follows comes from our own experience at Wellspring Ministries in Piet Retief. Added to this are my personal hopes for what may be possible in the future. Uzwelo orphanage Back in 2000, Wellspring Ministries negotiated with South African Railways to take over a dilapidated station. Although the building was well constructed, it had suffered from neglect. Together with the local community, we set about renovating the building. At the same time, we contacted the Child Welfare Department in Nelspruit and established the ground rules for setting up an orphanage. We appointed a Foster Mother for each six children. These Foster Mothers were screened by us to make sure that they were suitable.

Because we were unknown to this department, we agreed to register the Foster Mothers with the Welfare Department. We entered into a Back to Back agreement with the mothers, whereby the subsidy that they received from the Department would be passed on to us provided we paid their salaries. With these arrangements in place, we set about renovating the first of the three buildings. As soon as the building was ready, the first six orphans were placed in our care.

We finished renovating all the buildings and now have 27 children that have been placed in our care. The pace has been slow due to the amount of red tape involved. Care must be taken to ensure that all other possible avenues have been exhausted before the children are placed outside of the extended family.

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One of the advantages of living in a small town is that the vision was easy to communicate to the local public. The Senior Magistrate responsible for placing the children knew us personally and was able to assist in cutting through the vast amount of red tape. We also communicated our needs to Christians in America, Europe and Australia. Not only did they respond with money and practical necessities, but also some were able to come to Piet Retief and spent many hours interacting with the children. As one catches the heart of God and His deep compassion for orphans, one is able to come to terms with Jamess letter to the Church. For those who are uninitiated into the needs of orphans, perhaps a testimony of four of our children will shed some light. The children were found living on their own. The oldest was 12 and the youngest 8. They were three siblings living together with a cousin. They eked out an existence by begging and searching in trashcans. Between them, they had less than one years formal education. So, in addition to housing, feeding and clothing the children, we have opened an on-site school to give the children a very basic education. From this school, depending on their progress, they are entered into the local government school. Some of the difficulties in running an orphanage i. Time delays in obtaining child care grants from the Government. Period Number of children: Cost of food, clothes and education per child, per month. Red tape shortage: (6 x 1 x R500) per child and care per child iii. Maintenance and other costs per child R 1 000 R 3 000 R10 000 ii. Overhead costs including supervisory salaries R 500 Six months 1

The Lighthouse (Teen Challenge Piet Retief) Besides the orphanage, we are committed to a Christian residential centre, intent on helping youth break free of lifecontrolling addictions.

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What of the future?

If I lived in a perfect world and a perfect church, this would be my dream:

1. All the children in South Africa would receive a Christ-centred education. This would include an understanding: o o that each one of them is made in the image of God. that during His life on Earth, Christ set women free, and restored to them the value and worth equal to that of men. o that we are children of the Most High God. As such, we cannot and should not be treated as things to be bought and sold. Because of this, practices such as the payment of lobola o
119

should cease.

that sex is a good thing that God ordained as an act of union between man and woman as part of their marriage.

that each child has the right and the obligation to say No! to any person wishing to have sex with them outside of Gods ordained plan.

that to live outside of Gods ordained plan for enjoyment of sex is to incur consequences which, in these days, may bring about death through HIV / AIDS.

that it is possible to avoid becoming infected with HIV / AIDS, even though the statistics are stacked against them.

that, while condoms are a part of the solution, the educational focus should not be on condom usage but on a Christ-centred life.

that it is possible to find a life partner who is HIV free and to marry that person and live in freedom as husband and wife.

that even though people do sin and many choose to live outside of Gods plan for enjoyment of sex, God is merciful. However, we can choose to have eternal life through Jesus Christ.

2. Every member in the church would obtain a good understanding of the realities of HIV / AIDS and of their role as Christians to love, care and support those People Living With AIDS. (PLWA) o Following a period of intensive educational input, each person in the church would firstly answer a commitment survey, wherein they would indicate whether they were prepared to move on into the testing phase. o Based on the outcome of the survey, during one Sunday celebration service, every person in the congregation, starting with the Pastors and the Elders, would voluntarily allow him/herself to be tested for HIV /AIDS. The reason for this would be threefold: 1. To identify those within the congregation living in a high-risk HIV situation. (An example of a high risk situation would be being married to someone person who is HIV positive.) They can then receive counseling and pastoral care. 2. To identify those that are HIV/AIDS positive so that they can: immediately receive high quality counseling and treatment. receive continued pastoral care and support.

119

Lobola is a practice whereby the family of the groom makes payments to the family of the bride to consolidate a marriage relationship between two families. In practice, it enriches the father and transfers ownership to the husband.

http://www.genderlinks.org.za/amalungelo/amadocs2/ama2p32guard.pdf

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impose a ring fence on their sexual activity, so as to contain the problem.

To expose every member to the trauma that PLWAs constantly experience, and so stretch their level of compassion.

Following the first exposure to the horrors and fears of HIV / AIDS, the church would then select HIV / AIDS counselors and would start a clinic. The counselors would be trained to bring some sense of peace to those o o o o who must be tested for the first time. who are involved in a high-risk relationship. who are found to be HIV positive. who need to be placed on an Anti-retroviral course of treatment.

At the moment, the fear and prejudice that surrounds HIV /AIDS is so overwhelming that the people in the church may not yet be ready for such vulnerability. I believe that Gods Spirit, in His grace, can change their hearts and minds as He did mine. 3. Right now, what is possible would be an AIDS hospice where the church brings comfort to those who are dying and a safe house for abused women.

Unfortunately all of these ideas, no matter how practical, cost money, and lots of it.
BECAUSE HIV / AIDS WILL AFFECT EVERY PERSON ON THE PLANET IN ONE WAY OR ANOTHER,

we are not embarrassed to speak to our brothers and sisters in Christ throughout Europe, America and Australasia. In the times of the Apostle John, they spoke of the Church in Philadelphia or the Church in Laodicea - not Wellsprings, the N G K, the Catholics, the Methodists or the Anglicans. HIV /AIDS is a problem that affects our entire community. Differences in interpretation of minor issues in the Word cannot and should not impact our thinking when dealing with this attack of the enemy. As the Church of Jesus Christ in each town or city, we need to act now! Across the Nation, we need to set up orphanages, places of refuge, (where women can feel safe from abuse) hospices and HIV / AIDS clinics. We need to be seen to love each other as Christ has loved us. The people need to know that we are Christians by our love and forgiveness. Our prophets and prayer intercessors need to seek Gods face for creative ideas that can be tested by the doctors and scientists.
THIS IS A WAR THAT THE WORLD CANNOT AFFORD TO LOSE.

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IN CLOSING
In a recent study done in Mpumalanga
120

, the following factors have been identified as the causes and impact of

the spread of HIV / AIDS in South Africa Cause of spread in SA

Gender inequity and female subordination o o o o o Women as subordinate in patriarchal society Male denial and risky behaviour Blaming women for spread of HIV/ AIDS Neglecting young men in intervention programmes Womens exposure to poverty, high-risk survival practices.

Sexual violence, abuse and exploitation of women o o o Rape Sexual violence is normative behaviour Sexual exploitation of young girls and teenage women

Poverty and economic marginalisation o o o Disintegrating social cohesion Poverty, inequality, economic depravation and HIV Discrepancies in health expenditure

Inter and Intra country migration and mobility o o o o o o Good transport infrastructure Mining industry Female partners of migrant workers Long distance truckers Illegal immigrants International refugees

Fear, ignorance, denial, myth and cultural believes o o o o o o Cure for HIV/ AIDS Fear Condom use myths and misconceptions Sexual behaviour embedded in cultural belief Norms that frown upon sex education for children High prevalence of STDs

Service Providers o o o Not good role models, preaching what they do not practice Not user friendly Judgmental

120

HIV/AIDS In-Depth Study 2003 www.ledc.co.za/Docs/Ehlanzeni%20District%20Municipality/ IDP%20Document/SECTION%200_Cover.pdf

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Government Policies o o o Social grants promote nwanted/ unnecessary /teenage pregnancies, no control mechanism due to unemployment and poverty Promotes unsafe sexual behaviour

Impact of HIV/ AIDS

Impact on population

o
o o o

Negative growth rate

Impact on households Poor households faces greatest burden with least reserves Most severe impact on household level Impoverished communities and households

Psycho-social effects o o o o Major stress Affected school work performance, family relationship, capacity for childcare Social rejection and alienation Alcohol and drug abuse

Household economies o o o o o o Increased medical cost and other (transport) combine with reduced capacity to work double burden Other family members must care Depletion of reserves Dependence on old-age pension Reduced expenditure on education, food, housing etc. Remaining reserves cover burial costs

Impact on women o o o o Greater risk of infection Women headed households are poorer Abandonment and abuse Dependence on husbands male heir

Orphans o o o o o Most tragic long-term effect Street children & child headed households, grand parents Traumatised by death of both parents Infection through abuse, sex work, emotional instability Antisocial behaviour develops

Capacity of traditional coping mechanisms o o o Huge burden Weakened traditional coping mechanism in South Africa Welfare system overburdened

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When considering HIV AIDS, think over these thoughts from an Article from the South African Department of Health South Africa Communicating Beyond AIDS Awareness A Manual for South Africa121: HIV/AIDS is not only a health or a medical problem, but is also a social problem that has broad implications for the whole of society. As a result, action needs to be taken to deal with the disease within the context of all its consequences. Preventing HIV/AIDS is not simply a matter of personal choice. The contexts within which infection occurs are complex. Factors such as poverty, illiteracy, urbanization, gender relations and the like cannot be changed overnight. The challenge for each society is to identify factors that contribute to HIV infection, and the implications of such infection. Both short-term and long-term integrated responses need to be developed. An integrated strategy should include research, setting of goals, objectives and outputs, development of strategies, developing and refining resources, providing communication support and evaluating activities. HIV/AIDS affects men and women differently, and women are more vulnerable to infection and to the consequences of the epidemic. Time is not on our side. Even if the extrapolations in the chapter entitled What Will Happen If We Don't Get Involved, are grossly overstated, they nevertheless give an indication of the truth. So this is not the time to sit around pontificating whether AIDS is a disease or not. I believe that my research has shown it to be two things: 1. The end result of the virus HIV, wherein the individuals body is so utterly defenseless against the onslaught of opportunistic diseases that death is inevitable. 2. Very often, an impoverished, ill nourished, uneducated, homeless state of being.

Yet, I believe there is hope: If I can personally get involved and raise my voice in these backwoods of Mpumalanga, you can personally get involved and raise yours in your town or city, Together we can declare a State of War against AIDS122 and bring about:

a greater awareness of the realities involved. a greater compassion for those who are suffering from the disease. acceptance of those who are suffering from the disease as our family not lepers to be shunned just brothers and sisters with special needs. creative action throughout our communities; our region; our province; our country education for the unenlightened. professional training for health workers involved in testing and treatment. professional training for volunteers to counsel those who need to be tested and treated

121

South African Department of Health South Africa Communicating Beyond AIDS Awareness A Manual for South Africa www.cadre.org.za/BAC/BACpdf/ Comm%20Beyond%20Awareness.pdf Professor Ruben Sher Sunday Times 25 November 2001 http://www.suntimes.co.za/2001/11/25/insight/in12.as
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th

122

I believe the following:

Christians have not tapped into the creativity of the Holy Spirit to identify strategies that can be used in attacking this enemy and rescuing the victims.

The Church needs to play an integral part in this Declaration of War. If the statistics are correct that Christians form 68%123 of the South African population, then we owe it to the country to get involved and not stand idly by fiddling whilst Rome (South Africa) burns. If we declare The same Spirit that raised Christ from the dead dwells in us124 then we need to lead the way in this war.

As a nation, we need to take our heads out of the sand and look around at the reality that is HIV / AIDS. understand that HIV / AIDS is the enemy not those suffering from it. understand that women are equal to men not just things that can be ill treated and thrown away. look past our own needs and desires to the needs of the country. (This includes those who are currently victims of the disease.) As a continent, we are inextricably bound together and must fight this war, side by side. If we spent as much time and money fighting this real enemy as we do each other, we would be further down the road to healing. As the world, we need to realize that the problems of Sub Saharan Africa have far reaching consequences for all of us, so we cannot remain aloof to what is happening. If we all get involved, then we will
SUBSTANTIALLY "REDUCE THE LEVEL OF THE VIRAL LOAD IN SOUTH AFRICA 125

and, in so doing,
BREAK THE BACKBONE OF THIS EPIDEMIC.126

Because I believe that no man should profit from the suffering of another, the rights to this work have been assigned to Uzwelo Home. The price of the book has been purposefully held as low as possible to facilitate distribution. Should you have benefited from reading the book and wish to contribute to our work, please feel free to deposit your donation into the following account: Name of account: Bank: Branch: Bank Code: Account number Fund Raising Number : Social Services Registration number : Email address for Tax receipt Uzwelo Home First National Bank Piet Retief 270844 62032774699 017-627 11\1\4\3\1\2-5 admin@wellspring.org.za

123 124 125 126

Care overseas work South Africa http://www.careinternational.org.uk/cares_work/where/southafrica/southafrica_stats.htm Romans 8 v 11 Professor Ruben Sher Sunday Times 25 November 2001 ht://www.suntimes.co.za/2001/11/25/insight/in12.as Ibid
th

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ESSENTIAL READING
1. A human rights approach to AIDS prevention at work: The Southern African Development Communitys Code on HIV/AIDS and Employment. http://www.dec.org/pdf_docs/PNACJ406.pdf 2. An Enhanced Response to HIV/AIDS and Tuberculosis in the Public Health Sector http://hivinsite.ucsf.edu/global?page=cr09-sf-00

3. A series of articles written by the Health Systems Trust entitled South African Health Review 2002 http://www.hst.org.za/sahr/2002 a. b. AIDS and The Private Sector Chapter 12 - South African Health Review 2002 ftp://ftp.hst.org.za/pubs/sahr/2002/chapter12.pdf Anti-retrovirals Chapter 13 - South African Health Review 2002 http://www.hst.org.za/uploads/files/chapter13.pdf

4. A series of articles written by the Health Systems Trust entitled South African Health Review 2000 http://www.hst.org.za/sahr/2000 a. HIV / AIDS Current Issues; Chapter 14 South African Health Review 2000 http://www.hst.org.za/sahr/2000/chapter14.htm b. c. Facts, figures and the future; Chapter 15 South African Health Review 2000 http://www.hst.org.za/sahr/2000/chapter15.htm Models of community based care; Chapter 16 South African Health Review 2000 http://www.hst.org.za/sahr/2000/chapter16.htm

d. Tuberculosis in South Africa; Chapter 17 South African Health Review 2000 http://www.hst.org.za/sahr/2000/chapter17.htm 5. Bus Fare Please. The economics of Sex and Gifts amongst Adolescents in Urban South Africa http://hivinsite.ucsf.edu/global?page=cr09-sf-00 6. Child Sexual Abuse a handbook for parents and care givers http://www.cadre.org.za/pdf/VAWAchildsexualabuseparentsguide.pdf 7. Child Sexual Abuse and HIV / AIDS in South Africa A Review http://www.cadre.org.za/pdf/vawachildsexualabusehiv.pdf 8. Combating Sexual Violence in South Africa http://web.idrc.ca/en/ev-5085-201-1-DO_TOPIC.html 9. Gender based violence and HIV/AIDS in South Africa http://hivaidsclearinghouse.unesco.org/ev_en.php?ID=2348_201&ID2=DO_TOPIC 10. Halfway to the Holocaust: The Economic; Demographic and Social implications of the AIDS Pandemic to the Year 2010 in the Southern African Region. Dr Robert Shell, Director, Population Research Unit, Rhodes University, East London http://www.science.uwc.ac.za/stats/research/21_holoc.pdf 11. Hollowed generation | plunge in life expectancy hut by hut, AIDS steals life in a Southern African town by Michael Wines and Sharon LaFraniere, New York Times on November 28, 2004 http://stephenlewisfoundation.org/articles/2004-11-28-NewYorkTimes.html 12

HIV/AIDS In-Depth Study 2003 www.ledc.co.za/Docs/Ehlanzeni%20District%20Municipality/ IDP%20Document/SECTION%200_Cover.pdf

HIV/AIDS in South Africa - AIDS Policy Research Center at the University of California San Francisco. http://hivinsite.ucsf.edu/global?page=cr09-sf-00

13

14.

HIV and Sexual Behaviour Among Young South Africans: A national survey of 15-24 year olds 2003 http://www.lovelife.org.za/

15.

Impending Catastrophe revisited. An update of the HIV/AIDS epidemic in South Africa a report prepared for the Henry J Kaiser Family Foundation. This was on the Internet but has now been printed in a Pamphlet available from Lovelife.

16.

In Denial About A Deadly Future South Africas AIDS Apartheid http://mondediplo.com/2002/08/

17.

Information about HIV & AIDS Treatment Avert http://www.avert.org/hivtreatment.htm

18.

Integrated Community-based Home Care (ICHC) in South Africa http://www.cadre.org.za/pdf/Hospice efinal.pdf

19.

Mark Schoof's series of articles on HIV in Africa http://www.aegis.com/news/vv/1999/VV990401.html

20.

Nelson Mandela / HSRC Study of HIV/AIDS http://www.cadre.org.za/pdf/HIV Report.pdf

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21.

Poverty and Inequality in South Africa - Summary Report.htm http://www.polity.org.za/html/govdocs/reports/poverty1.html

22.

Risky Sexual Behaviour Amongst South African Teenagers And The Role Of HIV/AIDS Educational Programs: A Critical Literature Survey http://etd.rau.ac.za/theses/available/etd-09142004-30613/restricted/MastersResearchMiniThesis_.pdf

23.

Sexual Violence Against Girls in South African Schools http://www.polity.org.za/html/govdocs/reports/nongov/sexviolence/index.htm:

24.

South Africa Communicating Beyond AIDS Awareness - A Manual for South Africa http://www.cadre.org.za/pdf/CommBeyondAwareness.pdf

25.

The Long-run Economic Costs of AIDS: Theory and an Application to South Africa - Clive Bell,Shantayanan Devarajan and Hans Gersbach. www1.worldbank.org/hiv_aids/docs/BeDeGe_BP_total2.pdf

26.

The Origin of AIDS & HIV, and the First Cases of AIDS http://www.avert.org/origins.htm

27.

The Reformed Ecumenical Council 4_1_7 - Why are we losing the battle against AIDS? Dr Arnau Van Wyngaard http://community.gospelcom.net/Brix?pageID=7870

28.

U N AIDS REPORTS a. U N AIDS update report 2004 http://www.unaids.org/wad2004/EPI_1204.pdf_en/ EpiUpdate2004_en.pdf b. c. U N AIDS report 2004 U N AIDS report 2003 http://www.health-e.org.za/resources/ EpiUpdate2003_partI_en.pdf d. e. f. U N AIDS report 2002 No longer available on the internet can be ordered from UNAIDS U N AIDS report 2001 - No longer available on the internet can be ordered from UNAIDS AIDS scenarios 2025 report http://www.unaids.org/unaids_resources/images/AIDSScenarios/AIDS-scenarios-2025_report_en.pdf29. http://www.unaids.org/bangkok2004/GAR2004_pdf/UNAIDSGlobalReport2004_en.pdf

29.

Understanding the immune system How it works http://www.niaid.nih.gov/publications/ immune/the_immune_system.pdf

30.

Violence against women the problem facing South Africa http://www.ippf.org/resource/gbv/chogm99/foster.htm

31.

What is AIDS http://www.avert.org/geninfo.htm

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