Equity and HIV/AIDS

Between 1990 and 2005, HIV prevalence rates in South Africa jumped from less than 1% to around 29%. Combining ethnographic, demographic and historical insights, this article addresses the important question posed recently by prominent South Africanist scholars: Was Aids in South Africa ‘an epidemic waiting to happen?’ To date, important responses to this question have forefronted the legacy of colonialism and apartheid in order to challenge cultural models that reify an ‘African system of sexuality’ supposedly characterised by sexual permissiveness (for instance as contained in Caldwell, Caldwell and Quiggin, 1989, for a direct critique see Heald, 1995). In particular, the work of social historians has brought to attention the ways in which racial segregation and male migration fuelled an earlier epidemic of syphilis only partially quelled by the introduction of penicillin in the 1950s; moreover, they note how the forces of urbanisation, industrialisation, and Christianisation have long been argued to have destabilised African family structures.

The latest version of the Missing the Target report on AIDS treatment scale up offers a "no spin" assessment on treatment access -- the successes, challenges, and what needs to change at the national and global levels. The report points out that AIDS treatment delivery represents the best hope to build broader health systems -- but that we are in a new phase of treatment scale up where critical issues beyond simple delivery of ARVs require urgent attention. Governments and global institutions must act on the recommendations in our report to accelerate treatment delivery and address critical challenges in scale up. Without improved efforts, the world will fall short of new G8 AIDS commitments to deliver lifesaving HIV treatment and prevention services.

This progress report from the World Health Organisation (WHO) shows a steady increase in the global levels of access to antiretroviral therapy (ART) for people living with HIV. However, it shows less improvement in other priority areas of HIV treatment. The coverage rate for access to prophylactic ART by pregnant women, to prevent mother to child transmission of the virus, continues to be low. Similarly, the coverage of HIV counselling services and of interventions directed at intravenous drug users (IDUs) also remain at a low level. The report shows some improvement in the effective monitoring of HIV prevalence.

In Uganda, the areas worst affected by the violence were close to the border with Sudan, far from the urban centres around which most camps for internally displaced persons (IDP) grew. It is the urban areas, such as Gulu in northern Uganda and Yei in southern Sudan, which have the highest HIV prevalence rates. Years of encampment and dependency on relief handouts have had a profound effect on the traditionally conservative Acholi. Alcoholism and sexual violence have become particular problems, and the heavy presence of soldiers, with money in their pockets, has also helped give rise to a sex industry. Many areas of southern Sudan and northern Uganda are rapidly opening up to trade, and health workers are worried that unless information about HIV reaches these populations early enough, they will be unprepared for the possibility of a rapid spread of HIV.