[Ip-health] (Fwd) Mark Heywood on AIDS medicines victories - and durable challenges

Patrick Bond pbond at mail.ngo.za
Tue Jun 7 09:21:58 PDT 2011


*Nkosi Johnson Memorial Lecture, June 7^th  2011*

*Mark Heywood, Executive Director, SECTION27 heywood at section27.org.za 
<mailto:heywood at section27.org.za>*


*This speech is dedicated to the Ministers of Basic Education and Social 
Development in South Africa with the hope that it might influence them 
to meaningfully address the pain, loss of life and thwarted possibility 
it describes.*









It is a privilege to speak this evening in the name of one of South 
Africa's bravest young people and in the presence of another. Nkosi left 
us almost exactly ten years ago, he would have been 22 if still alive; 
Mandisa is full of life and true grit. Their lives overlapped. As she 
has just described, Mandisa was a 14 year old finding her difficult way 
as an orphan when Nkosi lost his 12 year old life on June 1 2001.

Although they did not meet each other their lives intersected, and had 
more in common that we dare think:

·Both had biological mothers who were ensnared in poverty;

·Both had fathers who deserted their mothers;

·Both had mothers who died of HIV, one naturally, the other unnaturally;

·Both found mothers who loved, cared for and empowered them; we must 
acknowledge Gail Johnson and Khosi Alma Mashego for their love and 

·Nkosi had HIV. Mandisa was spared HIV, but has by her own account been 
frighteningly close to the risk of infection.

But regrettably, as I will show in this lecture, these are 
characteristics they share with millions of other young people in South 

There is a lot that could and should be said about both individual 
lives. But today I want to reflect primarily on the lot of young 
boys/men, girls/women in SA today, and ask whether anything has changed 
from ten years ago? And if not, why not?

*/2001 and 2011: A comparison/*


*/The political environment is transformed:/*

The political environment around HIV has been transformed and is 
unrecognisable. It is now three years since, in September 2008, Manto 
Tshabalala Msimang was removed as Minister of Health, and Thabo Mbeki as 
President. We are now living in the third year of an unambiguous 
political will to tackle HIV and TB, led outstandingly by Health 
Minister Dr Motsoaledi, which is yielding results.

·In 2001: Nobody was on ARV treatment in the public sector; today the 
latest statistics claim that over 1.4million people have been initiated 
onto treatment since 2004;

·In 2001: there was a +-30% rate of vertical transmission amongst 
pregnant women with HIV; today, vertical transmission at six weeks post 
partum is reportedly down to 3.5% countrywide, which means that far 
fewer children like Nkosi are being born with HIV^[1] <#_ftn1>;

·In 2002/03 only 2.1% of eligible children had started ART. By 2007/2008 
the figure was reported to be 36.9%^[2] <#_ftn2>. Today it is reported 
that over 100,000 children have started treatment; this is still only 
30% of the children in need of treatment.^[3] <#_ftn3>

*/But the social and economic environment that drives the HIV epidemic 
has got worse/*

There are, however, still many negatives and many many challenges faced 
by South Africa. These challenges require a greater, broader and deeper 
political will, together with an understanding of how HIV impacts on 
other areas of life and vice versa, than we have at present:

·In 2001 there were high levels of stigma. In 2011 we have still not 
found a way to monitor or measure stigma, meaning that we know little of 
the lives of the many Mandisa's and Nkosi's of today;

·The violent behaviour of the young men who killed Gugu Dlamini remains 
unabated, both against other young men and women. We have to face the 
fact that the socially created penchant for violence amongst young men 
that led to the murder of Gugu Dlamini on 17 December 1998 is the same 
violence that murdered Noxolo Nogwaza on Sunday 24 April 2011, and 
before her Eudy Simelane, Nokuthtula Radebe, Nqobile Khumalo and 
others.^[4] <#_ftn4>

·There is an epidemic of violence amongst young people that leads to 
maiming and early death for far too many. According to a Statistics 
South Africa report released last year:


"The age group most affected by non-natural causes of death was 15--19. 
43,1% of recorded deaths in this age group were due to non-natural 
causes."  Within this age group: "11,8% of male non-natural deaths were 
due to assault, while 5,6% of female deaths were due to the same 
cause."^[5] <#_ftn5>

It is a tragedy that in the shadow of a Constitution that is pioneering 
on gender and sexual equality that :

*/In South Africa being young and a woman is a risk factor for unwanted 
pregnancy, rape, HIV and death:/*

Below is some of the evidence:

/Rising rates of HIV Infection:/

·Although there is some evidence of improved condom use among young men 
and women^[6] <#_ftn6>, there are still "desperately high" rates of HIV 
infection, particularly in women of Mandisa's age and younger;

·In this regard, what we have established of the facts about new HIV 
infections among young women remains disturbing:

In a recently published study of HIV incidence among young women in 
KwaZulu Natal^[7] <#_ftn7> with a median age of 22, HIV incidence was:

·6.5/100 person years amongst rural women

·6.4/100 person years amongst urban women

·17.2/100 person years amongst urban women under 20

According to the authors of the study: "Several studies and this study 
confirm the persistently high steady state HIV incidence rates, 
demonstrating the underlying transmission dynamics despite the scaled-up 
prevention and treatment efforts, which have failed to address the HIV 
prevention needs of young women."

/High rates of teenage pregnancy:/

·In 2007, nearly 50 000 pupils fell pregnant while in school, a 151% 
increase since 2003 (including 53 pupils in grade 3)

·According to the General Housing Survey (2010)^[8] <#_ftn8>, 4.9% of 
females between the ages of 13 and 19 reported being pregnant in the 
year preceding the survey.

·In the 2009 ante-natal survey, 13.7% of pregnant women surveyed between 
the ages of 15 and 19 were HIV positive; between 15 and 24 this figures 
rises to 21.7%.

·About 50% of the women in the survey were aged between 15 and 24 which 
means that this is the average age for most births in South Africa.

/High maternal mortality:/

Whilst we've learnt how to protect the child from vertical HIV 
transmission, we are not protecting the mother, due to the exceedingly 
high rates of maternal mortality, closely associated with HIV infection.

·Between 2005-2007 there was been a 20.1% increase in the number of 
deaths reported compared with the previous triennium (2002-2004).

·The largest cause of maternal death was AIDS (43.7%). ^[9] <#_ftn9>

In the middle of the nineteenth century Charles Dickens penned a 
permanent lament to the death of Pip, a young orphaned street sweeper, 

"Dead, your Majesty. Dead, my lords and gentlemen. Dead, Right Reverends 
and Wrong Reverends of every order. Dead, men and women, born with 
Heavenly compassion in your hearts. And dying thus around us every day."

The same words apply 150 years later to women  losing their lives as a 
result of pregnancy.

In reality, these 'different' issues are closely connected in a vicious 

For social and economic reasons girls and young women are vulnerable to 
early consensual and non-consensual sex; this contributes to high rates 
of HIV infection; HIV infection is a major cause of  maternal mortality; 
the death of young mothers, leaves another generation of young men and 
women, prey to the behaviours and social forces that restart the cycle.

*It is this cycle that must be broken.*


For a combination of reasons whilst in their teenage years young women 
are more vulnerable to HIV infection than men of the same age. ^[10] 
<#_ftn10> However whilst men have lower HIV infection rates in their 
teens, they 'catch up' in their twenties.^[11] <#_ftn11>

Unfortunately this cycle is not something that people escape after 
passing through the corridor of childhood, because...

*/Adult Risk behaviours are often Determined in Adolescence:/*

The WHO estimates that up to 70% of premature deaths in adults can be 
attributed to behaviour initiated in adolescence.^[12] <#_ftn12> If 
true, this is not good for South Africa.

Most young people in South Africa do not have quality lives. According 
to a compilation of research issued by the South African Institute of 
Race Relations (SAIRR)^[13] <#_ftn13>, in SA there are:

*SAIRR Summary of Findings*

Double orphans


859 000

Paternal orphans


2,468 000

Maternal orphans


624 000

Total orphans


3.95 million

AIDS Orphans


1.4 million

Number/proportion of children in child-headed households 98 000 (0.5%)


98 000 (0.5%)

Proportion of children with absent, living fathers


42% (1996)


48% (2009)

Proportion of children with present fathers


49% (1996)


36% (2009)

Proportion of children with present fathers:











Proportion of children with absent fathers


African up from 46% (1996) to 52% (2009)

Coloured up from 34% (1996) to 41% (2009)

Indian Down from 17% (1996%) to 12% (2009)

White Up from 13% (1996%) to 15% (2009)

*/Not surprisingly this, and a range of other factors, affects young 
people's attitudes to life and mental health:/*

"Many South African children are not growing up in safe and secure 
families. Some are affected by poverty, while others are burdened by the 
effects of the HIV/AIDS pandemic. This pandemic has resulted in an 
epidemic of orphanhood and child-headed households, which has left many 
children having to fend for themselves."

·The National Youth Risk Behaviour Survey (2008) of grade 8-11 learners 
found in the six months before the survey, 24% of youth had sad or 
hopeless feelings; 21% admitted to suicidal thoughts; 17% had a suicide 
plan; 21% had made at least one suicide attempt;

·Western Cape study: 17% of children and adolescents suffer psychiatric 
problems, major depressive disorder (8%) and post traumatic stress 
disorder (8%).^[14] <#_ftn14>

*/And mental health is directly connected to physical health and risk of 

According to researchers:

"Mental health disorders are accompanied by a considerable amount of 
impairment, suffering, stigma and family financial strain. There is also 
a high degree of continuity between psychiatric disorders in childhood 
and adolescence and those in adulthood. Seventy five per cent of adults 
with mental health problems experience the first onset before the age of 
24 years.

"Finally, mental ill-health is associated with physical ill-health. One 
good example of this is HIV infection. Young people with a psychiatric 
disorder are more likely to contract HIV infection than those without 
such a disorder. There are a number of possible reasons for this 
increased risk, such as inadequate sexual communication skills, 
susceptibility to negative peer norms, low self efficacy, decreased 
assertiveness, and reduced ability to negotiate safer sex."^[15] <#_ftn15>

This environmental assault on people when they are too young to 
understand it or fend it off helps to explain the cavalier attitude many 
young people are reported to have towards HIV and other risks to their 
lives. The evidence in this regard is complex and at times 
contradictory. It should not be over-simplified. Behaviour is mixed up 
with culture and context, both of which are changing. But:

-Despite risks of HIV many youth report a preference for prefer 'skin to 
skin'. Ironically, knowledge of HIV has deteriorated among young people 
in recent years.

-Condom use among young people is reported to be improving, but so are 
rates of teenage pregnancy

-Young women are simultaneously victims and agents of their own 
risk.^[16] <#_ftn16>


*In the words of respected anthropologist Suzanne Leclerc-Madlala there 
is a need "to engage with the dis-enabling context that gives sustenance 
to dis-enabling attitudinal and behavioural codes that continue to drive 
the HIV/AIDS epidemic."^[17] <#_ftn17>*

Where to start?


*/The central importance of basic education and a functional school to 
reduction of vulnerability to HIV amongst young people/*

It is well established that the higher and better the educational 
attainment, the lower the risk of HIV infection.^[18] 
<#_ftn18> According to one research study:

The relationship between educational attainment and HIV prevalence 
appears to change as epidemics mature. As educated individuals tend to 
have more control over their sexual behavior, the association between 
education and HIV depends crucially on behavioral intentions. In the 
absence of information about HIV transmission, many individuals may 
intend to have several sexual partners, increasing their risk of HIV 
infection. However, educated individuals are more likely to be exposed 
to HIV prevention messages and more likely to understand them. Given 
that HIV prevention messages become more prevalent with epidemic 
maturity, this leads to a hypothesis about the changing relationship 
between HIV and education. In the early stages of an epidemic, education 
is a risk factor for HIV infection. As an epidemic matures and 
prevention messages become more common, education is a protective factor 
against HIV infection.^[19] <#_ftn19>

Given this knowledge South African youth should be well protected, 
because section 29(1)(a) of the Constitution reads as follows:

*29. Education.---*(1) Everyone has the right-
/   (a) /to a basic education, including adult basic education;


And, as Chief Justice Ncgobo knows well, our right to education is 
founded in an international consensus on the importance of education and 
the duty on the state to provide it that is expressed as follows in the 
UN Committee on Economic Social and Cultural Rights (CESCR) 's /General 
Comment on Education/^[20] <#_ftn20>:


Education is both a human right in itself and an indispensable means of 
realizing other human rights. As /an empowerment right/, education is 
the primary vehicle by which economically and socially marginalized 
adults and children can lift themselves out of poverty and obtain the 
means to participate fully in their communities. Education has a vital 
role in empowering women, safeguarding children from exploitative and 
hazardous labour and sexual exploitation, promoting human rights and 
democracy, protecting the environment, and controlling population 
growth. Increasingly, education is recognized as one of the best 
financial investments States can make. But /the importance of education 
is not just practical: a well-educated, enlightened and active mind, 
able to wander freely and widely, is one of the joys and rewards of 
human existence/.





*/But our government is failing dismally in its duties to provide basic 
education to children:/*


·Of the 1 207 996 Grade 1 learners who started school in 2005 only 
948 213 made it to Grade 6;

·In 2005, 951 641 learners started grade 7. Six years later only 364 513 
passed matric;

·In 2009, 662,000 children were out of primary (80,000) or secondary 
(582,000) school;

·In October 2009 the Department of Basic Education conducted an audit to 
establish the number of Quintile 1 (poorest) schools that had access to 
basic resources for grades R to 6. The majority did not have the most 
basic resources to teach literacy and numeracy.

This conference should think deeply about this issue. We cannot afford 
to be selfish & siloed in our approach to rights. The imperatives of HIV 
been not sufficiently linked to other major social challenges. Education 
rights are health rights. We should demand libraries in schools, and 
enforceable minimum norms and standards for schools.

(some political will seen in taking over of schools in Eastern Cape, 
settlement in mud schools matter, but this needs to happen across the 
board, be monitored and sustained)

What lawyers would call a /sine qua non/ for HIV prevention amongst 
young people is the fulfilment of their right to basic education, including:

·Effective quality education

·Proper life skills education (which is not happening and must be 
addressed urgently by the Departments of Health and Basic Education)

·Access to condoms in schools



*/Conclusion: the National Strategic Plan on HIV & TB (2012-2016) must 
genuinely focus on Young People/*

In the current NSP 2007-2011 it is stated:

"Continued investment in and expansion of carefully targeted 
evidence-based programmes and services focusing on this age group remain 
as critical as ever. Young people represent the main focus for altering 
the course of this epidemic. "

Yet this has not happened. Whilst there have been effective programmes 
such as Soul City & Beat it! which talk to young people, these 
programmes have not been scaled up or sufficiently supported. They now 
also face threats due to the global pull back on promises to challenge HIV.

So in conclusion, so questions to think about:

1.How do we address young people in the NSP and not just pay lip service?

2.How do we use the schools HIV Counselling and Testing campaign and the 
Minister's School Health campaign to genuinely empower young people?

3.How do we bring young people into society as citizen activists for 
change and their own lives?

Mandisa and Nkosi Johnson have shown us a way. Old people cannot speak 
for young people! Young people need to genuinely become policy makers 
and implementers in HIV prevention.



^[1] <#_ftnref1> An Evaluation of the Effectiveness of the PMTCT 
Programme at Six Weeks Post Partum, (Medical Research Council, National 
Department of Health, unpublished MRC report, 2011)

^[2] <#_ftnref2> Children's Institute, HIV and Health, Children Starting 
ART, updated July 2010

^[3] <#_ftnref3> According to statistics released by the Department of 
Health (Health Epidemiology, Evaluation and Research) by August 2010 
there were 105 123 children initiated on treatment.

^[4] <#_ftnref4> For the names of more women raped and murdered, see 
/Act to End Rape/, Lesbian and Gay Equality Project.

^[5] <#_ftnref5> Statistics South Africa, Report on /Mortality and 
causes of Death in South Africa in 2008: Findings from death 
Notification/, 2010 

^[6] <#_ftnref6>/South African National HIV Prevalence, Incidence, 
Behaviour and Communication Survey, 2008. A Tide Turning Among 
Teenagers? /p 66: "A key finding of this study is that there has been a 
dramatic increase in the number of people reporting using condoms at 
last sex. The greatest improvement was seen among youth (15--24 years), 
adult males, and even among females who have traditionally had low rates 
of reported condom use, where we have seen an improvement in 2008."

^[7] <#_ftnref7> Karim et al, Stabilising HIV Prevalence Masks High HIV 
incidence Rates amongst Rural and Urban Women in KwaZulu-Natal, South 
Africa, /Int J Epidemiol/, 2010;1-9. It is admitted that South Africa 
doesn't know enough about HIV incidence. This is one of the challenges 
for the next NSP. However, the trends reported by Karim et al are 
confirmed in other studies. See SANAC, /The HIV Epidemic in South 
Africa, What do We Know and How Has It Changed?/ April 2011.

^[8] <#_ftnref8> Statistics South Africa, General Household Survey, 2010.

^[9] <#_ftnref9>Fourth Report on Confidential Enquiries into Maternal 
Deaths in South Africa, 2005-2007.

^[10] <#_ftnref10> See SANAC Epidemic report at p 70: "In young women 
aged 15-24 it was estimated that HIV incidence was over 8 times higher 
than in young men aged 15-24."; at p71 "Holding other factors constant 
in multiple regression, women faced a 53% higher hazard of 
sero-conversion than men."

^[11] <#_ftnref11> Check Prevalence statistics at 20 and 25

^[12] <#_ftnref12> WHO, 2001, The Second Decade: Improving Adolescent 
Health and development

^[13] <#_ftnref13> SAIRR, /First Steps to Healing the South African 
Family/, March 2011

^[14] <#_ftnref14> Kleintjies S et al, The Prevalence of Mental 
Disorders amongst children, adolescents and adults in the Western Cape, 
South Africa. /South African Psychiatry Review/, 9: 157-60 (2006)

^[15] <#_ftnref15> A Fischer at al, Mental Health and Risk Behaviour, 
South African Child Gauge, 2009/2010, Children's Institute, University 
of Cape Town. See also, L Lake and L Reynolds, Addressing the Social 
Determinants of Health, where it is recorded that infant mortality is 
46/1000 live births in mothers with a matric education and higher and 
84/1000 where a mother has no education. Also, Children's Institute, HIV 
and Health -- Distance to Nearest Clinic, July 2010, 40.4% of children 
(7,588,000) live "far" (more than 30 mins irrespective of mode of 
transport) from nearest clinic.

^[16] <#_ftnref16> Read Mark Hunter, Love in the Time of AIDS, 
Inequality, Gender and Rights in South Africa, UKZN Press 2010. @ p 6 
"... We must pay more attention to how the coming together of low 
marriage rates and wealth and poverty in close proximity can today drive 
gender relations  and material sexual relationships  that fuel AIDS."

^[17] <#_ftnref17> S Leclerc Madlala, Youth, HIV/AIDS and the Importance 
of Sexual Culture and Context, /Social Dynamics/ 28:1 (2002): 20-41

^[18] <#_ftnref18> See The HIV Epidemic in South Africa, pp 51-54

^[19] <#_ftnref19>Joint Learning Initiative on Children and HIV/AIDS, 
Learning Group 3: Expanding Access to Services and Protecting Human 
Rights, Educational access and HIV prevention: Making the case for 
education as a health priority in sub-Saharan Africa, M Jukes, S 
Simmons, M Smith Fawzi

^[20] <#_ftnref20>UN Committee on Economic, Social and Cultural Rights 
(CESCR) General Comment No. 13 (The Right to Education) 


Executive Director


www.section27.org.za <http://www.section27.org.za/>

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