No. 24: Spaces of Vulnerability: Migration and HIV/AIDS in South Africa

Seventy per cent of the 36 million people infected worldwide with HIV live in Sub-Saharan Africa and within this region the countries of Southern Africa are the worst affected. The eight countries with the highest rates of infection are in Southern Africa, followed by six countries in East Africa, and then five other countries, only one outside Africa. The reasons why the highest rates of infection in the world occur in Southern Africa are unclear. Although the countries of the region have much in common, their histories over the last twenty years have been very different. A number of different factors have been advanced to explain the general picture of HIV/AIDS in South Africa including its rapid spread, high prevalence and uneven distribution. They include poverty and economic marginalization; differing strains of HIV; high rates of sexually transmitted disease and other opportunistic infection; sexual networking and patterns of sexual contact; the presence or absence of male circumcision; and the role of core-groups such as commercial sex workers. These factors are discussed in greater detail in the paper, reviewing the current state of knowledge about each in South Africa. The paper argues that a key neglected factor in explaining the rapid spread and prevalence of HIV/AIDS in Southern Africa over the last decade is human mobility. The paper therefore examines what is currently known about the connections between migration and HIV/AIDS. Although both migration and HIV have been examined separately in South Africa, we are still far from understanding in detail just how and to what extent migration affects the spread of HIV. Part of the reason for this is that studies of migration and disease tend to concentrate on the urban, or ‘receiving’ areas with little attention being paid to people living in the rural or ‘sending’ areas. Furthermore, there have been very few well-designed epidemiological studies documenting the relationship between migration and infectious diseases. Even more importantly, at this late stage of the Southern African HIV epidemic, there have been few intervention programmes, even on a small scale, which attempt to reduce transmission among migrants and their rural or urban partners. Without a proper understanding of the social, behavioural and psychological consequences of migration, it will not be possible to understand the consequences of migration for the spread of HIV and the particular vulnerability to infection of mobile populations. To effect this conceptual refocus on the social (and sexual) disruption that accompanies migration and mobility, a number of reorientations are required, including: A more detailed understanding of the complex and changing patterns of migrancy in its different forms; Appreciation of the particular vulnerabilities of migrants as migrants (and those with whom they interact) and hence the economic, social, sexual and gender regimes associated with migrancy; Since generic HIV/AIDS interventions seem to be having so little impact in migrant settings and situations of high mobility, there is a need to develop models of intervention that are sensitive to the circumstances of mobile people; As attention is increasingly directed towards models of care and the development of appropriate ‘toolkits’, there is a need to develop interventions appropriate to the situation of migrants and their divided households. The paper argues that none of these objectives can be adequately reached without attention to both the macro- and micro-geographies of mobility, social connectivity and sexual behaviour. The connections between migrancy and HIV/AIDS are more difficult to unravel because HIV/AIDS arrived in the region at a time when population mobility and systems of migrant labour were undergoing considerable change. Migrancy is, by its very nature, highly dynamic and has changed dramatically in scope, scale and diversity over the last two decades. Today it is much more difficult to map the prevalence and spread of disease onto spatial patterns of migration than it was in the past. Several important migration changes that coincided with the advent of HIV/AIDS need to be mentioned: The collapse of apartheid brought new opportunities and reasons for migration across borders within the region. Migrants from neighbouring countries and further afield see South Africa as a new place to trade, shop, seek essential services, work and seek asylum. South Africa’s formal trade with the rest of the continent has exploded, goods carried in the main by long-distance truckers. Informal sector cross-border trading has also expanded dramatically since the end of apartheid. Significant growth in levels of urbanization in South African cities. One consequence has been the displacement of the rural poor to the towns. The new gendering of migrancy. Women are becoming considerably more mobile, migrating for formal and informal work in ever-growing numbers and travelling more frequently for a variety of social and other reasons. The mining industry persists with its regional single-sex contract labour system but there are much higher levels of social contact between migrants miners and people living near the mines. The vulnerabilities to HIV of people (migrant and non-migrant, mobile and relatively immobile) associated with this changing regime of migrancy are poorly understood. The evidence seems to suggest that migrants and migrant households in town and countryside are particularly at risk. So too are the residents of non-migrant communities with whom migrant workers interact on a daily basis. After discussing the general evidence on the causal connections between HIV/AIDS and migration in South Africa, this paper seeks to move the South African debate from the macro- to the micro-scale. By reviewing the findings of research in three different settings the complexity of the connections between migration and HIV/AIDS begins to emerge. The case study areas are spaces of vulnerability, places in which to observe why migrants and those with whom they come into contact are highly susceptible to HIV infection, and hence to develop approaches to decreasing this vulnerability. If workable interventions, based on a sound understanding of local regimes of migration and sexuality, can be developed in disparate case studies such as these, then such best-practice models could have much wider relevance for resisting the ravages of the epidemic. Much can still be done to reduce the impact and the spread of HIV in South Africa. Mother-to-child transmission could be substantially reduced using standard drug regimens. Control of curable STIs would reduce transmission of HIV. The effective promotion of condoms and a reduction in high risk sexual behaviour would have an effect in the longer term. Tuberculosis prophylaxis could substantially reduce tuberculosis morbidity and mortality among those with HIV and this is particularly important in the context of gold mining. The public health implications of the provision of free anti-retroviral therapy to people who are HIV-positive need to be examined. And adequate resources must go to the development of a vaccine for HIV subtype C. None of these interventions are likely to be effective without a sound understanding of the reasons why Southern Africa is the worst affected region in the world, why the epidemic has spread in this region more rapidly than in any other, and why there are such great differences in the infection rates in different provinces, between men and women and critically between migrants and non-migrants. In addition, in all of these interventions special attention should be given to people at high risk of infection, which includes not only commercial sex workers, but also migrants and the partners of migrants. In this context, effort needs to go into the development of epidemiological models to understand the current state and the likely future course of the epidemic, to provide a context for planning and designing interventions, and to evaluate the effectiveness of such interventions. This paper highlights the current state of knowledge about the linkages between HIV/AIDS and migration but it is abundantly clear that there are large gaps in our knowledge of the extent to which migration, and the particular forms of migration that are found in Southern Africa, can explain why the levels of infection in this region are so much higher than anywhere else in the world. Areas in which more work is urgently needed include: Research on the dimensions and social and health impacts of cross-border and internal migration. To what extent does migration contribute to the overall spread of HIV and other STIs? What steps are being taken to ensure that all migrants, legal as well as undocumented, can readily access the treatment services for STIs and HIV prevention programmes? The economic consequences of out-migration from labour-sending areas have been studied in some depth. But what are the consequences of such migration for the sexual health of those who are left behind? As migrants return home with HIV, suffering from other opportunistic infections and soon to develop AIDS, what are the economic implications for their families and communities who will not only lose a bread winner but must also find the resources to provide some level of care for the dying men and women? As the gold mines, in particular, retrench more men and as the economy slows down and unemployment increases, there are indications that more and more women are migrating in search of work. Because of the highly discriminatory labour market, some will have no choice but to engage in commercial sex work. All are likely to be at increased risk of HIV. What kinds of public health interventions can be developed to assist women at such high risk? While it is certain that migration has fuelled the epidemic of HIV in Southern Africa, infections are now so widespread that it seems likely that migration is no longer driving the epidemic. However, programmes to control the epidemic will certainly be considerably less effective if migrant workers continue to spread infections. Programmes aimed at supporting migrants should be given the highest priority but much more work is needed to provide an understanding of the social, behavioural and sexual context of the lives of migrants Perhaps, most importantly, policy issues need to be addressed including the nature and extent of migration, the rights of migrant workers, and the kinds of services to which they have access. This must be done both for those in the formal and in the informal sector and even undocumented migrants must be able to access health services without fear of exposure. The epidemic of HIV/AIDS threatens to devastate much of Southern Africa. Dealing with the epidemic must be given the highest priority and treated with the greatest urgency. However, unless the issues of migration and disease are understood and dealt with effectively, it is unlikely that the greater struggle to control and manage AIDS can be won

Incidence of HIV infection in rural KwaZulu-Natal in the context of the epidemiology and impact of HIV/AIDS in South Africa.

Thesis (M.Med.)-University of KwaZulu-Natal, Durban, 2007.South Africa has had one of the fastest growing HIV epidemics in the world and almost 30% of women attending public antenatal clinics (ANC) are currently infected with the virus. But as the epidemic is starting to level off and antiretroviral therapy (ART) is becoming increasingly available, few methods exist to determine the impact of ART or other interventions on the epidemic in South Africa. This thesis explores the epidemiology and dynamics of HIV infection and investigates the potential impact of ART. Methods Total and age-specific prevalence data are analysed in time and space and are used to investigate patterns of infection in men and women, urban and rural, and low and high risk populations. Dynamical models are developed to estimate incidence from age-specific prevalence and trends over time and are compared to laboratory-based estimates of recent HIV sero-conversion. Incidence is estimated in different populations in South Africa. A dynamical model is developed to estimate the impact of ART on the future course of the HIV epidemic. Results HIV prevalence varies geographically and by age, sex and race. The average female-tomale HIV prevalence ratio is 1.7 and prevalence peaks at an older age among men than women. The age at which prevalence peaks among women has increased from 23.0 to 26.5 years between 1995 and 2002. Four patterns of infection are identified: among pregnant women attending ANCs, among men and women in the general population, and among migrant workers. HIV incidence among ANC attendees peaked in the mid to late 1990s (at 6.6% per year nationally) with variation between provinces. Current estimates of HIV prevalence and incidence among the general population in South Africa (aged 15-49 year) are 18.8% and 2.4% per year, respectively. Age-specific incidence estimates from dynamical models and laboratory methods are in good agreement provided the window period for the laboratory method is increased. Over the next ten years the provision of ART could avert 1 to 1.5 million deaths depending on whether it is provided when the CD4 cell count falls to 200 or 350 cells/ul. By 2015 about 1.1 million people will be receiving ART but this will have little impact on the incidence of HIV and scaling up of prevention efforts remains urgent. Conclusions The thesis explores some of the determinants and patterns of HIV prevalence and incidence in South Africa in order to find better ways to manage the epidemic of HIV, monitor changes and evaluate progress in control efforts. In order to fight the epidemic we need to mobilize the best possible science in support of those people and communities affected by the epidemic

An evaluation of the respiratory health status of automotive spray-painters exposed to paints containing hexamethylene di-isocyanates in the greater Durban area

No Abstract

Focusing the HIV response through estimating the major modes of HIV transmission: a multi-country analysis.

OBJECTIVE: An increasing number of countries have been estimating the distribution of new adult HIV infections by modes of transmission (MOT) to help prioritise prevention efforts. We compare results from studies conducted between 2008 and 2012 and discuss their use for planning and responding to the HIV epidemic. METHODS: The UNAIDS recommended MOT model helps countries to estimate the proportion of new HIV infections that occur through key transmission modes including sex work, injecting drug use (IDU), men having sex with men (MSM), multiple sexual partnerships, stable relationships and medical interventions. The model typically forms part of a country-led process that includes a comprehensive review of epidemiological data. Recent revisions to the model are described. RESULTS: Modelling results from 25 countries show large variation between and within regions. In sub-Saharan Africa, new infections occur largely in the general heterosexual population because of multiple partnerships or in stable discordant relationships, while sex work contributes significantly to new infections in West Africa. IDU and sex work are the main contributors to new infections in the Middle East and North Africa, with MSM the main contributor in Latin America. Patterns vary substantially between countries in Eastern Europe and Asia in terms of the relative contribution of sex work, MSM, IDU and spousal transmission. CONCLUSIONS: The MOT modelling results, comprehensive review and critical assessment of data in a country can contribute to a more strategically focused HIV response. To strengthen this type of research, improved epidemiological and behavioural data by risk population are needed