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Understanding the HIV/AIDS Epidemic in South Africa

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Assignment Part A: Understanding the HIV/AIDS Epidemic in South Africa

1. How many people in your county are infected with HIV? Which are the most affected population groups? How has the epidemiology of HIV in your country changed over the last 15 years?

As of 2020, about a 7.8million people in South Africa are infected with the deadly virus of HIV. Among these, 19.1% is the adult prevalence of HIV, which roughly accounts for every 1 in 5 adults infected with HIV (Probert et al., 2022). In 2022, the country reported 85,796 deaths due to AIDS. Though the number of deaths caused by AIDS has significantly falls overtime, but still is one of the highest globally (Statista.com. 2022).

Figure 1: Number of deaths from HIV/AIDS in South Africa

South African black community is the most affected population group due to HIV. As per the statistics, 13% of South African Black people are infected with HIV, while only 0.3% of South African White. The prevalence of HIV is higher among Black African women than men. About 63% of all the adults infected with HIV are women, and 64% of new infections occur among women (Johnson et al., 2022). So it can be said that Black African Women are the most vulnerable population group in the country.

The HIV epidemic emerged in South Africa in the year 1982. By 1990 the HIV rates in the country rise nearly about 60% due to the ignorance of the issue by the Government. In 2000, the issue of HIV came into the focus of the South African Government (Jewell et al., 2020). In 2004 the free antiretroviral treatment introduced in the country and South Africa showed a steady decline in the new cases of HIV.

Figure 2: New HIV infection in South Africa

In the last 15 years, South Africa has taken several measures, including free ART treatment, condom promotions and so on at the country level, which enhances the level of awareness among the people and the country, and reported a decline in the annual new infection cases to a significant level. However, South Africa is still one of the most HIV-prevalent countries in the world which account for 19% of global HIV cases (Thami and Chimusa., 2021). Nearly about 3million people PLHIV affected people required active attention.

2. Describe the challenges to implementing effective interventions for HIV prevention among Black South African women.

Young South African women continue to be at the centre of the HIV epidemic in spite of concerted preventative measures. The risk of HIV infection among young women in South Africa is very high. HIV infection prevalence in those aged 15 to 24 in 2005 was 4.4% for men and 16.9% for women. Because of a number of factors, such as poverty, violence against women, cultural norms that encourage intergenerational sex, non-condom use, and a preference for "dry sex," political obstacles that may have prevented an aggressive HIV response, recreational drug use, and biological factors like the high prevalence of STDs, this country has a high HIV prevalence (Ferguson et al., 2022). Due to a lack of education and economic opportunities, women in South Africa live with a lower position in society, which make it more challenging for policy maker to design and implement effective intervention targeting women. Girls are often forced to leave school at an early age; due to a lower level of education, the stigma related to HIV is higher among women, which restricts them from participating in public health programs. The sociological framework doesn't provide women much decision-making power in terms of their sexual relationship with their partners; this challenge can be termed as a relational barrier. Lack of communication and transparency with partners, "burnout" associated with attempts to bring up condom use with partners, and overdependence on partners (Andersson et al., 2020). Further, common challenges such as poverty, community-level barriers, and men's dominance also cause significant challenges at the policy level.

3. Describe the impact of stigma and discrimination on people living with HIV. Provide an example of how South Africa has addressed this issue.

Discrimination and stigma both contribute significantly to the spread and continuation of the HIV epidemic. People who have HIV or AIDS frequently face stigma and discrimination. Beyond only those with HIV, this effect spreads far throughout society, interfering with social cohesion and making HIV prevention and treatment more challenging. HIV is kept hidden from view by stigma, which lessens the need for behaviour modification (Gichane et al., 2020). Another effect of stigma is a desire to conceal one's own condition, which prevents people from getting tested or receiving treatment. Stigma damages a person's identity and ability to handle the illness on a personal level. The prospect of disclosure is restricted by fear of prejudice, even to potentially significant sources of support like family and friends. Finally, stigma affects behaviour change because it makes it more difficult to engage in safer sexual behaviour. A desire to use condoms, for example, may be perceived as a sign of HIV, which could result in stigma and rejection. HIV vulnerability and the stigma and discrimination that go along with it are related to current injustices and stereotypes, such as racism, poverty, intolerance, and inequality between women and men. So, regardless of race, gender, or economic status, those who are most negatively impacted are already at a disadvantage (Ferguson et al., 2022). A man's hostility to condoms, the possibility of abuse and violence in the relationship, and reliance on a male partner for financial or social support can all put a woman's safety in sexual relationships between women and men at risk. However, regardless of the situation, the lady can be held accountable for spreading the illness. Stigma reduction must be a major goal of all therapies. However, the task's difficulties shouldn't be overlooked. The continuation of prejudice based on traits like colour, gender, and sexual orientation, however, highlights how challenging the process is.

South Africa has specific legislation to protect the right of people with HIV/AIDS. As per the legislation of South Africa, “people with HIV have the right to live their lives with respect, dignity and freedom from discrimination and blame” and the people with HIV/AIDS has the same right as any other citizen of the country. Any discrimination with HIV affected people is a punishable offence. Under this legislation, HIV/AIDS affected women have the full right to make decision about their pregnancy; no one can force women to terminate her pregnancy if she is HIV positive (kznhealth.gov.sa. 2022). The legislation of the country provide the legal support to the HIV affected people specially against discrimination but the problem is deep-rooted in the through process of the society, due to which in spite of well defined laws, discrimination is still there. However, in the past several years, South Africa has taken several initiatives to deal with the stigma and accelerate the HIV response of the country. One such campaign targeting the young girls of the country is 'Entitled SheConqueres'. SheConquers is designed around a five-point plan that aims to expand educational possibilities for young people, especially young women while reducing new HIV infections, teenage pregnancies, and gender-based violence among young women and adolescent girls (Gichane et al., 2020).

4. What the disease poses a significant burden of disease in South Africa? An argument on either “for” or “against” reducing the current funding for HIV prevention and directing to other diseases

Apart from the high prevalence rate of HIV/AIDS, the diseases that are the primary cause of high mortality in the country:

Ischemic heart disease and respiratory diseases. As per the governmental report, in 2017, 58 per cent of the deaths caused in South Africa due to non-communicable diseases, whereas the death from communicable diseases isaccounted for 32 per cent. The two significant killer diseases for the country are tuberculosis, whose prevalence rate in the country is 6.5 per cent, and Diabetes Mellitus, whose prevalence rate is 6 per cent. The death causedby heart diseases in South Africa is 5 per cent, same for Cerebrovascular diseases. Additionally,Influenza, Pneumonia, Ischaemic heart disease, and chronic respiratory disorders are the other diseases that considerably increase the disease burden for the country (PalucciandDelogu, 2018).

Argument  on “for” reducing the current funding for HIV prevention and directing to other disease in South Africa:

According to AIDS activists and researchers, starting from the former president of South Africa, Thabo Mbeki, to the current time (in the presidential period of Cyril Ramaphosa), the government’s negligence to the HIV/AIDS policies is causing massive loss of human lives. The survey report says in 2000 to 2009-10, more than 330,000 people died prematurely from HIV/AIDS as the government cut short the funding for life-saving treatment for the prevention of HIV, with more than 40,000 deaths among children (Eaton et al., 2012).Another important indication of the decline of the Governmental funding program in South Africa is the delayed launch of AZT to prevent mother-to-child transmission of HIV. The governmental restriction on the use or supply of nevirapine and other drugs to stop the spreading of HIV among children isanother indication that Government is reducing current funding “For” HIV prevention (World Health Organization, (2021).

In South Africa, HIV/AIDS has a detrimental impact on the domestic tax base as well as on Governmental revenues. Additionally, external grants account for a significant proportion of health expenditure for the country, and expenditure related to HIV/AIDS is very high. Though, in the country, these external grants us not directly disbursed from the government budget, rather than from the donor of implementing agencies in coordination with NGOs and International healthcare agencies. Increased attrition has a detrimental impact on the governmental operations. Thus, the government has decided to cut short the funding for HIV prevention and other diseases. For example, in 2003, the Government of South Africa donated $22 million to help cover the ARV cost in the country (Iwuji et al., 2020).

Additionally, the government has amended the “Bill of Rights” that protects all the people. According to this bill, people living with HIV in the country will access the same rights as other people. According to this bill, people with HIV/AIDS can get governmental incentives to access medical support and care.

5. Where the effort should be made to achieve the global targets for HIV in South Africa?

HIV Cascade of Care, also known as the Care Continuum, is a framework where service providers and the policymakers are used to measure the progress of service outcomes according to the steps to deliver treatment for HIV.  This framework can allow us to assess all the development towards the HIV prevention and care plan. This framework is also essential to identify and address the gap in sustained care practice. Considering the concept of Cascade of Care for HIV prevention and treatment process, focus can be given tothe current HIV project in South Africa, which reaches to the 90-90-90 target (Iwuji et al., 2020). According to the MSF’s project, in the country, 90 per cent of the people with the age group of 15 to 24 years in South Africa are currently living with HIV and they are aware of their status; 90 per cent of people know that they are HIV positiveand should have to go through Antiretroviral therapy, and 90 per cent of the people on Antiretroviral therapy has acquired a viral load which is undetectable. This status refers to the focus or effort that will be given to strengthening the conventional healthcare service, specifically on the testing and treatment servicefor HIV for the people. The intervention for the prevention of HIV in South Africa is still not reaching to the community level, specifically in the rural region (Simelela et al2015). In the country, many people do not have the access to conventional health services, which is the key to preventing the HIV epidemic. The effort is still giving at developing engagement of local civil society, health staff and health practitioners, traditional leaders and their members to the prevention campaign so that every single individual can get the fundamental knowledge and health care support to cope with the onset of AIDS (Stevenson et al., 2020).An increase in the test for HIV/AIDS should be implemented at the primary level, every people will be tested, and if diagnosed with HIV, they will be sent to the treatment or Antiretroviral therapy at minimal cost, including the people who are much less likely to test for HIV and link to care. This not only can help the government to reduce the disease burden but also impact on Governmental health-related expenditure positively.Therefore, as a whole, it can be stated that, the Government of the country has the necessity to stress on testing and treatment to eradicate the HIV from society. The Government can take necessary initiatives to mass-testing campaign for the people with the age group of 15 to 24 years. After necessary testing, based on the test report, the healthcare providers can provide ART services to the people with vulnerability of HIV/AIDS at minimal cost. This attempt can help the Government to reach to every individuals of the country with necessary HIV treatment program. The age group 15-24 years is considered as one of the most vulnerable age groups towards the onset of HIV or AIDS, due to unprotected sexual interaction, and lack of knowledge. Therefore, mass testing and treatment at minimal cost can restrict this specific age group from being infected with HIV. 

Assignment Part B

1. How do the result of this paper fit into the broader existing evidence base?

The result of the data interpretation of the paper can fit the existing evidence regarding the impact of HIV/AIDA in south Africa. The thorough analysis of the result shows the practical problems related to the large-scale implementation of Anti-retroviral therapy in Africa. According to CSIS or centre for strategic and international studies (based in the online research), in 2019, 60- per cent of the women population in the country were living with AIDS/HIV. Nearly 4000 people are affected by this disorder every year. The problem is that the country's HIV response related to the treatment scale-up has been stalled, and the new infection rate among young men and women is alarmingly high. In support of this statement, if focus can be given to the article written by (Fairall et al., 2010), it has been seen that there is robust evidence that proves the shifting task of ART or anti-retroviral therapy from doctor to other health care workers is scarce. This article uses a pragmatic, parallel and cluster-randomized trial process from June 2008 to 2010. This method aimed to assign 31 primary care ART clinics to implement the STRETCH program. Considering the result, it can be seen that the viral load among the control group was slightly higher than the cohort group, and that did not differ much between the groups in patients' baseline CD4 of 200 cells per microliter. This result also shows that the primary responsibility for ART to primary care nurses from doctors on a large scale has not been improved much in the country. Lack of clinical and management support makes the ART less effective than the STRETCH program (Magidson et al., 2021). Therefore, the data or information that was discussed in Assignment A is entirely similar to the article used in Assignment B. both Assignments indicate the fact that despite many implications, task shifting of primary responsibility for ART from general doctors to primary care nurses cannot reduce the onset or prevalence rate of HIV in the country.In other words, based on my observation and analysis, I, as a student, can completely agree with the information that I have gained in previous studies and from this article regarding HIV treatment (Wood et al., 2015). Both the discussions indicate the fact that, though the Government of South Africa has achieved the first 90 targets, it falls short. Despite 5 million people in the country now getting treatment and healthcare support related to HIV/AIDS, that is equivalent to only 70% of the total population. The studies that have been carried out by me in a prior and recent article on HIV treatment in South Africa indicates the same fact, that poor retention in health service is one of the major reason, the people of the country do not get necessary healthcare support and Governmental aids to deal with the onset of HIV/AIDS (Magidson et al., 2019).

2. What are the public health and policy implications of the findings

If the actual findings that the shift of primary responsibilities for ART from doctor to primary nurses can be placed apart, then it can be stated that this article, used in assignment B, can have positive impact public health. This is because this article actually showcases the lack of implementation of intervention policies for the eradication of HIV at a basic level. Additionally, the trail had followed high-standard with an enrolment of valid samples. Additionally, in this article, the final data are linked with the laboratory, hospital data, and actual mortality data made in examination significantly impact the health outcome. Additionally, the data of interpretation accessed from this research article can be used as an indicator of care quality (Safren et al., 2021). During this trial program, an attempt has been made where Free State Health Department took the initiative to improve access to doctors for the people in the country. This, in turn, can strengthen the primary healthcare development of the country and expand easy access to primary support on the onset of HIV. This article can also increase the knowledge and awareness about the ART program and inform people about the visit to a specific clinic to review the problem cases (Fairall et al., 2010). According to the article, it can be seen that in primary analysis of 9252 people, number of death rate in HIV is 997, with the person-years at risk is 74,256. In control group, the number of deaths is 747 with the number of persons at risk per year is 51861. This refers the increased number of shifts in the intervention group. The study was limited by the restriction of follow-up to 18 months and CD4 cell count for viral load after 12 months of ART.The result of the article is, moreover suitable to the data set of AIDS/HIV in other parts of Africa (Maskew et al., 2019).

Additionally, this article can accelerate the implementation and use of the STRETCH program as one of the feasible and effective modes of treatment for HIV/AIDS. With this program, the awareness of accessing ART as the primary treatment process for HIV can be increased among the country's people. The rate of clinical visits to primary nurses and doctors can be enhanced among the population.

3. What is the recommendation for the results of the study?

In this article, the policy approach has not been examined much. The primary aim of this article was to evaluate the result related to the task shifting of antiretroviral treatment from doctors to primary care nurses in South Africa. This article focuses on parallel and cluster randomized trial processes among cohort groups 1 and 2 and the control group by measuring the CD4 level after ART or anti-retroviral therapy. This article shows that due to a lack of awareness and information about the STRETCH program or ART, people in both the cohort and control groups show a similar level of CD4 baseline. Thus the mortality rate among these two groups did not vary much. To better the outcome of this article, the researchers can focus on current Governmental policy patterns for the HIV treatment process. In this article, VMMC or voluntary medical male circumcision and Caprisa or the Programme for Research in South Africa, can be included to demonstrate the current HIV policies applicable in the chosen country and chosen population (black African women) (Safren et al., 2021). In the country, one of the significant challenges to providing ART services is the difficulties in reaching the women population. Though currently, many black women come to the clinic when pregnant. The findings or the data which are being represented in the following article can be used in other articles based on the treatment of HIV/AIDS in another country. This article showcases the Governmental intension as well as lagging in providing necessary treatment to people with 15 to 24 years of age and suffering from HIV, along with the possible treatment policies. Therefore,  itwill be appreciated by me to use the current health policies and other approaches to treating HIV/AIDS in South Africa mentioned in this chosen article for further research if carried out. This interpretation can enhance the quality and validity of the data considerably. More specifically, it can be stated that the information or data regarding  ART or delayed HIV treatment and its impact on the mortality rate or risk factor in society and on population(age group of 15-24 years majorly) can provide in-depth information. In current days, several researches are being carried out based on ART, and HIV/AIDS treatment in South Africa as well as across the globe. The information that has been acquired from the specific article can be used in future research to highlight the treatment policies and significance of early testing and treatment, and follow-up of prevention policies in society when it comes to protecting a specific population group from the onset of HIV.


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