In South Africa HIV infection is decreasing, safe sex increasing

South Africans have made substantial changes to their sexual behaviour and fewer people are living with HIV than was previously estimated, according to results from the biggest household HIV/AIDS study ever undertaken in the country.

The independent study was commissioned by former president Nelson Mandela, and is based on a representative sample of almost 10 000 people, 8840 of whom consented to anonymous HIV saliva tests.

An estimated 4.5 million people — 11.4% of the population over the age of two — are HIV–positive, which is lower than the government's estimate of 4.75 million people, and much lower than UNAIDS estimates based on data from antenatal clinics.

The latest UNAIDS fact sheets do note a decline, however, reporting that ''for pregnant women under 20, [South Africa's] HIV prevalence rates fell to 15% in 2001 (down from 21% in 1998). This, along with the drop in syphilis rates among pregnant women attending antenatal clinics (down to 2.8% in 2001, from 11% four years earlier) suggests that awareness campaigns and prevention programmes are bearing fruit. A major challenge now is to sustain and build on such tentative success''.

The Mandela study also found that since a health department survey was made in 1998, many more people have been practising safer sex.

''We found that the number of women who had no current sexual partner had increased, and condom use had increased significantly,'' said Olive Shisana, principal investigator for the study. ''For example, for women aged 15–49, condom use at last sexual intercourse has more than tripled, from 8% in 1998 to 29% in the present study, and amongst women aged 20–24 it has increased from 14% to 47%.''

Young people (aged 15–24) were most likely to use condoms: among those sexually active, 57% of males and 46% of females had used a condom the last time they had sex. Over 90% of youths and adults also said that they could get a condom if they needed one — mostly through the Department of Health's free condom programme at public clinics and hospitals.

Among 15–24 year–olds only 56% of males and 58% of females had previously had sex, and there were very low levels of partner turnover. Of those who were sexually active, 85% reported that they had had only one partner in the past year. For adults aged 25–49, the rate was 93%.

Nearly half of all males and over a third of females over 15 years of age reported that they had changed their behaviour as a result of HIV/AIDS. Steps taken included staying faithful to one partner, condom use, sexual abstinence and reducing the number of sexual partners. The survey found that African women aged 25–29 who lived in informal settlements were most at risk of HIV infection, but it also clearly showed that everyone could be affected.

The infection rate among whites was unexpectedly high, at 6.2%. This is considerably higher than in countries with predominantly white populations such as the US, Australia and France, where prevalence amongst whites is less than 1%. HIV prevalence amongst Africans was highest (12.9%). This can be explained by historical factors, such as labour migration and relocation. In addition, more African people live in informal settlements, which had the highest HIV prevalence of all household types (21.3%). Coloured (mixed race) prevalence was 6.1% and among Indians 1.6%.

Prevalence among children aged 2–14 years was unexpectedly high at 5.6%. Shisana said more research was needed to determine the causes of this, though sexual abuse and unsafe injections could be among them. Females accounted for 12.8% of those testing HIV–positive, and males 9.5%. Among those aged 15–24, 12% of females and 6% of males tested positive.

At a briefing to release the report, Mr Mandela appealed for prevention efforts to be increased. ''What is important is what we do on the ground to ensure that people understand how HIV is contracted and how to deal with it,'' he said. ''We have to smash the perception that if you enter a house where people have AIDS, you will contract the virus,'' he added.

Kerry Cullinan, Durban

World Health Organization Genebra - Genebra - Switzerland