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HIV Epidemic Analysis In South Africa
  • 4

  • Course Code: PHE7452
  • University: Birmingham City University
  • Country: United Kingdom


This paper critically analyses the threats to public health that HIV poses in South Africa, a nation with one of the highest rates of HIV prevalence in the world. The goal is to comprehend HIV as a complex public health issue that includes its epidemiology, the social and economic elements that fuel its spread, and the efficacy of current therapies.

The paper seeks to provide comprehensive measures to address the epidemic through an analysis of several public health models, legislation, and intervention options. In addition to offering insights on the state of HIV in South Africa at the moment, this analysis will offer future directions for enhancing health outcomes in the face of this serious public health issue.


Public Health Concern

With the greatest HIV epidemic in the world occurring in South Africa, HIV continues to be a serious public health concern. The broad scope of this catastrophe and the pressing need for action define it. South Africa hosts 20% of all HIV-positive individuals worldwide, and the nation also accounts for 20% of newly diagnosed cases of the virus (Bekker et al., 2023).

In some localities in KwaZulu-Natal Province, the incidence rates among adults surpass 15%, indicating that the epidemic is particularly severe there (Achoki et al., 2022). An estimated 7.5 million South Africans were expected to be HIV positive as of 2019, with 72,000 AIDS-related deaths and 200,000 new infections recorded (Abdool Karim and Baxter, 2022).

nations having highest global incidence rates of HIV
 Figure: Nations having the highest global incidence rates of new HIV infections (2022)
(Source: Elflein, 2023)

Adolescent girls and young women (AGYW) are disproportionately affected by this epidemic; in fact, nearly one-third of new infections occur in this group (Gisselquist, 2021). Nearly 60% of women over the age of 15 have HIV, indicating notable gender differences in the virus's transmission (Monod et al., 2023). The focus of the epidemic on people in the reproductive and working age groups, who form the lion's share of the nation's labour force, serves to enhance the epidemic's impact still further.

Many social, economic and health-related factors have brought the country's high HIV prevalence about. It includes poor education, poverty, lack of job opportunity, violence against women and high levels of adolescent pregnancy (Ashley et al., 2022). With the spread of sex work and the shame attached to AIDS, this difficult battle is made even more so.

South Africa has recently made progress against the HIV epidemic in spite of these obstacles. Today, the government funds around 80 % of the HIV response and provides over four million people with lifesaving antiretroviral therapy (ART) (Mojola et al., 2021). However, the rate of new infections is still worrying, particularly among young men and women. For individuals between the ages of 15-24 particularly, the viral suppression ratio is less than 50 % (Bekker et al., 2023).

HIV's future in South Africa looks promising. By 2020, over three quarters (75 %) of people living with HIV had started treatment. Meanwhile the vast majority (92 %) of these knew their status and were virally suppressed (Cardenas et al., 2023). However, there is much more that needs to be done in South Africa's battle against HIV, such as solving the social and economic problems behind the epidemic.

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Public Health Perspective

The WHO's public health approach to HIV, which is much more than a mere provision of care for each individual patient, involves four steps. It involves expanding testing, simplifying and improving regimes of treatment, and strengthening laboratory monitoring (Nyasulu and Pandya, 2020). It means adapting tactics to the particular situation in areas with concentrated HIV epidemics. Also an essential part of this strategy is the smooth integration of HIV testing, treatment and care with prevention measures.

The goals are effective control of the HIV epidemic and universal health coverage. This method, with its great success in impoverished areas, has laid the foundation for treating millions of people in the world. This strategy has been widely used in resource-constrained environments, and was the base upon which treatment expanded to cover over 19.5 million people (Marinda et al., 2020). A global pledge has been made to eliminate AIDS as a threat to- public health by 2030. This is the aim, and there are opportunities to adjust this public health strategy to accommodate the problems that will arise.

Main Causal/Contributory Factors 

Identification of Factors 


A complex network of interwoven social factors is behind the South African HIV epidemic. High rates of HIV infection in some populations-in particular, adolescent girls and young women (AGYW), who are more vulnerable due to both social and biological factors-- is one of the most important of these (Mahlangu et al., 2019).

Some of the social factors are high rates of teenage pregnancy, and interpersonal and gender-based violence, a lack of high-quality education, and the widespread lack of employment and poverty (Orievulu et al., 2022). These therefore represent high-risk conditions for contracting HIV, due to the high prevalence of sexually transmitted Infections (STIs).

Another crucial factor is the pattern of HIV transmission. For instance, a man of 25 to 34, who infects younger women, may be able to infect his male partners for a longer period of time (Ashley et al., 2022). This cycle continues, and it has a major effect on transmission of HIV. Furthermore, because men are less likely to seek care and treatment, lower rates of viral suppression in this cohort can be attributed to cultural gender stereotypes and the belief that receiving healthcare is a sign of weakness.


One of the main causes of the epidemic is economic hardship, which modifies people's behaviour and increases their risk of HIV infection (Gisselquist, 2021). These economic difficulties are a result of the unequal distribution of income in South Africa. In addition, changes in the primary (agricultural, forestry, mining) and secondary (manufacturing, power, gas, water, and construction) sectors of the economy have resulted in increased unemployment (Bulled and Singer, 2020). The youthful and economically active population is particularly affected by this economic volatility. These are the groups most affected by HIV.

Furthermore, the HIV epidemic disproportionately affects residents in townships, which were previously classed as non-white urban areas during apartheid (Bhanye et al., 2023). The prevalence of HIV is higher in these areas—nearly twice as high as it is nationwide. People with lower socioeconomic status (SES) are more susceptible to stressors like food insecurity and poverty, which might raise their risk-taking behaviour when it comes to sexual activity. Over time, this can increase the chance of HIV acquisition.


Higher HIV/AIDS prevalence, particularly among women, is a result of societal norms around marriage that disregard the man's social life and traditional practices like polygamy (Meini and Bordogna, 2019). These social, cultural, and religious customs can foster settings that increase the risk of HIV transmission, especially if one partner has a history of promiscuity.

The stigma associated with HIV/AIDS and societal perceptions of open communication about sexual health also play a role in the epidemic's spread (Keene and Boyd, 2021). The problem is, HIV knowledge and prevention get drowned out by traditional cultural customs and beliefs. So the disease gets no fight against it.

Structural Factors and "Causes of the Causes"

 marmot framework
Figure: The Marmot Framework
(Source: Goldblatt, 2016)

Applying Marmot's method to the problem of how AIDS come into being in South Africa, it turns out that social factors are key. This also reflects the operation of one of the basic assumptions underlying the Marmot Framework, namely that health is a social gradient.

The spread of HIV is out of proportion to the underprivileged. HIV infection is aggravated by many factors including poverty, illiteracy and bad housing (Murwira et al., 2021). These diseases commonly cause greater engagement in risky behaviour, less healthcare access and lack of HIV prevention knowledge.

Also, the focus within the framework that health disparities are avoidable also coincides with what is required in a comprehensive approach to HIV prevention taking economic and social factors into account. Through laws and programs to offer housing, job opportunities and educational opportunities, the threat of HIV can be reduced by a considerable margin (Mojola et al., 2021). Local governments also have an important role here. They can come up with a solution to this particular community's problem.

The concept in the Marmot Framework that everyone has the right to a healthy quality of life is especially relevant with respect to fighting the AIDS epidemic in South Africa.

Tackling the underlying social and economic factors-social isolation and income inequality, one can create a climate where people are less susceptible to HIV in the long run (Monod et al., 2023). Under this strategy, the war against HIV needs to transform from one where prevention has been battled by purely medical means into an overall policy of strengthening society.

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Policy Support

South Africa's HIV/AIDS policy has undergone a number of significant changes and breakthroughs (Schmidt, 2020). There first was an interval of policy uncertainty and denial, especially under President Thabo Mbeki's presidency. For recognizing the link between HIV and AIDS too late, the Mbeki administration was denounced. As a result, the adoption of effective steps to combat the pandemic was delayed.

But when the National AIDS Council (SANAC) was set up in January 2000, it sought to enhance political leadership in the battle against HIV/AIDS and to encourage civil society to get involved. And there were noticeable improvements (Whiting, 2021).

The National Integrated Plan for Children Affected by HIV and AIDS and the HIV/AIDS/STD National Strategic Plan for South Africa 2000-2005 were two of the major initiatives introduced under SANAC (Henderson, 2022). These initiatives aimed to lessen the burden of HIV/AIDS on people and communities while also lowering the number of new infections, especially in young people. Comprehensive strategies for the widespread distribution of antiretroviral medications (ARVs) were noticeably lacking at first, despite these efforts.

When the South African government upheld a law allowing the country to produce less expensive, generic medications, including ARVs, in 2001, it marked a significant turning point (Molusi, 2023). This was followed in 2002 by an official affirmation of the policy that HIV causes AIDS and a court judgement requiring the government to administer the prenatal medication Nepravine to pregnant women who tested positive for HIV (Schmidt, 2020). The widespread availability of Nepravine and ARVs persisted to be restricted in spite of these developments.

Civil society movements, like the Treatment Action Campaign, increased their pressure on the government when it failed to appropriately handle the pandemic. As a result, a plan for universal ARV therapy was approved in August 2003, and the programme was set to start in March 2004 (Ashley et al., 2022). The goal of having a minimum of one service location for AIDS-related care and treatment in each of the 53 districts of the nation was accomplished by March 2005 (Bekker et al., 2023).

In recent times, South Africa has emerged as one of the countries with the most advanced legislation on HIV. In the 2020 Global HIV Policy Report, South Africa was mentioned many times for its numerous important policy initiatives for HIV treatment and prevention (Eike et al., 2022). As of 2019, 70 percent of HIV-positive people were receiving antiretroviral therapy in South Africa (Bhanye et al., 2023). This was a great improvement over 2014, reflecting the huge impact of these policy changes.

 Death due to hiv in SA
Figure: Number of Deaths in South Africa from HIV/AIDS (2002-2022)
(Source: Statista, 2023)

Thus, South Africa's current policy climate on HIV/AIDS adopted a comprehensive, twin-track approach to treatment and prevention. It symbolizes a departure from the denialism of years past in favour of an active, evidence-based approach that makes use of global recommendations and coincides with international objectives for fighting against HIV infection. Today, though, there are still problems-notably the problem of providing treatment for everyone, and the social and economic roots of this epidemic.

Public Health Interventions

In South Africa the strategy used to stop the spread of HIV has involved a combination of community action, client-based programs, changes in policies and cultural change along with behavioural change. to confront these various aspects of the HIV epidemic, from treatment and prevention through stigma and social attitudes.

Policy and Societal Change: Other intervention methods include changing policy and transforming society, which goes together with the formulation of the National Strategy Plan (2023- 28) for HIV, TB and STIs.

This policy change aims to reduce the incidence of new HIV infections, and enhance the lives of those already infected (Bhekisisa, 2023). Measures include upgrading medical facilities and extending ART to everyone. South Africa's government has passed laws to combat the discrimination against those with HIV/AIDS.

 NSP Framework
Figure: NSP Framework
(Source: Bhekisisa, 2023)

Client-Centered Interventions: Client-orientated interventions include, for example, antiretroviral medicine (ART). A recent study by Obeagu & Obeagu (2023) points to steadily increasing popularity. Similarly, the Prevention of Mother-to Child Spread (PMTCT) project works to reduce the spread infectious diseases. It begins during pregnancy and runs right through the third postpartum year to nursing cessation.
impact of antiretroviral therapy
Figure: Impact of Antiretroviral therapy (ART)
(Source: Schnoll et al., 2021)

Community Action: Examples of community action intervention include South Africa's She Conquers campaign under the auspices of Government and PEPFAR DREAMS initiative (Achoki et al., 2022). The projects focus on adolescent girls and young women access to information, materials and supplies to minimize their chances of contracting HIV. Financial assistance is combined with empowerment activities and sexual health education in these programmes.

Behavior Change: A strategy of behavioural modification is the pillar underpinning South Africa's HIV treatment policy. For instance, programs like Stepping Stones are designed to increase youth awareness of sexual health and minimize risky sexual behavior (Bhanye et al., 2023). Also like other programmes of this type, items such as the promotion of condom use in advertising, instruction on safe sex practices and a reduced consumption of stimulant drugs are always invariably involved.
South Africa's HIV response can be analyzed by examining different interventions through public health model lenses. 

Health Conceptualization: Bio-medically oriented interventions that are largely aimed at treatment and prevention of transmission of diseases. Examples include the administration of antiretroviral medication (ART) and Prevention of Mother-to-Child Transmission (PMTCT) (Kameni et al., 2022). In contrast, such programmes as DREAMS and She Conquer focus not just on biomedical aspects but also on social determinants of health such as education, gender equality and economic empowerment.
 socio ecological model
Figure: Socio-ecological model
(Source: Garney et al., 2021)

Societal Change:
In this case, the socio-ecological model—which emphasises the impact of interpersonal, social, community, and individual influences on health behaviors—can be used (Garney et al., 2021). Adolescent girls and young women are the target of interventions like DREAMS and She Conquers, which challenge gender conventions and empower women in an effort to affect broader societal change. Conversely, scientific therapies such as antiretroviral therapy (ART) essentially aim to enhance the current health order, without necessarily changing larger socioeconomic processes.

Expert-Led vs. Participatory Approaches: Based on professional health service delivery, Beattie's model indicates that interventions such as ART are more expert-led (Jonas et al., 2023). Programmes like Stepping Stones, on the other hand, include the community and adhere to a more bottom-up, participatory approach. But certain community-based solutions may not give communities the full power they deserve, particularly if they are more directive than cooperative.

In essence, HIV interventions in South Africa basically differ in how they conceptualise health, how much of an emphasis they place on social change, and how much emphasis they place on expert-led versus participatory techniques. The long-term success of HIV control may also depend on how successfully biological interventions address broader societal challenges and meaningfully engage communities, even as biomedical interventions are essential for immediate health gains.


 nuffield ladder
Figure: The Nuffield ladder
(Source: Stillman, 2023)

The Nuffield ladder offers an ethical framework for assessing the trade-off between individual rights and public health objectives when it comes to the numerous HIV interventions implemented in South Africa (Stillman, 2023). The ladder's rungs, which go from least to most invasive treatments, make it easier to evaluate how each strategy will affect morality.

•    Information and Education (Least Intrusive): Public awareness campaigns and educational initiatives for HIV prevention and transmission are examples of interventions that are located at the bottom of the ladder (Cardenas et al., 2023). And because they respect human autonomy and provide information for better health decisions, these are quite clearly morally permissible. However, if people lack the means or the social support to take action on this information, they are less successful.

•    Guiding Choices through Incentives: Farther up the ladder are interventions like DREAMS, which provides young women with financial and educational support (Nyasulu and Pandya, 2020). They create conditions that encourage people to make healthier choices, such as rewarding frequent health examinations or safe sexual practices. That in turn influences people's behavior. These approaches retain individual autonomy but are more aggressive ethically.

•    Guiding Choices through Disincentives: At the top of the ladder, interventions include laws against unprotected sex aimed at discouraging dangerous conduct (Whiting, 2021). However, even while always respecting personal choice, these methods gradually intrude upon autonomy in the service of public health.

•    Restricting Choices (More Intrusive): Requiring testing in some high-risk groups or disclosing HIV status to potential partners is more intrusive and directly restricts personal freedoms (Achoki et al., 2022). When there is a serious risk of harm to others, these actions can be morally permissible, but people's rights and privacy must be carefully taken into account.

•    Eliminating Choices (Most Intrusive): At the top of the scale would be treatments that completely take away a person's ability to make decisions, including mandatory treatment or, in severe circumstances, isolating HIV-positive individuals (Keene and Boyd, 2021). These extremely invasive and morally dubious tactics are only acceptable in dire situations involving public health, when there is no other way to stop widespread harm.

The majority of HIV interventions in South Africa seek to strike a compromise between the need to manage the HIV epidemic and individual liberties, as revealed by an ethical framework analysis of these initiatives using the Nuffield ladder.

Main goals of interventions are to encourage, direct and reward healthy lifestyle choices while respecting rights and autonomy. There are various criteria for the ethics of any intervention, such as the degree of intrusion, whether it is in the interest of public health, and the extent to which privacy and individual rights are respected.


South Africa's response to the AIDS epidemic has taken a comprehensive, multifaceted and ethical response. However, relying mostly on denial has been a huge step backwards from the adoption of evidence-based policy frameworks such as the National Strategic Plan for HIV, TB and STIs.

Many public health interventions have been put in place, including medical strategies like antiretroviral therapy (ART) and PMTCT, as well as larger campaigns such as DREAMS and She Conquers. They focus on populations such as adolescent girls and young women and address both the social causes of HIV, and its physical features.

From an ethical point of view, these interventions aim to improve public health while generally respecting individual autonomy. Check them out from the Nuffield ladder. In a few places, the answer might be improved.

It is clear that specific efforts are needed to increase male engagement in HIV testing and treatment, as males and out-of-school youth continue to participate with existing programmes at a lower rate. Initiatives for societal change might also be strengthened to address more serious problems like HIV stigma and gender inequality.

Essentially, even though South Africa's response to the HIV epidemic is in line with the main contributing factors, ongoing modification and advancement are crucial. This entails improving approaches for groups that are now underrepresented in HIV interventions as well as stepping up initiatives to change cultural norms and attitudes about gender roles, HIV, and stigma.

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