National HIV and Syphilis Sero-Prevalence Survey 
of women attending Public Antenatal Clinics in South Africa
2000

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TABLE OF CONTENTS

PREAMBLE

This report is the 11th annual report of the status of HIV prevalence in South Africa. The first antenatal survey was conducted in 1990 when for the first time South Africa was able to provide an estimate of HIV infection. That first survey further provided a baseline from which HIV trends have been assessed on an annual basis.

As a global initiative spearheaded by WHO and later UNAIDS, antenatal surveys are the recommended surveillance tool to estimate HIV in populations. Whilst this tool as all tools has a few inherent limitations, the international consensus remains that they are still the most useful tool to assess HIV prevalence in areas of high HIV endemicity. South Africa is internationally recognised to have one of the most reliable surveys conducted by middle income and low-income countries. The South African Survey utilises a scientifically selected (large) sample of sentinel sites which are representative of the entire country, as opposed to nominating a few conveniently selected sentinel sites.

In 1995 we took a decision to revisit the methodology of the antenatal survey to further improve on the tool, which assists us to map the trends in HIV prevalence. We recognised two broad areas to strengthen for which we developed a two-phased implementation approach.

The first was the need for strengthening the general methodology in respect of sampling, quality control, particularly of laboratory procedures and a number of field procedures. In collaboration with partners at the Medical Research Council and Academic institutions we began to phase in these modifications between 1997 and 2000.

The second area involves investigations into HIV rates amongst private sector clinic attendees as a mean of better understanding HIV prevalence rates amongst women from population groups other than African women and to confirm whether our suspicion that overall HIV rates will not be markedly different when women for all population groups who can afford private care are investigated. In addition to these activities we are strengthening our ability to model and estimate HIV in men, non-pregnant women and infants facilities.

The antenatal survey is only one tool to assess aspects of the epidemiology of HIV in a country. Second generation surveillance activities introduced end of 2000 to 2001 will include extensive behavioural surveillance activities which will assist in understanding changing trends in HIV associated behaviour and which will be critical to assessing the impact of our behavioural intervention strategies. Numerous comprehensive studies including assessments of the impact of HIV on national demographic on human resources and on the social and economic sectors are already being conducted

Studies that will be able to detect HIV incidence trends are already being tested using state of the art technology, in collaboration with the CDC, Atlanta. These studies will provide much needed information on new and recent HIV infections occurring in our communities. Other arms of the expanded surveillance system will include prompt syndromic treatment and management of STIs at health provision points.

We are encouraged to see that the trend observed between 1990 and 1998 – an exponential rise, has begun to slow down between 1998 and 2000. As the antenatal survey is a proxy indicator for the development of the HIV epidemic in the general population, the findings for HIV and syphilis in the last three years suggest a slower progression of the pace of epidemic.

Finally, intervention programmes must be strengthened. The multi-sectoral approach with an emphasis on local level activity is critical. We thank our partners most sincerely and encourage a continuation of our collaboration to meet the challenge.

Dr M E Tshabalala-Msimang
Minister of Health

ACKNOWLEDGMENTS

Many individuals have participated in the conduction and completion of the 2000 HIV and Syphilis Survey among women attending public antenatal clinics in South Africa with great commitment and dedication.

I would therefore like to thank the Provincial Heads of Departments for the support given throughout the execution of this annual survey. Many thanks to the provincial co-ordinators M Kutu (EC), L van der Bank (FS), S Moss (GP), B Singh & V Magaqa (KZN), B Harris (MP), R Rabie (NC), F Monama & M Naicker (NW), P Moetlo (NP), N Shaikh (WC), as well as staff in participating clinics.

Thanks to all the testing laboratories, the Virology Departments of the Cape Town and Natal Universities, the Microbiology Department of the Medical University of Southern Africa (MEDUNSA), the National Institute for Virology (NIV) and the South African Institute for Medical Research (SAIMR) who have worked hard to ensure good quality data. We acknowledge the contribution of the Statistician-General and staff of Statistics South Africa in the finalisation of this document.

Sincere thanks to Dr Jonathan Levin, Medical Research Council (MRC) statistician, for assisting with the analysis and verification of the survey findings.

Special thanks go to antenatal clinics attendees who participated in the survey without whom the survey would not have been possible.

Finally, I would like to acknowledge the unit that is responsible for the co-ordination of the survey. Dr Lindiwe Makubalo, Cluster Manager: Health Information, Evaluation and Research and Dr Rose Mulumba, Deputy Director: Health Systems Research, Research Co-ordination & Epidemiology, notably Ntomboxolo Bikitsha for compiling this report, Lusanda Mahlasela, Caron Johnson, Kentse Mogodiri and Leonard Mudzanani, and everyone who played a role in the co-ordination of this study and compilation of this report.

Dr Ayanda Ntsaluba
Director-General: Health

1. INTRODUCTION

The purpose of the study is to monitor HIV and syphilis prevalence trends among public antenatal clinic attendees. The findings are used to inform intervention programmes, guide policy formulation and as an advocacy tool for raising public awareness. These annual surveys have over the years established themselves as the cornerstone of HIV and syphilis surveillance in South Africa. Plans and pilot projects are currently underway to build, based on the principles of second generation surveillance, an expanded national surveillance system for sexually transmitted diseases (STDs)/HIV and AIDS. The methodology and principles on which the survey is based are well established and internationally accepted. South Africa has one of the fastest growing epidemics compared to other SADC countries (DOH, 2000).

In the absence of testing for HIV in the South African population, different methods are used to estimate the national HIV prevalence for the whole population. The antenatal survey of pregnant women is one of the tools used to achieve this. While a particular survey could be sound (if proper sampling procedures are followed), there are problems in generalising the results from a special group to the whole population. Even if adjustments are made to account for the lack of representativity of the samples, these results must, nevertheless be used with caution.
 

2. OBJECTIVES OF THE SURVEY

The specific objectives of the 2000 survey were to determine, in women attending antenatal clinics of the public health services, at the end of 2000 estimates of:

• The national point prevalence of HIV and syphilis in South Africa,
• To describe HIV and syphilis prevalence in terms of time, geography (province) and age,
• To map the prevalence trends of HIV from 1990 to 2000 and from 1998 to 2000 for syphilis
• To use the data to estimate projections of HIV infection in the general population.
   

3. SURVEY METHODOLOGY

3.1 Study design

An anonymous, unlinked, cross-sectional survey was conducted among pregnant women attending antenatal clinics of the public health sector in South Africa. First time antenatal clinic attendees (during the current pregnancy) were eligible for inclusion in the study. The survey ran concurrently across the nine provinces, during the month of October 2000. The month of October has been adopted based on experience from the October Household Surveys (OHS) that are undertaken by Statistics South Africa (SSA) annually. During this period, the population tends to be more stable in terms of mobility (SSA:OHS, 1997).

A standard national protocol was developed in collaboration with the Medical Research Council (MRC) and other partners and has been phased-in over a three-year period. It has strengthened the study methodology, in particular sampling and quality control. All nine provinces follow the protocol closely. Implementation of this protocol has been monitored closely and gradual phasing-in was adopted so as to ensure that expected prevalence trends are not disrupted.

3.2 Study administration

The National Department of Health (co-ordinating office) hosted a planning workshop before commencing the study. At this workshop sample sizes were determined and the roles and responsibilities of provincial co-ordinators and others involved in the study were agreed and clarified.

Provincial co-ordinators were responsible for overseeing the smooth running of the survey in each province, ensuring that the proper sampling method was applied and that the sites were prepared.

Their co-ordinating role also entailed making arrangements for the fieldwork materials (5 ml vacutainers with SST gel and clot activator, paired bar-code labels, and data capture sheets) to be delivered on time.

Finally each provincial coordinator was responsible for overseeing the data entry process, as participating laboratories generated test results.

A preparatory workshop was also held for laboratory co-ordinators to ensure adherence to standard operating procedures (SOPs) for testing as well as quality assurance for both HIV and syphilis. The laboratory co-ordinators ensured the effective running of the Enzyme Linked Immunosorbent Assay (ELISA) used for HIV testing and Rapid Plasma Reagin (RPR) tests for syphilis. Using the bar-code label on each data-capture sheet, the results for each test were filled-in and the data capture sheet sent back to the provincial co-ordinator for data entry.

The laboratory co-ordinators were also responsible for the proper storage and shipment of all HIV positive sera to the University of Natal-Durban (UND) Virology laboratory for pilot HIV incidence testing.

The national co-ordinating office was responsible for the overall co-ordination of the survey, the procedural audit of the survey, processing of survey data and preparation of this report.

3.3 Field Logistics

Field logistics for the study were elaborate as large distances were covered between the 400 participating clinics. Not all clinics were easily accessible but their inclusion was however critical for achieving a representative sample of women. Other logistical arrangements included transporting blood specimens from clinics where they were collected to laboratories for testing.

The SAIMR network of courier services was employed for this purpose, except in deep rural areas where private contractors were brought in. Some logistic problems experienced during the fieldwork were sorted out during the procedural audit.

3.4 Sentinel population

The sentinel population for the study comprised pregnant women. The choice of pregnant women is based on international scientific practice.

Pregnant women are normally preferred as they are sexually active, constitute an easily identifiable, accessible and stable population, and are more likely than other groups to be representative of the general population. In addition, this group obtains health care at facilities where blood is drawn as part of routine medical services offered for women’s health.

As only public sector health facilities are sampled, there is an inherent under-representation of race groups other than African women. A total of 16 607 women (blood specimens) were included from the 400 sites in 2000.

3.5 Sampling methodology

The sampling method used was a systematic cluster random sample in which weighting is conducted using the probability proportional to size (PPS) technique. Each selected clinic/site is the primary sampling unit (PSU). This means that at each clinic, all first time antenatal clinic attendees have the same chance of being selected for the study. The PPS method was used in all nine provinces in the year 2000.

3.6 Inclusion criteria/procedures

In South Africa 80% of all pregnant women, of whom 85.2% are African, attend public sector antenatal clinics (SADHS, 1998).

This means that the sample of women participating in the HIV/Syphilis survey is predominantly African and somewhat under-represents women from other race groups. However, it should be noted that private sector users overall, represent only 20% of all users.

In the public health sector, when women present at the antenatal clinic, blood specimens are routinely taken to test and, if necessary to treat the women for syphilis. At all public facilities providing antenatal care (as part of the routine health education and promotion procedures), there is a slot on syphilis and other sexually transmitted infections (STIs) and why it is important to draw blood to test for syphilis. It is rare for pregnant women to decline syphilis testing. Five millilitres of blood are drawn into a tube, which is labelled with the woman’s name, age and the facility. When the test results are brought back, women are informed of their syphilis status and if they are positive they are treated.

In October each year, the opportunity to take blood at the same time as when it is taken for routine syphilis testing (a second vacutainer which is labelled with a bar-code only) is used for survey data collection. However, in accordance with ethical principles and guidelines for research, in each sentinel site (participating clinic), women are informed of the survey and requested to participate. This opportunity is further utilised to inform the women that the survey is unlinked, anonymous and confidential. Those women who choose to participate in the survey but at the same time would like to know their HIV status, are encouraged to visit the voluntary counselling and testing (VCT) facilities.

For this survey women attending each of the participating clinics for the first time in the current pregnancy were eligible for inclusion in the study. This survey is anonymous as no personal identifiers (names, ID number, address, etc) are used on the blood sample of the participant. Instead bar-coded numbers are used to ensure anonymity of the participants, to facilitate laboratory procedures and minimise the chances of errors during the handling of the blood specimens.

3.7 Sampling sites

The 1997 standardised national survey protocol proposes that specific sites be chosen from each region and that the same sites are used in future studies. This approach is more compatible with the principles of sentinel surveillance and has been used successfully in KwaZulu-Natal for the past nine (9) years.

In 2000, a total of 400 sites (clinics) participated in the survey. All sites were asked to consider for inclusion in the sample the first forty antenatal attendees (during the current pregnancy) in the period 1^st to 31^st October 2000.

3.8 Laboratory testing

In accordance with the recommendations of the World Health Organisation (WHO) on HIV screening for surveillance purposes, blood specimens were tested with one ELISA (Abbot Axysm System for HIV-1/HIV-2) in all provinces except the Western Cape. Serum that was reactive on this test was considered HIV antibody positive. Due to the low HIV prevalence rate in the Western Cape province (less than 10%), two ELISA tests were used. Any serum found reactive on the first assay was retested with the second ELISA test, which was based on a different antigen preparation or a different test principle.

Serum that was non-reactive on the first test was considered HIV antibody negative and was not retested. The specimens were also screened for active syphilis using the RPR test. All positive sera were stored for the pilot HIV incidence testing.

3.9 Quality assurance

The National Institute of Virology (NIV) was responsible for the quality control of the HIV prevalence testing.

A panel of twenty specimens was sent by the NIV to each of the seven laboratories participating in the sero-prevalence survey, namely the South African Institute for Medical Research (SAIMR) central laboratory in Johannesburg, the SAIMR provincial laboratories in Bloemfontein, Kimberley, Port Elizabeth, Cape-Town and the virology laboratories of the University of Natal-Durban (UND) and Medical University of Southern Africa (MEDUNSA). All participating laboratories were asked to test each of the twenty specimens in the NIV panel for HIV antibodies.

In 2000 MEDUNSA was tasked with the responsibility for the external quality control for syphilis in all laboratories. A panel of twenty specimens was sent by MEDUNSA to all testing laboratories responsible for the sero-prevalence survey. In cases where discordant results were found, the laboratory had to retest the specimens.

3.10 Data processing and analysis

Data analysis was done using the EPI INFO 6 and STATA software packages. These packages are preferred because they have the option of assuming a clustered random sampling design in their analysis instead of simple random sampling. Developed jointly by the World Health Organisation (WHO) and the Centers for Disease Control and Prevention (CDC), EPI INFO 6 is also freely available and already used extensively in most provinces by surveillance officers. Copies of an EPI INFO 6 programme modified for the purpose of the survey were made available to each of the provincial survey co-ordinators for data entry during the planning workshop in August 2000.

The sampling of clinics within provinces was done using Probability Proportional to Size (PPS), with the measure of size being the number of first antenatal visits in October from the previous year. This method ensures a self-weighting random sample within each province i.e. each first time antenatal clinic attendee in the province has the same probability of being sampled.

The sample sizes vary from province to province with a range of 800-3 500 blood specimens, per annual survey, with provinces with larger populations of women in their reproductive age e.g. KwaZulu-Natal, Gauteng having larger samples than small provinces e.g. Northern Cape. In 2000, a total of 16 607 specimens were collected nationwide from 400 participating clinics. Out of the 16 607 blood specimens, 2 900 samples were from teenagers (<20 age group). Further details on sample size and completeness are provided for the past four years in Appendix 1.

Out of the 61 094 women who participated in these surveys over the past four years 1997-2000 syphilis serological results were reported for 60 849 and HIV antibody results were reported for 60 922 (Appendix 1). For 0.4% and 0.3% of the participants no results were available for syphilis and HIV respectively. No significant pattern is observable for reporting completeness for both HIV and syphilis over the four-year period; there are very small proportions of women with missing test results for both HIV and syphilis.
 

4. SURVEY RESULTS

4.1 HIV prevalence

4.1.1 National HIV prevalence

Based on the 16 548 blood samples tested in October 2000, it is estimated that nationally, 24.5% of the women who presented at the public health facilities (for the first time during that current pregnancy) were infected with HIV by the end of year (see Figure 1).

This is compared to 22.4% in 1999 and 22.8% in 1998. No exponential increase in HIV prevalence has been noted in South Africa since 1998. The estimated doubling time of what was then considered to be one the fastest growing epidemic was estimated to be around 18-24 months.

Figure 1 National HIV prevalence trends among antenatal clinic attendees in South Africa: 1990-2000

4.1.2 Provincial HIV prevalence estimates

Point prevalence rates for HIV infection in the nine provinces for the year 2000 were estimated as follows: KwaZulu-Natal (KZN) 36.2%, Mpumalanga (MP) 29.7%, Gauteng (GP) 29.4%, Free State (FS) 27.9%, North West (NW) 22.9%, Eastern Cape (EC) 20.2%, Northern Province (NP) 13.2%, Northern Cape (NC) 11.2% and Western Cape (WC) 8.7% (see Table 1 and Figure 2).

Table 1: Provincial HIV prevalence: Antenatal clinic attendees, South Africa 1998-2000

All the provincial increases were not significant except in Gauteng and Kwa-Zulu Natal that showed significant increases for 2000.

Figure 2. HIV prevalence by province among antenatal clinic attendees in South Africa in 2000

Meanwhile all provinces have been advised to work towards stabilisation at the lowest possible level of HIV prevalence, as this would minimise the impact of the epidemic in terms of mortality and morbidity as well as the broader impact at the social and economic level.

4.1.3 HIV point prevalence estimates by age group

Between 1999 and 2000, HIV point prevalence increased significantly among women in their twenties only. Pregnant women in their late twenties show the highest infection rate at 30.6% whereas survey participants aged 20-24 yielded a point prevalence of 29.1%. It is important to note that over the years, women in their twenties have consistently shown the highest levels of HIV infection, making up on average, not less than half of the adult HIV positive population. It goes without say that the implications of such a distribution at social and economic levels are matters for concern. What is more this also significantly impacts on maternal care and child survival.

As observed previously, HIV infection is clearly present in older women with rates of 10.2% and 13.1% found in the 40-44 and 45-49 age groups respectively. Due to small sample sizes estimates in these age category these data should be interpreted with caution (see Table 2 and Figure 3).

Table 2: HIV prevalence trends by province among antenatal clinic attendees in SA 1998-2000

*Note the wide Confidence Intervals (CI) is a result of the smaller numbers of women who participated in the study

It is encouraging to see that HIV prevalence among teenagers has not increased for the third consecutive year. This is consistent with findings from the Demographic and Health Survey that showed condom use to be higher among female teenagers than in all other age groups (SADHS, 1998). However, the increase in HIV prevalence in older women (particularly those in their twenties) might be an indication that infection is simply delayed and not avoided. The SADHS also noted that although the use of condoms was highest among adolescents (almost 20 percent), this figure needed to be increased.

Figure 3: HIV prevalence by age group among ANC attendees in South Africa in 2000

4.1.4 Extrapolation of HIV infection to the general population

The antenatal survey gives estimates of HIV prevalence among pregnant women in South Africa. No direct information is currently available on infection rates among non-pregnant women, men, newborn babies and children. In order to obtain an estimate on the approximate numbers of South Africans infected with HIV at the end of 2000, projections are therefore made to extrapolate the total number of people who would have been infected by the end of the year. The estimates of infection among the general population need to be interpreted with caution, as there are inherent limitations in the methodology used (see Appendix 2). Projections of the estimated number of infected people infected with HIV in South Africa at the end of 2000 are as follows:- Women aged 15-49 years (2.5 million); men aged 15-49 years (2.2 million) and babies (106109). This results in a total of 4.7 million South Africans being infected with HIV at the end of 2000. These estimates suggest that approximately 1-in-9 South Africans are infected with HIV.

4.2 Syphilis prevalence

4.2.1 National syphilis prevalence

Based on the 16 575 blood samples tested in 2000, it is estimated that nationally, 4.9% were infected with syphilis by the end of year (see Figure 4).

This prevalence rate is more than half of what the national figure was in 1997. However, as shown by the provincial breakdown, surveillance of other sexually transmitted diseases needs to be implemented nationwide to yield better predictors of behavioural change. Infact the syphilis prevalence rate might be a better indicator of access to primary health care and quality of care than behaviour, as it is routine to treat all women whose results show an active syphilis infection.

Figure 4: Syphilis prevalence trend among antenatal clinic attendees in South Africa, 1997-2000

4.2.2 Provincial Syphilis point prevalence estimates

Syphilis prevalence rates in the different provinces reflect a different trend from HIV infection. While all provinces have fairly low rates (below 10%) compared to HIV, there are definite inter-provincial differences. The low rates may reflect intensive programmes that are in place for screening and treating syphilis. A significant decrease was observed in all provinces except GP, NC, FS and MP between 1999 and 2000. GP was the only province to experience a significant rise between 1999 and 2000.

Provincial prevalence trends across the nine provinces show less consistency than age group estimates. Infection levels reflect differing geographical variations across the nine provinces as compared to HIV infection rate estimates.

4.2.3 Syphilis point prevalence by age group

A steady, striking and significant decline in prevalence rates among pregnant women in all age groups is observed at national level (Table 3 & Figure 5).

Table 3: Syphilis prevalence by age group among antenatal clinic attendees in South Africa, 1998-2000

Figure 5: Syphilis prevalence trends by age group among antenatal clinic attendees in South Africa 1998-2000

5. DISCUSSION

Different epidemiological patterns are observed in HIV and syphilis trends in South Africa. National prevalence rates for syphilis infection have significantly decreased over time while HIV prevalence shows no significant increase between 1998 and 1999, and only a slight increase for 2000. Based on the past trend in prevalence, it is possible to obtain fairly good estimates for a few years in the near future (see Table 4). As such, an estimate of 24.5% in 2000, given an estimate of 22,4% in 1999 is plausible. On a year-to-year comparison, this means a 9,3% increase. It is estimated that 4,8 million persons were infected with HIV by the end of 2000. This estimated figure compares with Statistics South Africa’s estimate of 4,5 million as these figures lie within the same confidence intervals.

5.1 HIV TRENDS

The HIV point prevalence rate is estimated at 24.5% for women who presented (for the first time during the current pregnancy) in public antenatal clinics during the month of October 2000. The HIV infection rate estimates for the years 1990 to 1998 showed a steady increase.

Between 1999 and 2000, HIV infection increased only among women in their twenties. The findings around patterns of distribution of HIV by age call for prevention efforts to be sustained beyond the youth category, which has constituted most of the target population of such efforts so far. Infection levels among the teenagers have ceased to increase since 1998 (see Table 2). This is encouraging since teenage girls are particularly vulnerable to HIV infection and may contract the virus from older men.

Findings from the largest ever national survey conducted among teenagers, indicate that 70% are concerned about the risk of contracting HIV and AIDS.

While 75% of sexually inexperienced teenage girls report that they would use a condom or would insist on their partner using a condom, a smaller percentage (55% of both girls and boys) of those who are sexually experienced (anything more than kissing or touching) say they always use a condom when they have sex.

This figure is significantly higher than that reported in the SADHS, where the rate of condom use at last sex ranged from 19% with a marital partner to 21% with an unmarried partner. In addition, 82% of sexually experienced teenagers, reported having only one partner. This may suggest that most of the girls who fell pregnant in 2000 had one partner and were thus not particularly at risk of contracting HIV. The decline in syphilis prevalence may support this argument of mutual fidelity among teenagers.

The levels of HIV prevalence in South Africa continue to reflect large geographical variations between the provinces (see Figure 2), with Kwa-Zulu Natal consistently reflecting the highest HIV prevalence rate. The Western Cape prevalence rate continues to remain below ten percent, with however a figure close to the upper limit of its confidence interval. Past trends in this province have consisted in sharp increases in HIV infection levels. HIV prevalence increased in all provinces except Free State and North West, however, all the changes were statistically insignificant (i.e. the rates fell within the same confidence intervals for the two years) except for the increase experienced in Gauteng and Kwa-Zulu Natal.

5.2 SYPHILIS TRENDS

Syphilis prevalence rates in the different provinces, by age reflect a different trend from HIV infection. A steady, striking and significant decline in prevalence rates among pregnant women in all age groups was recorded at national level (see Table 3) for the past three years. At national level, the syphilis infection rate is estimated to be 4.9% in 2000 compared to 6.5% in 1999 and 10.8% in 1998.

However, provincial syphilis prevalence trends across the nine provinces (see Table 3) showed less consistency than the age group estimates. Infection levels reflected differing geographical variations across the nine provinces as compared to the age group estimates. A significant prevalence decrease was observed in all provinces except FS, GP, NC and WC in year 2000.

The decline in syphilis can be attributed to a number of reasons such as:

• Improved case management of syphilis through the routine screening programme of the ANC attendees of public health facilities;
• Increasing awareness through health promotion and prevention activities;
• media campaigns and other educational programmes;
• Increasing mortality due to concomitant HIV and syphilis infections;
• Happenstance treatment with antibiotics for other conditions.

5.3 IMPLICATIONS OF THE SURVEY FINDINGS

5.3.1 GENERALLY

The noted trend towards a more mature the epidemic does not take away the need for a concerted effort to continue in order to preserve the gains made. Prevention efforts need therefore to be sustained over time. All provinces should work to reach the stabilization phase at the lowest possible level in order to minimise impact on mortality, morbidity as well as at the social and economic level.

5.3.2 AT POLICY LEVEL

The survey findings suggest a positive impact of the PHC policy (universal access to care) on the health of our pregnant women. This gains achieved in the area of detection and treatment of syphilis should be preserved. The success of this intervention not only deals with improved access but also better quality of the care offered (effective treatment of STDs).

Such positive experiences need to be preserved and expanded to non-maternal care and more importantly to the private sector.

It has been established that the treatment of STDs in the public sector is more effectively performed than in the private sector where the driving principle remains profit.

Success in the management of other STDs will depend significantly on district, local structures and communities’ ability to translate good policy formulation into effective implementation of programmes at ground level.

5.3.3 AT PROGRAMME LEVEL

There is a clear need to preserve the gains made among teenagers through Information, Education and Communication of awareness messages.

Also important is the need to sustain the positive behaviour change in that age category, through adulthood, particularly among those in their 20s. Targeted campaigns and adapted material for adults assumed or perceived to be at a lesser risk should be conceived as a matter of urgency, as women in their twenties comprise nearly 60% of those infected with HIV.

The survey findings have also highlighted the fact that while we might be seeing a stabilization of the epidemic, the burden of those who are already infected with HIV remains.

While efforts towards sustaining gains made in terms of prevention need to continue, appropriate care and support will continue to remain one of the priorities of service provision and resource allocation. This will be achieved through the implementation of strong programmes (for Maternal, Child and Women Health, TB, Communicable Disease Control and others) in order to deal with the impact we are seeing in increased child, maternal and adult mortality.
 

6. CONCLUSION

HIV surveillance was initiated in 1990, with the introduction of annual surveys among antenatal clinics of the public health sector. These surveys have over the years established themselves as the cornerstone of HIV surveillance in South Africa. Findings from the 11^th in this series of survey have highlighted the fact that although the epidemic has ceased to grow in an exponential manner, 4.8 millions of South Africans are infected with HIV, most of them being at the prime of their age.

With the change in trends of HIV in the past three years, a change in the trend among teenagers has also been noted. This latter finding is supported by other studies suggestive of more positive behaviour among adolescents, than among any other age categories. The awareness campaign efforts, in this particular category seem to be bearing fruits.

Of concern however is the fact that such behaviour does not seem to be maintained through adulthood, suggesting that HIV infection might simply be being delayed and not prevented, as should ultimately be the aim. Recent international literature has drawn attention to the fact that people perceived to be at lesser risk of infection with HIV (mature adults, people in stable relationships, etc) are in fact more susceptible to infection than was previously thought. This calls for group specific targeted interventions, among and beyond the teenagers in order to reduce transmission rates.

The significant decrease in syphilis infection rates is quite encouraging and at the same time justifies a consideration by the Department of Health to extend syphilis screening beyond antenatal clinic attendees. Consideration should be given to implementing a universal policy offering routine screening to all women in their reproductive ages for syphilis, chlamydia, chancroid, gonorrhoea and trichomoniasis at both primary and secondary levels of care. I

It is estimated that the current antenatal clinic-screening programme for syphilis can only alert about 6% (estimated proportion of pregnant women that are treated through the antenatal clinic screening programme) of 15-49 year olds each year for just one infection (syphilis). If screening for more treatable bacterial STIs was offered through Primary Health Care (e.g. family planning clinics) the Department of Health might reach 50% of 15-49 year olds. The surveillance programme needs to be extended beyond antenatal clinic attendees of public sector clinics to include the private sector and male populations.

Plans for inclusion of sentinel private sector antenatal facilities will inform on the prevalence of HIV and syphilis among population groups other than African. This information will be useful in implementing targeted interventions among all South Africans.

Further, the findings for both HIV and syphilis suggest a need for more research into other aspects of HIV and STDs. It is against this background that the Department of Health is intensifying the understanding of transmission by embarking on a project to look at determinants of infection. The proposed Behavioural Survey will generate more information for linking sexual and social behaviour patterns to the HIV and AIDS epidemic. Incidence studies initiated in 2000 will give an indication of new HIV infections in South Africa and provide a useful tool with which it can be determined to what extent the implemented intervention programmes are succeeding.
 

7. REFERENCES

1. Department of Health, 1999. National HIV sero-prevalence survey of women attending public antenatal clinics in South Africa.
    
2. Bikitsha NI, 2000. HIV and Syphilis trends among antenatal clinic attendees in South Africa 1997-1999.
    
3. Department of Health, 1998. South African Demographic & Health Survey.
    
4. Statistics South Africa, 1997. October Household Survey.
    
5. White paper for the Transformation of the Health Sector in South Africa.
6. Statistics South Africa, 2001. Comments on the findings of the 11^th antenatal HIV survey, by the Statistician General.
    
7. Henry J Kaiser Foundation, 2001. Hot Prospects Cold Facts: Portrait of Young South Africa.

Appendix 1: Antenatal clinic survey participants 1997-2000

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