South Africa: HIV/AIDS among vulnerable groups

With a national HIV prevalence rate of 18.8 per cent among adults aged 15-49, South Africa has the highest absolute number of people living with HIV in the world - 5.5 million out of a world total of almost 40 million, according to UNAIDS.

However, certain groups are more exposed to the virus than others. Of particular concern to policymakers and UNODC are prisoners and drug users, among whom HIV prevalence levels are much higher than in the general population.

South Africans used to struggle for democratic rights. Now, the struggle has turned to provision of HIV/AIDS treatment. Copyright: Zapiro/Mail and Guardian.

HIV and prisons

Although a national HIV prevalence rate for prisons is not available, reports have indicated that in some institutions, it can reach 40 per cent. In the absence of adequate HIV prevention and care in penal institutions, the virus spreads there and in the communities inmates return to upon release.

As in many developing countries, South African prisons are seriously overcrowded. Official statistics show that there are approximately 160,000 prisoners, whereas the capacity is 115,000. In some prisons, such as Westville in Durban and Pollsmoor in Cape Town, there may be up to six prisoners in a cell built for one.

"The overcrowding is a total violation of the prisoners' human rights," says Venessa Padayachee, a programme specialist with the National Institute for Crime Prevention and the Reintegration of Offenders (NICRO). "It not only causes victimization in the prison but also hardens the inmates and leads to rapes."

Reychad Abdool, a Kenya-based UNODC HIV/AIDS expert, agrees. He adds that sex among prison inmates, sometimes consensual, often not, is a sensitive subject.

"Governments are up to now very, very cautious about even discussing men having sex with men in prisons," Abdool says. "Of course this is a reality, but to get governments to talk about providing prisoners with condoms, we need to talk about it in the context of the overall management of prisons."

High-risk activities such as tattooing and piercing without properly sterilized equipment contribute to the high HIV prevalence rates in prison. The lack of sufficient treatment facilities also increases the risk of mother-to-child HIV transmission.

Drugs and the link to HIV

Another important factor in the spread of HIV in prisons is drugs. Many inmates used drugs before going to jail and many continue inside, despite no-drugs policies. 

"The continued use of drugs during incarceration has been associated with the increased spread of HIV," says Claudia Shilumani, HIV/AIDS National Programme Officer at the UNODC office in Pretoria. "Using drugs may lead to unsafe sexual practices which in turn expose people to the virus. Therefore, our work to reduce drug abuse in prisons is another measure towards HIV prevention."

One example of UNODC's work in prisons can be found in the juvenile section of Leeuwkop prison, north of Johannesburg. Most of the inmates are there for drug-related offences - such as buying, selling or manufacturing drugs, or stealing to pay for a drug habit.

As with adult drug-users, most juvenile inmates continue their drug habits inside prison. Some Leeuwkop inmates got tired of living in cells with a lot of drug use, and decided, in partnership with UNODC, the NGO Khulisa and the prison authorities, to start two "drug-free cells." To be eligible to stay there, inmates have to go through a basic drug awareness programme. They also sign a declaration, agreeing to obey 16 rules such as no smoking, no sodomy and no gangsterism, and they have to accept frequent, random drug tests. 

"So far, it's going well," says John, who is the leader of one of the drug-free cells. "In my cell, we not only talk about drugs, but also give the guys life skills and HIV prevention training. We get respect from other prisoners and it's seen as a privilege to live in this cell."

Jeromy Mostert, a psychologist at the prison, says the authorities are trying to support the drug-free cells as much as possible because drugs cause a lot of disruptive behaviour in the prison. The most popular incentive they can give inmates seems to be access to a TV for their cell.

Prisoners are locked in from 3 pm onwards and television helps to alleviate the chronic boredom.

"It's the first time we're running drug-free cells here, so we're on a steep learning curve," Mostert says. "But overall, it's positive. We're also pleased to see that some of the guys we trained here are now running a similar programme in the adult jail."

Injecting drug users

Injecting drug use is limited in South Africa. Of the estimated 13 million injecting drug users worldwide, less than a million are found in Africa. Cheaper drugs, such as cannabis, are generally preferred over injected drugs such as heroin.

However, UNAIDS has warned that "new epidemics of injecting drug use are being witnessed in countries of Sub-Saharan Africa." And judging from available treatment centre figures, treatment demand for heroin is on the rise in South Africa.

Reychad Abdool says that the drug scene could change quickly and policymakers should not become complacent as sharing syringes spreads the virus very efficiently.

"If you look at the situation in East Africa, for a long time, injecting drug use was not really a problem," he says. "But in the last few years, it's taken off, and caught the Governments off guard. Southern Africa should learn from their experience."  

Claudia Shilumani Reychad Abdool
Claudia Shilumani and Reychad Abdool are Africa-based HIV
experts for UNODC.