Major strides in prevention
The study found that there have been significant changes in sexual behaviour in South Africa over the past four years, when compared with the 1998 Demographic and Health Survey. This is similar to trends in Uganda.

'We found that the number of women who had no current sexual partner had increased, and condom use has increased significantly,' said Dr 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 28.6% in the present study, and amongst women aged 20-24 it has increased from 14.4% to 47%.'

Condom use amongst sexually active youth aged 15-24 is high, with 57.1% of males and 46.1% of females having used a condom at last sexual intercourse. This is supported by high levels of perceived access to condoms - with over 90% of youth and adults reporting that they could obtain a condom if they needed one. Condoms were most likely to be obtained through the DoH's free condom programme from public sector clinics and hospitals.

Only 55.6% of males and 57.9% of females aged 15-24 had previously had sex, and there were very low levels of partner turnover. Of youth that were sexually active, 84.7% reported that they had only one partner in the past year. For adults aged 25-49, the rate was 93.5%.

Self-reported behaviour change as a result of HIV/AIDS was also high. Nearly half of all males and over a third of females over 15 years reported that they had changed behaviour. Steps taken included staying faithful to one partner, condom use, sexual abstinence and reducing the number of sexual partners.

HIV prevalence

Overall: The study estimates the overall HIV prevalence in the South African population (over the age of two) to be 11.4%. HIV prevalence among those aged 15-49 was 15.6%.

Children under the age of two were excluded as the saliva-based HIV test could falsely record them as HIV-positive if their mothers were HIV-positive, as their mothers' antibodies are still present in their bodies at that age. Those living in institutions such as prisons and boarding schools were also excluded.

Gender: Females accounted for 12.8% of those testing HIV-positive, while 9.5% of males tested positive. Amongst the youth (15-24), double the number of females (12%) was infected as males (6%). Women are biologically more susceptible to HIV infection than men. Men are also more effective at transmitting the virus as semen is more infectious than vaginal fluid. Women may also have undetected sexually-transmitted infections, which increase the risk of HIV-infection.

Race: HIV prevalence among Africans was highest (12.9%). This can be explained by historical factors, such as labour migration and relocation, as well as the fact that more African people live in informal settlements.

The infection rate among whites was 6.2%. This is considerably higher than countries with predominantly white populations such as the US, Australia and France, where prevalence among whites is less than 1%. Prevalence among coloureds was 6.1% and among Indians, prevalence was 1.6%.

Provinces: HIV prevalence was highest in the Free State (14.9%), Gauteng (14.7%) and Mpumalanga (14.1%). Gauteng and the Free State have the highest proportion of their residents living in informal settlements, found to be a significant risk factor for HIV.

In contrast to the annual antenatal surveys which have consistently found KwaZulu-Natal (KZN) to have the highest prevalence, the province ranked 4th (11.7%). A possible explanation for the discrepancy is the fact that the sites for KZN's antenatal survey are along major transport routes, known to be high-risk areas for HIV. This study included rural and urban households. In addition, a relatively small percentage of people in KZN (5%) live in informal settlements.

It should be noted, however, that in terms of population numbers, KZN is a populous province. As a result, it has the second highest number of people living with HIV/AIDS after Gauteng.

The Western Cape was ranked 5th with a prevalence rate of 10.7%. This is higher than the antenatal survey (8.6%) which ranked the Western Cape as the province with the lowest HIV prevalence rate. One explanation could be the fact that a fairly high proportion of the province's population (12.8%) lives in informal settlements. The Eastern Cape had the lowest infection rate (6.6%).

Age: The highest prevalence rate was among the 25-29 age group (28%), followed by the 30-34 group (24%). The prevalence rate for children 2-14 was unexpectedly high at 5.6% and it remains unclear how these children were infected.

'The study draws no conclusion on how these children were infected, but states that possible factors to be investigated are sexual abuse and exposure to unsterile needles', said Dr Shisana.

Locality type: People living in urban informal settlements have the highest HIV prevalence (21.3%), followed by formal urban areas (12.1%). Tribal areas have a rate of 8.7% and farms 7.9%.

'The mobility and transient nature of life in informal settlements, rather socio-economic status, makes those living in these areas most vulnerable to HIV,' says Dr Shisana. This is reflected in the finding that 23.5% of men living in informal settlements reported more than one sexual partner in the past year, in comparison to 19.2% in tribal areas, 10.2% in urban formal areas and 8.2% in farms. Youth (15-24) in informal settlements also showed a significantly higher rate of sexual experience (74%) than their peers in rural areas (58.3%) and formal urban areas (53.2%).

There was no significant difference in HIV prevalence between those working (14.2%) and not working (12.1%). Wealthy Africans and less wealthy Africans had similar levels of risk.

HIV/AIDS communication

General levels of key aspects of HIV/AIDS awareness and knowledge were high, and myths such as AIDS being cured by sex with a virgin were believed by only 1.1% of adults 25-49 and 2.3% of youth aged 15-24. Most respondents indicated however, that they needed more information on HIV prevention, HIV testing, HIV/AIDS care, living with HIV/AIDS, treatment, orphan care and rights.

Attitudes to people with HIV/AIDS were found to be accepting and non-discriminatory. Knowing a person who was living with HIV/AIDS or who had died of AIDS was an important contributing factor to taking the epidemic more seriously.

Mass media channels, particularly radio and television, were found to be important sources of HIV/AIDS information. However, only 44.4% of people living in tribal areas watched television a few days a week or more.

Some 85.9% of children (12-14) and 75.7% of youth (15-24) reported that their main source of HIV/AIDS education was their school. Parents were also an important source of information for children (39.9%) and youth (54.8%).

Health workers were an important source of information for all age groups, particularly people aged 25-49 (76.8%). Faith-based organisations were also important.

When participants were asked what HIV/AIDS messages they remembered, condom messaging, understanding the fatal nature of AIDS, faithfulness, abstinence and partner reduction were prominent.

'We are concerned that there is still a need for HIV/AIDS information to be delivered in all South African languages,' said Warren Parker, director of Cadre. 'African languages (particularly seSotho, Tshivenda and Xitsonga) and Afrikaans seem to have been marginalised. Only 0.8% of Africans have English as a home language, and 83.5% of coloured and 60.2% of whites have Afrikaans as a home language'.

Voluntary counselling and testing (VCT)

It was found that 18.9% of respondents over 15 years of age had previously had an HIV test and were aware of their status. The main reasons for HIV testing however, were for insurance purposes, and in relation to pregnancy. It was also noted that nearly two thirds of those who were found to be positive in the study did not believe they were at risk of HIV infection.

There was high awareness of VCT services, although only one in five of those who were aware of services had made use of them. Concerns of people who had not been tested included confidentiality, cost and quality of services.

'It is important that a prevention and care strategy should include increased voluntary counselling testing services, coupled with access to better nutrition, improved healthy living and access to treatment using antiretroviral therapy. Such a strategy would help to alleviate the plight of people living with HIV/AIDS,' said Dr Shisana.

Public perceptions of political response

The government was generally perceived to be committed to dealing with HIV/AIDS, and publicly recognising its importance, but resource allocation was perceived to be inadequate by the majority of respondents. Some 96.5% of respondents 15 years and older supported the provision of anti-retroviral drugs for prevention of mother-to-child transmission (PMTCT), while 95% said government should provide anti-retroviral drugs for people with HIV/AIDS-related illness.