Between the time you ate breakfast this morning, and the time you go to sleep, 1 500 South Africans will have contracted HIV. Tomorrow, another 1 500 people will join the list of statistics, and the same number the day after.
You'd be forgiven if your first thought, on viewing these figures, is that South Africans obviously haven't taken preventive campaigns to heart, if infection rates remain so high. But in fact there is a high level of awareness, says Dr Francesca Conradie, deputy director of the Clinical HIV Research Unit in the department of medicines at the Wits Faculty of Health Sciences. The challenge lies in translating people's knowledge into action - the only way to reduce the rate of new infections.
Fortunately, the findings from the third national HIV prevalence, incidence and communication survey, conducted by the Human Sciences Research Council (HSRC), show that some successes have been recorded.
According to the study, HIV prevalence among children younger than two years has levelled off, while prevalence among children aged 2-14 dropped from 5,6% in 2002 to 2,5% in 2008. There was also a drop in prevalence in teenagers aged 15-19 years.
That's the good news. The bad news is that women of child-bearing age (25-29) remain the hardest hit by the pandemic, with prevalence remaining stable at 33%. An optimist would point to the slight decline in prevalence among adults aged 15-49 in the Western Cape, Gauteng, Northern Cape and Free State - but it's undeniable that more should be done.
This was the message driven home by health minister Aaron Motsoaledi in November, when he announced plans to drive a "massive" VCT (voluntary counselling and testing) campaign that would ensure more South Africans are aware of their status.
Francesca Conradie
Conradie welcomes the "strong stance" taken by Motsoaledi, as she maintains that strong leadership is one of the most effective means of tackling the virus. She points to the success of campaigns in Botswana and Uganda as proof.
That said, Conradie admits that it's not enough simply for people to know their status; they have to be prepared to take the next step - and this is one of the greatest obstacles facing health workers. Conradie's work with the Cipra SA protocol - a randomised clinical trial that assigned HIV-infected patients to care by primary health-care doctors and nurses - as well as her involvement at the Sizwe Tropical Disease Hospital, illustrates this clearly.
"We found that people would submit to testing, but would fail to follow through with a repeat visit to obtain their results," she says.
This can be addressed through the use of Rapid tests, which provide immediate results with significant accuracy - but Conradie laments that many patients are lost between testing and therapy. "It's understandable," she concedes. "A positive test has huge psychological implications. People experience great anger and fear, which are significant demotivators."
Conradie acknowledges the success of youth education programmes, which appear to have encouraged many adolescents to delay becoming sexually active - as proved by the slight drop in prevalence among this age group.
However, there are certain social issues and dynamics that remain problematic. Conradie singles out transgenerational sex as a particular concern. This is a phenomenon that's becoming increasingly common as young girls establish relationships with older men in return for financial or other rewards. This trend is present throughout the continent, but has had a noteworthy effect in SA, where it's led to a peak in infections among young girls and older men.
Another dynamic that has helped to spread the pandemic throughout Africa is the pattern of sexual concurrence - individuals conducting relationships with several partners at one time. The result, Conradie says, is a "spider network" that results in infections spreading with devastating effectiveness and speed. "Women are particularly disempowered as it's more difficult to negotiate the use of condoms in an established relationship," she says.
Other important issues include the management of programmes. Conradie cites two cases in point: the drug shortages experienced in Free State clinics during the past year, as well as the lack of sufficient milk supplies that plagued a number of public-sector institutions nationwide.
"Like any other supplier, it's important to monitor stocks, and when they run low, to order new reserves," she says. "The issue of poor management is one that can be easily fixed by introducing more rigorous processes."
On the whole, however, Conradie is impressed with the work done by the public sector. A glance at the workings of Helen Joseph Hospital, for instance, shows that 15 000 patients have received treatment during the past five years. So effective has the programme been that the hospital can refer patients already receiving stable therapy to other treatment facilities.
Meanwhile, a significant number of workplaces have implemented testing initiatives. However, there remains room for more public-private partnerships. For example, the training of private-sector GPs to participate in government therapy programmes would provide welcome relief from the burden of public institutions. Consider, for instance, that Conradie's programme treats up to 400 patients per day. That's a hefty volume. Consider how much more efficiently patients could be treated if hospital workers had to address only the most serious cases, while more stable patients could receive check-ups at a private facility.
WHAT IT MEANS
 New infections still unacceptably high
Lack of follow-ups on tests is another challenge
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Are there any aspects of the response to the virus - in both the public and private sectors - that require dramatic change? Conradie says work is being done to introduce more effective drugs that are more accessible and carry fewer side effects. This is no small task, as it involves addressing questions of logistics and capacity; as it would be necessary to train staff on the new regimens. At this point, it's therefore impossible to tell how close SA is to changing medical guidelines.
But she is confident that Motsoaledi's emphatic position on HIV could have a marked positive effect on the disease's trajectory in this country. After all, if strong political guidance has proved an effective weapon elsewhere in Africa, there is no reason why it shouldn't do the same here.
