Recommendations for policy in the Western Cape Province regarding the prevention of Major Infectious Diseases including hiv/AI

Table 3: Sub-districts by HIV prevalence and TB cases, 2005

KEY to districts
1	Metro	4	Overberg
2	West Coast	5	Eden
3	Cape Winelands	6	Central Karoo

Population age and migration breakdown
HIV prev	District	Sub-district	Population	% 16-25	% 26-45	% migration
33.0	1	Khayelitsha	329008	24	34	17
29.1	1	Klipfontein	344441	20	31	10
17.8	3	Stellenbosch	117706	25	30	24
17.4	5	Bitou	29183	19	34	22
17.4	5	Knysna	51466	18	31	19
16.8	1	Eastern	396718	19	33	36
15.1	1	Tygerberg	461243	19	31	20
14.7	1	Mitchells Plain	430175	22	32	23
13.3	5	George	135405	18	32	24
13.0	2	Saldanha Bay	70439	18	34	28
12.7	1	Northern	361400	18	35	36
12.5	4	Theewaterskloof	93279	18	34	15
12.5	4	Overstrand	55738	17	29	40
12.5	5	Hessequa	44120	15	29	20
12.5	5	Mossel Bay	71495	17	31	23
10.8	1	Southern	280858	18	32	25
10.5	3	Witzenberg	83573	18	33	17
10.5	3	W'lands WCDMA02	6498	19	36	35
10.0	4	Cape Agulhas	26183	14	30	19
10.0	4	Swellendam	28080	16	31	13
10.0	4	O'berg WCDMA03	254	13	39	78
8.9	3	Drakenstein	194413	19	32	15
8.9	6	Laingsburg	6682	14	31	25
8.9	6	Prince Albert	10512	15	29	21
8.9	6	Beaufort West	37101	18	28	14
8.9	6	Cent Karoo WCDMA05	6183	14	26	17
8.4	3	Breede valley	146028	19	31	11
8.4	3	Breede river winelands	81274	17	31	20
7.5	1	Western	289343	20	31	39
6.5	5	Kannaland	23969	15	28	11
6.5	5	Oudsthoorn	84694	17	28	12
6.5	5	Eden WCDMA04	14599	17	30	16
6.2	2	Bergrivier	46324	17	34	21
6.2	2	Swartland	72118	17	33	19
5.8	2	Matzikama	50210	16	32	16
5.8	2	Cederberg	39326	16	32	20
5.8	2	W Coast WCDMA01	4255	14	25	15

Table 4: Sub-districts by HIV prevalence age and migration.

Selected socio-economic indicators
HIV prev	Dis- trict	Sub-district	Population	% grade 12 educ-ation	% Weighted individual income < R1600	% piped water in dwelling	% informal settlement
33.0	1	Khayelitsha	329008	13	94	20	64
29.1	1	Klipfontein	344441	15	85	67	20
17.8	3	Stellenbosch	117706	16	82	72	13
17.4	5	Bitou	29183	16	85	46	17
17.4	5	Knysna	51466	17	84	52	25
16.8	1	Eastern	396718	16	80	70	15
15.1	1	Tygerberg	461243	20	72	88	4
14.7	1	Mitchells Plain	430175	13	86	59	23
13.3	5	George	135405	16	84	60	16
13.0	2	Saldanha Bay	70439	15	81	67	14
12.7	1	Northern	361400	21	70	76	11
12.5	5	Hessequa	44120	13	87	69	4
12.5	5	Mossel Bay	71495	17	82	63	12
12.5	4	Overstrand	55738	19	80	72	14
12.5	4	Theewaterskloof	93279	10	90	60	17
10.8	1	Southern	280858	19	74	82	11
10.5	3	W'lands WCDMA02	6498	6	95	56	1
10.5	3	Witzenberg	83573	9	91	68	9
10.0	4	O'berg WCDMA03	254	22	48	92	0
10.0	4	Cape Agulhas	26183	13	84	78	6
10.0	4	Swellendam	28080	11	89	65	6
8.9	6	Laingsburg	6682	8	91	59	1
8.9	6	Beaufort West	37101	11	90	61	2
8.9	6	Prince Albert	10512	6	93	55	3
8.9	6	Cent Karoo WCDMA05	6183	4	95	37	5
8.9	3	Drakenstein	194413	14	85	66	15
8.4	3	Breede river winelands	81274	10	90	62	5
8.4	3	Breede valley	146028	13	87	61	11
7.5	1	Western	289343	25	62	84	8
6.5	5	Kannaland	23969	8	92	67	1
6.5	5	Eden WCDMA04	14599	7	95	40	2
6.5	5	Oudsthoorn	84694	12	89	58	8
6.2	2	Bergrivier	46324	12	88	75	2
6.2	2	Swartland	72118	13	85	72	3
5.8	2	W Coast WCDMA01	4255	7	91	44	2
5.8	2	Cederberg	39326	10	91	67	4
5.8	2	Matzikama	50210	11	88	64	5

	KEY
	percent among highest 5
	percent among lowest 5

Table 5: Sub-districts by HIV prevalence and selected socio-economic indicators


Appendix 2: Sex tourism in Cape Town: a case study
Sex tourism in Cape Town has been referred to by Cape Town head of tourism, Cheryl Ozinsky, as “circumstantial” as a product of visitors on business and tourists seeking out the services of sex workers (Ozinsky 2004). This contrasts with an understanding of ‘sex tourism’ as a formalised trade in visits to the region specifically for sex – a phenomenon that has not been formally documented in Cape Town. Approximately 1.2 million tourists from other countries visit Cape Town every year (Slaughter,1999), in addition to 4.2 million South Africans, and Ozinsky argues that there is a need acknowledge sex tourism as a part of tourism with a view to regulating these activities.
It is important to distinguish the adult prostitutes from child sex work (Ballim,2006). Adult sex work in the city of Cape Town includes female and male sex workers and takes the form of street sex work as well as those sex work located in bars, clubs, massage parlours and escort agencies. There are also children who trade sexual favours for money or other favours and who may be viewed as sexually exploited children (Molo Songololo, 2006). The trafficking of women and children for sex is a further aspect that may overlap both the adult and child groups of the commercialisation of sex (IHCAEC,2006).
The Sex Worker Education and Advocacy Task force (SWEAT) (SWEAT,2005) conducted a demographic survey of 200 adult sex workers in the Cape Metropole area in 2005. The majority of the sample were female (93%) and were aged 22-29 years – 31% were Black, 54% Coloured, 14% White and 1% Indian. Only half had an education level of Grade 11 or 12, and half indicated that they started commercial sex work because they were unable to find other employment. Just over one fifth, 22%, chose to do the work because it allowed them to earn more money than in any other job. Their earnings differed according to whether they worked on the street or indoors and daily income ranged from R80 to R1700.
While there is debate around the constitutionality of the Sexual Offences Act (which prohibits sex work?), at issue is the question of mandatory health testing of sex workers for sexually transmitted infections that may potentially infect others. Compulsory HIV testing contravenes the AIDS charter, as well as the right to privacy, freedom and security as laid out by the Constitution. Criminalisation of HIV positive sex workers may discourage VCT and/or other regular health checks.
Unprotected sex includes risk of HIV infection to both to the sex worker and his/her client (SWEAT,2005). These risks are exacerbated in the case of co-infection with other STIs, existing genital trauma as well as in the case of anal sex, ‘dry sex’, and other sexual practices that involve genital trauma. Even where condoms are used, correct use is necessary, and some sexual practices may include a higher risk of condom breakage. Sexually exploited children are also likely to be more vulnerable, as a product of lesser capacity to insist on protected sex.
Poverty is linked to a higher prevalence of sex work and sexual exploitation of children (Molo Songololo,2006; IHCAEC,2006). This occurs both in the cities, and along trucking and other transport routes (Ramjee and Gouws,2002;Slaughter,1999) and illegal immigration from other African countries also increases the likelihood of sex work occurring as a means to secure income (Lurie,2003).
There is little formal data on sex work in Cape Town. Marge Ballim (Ballim,2006), who runs a rehabilitation programme, Inter Outreach, for sex workers wishing to move out of such work notes that the majority of those she works with are HIV positive – typically finding out their status when they enrol at the centre. Pregnancy and drug use is also noted.
ATICC (AIDS Training , Information and Counselling Centre) and the non-medical Voluntary Counselling and Testing site at Atlantic Christian Assembly Church in Sea Point provide HIV-related services to sex workers. SWEAT feels that mandatory HIV testing would increase the risk of contracting HIV as negative HIV status may create a false sense of security, causing clients and sex workers to be less vigilant about practicing safer sex (SWEAT,2005). They further note that criminalising sex workers who are infected would discourage them from being tested.
Substance abuse and socio-economic disadvantage are associated with increased risk for HIV infection, and this case study illustrates these links (Dunkle et al,2004). Drug abuse, poverty and unemployment must be considered as distal risk factors to be addressed in relation to addressing sex work and sexual exploitation of children.


References
Cheryl Ozinsky, chief of Cape Town Tourism, speaking at the African and European Conference on Traveller’s Medicine in Cape Town in 2004. Pienaar J. Sex tourism, the enemy within. 2004 Die Burger 11/02/2004

Available from: http://www.news24.com/News24/South_Africa/News/0,,2-7-1442_1481979,00.html

Slaughter B. Cape Town promotes sex tourism. 1999 World Socialist Web Site

Available from: http://www.wsws.org/articles/1999/oct1999/saf-o05.shtml

Ballin M. Prostitution: Why prostitution should not be decriminalised

Available from: http://www.christianaction.org.za/articles/whyprostitutionnotdecrim.htm

Molo Songololo. Children on the edge: Strategies towards an integrated approach to combat child exploitation in South Africa

Available from: http://www.genderstats.org.za/documents/ChildSexExploit.doc

International Humanitarian Campaign Against the Exploitation of Children. SOUTH AFRICA is a country of Origin, Transit and Destination

Available from: www.gvnet.com/humantrafficking/SouthAfrica.htm

Sex Workers Education and Advocacy Task force. Demography survey 2005.

Available from: http://www.sweat.org.za/

Ramjee G, Gouws eA E. Prevalence of HIV among truck drivers visiting sex workers in KwaZulu-Natal, South Africa. 2002. Sex Transm Dis. 2002 Jan;29(1):44-9.

Lurie MN, Williams BG, Zuma K, Mkaya-Mwamburi D, Garnett G, Sturm AW, Sweat MD, Gittelsohn J, Abdool Karim SS. The impact of migration on HIV-1 transmission in South Africa. Sex Transm Dis. 2003 Feb;30(2):149-56.

Dunkle KL, Jewkes RK, Brown HC, Gray GE, McIntryre JA, Harlow SD. Transactional sex among women in Soweto, South Africa: prevalence, risk factors and association with HIV infection 2004. Soc Sci Med. 2004 Oct;59(8):1581-92

Appendix 3: Peer education in schools in the Western Cape
This report is adapted from the following editorial:

Flisher AJ, Mathews C, Guttmacher S, Abdullah F, Myers J. AIDS prevention through peer education. Editorial. South African Medical Journal. 2005; 95(4);245-248.

Present situation

A key element of the response of the Western Cape Health and Education Departments to the HIV/AIDS epidemic has been school-based HIV/AIDS peer education programmes. Although the Western Cape has had a curriculum-based awareness and life skills programme operational in schools, it is likely that HIV prevalence among 15 – 19 year olds continues to rise. With a view to scaling up prevention activities for school-going youth, the Departments of Health and Education have contracted 15 locally-based NGOs with experience in the field to implement a peer education programme in schools. The programme had been rolled out to 130 high schools in the province by 2006, and approximately 5700 peer educators had been selected and trained and were in these schools in 2006. The programme’s aim is to delay sexual debut, decrease partners, increase condom use and encourage abstinence and to encourage early sexual health seeking behaviour (as appropriate). The programme is funded from the Global Fund Grant awarded to the Western Cape Department of Health, as well as the Conditional Grant.

Evidence base

Reviews of school-based AIDS prevention programmes in sub-Saharan African concluded that the quality of the evaluations is generally low, which makes it difficult to draw confident conclusions about the efficacy of the programmes. Notwithstanding this, there is some evidence that the better-designed evaluations demonstrated programme effects. Specifically, the interventions revealed the expected effects on knowledge, attitudes and communication about sexuality. Some programmes also had an effect on behaviour. The evidence from the developed world is derived from intervention methodologies of higher quality. There is consensus that school-based interventions can be effective in reducing the extent of unsafe sexual behaviours as manifest by condom use, sexual frequency outcomes, communication with sexual partners, and objectively measured condom use and negotiation skills.

Given that there is evidence that school-based AIDS prevention programmes can be effective, the next issue is whether school-based programmes that are based primarily on peer education have been shown to be effective. One of the ways in which peer interventions are hypothesized to influence adolescent health behaviours is by influencing social norms. A large amount of research reveals the strong and consistent influence of social norms on adolescent sexual behaviour. Douglas Kirby, an expert in the adolescent health in the U.S., proposed that a simple conceptual framework concerning social norms and connectedness to those expressing the norms can be used to explain some of effects of the disparate adolescent sexual risk reduction interventions. Specifically, if a group has clear norms for (or against) sex or contraceptive use, then adolescents associated with this group will be more (or less) likely to have sex and use contraceptives. The impact of the group's norms will be greater if the adolescents are closely connected to this group than if they are not. This conceptual framework is supported by several theories of health behaviour and a large body of research. Kirby recommends giving greater consideration to norms, connectedness and their interaction in research and in the development of programmes to reduce adolescent sexual risk-taking. This can be achieved by designing and evaluating programmes that increase the connectedness between youth, and other youth or adults, who express clear responsible norms. This can also be done by mobilizing friends and “opinion leaders” to take a positive public stance on sexual risk-taking. Opinion leaders are visible, popular and well-liked members of selected (pro- and anti-) social networks, strategically selected for popularity, community respect and influence. They influence social norms among their peers through informal social contacts. This is in contrast to “traditional” peer educators who are often volunteers or chosen by teachers or health workers. There is no guarantee that “traditional” peer educators will possess the characteristics of opinion leaders or that they will be influential in their social networks. Opinion leader interventions are based on the diffusion of innovations theoretical model.

A “popular opinion leader” intervention has been shown to be effective at reducing sexual risk behaviour among adults in the US. A seminal series of studies was conducted by Kelly and colleagues, culminating in a randomized controlled trial among adult gay bar patrons in eight small American cities demonstrating that reliably-selected popular opinion leaders, trained to promote risk-reduction to their peers, were effective in achieving community-wide reductions in self-reported sexual risk behaviour¹¹ .

Studies focusing on changing social norms through the use of opinion leaders have been successful in a wide variety of other health interventions. These include designated driver programmes, interventions to improve the professional practice of health workers, and smoking cessation efforts.

In summary, the research base provides grounds to believe that the peer education intervention has been rolled out in Western Cape schools might be effective. Furthermore, it may be more likely to be effective if an opinion leader approach is followed, as opposed to more a traditional peer education approach.

Policy discussion