In 1997, a similar number of men, between 10 900 and 12 600, died in each age cohort from 25 to 29 years all the way to 70–74 years. By 2004, that pattern had disappeared. Deaths were then peaking sharply among men aged 30–44 years, men who should be in the prime of their lives. In 1997, roughly similar numbers of women were dying from 25 to 29 years up to 55–59 years, with deaths then increasing among older women. By 2004, that pattern had tilted dramatically. Most women were now dying between the ages of 25 and 39 years, three times as many compared with 5 years earlier [14–16]. That shows clearly that South Africans are dying in patterns that closely match those predicted by AIDS models.
HIV prevalence is highest among South Africans of low socioeconomic status
Even if HIV infections were evenly distributed among all income quintiles, as many as half the South Africans living with HIV would be individuals surviving below the poverty line. According to the United Nations Development Programme (UNDP) , 48.5% of the population was living below that income threshold in 2003. There is evidence, however, that HIV prevalence in South Africa tends to be higher among individuals with low skills and incomes (and lower among those with the highest skills and incomes). It is among the more disadvantaged and impoverished sections of society, who are predominantly black Africans, given the country's history of racial discrimination and dispossession, that the highest levels of HIV prevalence are found.
A national study among educators  found that HIV prevalence was highest among those of lower socioeconomic status: among those earning R132 000 (US$19 000) or more a year, HIV prevalence was 5.4%, whereas among those earning less than R60 000 (US$8000) a year, prevalence was 17.5%. An HIV prevalence survey among employees of the Buffalo City Municipality in 2004  found a higher prevalence among temporary than permanent staff, with infection levels highest in the lowest skills levels. Among health workers surveyed at private and public health facilities in four provinces , HIV prevalence was just under 14% among professionals but exceeded 20% among non-professional staff.
Among South African workers participating in a three-country seroprevalence survey of 34 major companies in 2000–2001 , HIV prevalence was 15% for unskilled workers, 18% for their semi-skilled counterparts and 20% for contract employees, but 7% among skilled workers and 4% among management staff. A recent analysis of the epidemiology of HIV in 22 public and private sector organizations in all nine provinces of South Africa  found that HIV prevalence among labourers was on average more than twice as high as among managers (12.4% compared with 5.3%).
Key indicators of poverty and inequality in South Africa
Many of the factors that appear to drive South Africa's AIDS epidemic are entangled in the social engineering and economic accumulation strategies that have moulded the society over the past 120 years. Large-scale circular migration and accelerated urbanization (encompassing ever-greater numbers of women since the 1980s) are salient features against a background of rising unemployment levels. Systematic dispossession and dislocation, the destabilization of social systems and disintegration of social cohesion (particularly in the urban peripheries) and the entrenching of highly unequal social relations helped create a social and ideological terrain (including the emergence of aggressive constructions of masculinity and sexual risk-taking) that hugely favours the sexual transmission of HIV . The AIDS epidemic is interlaced, in other words, with the circuits and terms on which power, opportunity and entitlements are distributed and desires and needs are pursued. In the case of South Africa, these are highly unequal [24–27]. The effects of AIDS morbidity and mortality are likely to reinforce those inequalities.
Despite the impressive achievements made since the end of the apartheid system in 1994, South Africa's unequal social structure continues to be reproduced. According to UNDP, income distribution remains highly unequal, as reflected in South Africa's Gini co-efficient, which stood at 0.578 in 2006, among the worst in the world. Poverty and inequality, according to UNDP, continue to express strong spatial and racial patterns .
Although classified as a middle-income country, South Africa's harshly skewed allocation of income and resources means that almost half the South African population, 48.5% or close to 22 million individuals, live on the poverty line [16,29]. As many as one-quarter of poor households are trapped in chronic poverty . In a recent countrywide survey , four in 10 respondents said they had gone without food or were unable to buy medicine they needed, three in 10 could not afford to pay for water, and six in 10 went without an income at some stage in the previous year.
Labour market trends account to a large extent for these trends. High and rising unemployment rates, along with an ongoing shift from permanent to casual employment, continue to widen income inequalities . The official (narrow) unemployment rate was 31.5% among black Africans in 2005 (compared with 5.1% among white individuals) and 37.1% of African women were jobless, according to the Labour Force Survey . The official (narrow) definition of unemployment refers only to those economically active individuals who sought employment in the 4 weeks before the survey. The expanded definition includes economically active individuals who are deemed to have been discouraged from seeking work . Almost three quarters of the unemployed had never had a job, according to the 1999 October Household Survey . The shedding and informalization of labour has hit black African women especially hard, many of whom have only sporadic access to poorly paid and insecure jobs but bear much of the responsibility for social reproduction.
Against a backdrop of modest but consistent economic growth, infrastructure development and service delivery has improved markedly on several fronts since 1994 . Generally, though, these efforts have not matched mushrooming needs, and with provision increasingly occurring under the aegis of the market, affordability is a central issue.
Savings levels are very low and debt levels are high. More than 90% of poor households are paying off debt each month, according to one recent study, and one quarter of them are ‘highly indebted’ . In another study , between three quarters and nine-tenths of households had no savings whatsoever.
Access to medical aid and other forms of health insurance is comparatively rare. Only 15% of South Africans have any form of medical aid, according to Statistics South Africa . Among low-income earners (individuals in households earning less than R6000 or US$850 a month) only 7% have some form of medical scheme coverage . The racial disparities are striking: three out of four white individuals belong to medical schemes, compared with one out of 14 black Africans . (Steps are underway to create a new class of medical scheme aimed at individuals with an income of R2000–6000 or US$280–850). Community-based burial insurance and ‘stokvels’ are widespread: as many as four out of five households in parts of the country belong to such schemes, but they provide meagre protection .
Two powerful dynamics interlace: on one hand, the deeply embedded social and economic inequalities that define South African society and, on the other hand, an AIDS epidemic that is disproportionately severe among the more vulnerable and historically disadvantaged sections of society.
The uneven impact of AIDS
The mainstays of South Africa's efforts to fend against the impact of the AIDS epidemic are antiretroviral therapy (ART) provision and home-based care. Although vitally important, each in its current form also expresses the kinds of prevailing inequalities that warp society.
Social and political activism, much of it spearheaded by the Treatment Action Campaign, compelled the South African government in 2003 to introduce a national ART programme. By the end of 2005, almost 200 000 of an estimated one million individuals in need of antiretroviral drugs were taking them. The shortfall in ART provision is especially acute in poorly resourced provinces where health systems are malfunctioning as a result of human resource and infrastructure shortages, as well as inadequate management capacity .
Slightly fewer than half of the people accessing ART were doing so through the private health sector , which is accessible to a small minority of South Africans . The bulk of antiretroviral provision, ultimately, will have to occur through the public health sector, which is already overburdened by AIDS, with both the demand for and the cost of health services likely to increase, and health workers coming under greater strain.
It has been estimated that a country with stable 15% prevalence could expect to see 1.6–3.3% of its healthcare personnel die of AIDS each year, a cumulative mortality rate over 5 years of 8–16% . According to research by the Human Sciences Research Council , AIDS was responsible for approximately 13% of deaths among health workers in 1997–2001, when the wave of AIDS mortality was still beginning to crest in South Africa. The need for well-trained health personnel has, however, never been greater. Completing the roll-out of the Government's ART programme will require an additional 3200 doctors, 2400 nurses, 765 social workers and 112 pharmacists in the public health system by 2009 . Need far outstrips supply.
Meanwhile, care needs surge. A survey of public and private healthcare facilities found that 28% of patients in medical and paediatric wards were HIV positive (46% in public hospitals), and their hospital stays were almost twice as long as those of non-AIDS patients (13.7 days compared with 8.2 days). Total bed occupancy rates have stayed approximately stable, which suggests that AIDS patients were ‘crowding out’ non-AIDS patients in the public sector . Studies in the Hlabisa district of KwaZulu-Natal found that clinic visits had increased by 88% in 1991–2001 and hospital admissions by 81% [44,45]. Almost three in four healthcare workers surveyed nationally have reported heavier workloads .
These trends are overlaid with wider inequities. A large share of South Africa's gross domestic product, approximately 9%, goes towards healthcare. The spending, however, occurs in a two-tier system. Approximately 60% of the funds pay for the healthcare of the 15% of (typically, wealthier) South Africans who belong to private medical schemes and who use the well-resourced, for-profit private health system. Annual per capita expenditure on healthcare in the private sector is almost six times larger than that in the public sector . An additional layer of inequity involves the loss of South African healthcare workers to industrialized countries that pay higher salaries and often provide better working conditions. More than 23 000 South African medical professionals were working in Australia, Canada, New Zealand, the United Kingdom and the United States in 2003, according to an Organization for Economic Co-operation and Development study .
Home and community-based care
In such a context, home and community-based care (HBC) becomes a vital part of dealing with the impact of the epidemic. A general shift towards HBC has been an important element of the post-1994 overhaul of the health system. In theory, such an approach marshals the respective strengths of households, the communities they constitute and the organizations they spawn, and the state, and creates ‘continuum of care’ that should boost the quality, scale and sustainability of care .
The current reality is less alluring. Patients and their caregivers are having to subsidize many aspects of care provision themselves, while, in turn, paying the costs of not receiving the levels of care and support they require. Essential needs, such as food and money for basic necessities, often go unmet [49,50].
Assessments of self-initiated care projects report that caregivers often lack the basic resources they need to perform their tasks safely and efficiently. More home-based care kits are being made available by government departments or donors, but training in care tasks, as well as psychological support and counselling for caregivers remains inadequate. Often caregivers themselves lack knowledge about AIDS, or are unaware that the individual being cared for is HIV positive . In such cases, basic precautions are neglected, and the caregiver risks becoming infected herself. When surveyed, caregivers routinely cite as major problems the mental and emotional strain their work entails [51,52].
The paucity, inconsistency and poorly coordinated nature of institutional support is one of the single biggest weaknesses in HBC currently. In such an erratic context, the ‘continuum of care’ relies heavily on the services of non-governmental organizations and community-based organizations, and on the toil and resources of individuals. Rather than constitute a cogent system, the overall tenor has been one of crisis management [53,54].
As currently practiced, HBC concentrates many of the material and emotional costs of AIDS care within the homes and neighbourhoods of South Africa's poor, with much of the burden resting on women. In so doing, HBC adheres to the same polarizing logic that defines South African society at large. It is intensifying the exploitation of poor women's labour, financial and emotional reserves, a form of value extraction that subsidizes the economy at every level from the household outward, but remains invisible in political and economic discourse .
It is vital that the state identifies and, drawing also on the assets of other sectors of society, implements mechanisms for providing better and more reliable support to poor households and communities that are engaged in community-level responses.
The impact on educational advancement
Especially vulnerable to rising AIDS-related morbidity and mortality rates are institutions of the state and civil society that are involved in the reproduction of ‘human’ and ‘social capital’, such as the education system.
A Human Sciences Research Council (HSRC) cross-sectional study among educators in 2005 found an HIV prevalence of 13% overall, with significant variations depending on age, income levels, race and area. Among educators in KwaZulu-Natal, and among those aged 25–34 years nationally, HIV prevalence was approximately 20%. In-service deaths among educators increased by 30% between 1997/1998 and 2003/2004; in KwaZulu-Natal there was an 80% increase in the same period. Along with contract termination and resignations, mortality now ranks among the top causes of staff losses, which is saying something in a sector in which, according to the HSRC study, more than half the educators polled said they wanted to leave the profession . Extrapolations from the HSRC survey suggest that at least 10 000 South African educators would be eligible for immediate antiretroviral treatment (based on a threshold CD4 cell count of below 200 cells/μl).
It has been estimated that approximately 30 000 educators would need to be trained annually to maintain current staffing levels and ensure swift replacement. The profession is not, however, attracting newcomers in sufficient numbers, partly as a result of concerns about employment conditions and insecurity. Meanwhile, training college cut-backs and other restructuring have hamstrung training capacity. Management and administrative skills are in especially short supply .
On current trends, absenteeism and personnel shortages in the public school system are likely to worsen, and educators' morale is likely to deteriorate further. At the same time, the demand for educators' skills in the private education system and in other sectors has been rising, increasing the odds of educators being lured out of the public school system . Unless counteracted, this can be expected to aggravate dysfunction and undermine the quality of services in the public education system, which predominantly serves poorer South Africans. If basic public school education suffers, the springboard for higher education and skills training weakens. This will limit the social mobility prospects of poor students, while also undermining the supply of highly skilled labour market entrants in an economy that has been geared to rely heavily on a strong, top-end skills base. Channels for quality educational advancement will of course be available, but mainly those who can afford them. Already, even secondary (high-school) education offers little protection against unemployment. At almost 30%, unemployment levels are high even among workers with secondary education . If the quality of public school education deteriorates further, against a backdrop of continuing marginalization of the poorest households, and of overall polarization, social mobility will be hobbled, trapping more in the mire of chronic poverty. It is likely that many of the estimated 2.5 million children (aged 0–17 years) orphaned by AIDS and other causes in South Africa will be particularly disadvantaged in their quest for an education.
Similarly, AIDS can be expected to corrode other institutions' capacities to provide predictable, consistent and acceptable standards of service. Already saddled with heavy workloads and compromised capacity, the police, correctional and judicial services, as well as administrative services at local government level, are especially vulnerable. So, too, the many community-based organizations that play vital welfarist roles at a local level, and which are often heavily reliant on the work of a few key individuals.
Deflecting the economic costs
That South Africa's epidemic will affect the economy at large seems beyond dispute, but it is less obvious what the extent of that damage might be . Some estimates seem to trivialize the effect of AIDS by suggesting a negligible effect on national economic output, whereas others anticipate severe damage [58–60]. The disagreements stem from the fact that the estimates rest on different assessments of the epidemic's demographic impact, about the channels along which AIDS affects the economy, and about the nature of those effects themselves.
The direct costs of AIDS to organizations and businesses tend to manifest in the form of higher healthcare costs and more expensive workers' benefits, whereas the indirect costs take the form of reduced productivity, loss of skills, experience and institutional memory, as well as (re)training and recruitment time and expenses. Indirect costs are significantly higher for skilled workers, as are employee benefit costs . In a serious AIDS epidemic, such costs can add up to a hidden employment or payroll tax .
South Africa has a very stratified labour pool, marked by shortages of highly skilled workers and a surplus of low and medium-skilled workers. Increased demand for an already-limited pool of skilled and highly skilled labour could push up wages and salaries at that end of the labour market. Some analysts expect the epidemic also to discourage private-sector investment in skills training and education, with companies more inclined to poach or lure top skills from elsewhere in the world, especially from other African countries . One effect would be to widen income inequalities.
A handful of major companies have introduced high-profile ART programmes for some of their employees, and several more also emphasize HIV prevention. At least one major retailer has diversified its operations abroad and tightened credit control systems in a bid to limit the anticipated effect of the epidemic on its market share . Most companies, though, especially medium-sized companies, seem to be taking AIDS in their stride. They have considerable leeway for deflecting the effects of the epidemic, and they are using it .
In bids to achieve greater flexibility in production and employment, companies continue to shift the terms on which they use labour, a trend that predates AIDS, but is having a huge effect on working South Africans' abilities to cushion themselves against the effects of the epidemic. AIDS is likely to intensify that trend . Companies have been intensifying the adoption of labour-saving work methods and technologies (spurred by a host of incentives) , the outsourcing and casualization of jobs (and the use of labour brokers for recruiting new workers), and cutting worker benefits [65,67,68]. When surveyed in 2004, almost one quarter of mining companies and almost one fifth of manufacturing companies reported that they were investing in machinery and equipment in order to reduce their labour dependency because of AIDS . Partly as a result of such changes, unemployment levels remain very high, and real wages for lower and medium-skilled workers have stagnated or declined (depending on the sector) in the past decade .
According to one survey, only one quarter of workers in the private sector have access to subsidized medical care . For workers with such access, medical benefits are now often capped at levels far too low to cover the costs of serious ill health or injury, whereas companies have been slashing employer contributions and requiring that workers pay a larger share of the premiums for the same benefits. By 2000, on average more than one third of workers with access to medical schemes had withdrawn from them because they could not afford to pay their contributions . According to one of South Africa's largest insurance companies, the burden of medical aid costs is being borne by employees . Regulatory changes proposed by the South African Government in 2006 could improve some workers' access to medical insurance schemes, but ‘casual’ and ‘piecemeal’ workers are unlikely to benefit. In addition, a major shift has also occurred from defined-benefit retirement funds to defined-contribution funds (the latter offering meagre help to workers felled, for example, by disease in the prime of their lives) [74,75]. The net effect is a whittling of benefits for those South Africans with jobs, at a time when they and their families face increased risks of severe illness and premature death. Left to fend for themselves, meanwhile, are the masses of ‘casual’ workers, and the unemployed.
Although such adjustments are enabling many companies (particularly larger ones) to sidestep much of the epidemic's impact, many thousands of small enterprises lack similar evasive abilities. As the epidemic shrinks household incomes, small businesses are likely to be badly affected, especially those in the ‘informal sector’ of the economy that rely heavily on the custom of poor households, such as informal retailers, spaza shops and ‘microenterprises’, which typically are operated by vulnerable households themselves. Reduced discretionary household spending as a result of AIDS is also likely to limit investment in informal sector activities . Such outcomes would further exacerbate the socioeconomic insecurity of poor households.
In such ways, many of the costs of the epidemic are ‘socialized’, trapped or deflected in the lives, homes and neighbourhoods of the poor. A massive, regressive redistribution of risk and responsibility is underway.
What can be done?
One obvious, long-term challenge is to prevent the spread of HIV more effectively. This will be no easy feat. There is some evidence of ‘positive’ behaviour change among young South Africans (including increased condom use and abstaining from casual sex) [9,77], but it is not yet clear whether this will prove significant enough to reverse the epidemic.
The extent of the epidemic's impact will also be shaped by the speed and extent to which ART is made available, and the degree to which treatment is adhered to. Universal and affordable access to ART, along with improved tuberculosis treatment programmes and an overhaul of the home and community-based care system, should be a priority.
In a society in which millions are impoverished in the midst of abundance, AIDS also underscores the need for an encompassing social package that forms part of an overarching programme of redistribution and rights-realization. This should include safeguarded food security, the provision of affordable (that is to say, decommodified) essential services, large-scale job creation and workers' rights protection, and the alignment of social transfers to unfolding needs. South Africa's development path, in other words, must acquire a much stronger redistributive character.
In the short term, the system of social transfers requires a radical, progressive overhaul, which should include the introduction of a universal social assistance instrument that can provide a minimum level of social support, such as a ‘basic income grant’, a device championed by the country's Social Development Ministry, trade unions, church organizations and much of the non-governmental organization sector for several years [78,79]. Poor households rely heavily on social transfers, especially, it appears, when affected by health crises , and there is ample evidence of the developmental functions of such transfers in the South African context [36,81–84]. The country's social transfer system has been expanded and made more equitable since 1994 . The current system, though, remains marred by several hindrances, including means testing, rigid eligibility criteria and a high relative cost of applying for grants . Financial simulations indicate that a ‘basic income grant’ of just R100 (US$14) per month could contribute substantially to reducing poverty and inequality in South Africa .
In conclusion, in a society with South Africa's characteristics, the AIDS epidemic feeds off and aggravates existing inequalities. In the wake of this epidemic, which is likely to last at least another generation, South Africa can anticipate deeper impoverishment, intensified polarization and wider inequality. The extent and duration of such an outcome will depend on whether South Africans can improve and expand HIV prevention, treatment and care efforts, and at the same time temper the social and economic factors that fuel the epidemic and intensify its impact.
Sponsorship: This study was supported by the UCLA Program in Global Health.
Conflicts of interest: None.
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Keywords:© 2007 Lippincott Williams & Wilkins, Inc.
HIV; AIDS; impact; inequality; poverty; women; household; home-based care; workplace; social protection