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The legacy of apartheid in South Africa, which has resulted in rampant poverty and gross racial disparities in education and health care, has made black South Africans highly susceptible to HIV/AIDS. South Africa’s HIV/AIDS epidemic, which is among the most severe in the world, is concentrated in its townships, where many black South Africans live due to the lingering effects of the Group Areas Act. A 2008 study revealed that HIV/AIDS infection in South Africa is distinctly divided along racial lines: 13.6% of black Africans in South Africa are HIV-positive, whereas only 0.3% of whites living in South Africa have the disease. False traditional beliefs about HIV/AIDS, which contribute to the spread of the disease, persist in townships due to the lack of education and awareness programs in these regions. Sexual violence and local attitudes toward HIV/AIDS have also amplified the epidemic. Although some education efforts and treatment and prevention programs have succeeded in spreading awareness about HIV/AIDS in townships, the impact of the disease remains severe.

Prevalence
In 2008, HIV/AIDS was most prevalent in the South African provinces of KwaZulu-Natal (15.8% HIV-positive), Mpumalanga (15.4% HIV-positive), Free State (12.6% HIV-positive), and North West (11.3% HIV-positive), while only 3.8% of the population was HIV-positive in Western Cape. These statistics demonstrate that there is a direct correlation between HIV/AIDS prevalence and black population size: KwaZulu-Natal, Mpumalanga, Free State, and North West are 86.0%, 92.0%, 87.1%, and 90.8% black, respectively, while Western Cape is 18.4% white and only 30.1% black. A survey conducted in 2010 indicated that HIV/AIDS infection among pregnant women is highest in KwaZulu-Natal (39.5%), Mpumalanga (35.1%), Free State (30.6%), and Gauteng (30.4%). These provinces have populations that are 86.0% black, 92.0% black, 87.1% black, and 75.2%, respectively. On the other hand, the provinces with the lowest percent of HIV-positive pregnant women – Northern Cape and Western Cape – have significant white populations. KwaZulu-Natal, South Africa’s largest and poorest province, is considered the epicenter of South Africa’s AIDS epidemic: it is estimated that more than 33% of the province’s 9.9 million inhabitants are HIV-positive. AIDS orphans maintain over 10% of KwaZulu-Natal’s households. In Khayelitsha, South Africa’s largest township, approximately 27% of adults and 40% of pregnant women in the township are HIV-positive.

Traditional beliefs about HIV/AIDS
Due to a lack of education programs, inaccurate beliefs about HIV/AIDS are common among township residents in South Africa. For example, many Zulus of KwaZulu-Natal hold the traditional belief that raping a child virgin will cleanse an HIV-positive individual of the disease. Police reports from the KwaZulu-Natal region demonstrate that child rape among the Zulu has roughly doubled since 1994, when this belief gradually began to spread. In addition, anonymous flyers posted in Durban townships in 1990 falsely claimed that South African men could become immune to AIDS by raping Indian women. These misinformed beliefs have led to increased rape and sexual violence in South African townships, which has accelerated the spread of the disease. In 1991, Durban traders threw an entire shipment of bright red oranges in the harbor because they believed that white farmers had injected the fruit with HIV-positive blood. These traditional beliefs about HIV/AIDS have hindered attempts to address the epidemic and have magnified its impact.

Stigma
HIV/AIDS stigma is widespread in South Africa: a 2002 national survey revealed that “26% of respondents… would not be willing to share a meal with a person living with AIDS, 18% were unwilling to sleep in the same room with someone with AIDS, and 6% would not talk to a person they knew to have AIDS." However, AIDS-related stigma is most severe among distinct groups in South Africa who lack access to reliable information about the disease. For example, many traditional groups believe that ancestral spirits and supernatural forces punish those who have failed to lead moral lives by infecting them with HIV. According to a study published in 2004, South Africans who attributed HIV/AIDS to spirits and the supernatural were more likely to claim that people with HIV/AIDS are dirty and repulsive. Many South Africans in townships believe that HIV is transmitted through proximity to HIV-positive individuals, which leads them to claim that people with AIDS should be socially ostracized. A study conducted in 2010 indicated that the majority of girls in a Cape Town township correlated thinness with disease – in particular, HIV/AIDS. Because of this, people who are slender or experience weight loss face discrimination. This form of stigma affects South Africans living in townships because rates of malnourishment are higher in townships than in other parts of South Africa. There is a clear trend among the factors that contribute to AIDS stigma: they are all more likely to exist among those who lack access to health care and AIDS education, which explains the prevalence of these beliefs in South African townships.

Sexual violence
Although many township inhabitants are knowledgeable about AIDS prevention methods, rates of condom use are still strikingly low. Studies suggest that fear of sexual abuse, which results from unequal power dynamics between men and women in South African townships, is the primary explanation for low condom use rates. Women in Khutsong reported that their relationship would deteriorate if they insisted that their partner use a condom because such a request demonstrates a lack of trust and respect. In addition, men who have tested positive for HIV often respond to their diagnosis by raping women and spreading the disease, either because they believe it will purify their blood or because they are afraid to die alone. Another theory, posited by Dr. Catherine Campbell, states that men in South African townships view rape as a way to maintain their masculinity in an environment that allows them little opportunity to successfully provide for their families. Township youths who resent the government’s failed attempts at post-apartheid integration often turn to crime, including rape, to express their frustration. These psychological conflicts among men in South African townships have contributed to South Africa’s rape epidemic and the spread of HIV/AIDS.

Solidarity
A sense of passiveness and solidarity among youths in South African townships has contributed to the spread of HIV/AIDS. According to a 1999 study, adolescents in the KwaZulu-Natal province of South Africa view HIV/AIDS as “a new part of growing up, surely not something to be eagerly anticipated, but accepted nonetheless as an almost inevitable consequence of being an adult." The South African rape crisis is fueled partially by the desire of South African adolescents to, out of fear and desperation, spread HIV/AIDS to their peers. Ubuntu, an African philosophy that promotes a spirit of brotherhood between and among community members, explains why township adolescents knowingly spread the disease – they believe that the entire community should share the burden. As a result of this, HIV-positive fathers will sometimes rape their daughters to guarantee their loyalty and care when their parent’s health begins to deteriorate. It is also likely that “a strong sense of peer group affiliation, forged during their years in South Africa’s war-ravished townships” has contributed to the adolescent need to share the frustration and hopelessness that accompany the disease. These adolescents were raised in the midst of the harshest stages of the struggle against apartheid, which may explain their intense solidarity.

AIDS orphans
Orphanhood is a severe consequence of the AIDS epidemic in South African townships. A 2006 study stated that there were 2.2 million AIDS-orphaned children in South Africa alone. AIDS orphans in an urban Cape Town township have been shown to have significant rates of depression, anxiety, post-traumatic stress, peer relationship difficulties, suicidal urges, and delinquency. These rates are higher than those of both non-AIDS orphans and non-orphans in South African townships. AIDS orphans are also less likely than non-AIDS orphans and non-orphans to attend and remain enrolled in school due to stigma and an increase in adult responsibilities such as care work and formal or informal employment.

Education
AIDS education in townships is a multifaceted issue. Male informants in the KwaZulu-Natal region, for example, claim that AIDS education is responsible for the rape crisis because it teaches HIV-positive individuals how to spread the disease. There is currently no law requiring AIDS education in South African schools. Government attempts to raise AIDS awareness have largely failed to reach South Africa’s underserved townships, where the quality of education is poor. However, there is a clear need for education programs in South African townships – a survey in Khutsong demonstrated that 70% of the community’s young men believed they were not vulnerable to infection.

A 1994 pilot study in an urban Cape Town township demonstrated the potential, but also the limitations, of AIDS education. The study compared AIDS knowledge in two schools, one of which underwent an intensive AIDS awareness program and one of which did not. Before the program, students in both schools were misinformed about HIV transmission – many believed that drinking from an unwashed cup and touching somebody with the disease could transmit the virus. Few students knew that using condoms, having only one partner, and attending clinics for information and tests can all help prevent HIV/AIDS. Before the implementation of the educational program, students in both schools also expressed hostility toward HIV-positive individuals – very few indicated that they would welcome an HIV-positive student into their class. They were also likely to underestimate the prevalence and severity of the disease. Following the completion of the AIDS awareness program, the students who had participated were more knowledgeable about “HIV transmission, prevention, and the course of the disease." However, hostility toward HIV-positive individuals decreased only slightly among the students after the program and the students did not demonstrate any intention to increase their use of condoms.

Treatment and prevention
Most of South Africa’s current anti-AIDS efforts target treatment rather than prevention. Although prevention programs are considered more cost effective, the pervasiveness of the disease has made treatment facilities increasingly important. However, treatment has played a limited role in South African townships due to the high cost of antiretroviral drugs and lack of infrastructure and trained professionals. Prevention efforts such as school education, education in the workplace, and mass media campaigns are concentrated in urban areas and have largely failed to reach the appropriate audience.

In Thailand, a policy requiring condom use in regulated brothels significantly reduced the spread of HIV/AIDS. However, AIDS in South Africa reaches beyond sex workers to the general population and is at a later, more severe stage. A 2003 study used the PLACE method to determine where in townships people meet new sexual partners in order to strategically focus prevention efforts in these locations. These locations included “bars, taverns, bottle stores, nightclubs, streets, and hotels” as well as local shebeens. The vast majority of these locations did not provide condoms or information about the transmission HIV/AIDS. Most patrons visit these sites daily or weekly; therefore, the PLACE method suggests that prevention efforts such as education and social support could be successfully focused on these popular venues.

A 2005 study determined that the introduction of antiretroviral medication, mother-to-child transmission prevention programs, and Doctors Without Borders clinics to Khayelitsha played a role in reducing the impact of the disease. These programs have “provided incentives for HIV testing, galvanized HIV/AIDS educators to reach populations most at risk, and decreased the HIV incidence rates in Khayeltisha." HIV voluntary counseling and testing programs have also had an impact on HIV/AIDS awareness, but have for the most part failed to influence behavior.

Churches
Churches in South African townships have largely failed to use their social and cultural influence to combat the HIV/AIDS epidemic. Many churches reject HIV-positive members due to “denial of the extent of the disease, ignorance about the causes and treatments, and traditional stances on sexual morality” as well as the belief that HIV/AIDS is well-deserved punishment for immoral behavior. In addition, many organizations such as the South African Church Leaders Association only formally acknowledged the severity of the HIV/AIDS epidemic within the last decade.

Despite these large-scale failures, some township churches have become actively engaged in preventing the spread of HIV/AIDS in their communities. Archbishop Desmond Tutu of the Anglican Church in the Western Cape founded the Desmond Tutu HIV Foundation and speaks openly and progressively about the role of education in battling HIV/AIDS. St. Michael’s Church in Khayelitsha has supported the efforts of the Millennium Development Goals by developing an HIV/AIDS clinic and orphanage known as Fikelela; this movement has spread to dozens of Anglican churches.

Attempts to address the epidemic
HIV/AIDS was largely considered a peripheral problem by the South African government and NGOs before the disintegration of apartheid in 1994.

National government
After apartheid was formally discontinued in 1994, the government made many efforts to combat HIV/AIDS at the national and provincial levels. The National AIDS Congress of South Africa (NACOSA) designed a plan to combat AIDS through national policy. The Khayelitsha District Management Team and an Information Team that focused on AIDS from an epidemiological angle were established after the HIV/AIDS Task Group formulated health plans for the nation in 1997. The national government appointed an AIDS program coordinator to Khayelitsha to monitor the disease in the region. Khayelitsha also implemented a mother-to-child-transmission prevention program in 1999. Somerset Hospital in Cape Town began to dedicate funding to HIV/AIDS research. However, at the turn of the century, when United Nations and World Health Organization reports stated that HIV/AIDS rates in South Africa were among the highest in the world and were steadily increasing, government efforts failed to meet demand. 450 voluntary counseling and testing centers and 800 trained counselors exist throughout the country, but these facilities are underused due to AIDS-related stigma and have therefore had minimal impact.

NGOs
NGOs have also played a role in combating and raising awareness about the HIV/AIDS epidemic. The Red Cross Society focused its care and awareness efforts in Khayelitsha and Nyanga through home-based initiatives and education programs in schools. Taxis outside Khayelitsha were involved in condom bash programs that educated the public about HIV transmission and handed out free condoms. National Progressive Primary Health Care (NPPHC), an NGO that trains community health workers and promotes health awareness through education, integrated HIV/AIDS into their program in response to the epidemic. The AIDS Training, Information, and Counseling Centres (ATICC) directed its HIV/AIDS education programs toward health care professionals in regions heavily affected by the disease.