South africa has the biggest and most high profile hiv epidemic in the world, with an estimated 6.3 million people living with hiv in 2013. In the same year, there were 330,0 new infections while 200,0 south africans died from aids related illnesses.1 south africa has the largest antiretroviral treatment programme globally and these efforts have been largely financed from its own domestic resources. For example, one study reported an hiv prevalence of 43.6% among msm in johannesburg and durban.5 by contrast, 10% of self identified msm from urban areas in western cape are reportedly living with hiv.6 many msm still face high levels of social stigma and homophobic violence due to traditional and conservative attitudes. These are prerequisites for the provision of hiv services for msm as well as other members of the lesbian, gay, bisexual and transgender lgbt community.

Moreover, many sex workers also inject drugs, exacerbating their vulnerability to hiv infection.14 female sex workers fsw are particularly affected with one study reporting an hiv prevalence of nearly 60% among fsw compared to 13% among women in the general population.15 educational organisations have reported difficulties in delivering hiv prevention services to sex workers due to on going police harassment. One study found that up to 70% of women who sold sex had experienced abuse by the authorities:16 he put me on the floor. The police officer raped me, then the second one, after that the third one did it again. Then the first one appeared again… he let me out by the back gate without my property. female sex worker, cape town 16 in light of this, the south african national aids council sanac recently commissioned the first ever study assessing the number of sex workers in the country. It is hoped that this report will enable south africa to better estimate the need for hiv services among this group in order to develop effective policy.14 data on hiv prevalence among people who inject drugs pwid in south africa is very limited and where it does exists, is based on small sample sizes.

However, pwid account for a comparatively low 1.3% of new hiv infections.17 one study has reported that up to 86% of south africans who inject drugs share injection equipment such as syringes and other drug paraphernalia.18 another study reported that some pwid re use equipment between 2 and 15 times.18 pwid are also associated with other high risk behaviours such as sex work and unsafe sexual practices. For example, the irare study demonstrated a strong link between drug use and risky sexual practices with up to 65% of pwid in south africa thought to practice unsafe sex.18 in 2012, an estimated 410,0 children aged 0 to 14 were living with hiv in south africa. From 2002 to 2012, hiv prevalence declined among children, due mainly to programmes to prevent the mother to child transmission of hiv pmtct. Between 2008 and 2012, annual hiv testing increased from an estimated 19.9% to 37.5% among men, and from 28.7% to 52.6% among women. The higher testing figures seen among women have been attributed to the added effect of the pmtct programme, which enables women to access hiv testing services when they go for antenatal appointments.25 in south africa, the link has also been made between an individual’s socio economic background and the likelihood that they will test for hiv.

Those who have taken an hiv test and know their status, are more likely to have a higher level of education, be employed, have accurate hiv knowledge and a higher perception of risk.26 another determining factor is whether an individual lives in an urban or rural setting. In this case, nurses rather than doctors initiate art lay counsellors rather than nurses carry out hiv tests and pharmacy assistants rather than pharmacists prescribe arvs. This increases the number access points to treatment and care by reducing the ‘bottlenecks’ in the healthcare system created by a shortage of staff able to provide vital hiv services.24 though treatment programmes have expanded rapidly, many south africans still begin treatment with a very low cd4 count. In 2009, it was reported that the average cd4 count at which patients started treatment in south africa was just 87.30 one study based in two durban clinics found that 60% of patients were tested when their cd4 counts were below 200. Of those who were eligible for treatment, more than a fifth died, mostly before beginning treatment.31 in other cases, individuals simply refuse treatment despite being eligible. A study in soweto found that of 743 newly diagnosed hiv positive adults eligible to begin treatment immediately, 20% refused. More than a third gave feeling healthy as the reason for refusing treatment despite having a low cd4 count, with many also co infected with tuberculosis.32 hiv prevention in south africa is centred on the national strategic plan nsp.

The previous nsp 2007 2011 oversaw a dramatic scaling up of south africa's antiretroviral treatment art programme with the purpose of decreasing the number of new hiv infections by reducing viral load. The current national strategic plan 2012 2016 is framed primarily around the unaids vision of zero new hiv infections, zero discrimination and zero aids related deaths. It has also committed to zero new infections due to mother to child transmission. 33 34 the latest nsp highlights south africa's commitment to ending mother to child transmission mtct of hiv.

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Over the past decade, the country has made great progress in this area due largely to improvements in the choice of antiretroviral drugs arvs and the widespread accessibility of the pmtct programme.35 when south africa first launched its pmtct programme in 2001, there was very limited intervention before and after childbirth. Guidelines have since been revised several times and are now largely based on who recommendations.35 by 2010, pmtct services were being offered at 98% of all healthcare facilities in the country. Moreover, by june 2011, the national htc campaign had tested 274,0 women with 78.5% of those diagnosed as positive being referred onto treatment.3 as a result, mother to child transmission of hiv in south africa has fallen to 3.5% meeting the previous nsps target of less than 5%.36 between 2009 and 2011, new annual hiv infections among children fell from 56,500 to 29,100.37 however, maternal mortality has not followed this trend. Male condoms are widely available and the female condom programme is one of the biggest and most established in the world.39 between 2007 and 2010, the distribution of male condoms increased by 60%, from 308.5 million to 495 million a year. However, in terms of condoms per person this only represents a small increase from 12.7 in 2007 to 14.5 in 2010.

In the same period, the number of female condoms distributed increased from 3.6 million to 5 million. However, it is widely acknowledge that female condoms are not as readily available as they should be.3 in recent years, condom usage in south africa has fallen. In 2008, 85% of 15 24 year old males reported using a condom during their last sexual encounter by 2012, this had fallen to 68%. The main objectives of the programme are to integrate hiv education into the school curriculum to avert new hiv infections and provide care and support for pupils already living with hiv. The programme is mostly implemented through life orientation lessons.45 however, in many places there is a shortage of teacher training on these issues. In 2008, teaching unions called for a life orientation module to be included in all teacher training.46 in some cases, gaps in the delivery of the life orientation curriculum are filled by independent organisations.47 in other instances, teachers report feeling uncomfortable about teaching a curriculum that contradicts with their own values and beliefs.48 high dropout rates in schools also compromise effective hiv and sex education. It has been suggested that prevention programmes should be focussed towards younger children while more of them are in education and before they become sexually active.49 in south africa, there have been a number of hiv awareness campaigns.

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The 2012 national communication survey on hiv/aids found that the country's hiv communication programmes were having a positive effect, particularly on youth aged 15 24 , with an increase in condom usage, uptake of htc and male circumcision. By contrast, knowledge around safe breastfeeding practices among pregnant mothers living with hiv remains low.50 the main hiv awareness campaigns include: khomanani was an aids awareness campaign launched by the department of health. The campaign utilised mass media including radio announcements and situational sketches on television.