As a province, KwaZulu-Natal recently led South Africa in antiretroviral treatment coverage and HIV viral load suppression. However, the province continues to grapple with disparities among vulnerable groups. Youth and young women are disproportionately affected, driven by socio-economic vulnerabilities and pervasive risky sexual behaviours among men. Stakeholders at the release of the province’s latest HIV household survey called for comprehensive interventions to empower women and engage traditional leaders in promoting safe sexual practices, with a view to curbing the ongoing spread of HIV in the province. By Jessie-Lee Smith
SABSSM VI fieldworkers visiting sites in KwaZulu-Natal in March 2022, Photo: HSRC
Statistics show that KwaZulu-Natal (KZN) when compared with other provinces, had the second-highest HIV prevalence rate at 16% and the highest number of people living with HIV in South Africa in 2022 (1,980,000).
However, the province also had the strongest performance in 95–95–95 goals compared to other provinces, having the largest proportion of people with HIV knowing their status, being on antiretroviral treatment (ART), and virally suppressed.
The HSRC’s Professor Khangelani Zuma presented this among the KZN findings of the Sixth South African National HIV Prevalence, Incidence, Behaviour, and Communication Survey (SABSSM VI) in Durban in September.
Zuma, the survey’s overall principal investigator, noted that KZN has had one of the most successful HIV programmes in the country.
When analysing the success of HIV interventions, he said, it was not only the total number of people living with HIV (Figure 1) that mattered but also the proportion who took their ART so diligently that they were virally suppressed and unable to transmit the virus.
Figure 1. Overall HIV prevalence, KwaZulu-Natal Province, 2017 and 2022
Source: HSRC
Treatment cascade
Figure 2 shows the status of KZN’s 95–95–95 treatment cascade, where 94% of people living with HIV in the province knew their HIV status. Of those who knew, 93.4% were on ART and of those on ART, 95.3% were virally suppressed.
Figure 2. 95-95-95 targets for PLHIV aged 15+ years, by selected demographics, KwaZulu-Natal Province, 2022
Source: HSRC
Behavioural drivers and traditional leaders
Zonke Ndlovu, from the Lubanzilwazi Resource Centre, spoke about the many programmes and projects that contributed to high treatment coverage. For example, she referred to a service at local clinics called “happy hour” for men. During these “happy hours”, men were not made to queue but allowed to walk in and be attended to immediately. She said that this had encouraged men, who were less likely to be in treatment, to increase their engagement with HIV services.
KZN also boasted the highest proportion of medical male circumcisions in the country, at 87.6% among those who had been circumcised. According to one attendee, traditional leaders championing circumcision played a significant role in accomplishing this. “Sometimes traditional leaders will even slaughter a bull in celebration of a young man being circumcised,” she said.
The same attendee argued that these leaders should play an extended role in encouraging other good health practices and safe sex behaviours in young men.
SABSSM VI showed that men participated more frequently in risky sexual behaviour. Men (12.3%) were three times more likely than women (4.8%) to have had sexual intercourse before the age of 15 and six times more likely to report having multiple sexual partners. Figure 3 shows that 18.6% of men, compared to 3.5% of women, engaged in having multiple sexual partners.
Figure 3. Multiple sexual partners in the past 12 months among people aged 15+ years, by sex and age, KwaZulu-Natal Province, 2022
Source: HSRC
Youth disparities
Zuma highlighted the disparities in population treatment coverage and viral suppression by age in KZN. Only 62.8% of HIV-positive youth between the ages of 15 and 24 were on treatment, and only 74% of them were virally suppressed.
“We have our work cut out for us when it comes to youth and children,” said Zuma.
University of KwaZulu-Natal (UKZN) lecturer Silingene Ngcobo emphasised the importance of home-based interventions, urging parents to actively engage in sex education and promote open communication on pregnancy, sexually transmitted infections (STIs) and HIV.
“Parental education is where primary socialisation happens,” said Ngcobo. “It needs to happen before they become sexually active.”
Thandekile Msibi, from the Zululand District Department of Health, suggested programmes to empower and educate mothers on broaching challenging topics with their children. She argued that this would help combat stigma and provide mothers with tools to raise their children with an understanding of safe sexual health practices.
Ndlovu proposed standardised disclosure programmes encouraging children who received their diagnosis themselves to share their status with parents or other available adults. Phakama Dlwati from the KZN Department of Health supported this proposal, saying that mental health support and dismantling myths were essential to improving disclosure and treatment uptake.
Ndlovu spoke about the importance of messaging in reaching youth and closing information gaps. She said messaging should be as robust as it was with COVID-19: “We need messaging coming onto our phones, on TV and in commercials”.
SABSSM VI fieldworkers visiting sites in KwaZulu-Natal in March 2022, Photo: HSRC
Reaching girls and women
Zuma also noted disparities between genders in HIV prevalence in KZN. Among young females aged 15–24, the prevalence was approximately 9.3%, nearly three times higher than the 3.3% observed in young males. For those aged 25–49 years, women had an HIV prevalence of 38.4%, almost double the 21.5% found in men.
For years, KZN leaders have been aware of “blessers” who leverage the economic vulnerability of young women for sexual favours. KZN Civil Society deputy chairperson Patrick Mdletshe said that unemployment in the region made young women more vulnerable to this phenomenon as it undermined their independence. Research on the problem of blessers showed that women often overlooked health risks such as HIV transmission in exchange for economic gains such as food and rent.
In July 2024, KZN stakeholders reissued warnings to male blessers, stating that the practice contributed significantly to teenage pregnancies and the spread of HIV.
Africa Health Research Institute researcher Luthando Zuma explained that even girls and young women who did not experience financial crises were under pressure to keep up with their peers. They would accept gifts such as hair treatments and phones in exchange for sexual relationships.
“We need to empower these girls and young women in the economy,” he said.
Attendees at the dialogue also identified a lack of spaces for women as a factor contributing to their vulnerability.
“We should respond to and strengthen prevention interventions within multicultural areas, schools, and recreational centres,” said Luthando Zuma.
UKZN researcher Ayanda Khumalo argued for sports, extramural activities and community spaces separate from school and work for women.
“Young girls, especially in the black communities, don’t have access to a third place [a place outside of school and home]. So, they tend to find solace in their boyfriends,” she said. “They often end up in relationships and having sex because they are bored.”
Sandile Zungu from the KZN Department of Education emphasised the importance of empowering girls and young women by fostering emotional intelligence, helping them to set boundaries, establish goals and build strong support systems.
Reaching men
Mdletshe said that while women were often taught self-care, men lacked similar guidance. Other attendees suggested community discussions about safe sexual practices, which would challenge prevailing norms and attitudes, and platforms specifically designed for men.
Zungu argued that increasing parental engagement with sons and empowering them with emotional intelligence could disincentivise them from “chasing after girls”.
Research contacts
Yolande Shean for SABSSM research enquiries, Dr Vuyelwa Mehlomakulu, a senior research manager, and Sbonelo Chamane, a master’s research trainee, in the HSRC Public Health Societies and Belonging Division
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