With high rates of early sexual debut, low condom use and practices such as ukuthwala and traditional circumcision, the Eastern Cape faces unique health challenges. In August 2024, the HSRC hosted a provincial dialogue in East London to respond to the regional results of the Sixth South African National HIV Prevalence, Incidence, Behaviour and Communication Survey (SABSSM VI). The event encouraged open conversations and explored community-driven solutions to regional HIV rates and the problems that drive them. Jessie-Lee Smith reports.
An HIV-themed mural near Fort Hare University in Alice, in the Eastern Cape. Photo: Lysippos, CC BY-SA 3.0, Wikimedia Commons
On 15 August 2024, the HSRC travelled to the Eastern Cape to launch the first of nine provincial dialogues and released the regional results for the Sixth South African National HIV Prevalence, Incidence, Behaviour and Communication Survey (SABSSM VI). HSRC researchers, partners and other relevant stakeholders held group discussions to promote collaboration and brainstorm solutions to regional problems highlighted by the SABSSM VI results.
“An important aim of the dialogues was to foster and facilitate difficult conversations, which could build and strengthen ideas on how to solve problems associated with HIV,” SABSSM communications manager Yolande Shean said.
With a population of about 6.7 million people, of whom approximately 61% live in rural areas, the Eastern Cape is one of South Africa’s most rural provinces. In 2022, SABSSM VI showed that the province ranked fourth highest in HIV prevalence for all ages (13.7%), down from 15.9% in 2017 (Figure 1).
Figure 1. Overall HIV prevalence by age group, Eastern Cape Province, 2017 and 2022
Source: HSRC
Traditions, myths and beliefs
One attendee at the event said ukuthwala (‘bride abduction’) may be contributing to rates of HIV in girls aged 15 to 19. Ukuthwala is the practice of kidnapping and forcing young girls into marriage. She spoke of a myth, believed by some, that having sexual intercourse with a virgin will cure a man of HIV. “The fact that [virgins] are being married or forced into marriages is actually affecting the statistics,” the attendee suggested.
Dr Pelisa Dana, the acting head of the Eastern Cape AIDS Council secretariat, spoke about difficulties faced when external stakeholders attempt to influence long-held community traditions and customs.
“While ukuthwala is not necessarily something that most people are comfortable with, outside influence may be met with resistance if individuals feel that intervention will trample on their customs,” Dana said. “Whatever programmes or interventions we implement, we have to take those practices into account.”
Another attendee supported this view, saying “programmes that respect and integrate local customs and beliefs can improve trust and participation from those in our communities”.
Circumcision
The World Health Organization recommends voluntary medical male circumcision (VMMC) based on studies showing a 60% lower risk of men acquiring HIV infection during heterosexual exposure.
HSRC chief research manager Dr Shandir Ramlagan expanded on this topic.
“A traditional circumcision does not always guarantee that all the foreskin is removed, and if some of the foreskin remains, the inner foreskin provides an entry point for HIV, like in uncircumcised men. Therefore, we always recommend medical male circumcision,” said Ramlagan.
In 2022, the Eastern Cape had the second-highest self-reported rate of circumcision in the country at 77.2%, which was 13.5 percentage points higher than the national average. The Eastern Cape also had the highest rate of traditional circumcision, with 85% of circumcised males circumcised traditionally, 14.3% circumcised medically, and 0.6% reporting both types (Table 1).
* Confidence Interval
**Self-reported male circumcision performed by a healthcare provider
*** Self–reported male circumcision not performed by a healthcare provider
Source: HSRC
An attendee shared concerns about illegal initiation schools, which operate without registration or regulation and conduct initiation practices such as traditional circumcision. Reports from some have revealed incidents of physical abuse. In severe cases, young men have suffered penile amputations or even death due to circumcisions performed by untrained traditional surgeons, which had led to complications like gangrene or sepsis.
By late July 2024, 14 youths had reportedly lost their lives during the winter initiation season in the Eastern Cape. The delegates were also concerned that children who suffered injuries or witnessed deaths at these schools did not receive counselling after the trauma, which in some cases led to depression and even suicide.
Members of this group suggested that the Departments of Social Development, Basic Education and Health should collaborate to intervene and solve some of these challenges.
Another participant suggested that collaboration between the Department of Health, educational programme developers and traditional leaders was critical to ensuring safer practices and better health outcomes for young men undergoing traditional circumcisions.
Child pregnancy and sexual debut
Early sexual debut is considered a driver of the HIV epidemic. In the 2017 SABSSM V report, the Eastern Cape had the highest number of children who experienced their sexual debut before the age of 15 (15.8%). In 2022, this rate was 15.3%. SABSSM VI showed that the proportion of individuals who reported experiencing sexual debut before 15 in the Eastern Cape was higher than the national average in 2017 (13%) and 2022 (11.2%).
“We know in the Eastern Cape we have high levels of child pregnancy,” said an attendee. “Children are not only being impregnated by adults but [also] by their peers.” This attendee suggested implementing and strengthening family planning services in schools.
Another attendee suggested promoting abstinence in schools. “We are focusing a lot on our prevention programmes on women and girls, and we need to start including boys and men in that conversation so that they also take responsibility for some of the behaviour,” she said.
Condom use
Of those aged 15 years and older in the Eastern Cape, 34.7% reported using a condom during their most recent sexual encounter. This is below the national average of 39.0%. SABSSM VI also revealed that 48.2% of individuals had never used a condom throughout their relationship with their last sexual partner (Figure 2). Attendees presented several social and cultural problems linked to low rates of condom use.
Figure 2. Consistency of condom use of participants 15 years and older with their most recent sexual partner in the Eastern Cape in 2022 (%)
Source: HSRC
Dana reported that some people did not favour the flavoured condoms distributed by the government, as their distinct odour could reveal “where a person has been”.
HSRC senior research manager Dr Vuyelwa Mehlomakulu agreed that female condoms remained unpopular and undesirable. “The purpose of developing female condoms was to empower women. But it seems as though women still follow their partner’s requests,” she said.
HSRC facilitator Kutloano Skhosana said that, in some communities, condoms were thought of as a man’s responsibility. “This makes women afraid of being stigmatised by wearing one herself,” she explained.
Skhosana also said that women may feel worried about being too “sexually forward” and, therefore, did not want to introduce condoms into sexual encounters. One idea her group had to combat this was to package male and female condoms together, distributing the responsibility of introducing condom use more evenly.
Skhosana’s discussion group also noted that many individuals primarily thought of condoms as a contraceptive or as a barrier to contracting and spreading HIV. But women often take other forms of contraceptives, she said, and “HIV is not scary anymore”.
She explained that antiretroviral therapy (ART) had significantly extended life expectancy for those with HIV, and this complicated efforts to promote consistent condom use.
Messaging
“We need to change the communication around condom use and not limit it to say, ‘if you use condoms, it will prevent HIV’ … people don’t associate the lack of condoms or usage of condoms with the sexually transmitted infections that they are getting,” said an attendee from another group.
HSRC PhD intern Thembelihle Ginyana, a coordinator at the Eastern Cape launch, said that messaging should educate women that condoms “are not mainly just to prevent pregnancy”.
At 88.3%, the Eastern Cape was one of only three provinces with under 90% of its HIV-diagnosed individuals on ART. Mehlomakulu pointed out that low ART coverage may stem from old treatment guidelines, which fostered a belief that being physically healthy meant there was no need to take up treatment. Members of her discussion group suggested that more education was needed to inform individuals about the importance of early ART and viral load suppression.
Sources and messaging mechanisms were a prominent theme at the Eastern Cape Dialogue. Ginyana suggested that reviving popular media outputs like the television series Soul City, which mirrored critical societal issues, could help spread messages related to sexual health and HIV treatment.
Sibusiso Senti, a district manager for GBV and HIV prevention programmes in Eastern Cape schools, said messaging needed to be modernised.
“We need to use platforms like TikTok and encourage peer-to-peer programmes,” said Senti. “It has been shown that messaging targeting young people is more effective when it comes from young people.”
Another attendee added that, today, the settings where young people have sex have changed. Messaging, therefore, needed to convey that condoms could be used fast and conveniently in a multitude of settings, including outside the bedroom. “The language also needs to accommodate what is happening now, without any judgement or stigma attached to it.”
Research contacts
Yolande Shean for SABSSM research enquiries, as well as Adlai Davids, senior research manager, and Thembelihle Ginyana, PhD intern, in the HSRC’s Public Health, Societies and Belonging Division
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