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13 May 2010

The health of our children: Results from a national HIV population survey

Human Sciences Research Council (HSRC)
Press Release

CAPE TOWN – Nearly all pregnant women in South Africa are making use of antenatal care clinics during pregnancy (97%), while nearly three-quarters have received antenatal services five times during their pregnancy (71.4%). There is also a high utilisation of public primary health care services for children in South Africa – although this does not always mean that services such as immunisation services are utilised.

These are some of the findings from a new study, The Health of our Children in South Africa: Results from a national HIV prevalence population survey , released in Cape Town today. The study is a further analysis of data gathered for the Third South African National HIV, Behaviour and Health Survey, 2008 which included adults and children. The survey sample for the children’s report comprised 8,966 children aged 0-18 and is nationally representative. This survey was the first to also capture the health of children aged 0-2 years old. View the study here:

The survey was funded by the US Centers for Disease Control and Prevention (CDC) using funds from the President’s Emergency Plan for AIDS Relief (PEPFAR) and the United Nations Children’s Fund (UNICEF). The research consortium consisted of the HSRC, the Medical Research Council (MRC), the Centre for AIDS Development, Research and Evaluation (CADRE), the National Institute for Communicable Diseases (NICD), the US Centers for Disease Control (CDC), and the United Nations Children’s Fund (UNICEF).

Key findings of the study
Maternal health

The Department of Health’s Ten Point Plan includes reduction of maternal and child mortality by improving the health status of this population. Therefore, access to good quality antenatal care and primary health care for pregnant women, mothers and children are crucial to reducing mortality.

The study found that 97% of pregnant mothers had accessed antenatal care during pregnancy and that nearly three-quarters (71.4%) had received antenatal services five times during their pregnancy. Furthermore, during labour, the majority of mothers have had access to a trained birth attendant. The study found that the majority of children under the age of two were born in a health care facility (hospital/clinic) with nurses or a midwife attending to the majority of births. Despite good access to health care for pregnant women, maternal mortality remains high (at about 2,500 per year) and this suggests that challenges remain with the quality of health care provided. The most common causes of maternal deaths were hypertension, obstetric haemorrhage, pregnancy-related sepsis, and pre-existing maternal diseases. A major cause of death that cannot be overlooked is AIDS, which is the biggest contributor to maternal deaths.

Download the Maternal Health and Child Health fact sheet:

Child health

It was found that there was a high utilisation of public primary health care services for children in South Africa. High utilisation does however not always result in recommended services being accessed. For example, prevention services such immunisation are critical, yet the study found that while there was overall good coverage of BCG vaccination against tuberculosis for children, levels of immunisation for Measles, Diphtheria, Tetanus, whooping cough (Pertussis), Polio, Haemophilus influenzae and hepatitis B were low and could still lead to outbreaks of disease – for example, the recent outbreak of measles which occurred in Gauteng in September 2009.

Feeding practices

Feeding practices have a direct impact on the survival of babies as it affects their nutritional status, growth and general health. The study found that mixed feeding was the most common method of feeding in South Africa with only 25.7% of babies exclusively breastfed, 22.5% exclusively formula-fed and 51.3% mixed fed during their first six months.

Although breastfeeding increases the survival chances and the health of a child by decreasing infant morbidity and mortality rates, it still is a major route of mother-to-child transmission of HIV. For this reason, formula feeding has been recommended as one of the strategies in preventing HIV transmission from a mother to her newborn. But published South African studies have found that mixed feeding was associated with a high risk of HIV in young children in the first three months of life compared to exclusive breastfeeding.

In November 2009, WHO and UNICEF issued a new guideline on HIV and infant feeding. The new guideline was based on significant programmatic experience and research evidence accumulated in various countries, including South Africa. The evidence has indicated that antiretroviral interventions to either HIV-positive mothers or HIV-exposed infants can significantly reduce the risk of postnatal transmission of HIV through breastfeeding.

This new guideline calls on countries to revise their national recommendations on infant feeding in the context of HIV. This would imply that health services that are keen to provide their infants with the greatest chances of HIV free survival, will need to counsel and support mothers who are confirmed to be HIV-infected to either breastfeed exclusively and receive ARV interventions or to avoid all breastfeeding ( reference: World Health Organisation Rapid Advice: revised WHO principles and recommendations on infant feeding in the context of HIV – November, 2009).

HIV prevalence

The study found that the HIV prevalence among infants 0-2 years of age was 2.1%, which is lower than the 3.3% average in the age group 0-4. This pattern could indicate a possible positive impact of the national prevention of mother-to-child HIV transmission (PMTCT) programme in the two years before the study took place. During that period, coverage had significantly increased to reach almost three-quarters of HIV-positive mothers with antiretroviral treatment. The prevalence of HIV infection varied by province.
The lowest prevalence was found in the Western Cape at less than 1%, while low to intermediate HIV prevalence was observed in Northern Cape, Eastern Cape, North West and Limpopo (less than 3%). Provinces with higher HIV prevalence were Gauteng and Free State (both 3.1%), KwaZulu-Natal (3.4%) and Mpumalanga (4.5%).

    •    Download the HIV Prevalence in Children fact sheet:

    •    Download the Cultural Practices fact sheet:

Health status of children

Using an internationally recognised question on health status, the survey assessed the perceived health status of children in South Africa and found that  an overwhelming majority of children aged 2-18 years had excellent or good health (94%), with only very small proportion having fair or poor health. The health conditions most common among children aged 2-18 years were asthma, allergies and poor vision.

Using health care services at primary care level provides an opportunity for screening of  diseases that may lead to early diagnosis, promotion of health and access to treatment. The study found that in the year prior to the study, among children under two years of age around two thirds (66.9%) had visited a public outpatient clinic, with an average number of visits of 3.9 times per year compared to 22.6% of children who visited a private outpatient clinic, with an average number of visit being three times per year. The results of health care utilisation over a period of six months show that children aged 2-11 years were more likely than older children to have visited health-care facilities.

Analysis of information on hospitalisation showed that one in five children under the age of two had been hospitalised for more than six days in the past year. Children with HIV were admitted to hospital more frequently than other children (17% compared with 4, 7%). Furthermore, children had a poor health status were more likely to have hospitalisation levels that were three times higher compared to those with an excellent or good health status.

    •    Download the Health Status of the Child fact sheet:

Risk factors for HIV among children 12 years and older

The study found that among children aged 12-14 years, more than one in ten males (10.8%) and one in seven females (14.5%) had previously had sex.

Most of the young males in this study tended to have sex with partners in their own age groups. It was also found that more than a quarter of females aged 12-18 years (26.4%), had most recently had sex with males who were five or more years older than themselves. This puts the females at risk for HIV at an early age because older male partners are more likely to be HIV positive.

Among those who were sexually active in the group 15-18 years of age, more than a quarter of males (29.2%) had more than two sexual partners in the past year. This was lower for females (9.5%). However, it appears that most of these sexual acts were protected. Condom use at last sex among those aged 15-18 is reported to be high, 92.1% among males and 83.9% among females.

    •    Download the Risk Factors for Children fact sheet: 

Risk environments for children

This study identified potential risk factors for HIV infection among children at home and at school. It was found that about half of young children aged 2-10 years were exposed to high-risk activities such as being sent on an errand alone (46.1% reported ‘never’) and around two fifths being sent out without any adult supervision (about 61.2% reported ‘never’). It was noted that male educators sometimes proposed relationships with girls at school  (8.1%) and this is of major concern.


The premature death of young adults results in children being left without parents. The study found that more than 2.5-million children aged 2-18 years had lost at least one parent, and 419,000 had lost both parents. Eastern Cape had the highest proportion of orphans – 23.2% – followed by KwaZulu-Natal at 19.4%. Poor areas such as   rural informal areas were found to have the highest burden of orphanhood.

    •    Download the Orphans and Child Headed Households fact sheet:  

Children and communication
Although children aged 12-18 were found to have good access to broadcast and print media for AIDS communication, there was lower access to national AIDS communication programmes in rural areas, as well as among home language speakers of English, Afrikaans, Tsonga or Venda. Although parents were seen as an important source of information on sexual matters, and were discussing sexual abuse with children, they were less likely to discuss HIV transmission or prevention.
It was recommended that national mass media communication programmes focus on complementing school-based programmes and that the government’s HIV/AIDS campaign include a focus on children.

    •    Download the Communication fact sheet:


Recommendations for younger children include strengthening of the primary health care system, particularly expanding the number and scope of work of community health workers to include high impact but low-cost child health and nutrition interventions. Sick children should routinely be tested for HIV and those with advanced HIV should be referred for ARV treatment and properly managed, which is now government policy.
An accreditation system should be introduced as a matter of urgency to regularly monitor the quality of care in health facilities and serve as a mechanism to hold health managers accountable for the health outcomes of mothers and children.

With regard to risk to sexual abuse and HIV at community level, the protection of children requires all stakeholders (parents/caregivers and educators as well as children) to act in concert in identifying and minimising these risks. The abuse of pupils by some teachers should not be tolerated, and disciplining those responsible is an important a task that falls to the Department of Education and the Council of Educators.

With respect to communication, it was recommended that national mass media communication programmes focus on complementing school-based programmes and that the government’s HIV/AIDS campaign include a focus on children.

Another recommendation is that the HIV and infant feeding guidelines in South Africa should be updated, based on the new WHO Rapid Advise so as to include the provision of antiretroviral therapy for the HIV-positive mother or the HIV exposed infant. This will significantly reduce the risk of postnatal transmission of HIV through breastfeeding.

Download the full report: The Health of our Children in South Africa: Results from a national HIV prevalence population survey