1. COMMENTARY ON SABSUM 4 Donald Skinner Research on Health and Society Stellenbosch University

2. The SABSUM reports are always key points at which to consider the growth and direction of the epidemic in South Africa. This particular survey report comes at a point where incidence appears to be reducing generally. This is also a point at which ARVs have become more generally available, so prevalence levels remain very high. Our role is to highlight issues that we felt were important to us that were highlighted in the results.

3. Epidemic in the Coloured population In our research among Coloured people attending shebeens and taverns, and amongst those using tik \ methamphetamine we have been finding increasing levels of HIV. In the community where our research is, clinic nurses reported at least one person a day testing positive amongst local Coloured community. Western Cape DoH person reported higher levels of HIV+ results amongst young women and older men amongst those presenting for testing in the clinics. The latter two points were felt to be new and increasing over time. But this is not scientific and no formal review of the clinic stats has been done.

4. SABSUM 4 data 200520082012 White0.60.3 Indian/ Asian 1.60.30.6 Coloured1.91.73.1 Black/ African 13.313.615.0

5. This trend is supported in the ante natal data. Although change still within the confidence limits, it is concerning. There are areas of concern around risk which appear to be increasing. High and increasing levels of substance use. Alcohol use is very high, and from our research appears to be increasing amongst women. Tik \ methamphetamine use high in both men and women.

6. High levels of gender violence, domestic violence, sexual violence and child abuse. Generally high levels of community violence and gang activity. High levels of stigma in the Coloured community. AIDS is seen as a Black African disease. So it remains hidden. The myth also reduces the need for protection behaviour.

7. Age gender distribution of infection The pattern remains of women getting infected younger, from 18 to 25; and men older from 35 up. While the emphasis on cross generational relationships is important I do feel that other important considerations need greater attention.

8. Gender violence The impact of gender violence especially sexual violence, as a means of transmission and as a systematic way of breaking down young women so that they cease to protect themselves. This stems from existing constructs of power and ideas around masculinity. Dangerous as men feel invulnerable, and women feel disempowered, worthless and damaged. Reduces the felt need to use condoms or to stick to one partner.

9. Substance use Substance use and the risky sexual practices that are associated with it, including sexual exchange and lack of capacity to stay safe when under the influence. Sexual exchange is formal and informal sex work, and direct exchange for alcohol or drugs. Underage girls are starting to use substances and they are even more vulnerable. For women loss of power in sex exchange and intoxication makes it harder to use condoms. These may also explain why older men are getting infected as they are most often the customers.

10. Opportunities for protection strategies are being missed Legalisation of sex work, so that these women and men can be protected. Decriminalising of certain drugs and offering better rehabilitation Intervening in a more consistent and high profile way to reduce gender violence. Less tolerance of people who do commit these offenses or make light of gender violence Concerns around the impact of traditional legal systems on women’s rights Need to raise awareness in the Coloured community about the potential for the epidemic to rise in this group