Series Editor: Jonathan Crush

Southern African Migration Project

Migration Policy Series No. 24

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Seventy per cent of the 36 million people infected worldwide with HIV live in Sub-Saharan Africa and within this region the countries of Southern Africa are the worst affected. The eight countries with the highest rates of infection are in Southern Africa, followed by six countries in East Africa, and then five other countries, only one outside Africa. The reasons why the highest rates of infection in the world occur in Southern Africa are unclear. Although the countries of the region have much in common, their histories over the last twenty years have been very different.

A number of different factors have been advanced to explain the general picture of HIV/AIDS in South Africa including its rapid spread, high prevalence and uneven distribution. They include poverty and economic marginalization; differing strains of HIV; high rates of sexually transmitted disease and other opportunistic infection; sexual networking and patterns of sexual contact; the presence or absence of male circumcision; and the role of core-groups such as commercial sex workers. These factors are discussed in greater detail in the paper, reviewing the current state of knowledge about each in South Africa.

The paper then examines the connections between migration and HIV/AIDS. Although both migration and HIV have been examined separately in South Africa, we are still far from understanding in detail just how and to what extent migration affects the spread of HIV. Part of the reason for this is that studies of migration and disease tend to concentrate on the urban, or 'receiving' areas with little attention being paid to people living in the rural or 'sending' areas. Furthermore, there have been very few well-designed epidemiological studies documenting the relationship between migration and infectious diseases. Even more importantly, at this late stage of the Southern African HIV epidemic, there have been few intervention programmes, even on a small scale, which attempt to reduce transmission among migrants and their rural or urban partners.

Without a proper understanding of the social, behavioural and psychological consequences of migration, it will not be possible to understand the consequences of migration for the spread of HIV and the particular vulnerability to infection of mobile populations. To effect this conceptual refocus on the social (and sexual) disruption that accompanies migration and mobility, a number of reorientations are required, including:

The paper argues that none of these objectives can be adequately reached without attention to both the macro- and micro-geographies of mobility, social connectivity and sexual behaviour.

The connections between migrancy and HIV/AIDS are more difficult to unravel because HIV/AIDS arrived in the region at a time when population mobility and systems of migrant labour were undergoing considerable change. Migrancy is, by its very nature, highly dynamic and has changed dramatically in scope, scale and diversity over the last two decades. Today it is much more difficult to map the prevalence and spread of disease onto spatial patterns of migration than it was in the past. Several important migration changes that coincided with the advent of HIV/AIDS need to be mentioned:

After discussing the general evidence on the causal connections between HIV/AIDS and migration in South Africa, this paper seeks to move the South African debate from the macro- to the micro-scale. By reviewing the findings of research in three different settings the complexity of the connections between migration and HIV/AIDS begin to emerge. The case study areas are spaces of vulnerability, places in which to observe why migrants and those with whom they come into contact are highly susceptible to HIV infection, and hence to develop approaches to decreasing this vulnerability. If workable interventions, based on a sound understanding of local regimes of migration and sexuality, can be developed in disparate case studies such as these, then such best-practice models could have much wider relevance for resisting the ravages of the epidemic.

Much can still be done to reduce the impact and the spread of HIV in South Africa. Mother-to-child transmission could be substantially reduced using standard drug regimens. Control of curable STIs would reduce transmission of HIV. The effective promotion of condoms and a reduction in high risk sexual behaviour would have an effect in the longer term. Tuberculosis prophylaxis could substantially reduce tuberculosis morbidity and mortality among those with HIV and this is particularly important in the context of gold mining. The public health implications of the provision of free anti-retroviral therapy to people who are HIV-positive need to be examined. And adequate resources must go to the development of a vaccine for HIV subtype C .

None of these interventions are likely to be effective without a sound understanding of the reasons why Southern Africa is the worst affected region in the world, why the epidemic has spread in this region more rapidly than in any other, and why there are such great differences in the infection rates in different provinces, between men and women and critically between migrants and non-migrants. In addition, in all of these interventions special attention should be given to people at high risk of infection, which includes not only commercial sex workers, but also migrants and the partners of migrants. In this context, effort needs to go into the development of epidemiological models to understand the current state and the likely future course of the epidemic, to provide a context for planning and designing interventions, and to evaluate the effectiveness of such interventions.

This paper highlights the current state of knowledge about the linkages between HIV/AIDS and migration but it is abundantly clear that there are large gaps in our knowledge of the extent to which migration, and the particular forms of migration that are found in Southern Africa, can explain why the levels of infection in this region are so much higher than anywhere else in the world. Areas in which more work is urgently needed include:

The epidemic of HIV/AIDS threatens to devastate much of Southern Africa. Dealing with the epidemic must be given the highest priority and treated with the greatest urgency. However, unless the issues of migration and disease are understood and dealt with effectively, it is unlikely that the greater struggle to control and manage AIDS can be won.