Series Editor: Jonathan Crush

Southern African Migration Project

Migration Policy Series No. 31

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Executive Summary

South Africa is experiencing one of the fastest growing HIV epidemics in the world. Among women attending antenatal clinics nation-wide, the prevalence of HIV infection increased from 0.76 per cent in 1990 to 26.5 per cent in 2002. Among the nine South African provinces, KwaZulu/Natal has consistently had the highest antenatal HIV prevalence: 36.2 per cent in 2000. The epidemic is by no means limited to urban areas. As in the rest of Sub-Saharan Africa, the predominant mode of urban and rural transmission is heterosexual intercourse.

Migration is one of many social factors that have contributed to the AIDS pandemic. Previous studies have shown that people who ar e more mobile, or who have recently changed residence, tend to be at higher risk of HIV infection than people in more stable living arrangements. In Uganda, for example, people who have moved within the last five years are three times more likely to be infected with HIV than those who have lived in the same place for mor e than ten years. In an South African study, people who had recently changed their residence were thr ee times more likely to be infected with HIV than those who had not. It is not so much movement per se, but the social and economic conditions that characterize migration processes that puts people at risk for HIV.

The role of migration in the spread of HIV to rural Africa has con - ventionally been seen as a function of men becoming infected while they are away from home, and infecting their wives or regular partners when they r eturn. However, the precise way in which migration contributes to the spread of HIV and other STD’s in rural areas is complex and not well understood. Partly this is because few studies have considered both ends of the migration process - those who leave home as well as those who remain behind. Understanding both ends of the migration spectrum has important implications for the development and implementation of intervention programmes, especially if it is possible to establish the relative risk of infection among different groups of migrant and non-migrant men and women.

This study set out to understand the extent to which the HIV epidemic in rural South Africa has been driven by urban migrants returning to their rural homes. The aim was to examine the social and behavioural factors that shape and determine the spread of infection from migrant men to their female partners and vice versa. The paper investigates the rates of HIV infection in migrants and non-migrants in order to understand the risk factors and transmission dynamics of the epidemic in South Africa.

The study ar ea chosen was the Hlabisa/Nongoma Districts in Kwazulu/Natal. The paper does not mean to suggest that what happens in these districts is necessarily typical of all districts. However, the findings run counter to established ideas about urban to rural transmission and could therefore constitute a set of hypotheses to be tested in other rural districts.

The study tested the hypothesis that migrants and their partners are at increased risk for HIV compared to non-migrants and their partners, and investigated potential risk factors for HIV infection. Male migrants from two adjacent rural districts (Hlabisa and Nongoma) were recruited for the study at two migration destinations: Carletonville and Richards Bay. Three gold mines in Carletonville and three factories in Richards Bay were selected because they employ large numbers of people from Hlabisa and Nongoma districts. Those who agreed to participate were administered a detailed questionnaire and offered voluntary counselling and testing for HIV and STDs. In addition, migrant men were asked a series of questions in order to locate and identify their rural partners. Once a participating partner of a migrant man was identified, a nonmigrant couple living within a radius of one kilometre of each migrant household was identified and invited to participate. In the final analysis, 260 men and 228 women took part in the study. One hundred and ninety-six migrant men were recruited at their workplaces, and 64 nonmigrant men were recruited in Hlabisa/Nongoma. One hundred and thir ty female partners of migrants and 98 female partners of nonmigrants were recruited in Hlabisa/Nongoma Districts. None of the women were migrants.

The major findings of the research were as follows:

A statistical univariate analysis showed that the most important risk factors for HIV among men were: (a) being a migrant; (b) being less than 35 years old; (c) having one or more casual partners; (d) having symptoms of STDs in the last 4 months; and (e) ever having used a condom. Those with current STD symptoms, symptoms in the last 4 months, or a history of STD symptoms were more likely to be HIVinfected than those who had never had STD symptoms. Those who hadused condoms at least once were more likely to be HIV positive than those who had not. The probability of being infected with HIV was not significantly associated with income, education or lifetime number of partners.

In a multivariate analysis the risk of HIV infection remains higher among (a) migrant than non-migrant men, (b) those who report recent - ly having STD symptoms and (c) those who have lived in more than four places compared to only one place. Those who said that they have used condoms were actually at increased risk of HIV infection compared to those who said that they had not. But this is obviated by the fact that those who report having used condoms are also likely to have had more casual partners than those who say that they have never used condoms. For women, the strongest association with HIV infection was with the number of lifetime partners. Women who had had more than one lifetime sexual partner were five times more likely to be infected with HIV than women who had only one lifetime partner. Age was also a significant risk factor for HIV, with younger women more likely to be infected than older women. Women who reported having sexual intercourse for the first time at or before the age of 17 years were more likely to be HIV-positive (24.5 per cent) than those who reported a later age at sexual debut (14.3 per cent).

These findings are a mix of the pr edictable and the counter-intuitive. With consistent use of condoms so low, it is predictable that even those who have used them at least once would show little protection from infection. Also, the study confirms that migrant men are more vulnerable to infection than non-migrant men. As expected, rates of infection among female partners of migrants were higher than amongst partners of non-migrants. However, the dif ferences are not statistically significant. The question is how to explain the fact that 16.5% of women who were partners of non-migrants were infected with HIV. To explain this anomaly the study looked at patterns of infection amongst couples and found the following:

Migration has undoubtedly played a major role in the spread of HIV. Its precise role was more important – and more easily measured – in the early stages of the epidemic than in the later stages. The fact that the odds of a migrant man being infected is 2.4 times the odds of a nonmigrant man, even at this advanced stage of the epidemic, highlights the importance of migration as one explanation of the size and rapidity of spread of the Southern African epidemic.

The patterns of HIV discordance (one infected partner) were unexpected and shed light on the role of migration in the spread of HIV to rural areas. It has long been assumed that the primary direction of spread of the epidemic has been from returning migrant men, who become infected while away at work, to their rural partners when they return home. If this wer e the case, the male would be the HIV infected partner in most of the discordant couples; however, in nearly one-third of the discordant couples the female was the infected partner and the male was uninfected.

While this confirms the importance of migration as a risk factor for infection in both men and women, it changes our understanding of the way in which migration enhances the risk. We have found that migration is a risk factor not simply because men return home to infect their rural partners, but also because their rural females partners – both those who are partners of migrants and those who are partners of nonmigrants – are likely to become infected in the rural areas from outside their primary relationships.

One might hypothesize that with their partners absent, women are be more likely to have additional sexual partners, and as a result to increase their risk of becoming infected. Additional partners may, of course, also be migrants. The fact that the patterns of HIV discordance are similar in migrant and non-migrant couples indicates that evensome partners of non-migrant men become infected prior to their husbands. The specific circumstances in which rural women take on additional relationships needs further investigation, as well as the ways in which these relationships increase risk of HIV infection. Research is needed to better understand the complex social and sexual lives of women living in rural areas, especially in relation to the migration status of their partners. Understanding these dynamics could help to promote the development of new approaches for HIV prevention among rural women.

For everyone, male and female, migrant and non-migrant, the risk of becoming infected from outside is greater than the risk of becoming infected from inside the spousal relationship. While we expected that migrant men would be more likely to be infected from outside their spousal relationships, we did not expect that to be true for the other groups, including women whose partners were and were not migrants. This study demonstrates the complexity of HIV transmission in the presence of large-scale male migration and the need to address the spread of disease among, especially, young rural women, not just women living in migrant r elationships. What has not been acknowledged to date is the role of local, rural transmission in this complex epidemic. The findings of this study show that it is important to include rural areas if HIV treatment and prevention programmes are to succeed in reducing the spread of HIV. In addition, further work is necessary to more fully explore the complex patterns of sexual networking, particularly among women in rural areas.

Although this study focused only on male cir cular migration within South Africa, and from the perspective of only two rural health districts, circular migration is in fact extr emely common throughout Souther n Africa. It is important to recognise, however, that other types of migration do exist, and may play an important role in facilitating the dissemination of HIV throughout the Southern African region. Further studies that focus on other types of migration – particularly female migration – are urgently needed.