written by Basil Fahrlaender, Embassy of Switzerland in Pretoria, South Africa
South Africa is not ageing yet
Demographics in South Africa do not really fit in the classical scheme of an ageing society, as observed in most industrialized countries. The expression “the Baby Boomer generation”, that has become a sort of a general concept describing the demographic transformation of western populations, is thus not much of an explanation for a understanding of the South African reality. South Africa has till today a very young society. Almost half of all South Africans are currently younger than twenty-five year old and only one out of twenty South Africans is 65 or older. The demographic pyramid remains therefore very flat and speaking about an ageing society can be a bit misleading.
The life expectancy at birth, which obviously has an important impact on the distribution of age groups, of South Africans is not yet comparable to the one of high-income countries, simply because the public health system struggles to deliver sometimes even basic treatments to the poorer and often rural segments of society. This has as consequence that age expectancy at birth never exceeded 62 in the last fifty years. The challenge so far, is therefore not really to cope with an ageing society, but rather to allow to South Africans to age.
HIV and life expectancy
From the early 90s, one can even observe a dramatic decline of the life expectancy of South Africans, which dropped to only 52 years in 2005. This evolution, which goes completely against global trends, has as consequence that the South African population will, in average, die younger than the population of the so called “least developed countries” in the world. The cause of this decline lies largely in the expansion of the HIV pandemic in southern Africa.
How devastating the HIV pandemic has been and still is for the South African population can be illustrated by a few numbers. South Africa has today roughly 7 million people living with HIV, the biggest HIV-positive population in the world. Almost 20% of adult South Africans – between 15 and 49 years old – have been infected by the virus. The acuteness of the pandemic explains how that single virus has had such a tragic impact on life expectancy in South Africa.
The paradox of the situation is that South Africa faces similar issues than ageing western societies when it comes to challenging dependency ratios. These ratios compare the productive part of a society to the dependent population in order to measure the pressure on the labor force. An ageing society faces an increase of an elderly retired population reliant on intensive social care. The HIV epidemic in South Africa has produced 2 million orphans which are now in different dependency relations with either other family members, state institutions or NGOs.
The tipping point
As mentioned, 2005 was the year when life expectancy reached its lowest point. At this stage, half of all the deaths in the country were caused by AIDS. The year marked nevertheless also a tipping point and this for a simple reason: the South African government implemented its roll out plan of HIV treatments. That means that public health institutions started to distribute massively antiretroviral drugs (or simply ARVs) to HIV-positive people without private health insurance. This new strategy reversed the tendency and South Africans were getting older again!
These gains were obtained through a massive public intervention. In 2004, only 4% or 55000 thousand patients with advanced HIV received an ARV treatment. Two years later, more than 300 000 people were treated and in 2015, 3.4 million South African were receiving ARVs. This year, the government declared that every HIV-positive person will be entitled to receive medication from the state. This is a further enlargement of the program, because so far patients had to wait until the disease had severely affected their immune system.
One of the biggest achievements of the current HIV strategy is definitely in the field of the prevention of mother to child transmission. A particular effort in testing and treating pregnant women is and has been done in the last year. As a result, transmission of the infection of exposed infants has dropped to below 2%. This is a major success and the belief is here today that this kind of transmission could totally be eradicated in a near future.
South Africa as an innovation hub in the fight against HIV
Since South Africa’s new approach towards a massive public response to the disease was implemented, the situation for the HIV-positive population has largely improved. In the meantime, the country has also become one of the leading research hubs in order to develop new ways to fight against the virus. Different research institutions, such as the Africa Centre for Health and Population Studies, the Centre for the AIDS Programme of Research in South Africa (CAPRISA) but also the Human Science Research Council have become leading actors in the knowledge production on the pandemic.
CAPRISA, for instance, was a crucial institution in the development of the recently introduced pre-exposure prophylaxis – or simply PrEP. PrEP is a new strategy aimed at reducing new infection by lowering the risk of contracting the virus through a preventive distribution of very specific ARVs to populations at high-risk. Researchers from CAPRISA were involved in testing this new method, monitoring its deficiencies and looking for solutions to these deficiencies. One of the problems with PrEP is that it requires a high level of discipline because the medication has to be taken on a daily base. Current research focuses therefore on developing new methods that are based on longer acting products.
PrEP has been identified by the South African government as a way to reduce the ongoing high incidence rate and it has been decided to distribute the drug to high-risk groups, at an initial stage to sex-workers. This decision reveals the very strong relation between research and government policies. Furthermore it reflects how research is driven by requirements of practicability in order to implement innovative policies.
A new large scale HIV vaccine trial will also be launched throughout South Africa anytime soon and is expected to provide information by 2020. It is the first trial of this kind in a long time and it is hoped that it will lead to the first licensed HIV vaccine ever. It might not result on a complete immunity but is expected to reduce drastically the chance of being infected. Even though this vaccine has been developed by various international partners, one of the leading institutions contributing to it is the South African Medical Research Council (SAMRC). The tests will actually be led by the head of SAMRC and globally renowned South African AIDS researcher and activist, Dr. Glenda Gray.
The epidemic in its social context
HIV pandemic related research in South Africa is not purely done in a medical perspective. Hard sciences are obviously leading when it comes to treatment and crucial when it comes to reducing the incidence rate. A comprehensive HIV/AIDS response nevertheless requires also an understanding of the social dynamics of the pandemic. Social sciences are therefore highly challenged, when it comes to provide data and theory in order to make sense of the propagation of the virus. Only a thorough study of the South African society will allow the implementation of a robust strategy, because such a strategy, and the different elements it contains, has to be suitable for the local social context.
The social reality in the South African HIV propagation is very much a reality of power relations and a symptom of poverty. To understand the propagation of the virus, you have to deal with social life and how it affects gender and class relations or the way different age groups interact with each other. The PreEP strategy of the South African government makes particularly sense when one knows that prostitution is accountable for more or less 20% of the new infections and that the social status of sex workers does not allow them to negotiate condom usage at all time.
Toward an ageing society and its challenges
Much has been achieved so far and thanks to its firm stand in the fight against HIV, South Africa is ageing again. Nevertheless, the burden of the epidemic is still extremely heavy. Demographic trends suggest that the proportion of the population over 60 years old will double within the next 35 years to reach 15% by 2050. This increase of elderly people is happening in a very different context than it does in high income countries. The traditional demographic transition of industrialized countries occurs through a shift towards low fertility and mortality rates. In South Africa, because of HIV, mortality, especially among younger people, remains high. The deregulation of mortality through the virus will therefore affect the distribution of age groups and in relative terms increase the proportion of elderly and old people in the society.
Here dependency ratios are again going to be a big issue, knowing that an important part of the active population has been wiped out. The population mostly affected by the disease is traditionally the one that supports the older population in a South African setting. This older population will not only be left without familial solidarity networks, in many cases they will even have to look after their grandchildren. Poverty is therefore very likely to increase for this older population and it is not clear now if and how their access to basic services including social and health care will be granted in the future.
The challenge, here, is not only a demographic one, but appears to be a very political one too. Older people do not seem to get much attention in the public space so far. While the political agenda of the country is often focusing on a very vocal urban youth, the aging population tends to be left out. This can be justified, when one considers that affordable quality education is a huge issue in the country or youth unemployment reaches 40%. The context of important public spending constraints is obviously not helping neither. The reality, nevertheless, is maybe also that the older population is much easier to handle, because of long standing and stable political loyalties and very little specific demands that are coherently addressed to decision makers. This leads to a lack of visibility, which is certainly increased through the fact that many retired people leave the urban areas to go back to the rural regions were they originate from.
However, it would definitely make sense to act proactively, in order to be prepared for the future. As a country of many challenges, South Africa has here the opportunity to anticipate the needs related to its demographic transition. What will be done remains open so far.
 2008 Country Progress Indicators, 2008 Report on the Global Aids Epidemic, UNAIDS.
 South Africa Global AIDS Response Progress Report (GARPR) 2015, SANAC.
 Alice Nabalambaa and Mulle Chikoko, Aging Population Challenges in Africa, African Development Bank, 2011.