Sindi Mbandlwa, an athletic-looking 24-year-old in light brown jeans and matching jacket, settles her chair, places her arms resolutely on the bare circular pine table and begins to tell her story with a quiet strength and determination.

I have been raped many times," she says without any hint of apology or further introduction. "I have to remind myself everyday that it wasn't my fault. I often think that if this hadn't happen I wouldn't be facing the problem of HIV."

Mbandlwa's story rape and HIV infection is one of many - but her courage to talk about it highlights the need to protect the rights of women and young girls. Her situation illustrates the complexity of fighting HIV/AIDS in the country.  It throws a painful spotlight on the need to empower women in the fight against HIV and AIDS, and the pressing need for AIDS education and re-socialisation in order to combat the disease.

Against a backdrop of South Africa's new constitution with its respect for human rights and dignity as well as the Millennium Development Goal (MDG) promise to halt and reverse the spread of HIV and AIDS, malaria and other diseases by 2015 - something clearly has to be done.

The first case of HIV was diagnosed in South Africa in 1982. In 1990 the first ante-natal surveys were conducted to test for HIV prevalence in pregnant women attending clinics, finding a prevalence of 0.8 percent.

These antenatal surveys are conducted annually and show an alarming increase in the prevalence of HIV in South Africa. Jumping from 1,4 percent in 1991 to 10,4 percent in the four years to 1995. In 1998 it was up to 22,8 percent and  by 2003 it was 27,9 percent - compared to a global HIV prevalence of one percent.

In December 2002 a new HIV prevalence test was conducted by the Human Sciences Research Council in collaboration with the Medical Research Council (MRC) and the Centre of AIDS Development, Research and Evaluation, by sampling 9 963 people country wide. This test, which included people who were not sexually active and those who had elected to use preventative measures, found a national HIV prevalence of 11,4 percent - or 4,5 million people infected with HIV in South Africa.

Response to the pandemic in South Africa was initially slowly and uncoordinated as both government and civil society moved from a position of  denial, to slowly educating people about the disease, and then to a more intensive education about what could be done to enhance the lives of people living with HIV.

Focus has been primarily on the prevention of the spread of HIV, promoting awareness of HIV and safe and healthy lifestyle. More recently attention has been given to treatment, care and support - both in the provision of Anti-RetroViral treatment (ARVs) and the prevention of mother to child transmission (PMTCT) and nutrition.

Women in South Africa are more likely to contract HIV and AIDS than men, partly due to biological vulnerability but also due to social vulnerability.

One area to be addressed is the provision of female initiated protection agents like microbiocides and female condoms said Thesla Palanee from the MRCs HIV Prevention Research Unit. "There is no use in educating people to use condoms when we only provide condoms that need to be worn by men," said Palanee.

The other is gender-based violence. "We need to challenge socialisation," said Johanna Keller from AIDS Legal Network. "We have been brought up with beliefs about correct sexual behaviour and sexual norms - but these beliefs should always be seen in the context of what the rights of the individual are, irrespective of gender, or fear of judgement and discrimination.

Research based on 40 interviews with female Grade 11 pupils from four high schools in the rural district of Ugu in KwaZulu-Natal show a strongly paternalistic society in which violence is a culturally accepted form asserting power - and is even seen as demonstrating an expected level of affection.

According to researcher Siyabonga Dlamini, from the University of KwaZulu-Natal, gender violence is an expected part of life for female pupils in rural schools in the province.
In response to questions regarding sex, the expectation of force compliance is apparent, said Dlamini.

"The girl will be saying no, but the boy will be using his power to push her down," said one of the pupils. Another agreed, saying, "Sometimes you are afraid that if you say no he will beat you."

Social transformative programmes, lasting a few hours a week, over several weeks appear to have the largest impact on HIV prevention, said Rachel Jewkes from the MRCs Gender and Health Research Unit.

The unprecedented increase in the rollout of ARVs since 2003 has resulted in the decrease of adult mortality of those infected with HIV said Kobus Herbst from the Africa Centre for Health and Population Studies based at the University of KwaZulu-Natal.

However, while ARVs are having a positive impact, the treatment is not reaching all of those in need.

Despite the fact that PMTCT is available, UNICEF claims that 260 children are born HIV positive every day in South Africa. Most die before their second birthday making HIV and AIDS the largest cause of death for children under five.

Only 17 percent of HIV positive pregnant women have access to treatment to prevent infection of her baby, said Professor Glenda Gray of Wits University's Peri-Natal HIV Research Unit. She added that 300 000 children get HIV through breastfeeding every year, with breast feeding accounting for 40 percent of all HIV transmissions. This could be avoided by the provision of ARVs to the breast feeding mother.

Dr Dingie van Rensbrug of the University of the Free State expressed concern that progress in providing AIDS drugs came at the cost of weakening other medical facilities and programmes. This fear is supported by research in Gauteng Province which shows that HIV care is impacting on those not infected.

"As a result of HIV positive patients having a longer stay in hospital and needing a higher level of care, there is a lack of beds available for those not infected with the virus. HIV negative deaths in Gauteng provincial hospitals are increasing as a result of the burden for caring for HIV positive patients," said Francis Akpan of the Multisectoral AIDS Unit in Gauteng.

The MDGs were set in 1990 and if progress is measured off this base, South Africa has done little to contain the spread of the virus. Compared to a prevalence of less than one percent in 1990, South Africa had more than 345 000 AIDS-related deaths in the last year; has a national HIV prevalence of at least 11 percent, and a prevalence rate of more than 30 percent of pregnant women attending ante-natal clinics in the country.

Even the effectiveness of education campaigns have been brought into question. "The number of South Africans who have tested for HIV/AIDS after a quarter of a century of knowledge of the disease, currently languishes at about two out of every hundred people," said Dr Francois Venter, clinical director of the Reproductive Health and HIV Research Unit at Wits.

The South African government's new HIV / AIDS and Sexually Transmitted Infections National Strategic Plan ambitiously aims to halve the rate of new HIV infections by 2011 and to treat, care for and support 80 percent of those already living with the HIV and AIDS and their families. Many question whether this will be achieved within budget and whether there is sufficient expertise for the new plan to work. "Without radical restructuring of South Africa's state health service there is no way the country will hit the target of getting more than 400 000 people on anti-AIDS drugs by 2011," said Dr Venter.

Sindi Mbandlwa feels strongly about this too. She works as a volunteer for Gender AIDS Forum, and focuses on the need to empower women with competence and confidence to confront issues of power, gender and sexual and reproductive health.
"I'm tired of hearing the same discussions, on the same old topics, relating to HIV and AIDS… and I'm tired of all the empty promises," said Mbandlwa.

•  This article by Sharon Davis was published in a conference handout at  the SID 50th Anniversary Conference in the Hague on 4 July 2007