Informal settlements and HIV in South Africa:

the need for a developmental local response

Jo Vearey (Wits/HEARD)Liz Thomas (Wits/MRC)

Lorena Nunez (Wits)Jacques Bezuidenhout (University of Nijmegen)

Scott Drimie (IFPRI-RENEWAL/Wits)

SAHARA Conference2nd December 2009

Johannesburg, South Africa

Overview

• Why a focus on urban informal settlements and

HIV?

– The importance of urban when considering HIV.

– Key findings from research studies.

– Urban informal settlements as a “neglected space”.

• The role of “developmental local government” in

responding to HIV and informal settlements:

– The urgent need for local level developmental responses.

Why a focus on HIV and urban informal settlements?

Structural and contextual factors

Housing ? Urban ?

SADC, 2006

A focus on the urban:

an increasing urban population

World Urbanization Prospects (2005 Revision), United Nations, Department of

Economic and Social Affairs

By 2030, 50% or more of the African

population will be living in a city

Ranking of urban HIV epidemics (ESA) among national epidemics

Est. number Adult PLHA (2007)

Est. number Adult PLHA (2007)

1 South Africa 5,400,000 21 Ghana 250,0002 Nigeria 2,400,000 22 Myanmar 240,0003 India 2,300,000 Maputo 220,000

Gauteng 1,550,000 23 Carribean 220,0004 Mozambique 1,400,000 24 Mexico 200,0005 Kenya 1,400,000 Lusaka 185,0006 Tanzania 1,300,000 25 Angola 180,0007 Zimbabwe 1,200,000 26 Chad 180,0008 USA 1,100,000 Nairobi 180,0009 Zambia 980,000 Dar Es Salaam 180,000

10 Russian Fed 940,000 27 Swaziland 170,00011 Ethiopia 890,000 28 Colombia 160,00012 Malawi 840,000 Port Elisabeth 155,00013 Uganda 810,000 29 Italy 150,000

Durban 730,000 Addis Abeba 150,00014 Brazil 710,000 30 France 140,00015 China 690,000 31 Spain 140,00016 Thailand 600,000 32 Central African Republic 140,00017 Cameroon 500,000 33 Rwanda 130,00018 Ukraine 430,000 34 Argentinia 120,00019 Cote d'Ivoire 400,000 35 Burkina Faso 120,000

Cape Town 315,000 36 Togo 120,00021 Vietnam 290,000 Kampala 110,00022 Botswana 280,000 East London 105,00023 Indonesie 270,000 …20 Lesotho 260,000 Pakistan 94,000

Harare 260,000 Bulawayo 90,000UK 77,000Luanda 70,000Henk Van Renterghem, UNAIDS (2009)

HIV prevalence in adults aged 15 – 49 years by

locality type, South Africa, 2005

25.8

13.9

17.3

13.9

0

5

10

15

20

25

30

Urban informal

settlements

Urban formal Rural informal

settlement

Rural formal

Locality type

HIV

pre

va

len

ce (

%)

(HSRC, 2005)

Why a focus on HIV and urban informal settlements?

Why a focus on HIV and urban informal settlements?three key points

Urban informal settlements in South Africa are associated

with some of the highest HIV prevalence globally.

1. Effective responses to address both the vulnerability to – and impact of -

HIV in informal settlements are currently lacking.

2. UN MDG 7, Target 11, “Cities without Slums”: “By 2020, to have achieved a

significant improvement in the lives of at least 100 million slum dwellers”

• In South Africa, the MDG target has been (mis)interpreted as the ‘eradication of

informal settlements’.

• A lack of respectful in situ upgrading.

3. Urbanisation in developing countries involves informal settlements

(Bocquier, 2008)

• An urgent need to engage with the realities of urban growth, and increasing

urban poor populations – including those residing in informal settlements.

• Action from Regional, National, Provincial, Local levels.

Sol Plaatjies informal settlement

n = 200

RENEWAL:urban informal settlement compared to urban formal

• Food security is poor;

• Perception of risk of HIV is greater;

• Residents are mostly internal South African migrants and female;

• Access to basic services is limited.

24 hours Dietary Diversity Score:respondents residing informally are more likely to have a

deficient dietary score

0

10

20

30

40

50

60

70

Deficient Sufficient Diverse

Rel

ativ

e fr

equ

ency

Informal

Formal

Chi-square 89.880;

p = <0.0001

Score 0 - 3 Score 4 - 6 Score 7 - 9

24 hour Dietary Diversity Score

In a context of high HIV prevalence, urban informal settlements have poor food

security.

Perception of risk of HIV

0

10

20

30

40

50

60

70

No Risk Risk

Perception of risk of HIV

Rel

ativ

e fr

equ

ency

(%

)

Informal

Formal

Chi-square = 14.221; p = 0.0002

In a context of high HIV prevalence, urban informal

settlement residents perceive themselves at risk

of HIV

Inadequate access to basic services

• No electricity (despite upgrading)– Paraffin and candles

• Water– Communal taps

• Sanitation– Communal toilets

– Open bush

• Waste removal– Irregular collection

– Dumping

• Negative impact on health, especially for people living with HIV.(Mporetji, 2008; Bezuidenhout, 2009; RENEWAL, 2009)

Housing

Schooling

Transit camps

Development…..

The role of local

government in

responding to HIV

and informal

settlements

Developmental local government

“local government committed to working with citizens

and groups within the community to find

sustainable ways to meet their social,

economic and material needs and improve

the quality of their lives”

(RSA, 1998: 23)

National Strategic Plan (NSP) for HIV &

AIDS and STIs, 2007 - 2011

• Recognition of: – Informal settlements;

– The importance of local government in

implementing an effective response.

• However:– No framework or guideline for how to

implement local level developmental responses

to HIV in informal settlements.

Key findings

Urban informal settlements

• Informal settlements present a range of development challenges to local government:– High HIV prevalence;

– High perceived risk of HIV;

– Inadequate food security;

– Poor access to basic services;

– Inappropriate development process;

– Mobility – the importance of “home”.

• Residents experience HIV in an integrated way:– It is not possible to ‘divorce’ HIV from their other urban

development needs.

Establishing a local-level response to

informal settlements and HIV

• HIV is not viewed as a developmental challenge.

• Challenges:– Enabling a developmental response;

– Establishing partnerships with and between local government departments;

– The amount of time required to establish a sustainable interventions;

– The expectations of external funding agencies;

– The frustrations of community participants.

Responding to HIV in urban informal

settlements

• There is currently a lack of guidance for cities on how to respond to HIV –

particularly within urban informal settlements.

• Local government must take action on the determinants that increase vulnerability to HIV, and on the impacts of HIV.

• Viewing HIV as a central development challenge requires local government to “get the basics right”:

– Provision of basic services - HIV is more than a health issue.

• A broad, integrated, multisectoral response is required to address the challenges

outlined:

– Commitment by all partners to work together.

– Inter-sectoral understanding and action by all partners including local government.

– Commitment to working with and being informed by community views and priorities.

– Need to draw on community strengths.

Future research

• Intervention research - piloting new interventions:

– A current lack of intervention studies;

– Multisectoral responses are required;

– Appropriate funding streams that understand the importance of time are required;

– Linked to process evaluations.

• Smaller city and town research is needed.

• Functionality of local AIDS councils.

• Political buy-in to urban interventions.

Acknowledgements

• Sol Plaatjies community

• Sol Plaatjies photo project participants

• Simon Mporetji

• Pinky Mahlangu

• City of Joburg HIV Directorate

• Jozi Ihlomile volunteers

• Market Photo Workshop

• Planact

• RENEWAL & IDRC

• Atlantic Philanthropies