How South Africa’s richest province is losing its STI battle

Abi Dlodlo has been a sex worker in one of Johannesburg’s toughest inner city districts for 15 years. In recent years, she says she has noticed a new attitude among her young clients.

Despite South Africa’s decades long struggle with HIV which saw around 50,000 people die from AIDS-related deaths last year, these customers do not want to wear condoms.

The clients, who are mostly university students, argue with her that they are safe because of  protective anti-HIV pills they can take either before sex (pre-exposure prophylaxis or PrEP), or after (post-exposure prophylaxis or PEP).

“They’re a new breed of clients,” she told the Telegraph. “They talk sweetly. They offer to pay more for unprotected sex, boasting that PrEP and PEP have got them covered.

“I refuse; they up the money, betting on the thrill of unprotected sex”.

Their attitude is a sharp contrast to that of her clients before PrEP and PEP were widely available, she says. Back then, they did not pressure her to have unprotected sex because they dreaded HIV.

South Africa’s huge rollout of anti-retroviral drugs to treat HIV among those who have the virus, or to protect those who do not, means the country has the  world’s largest HIV treatment programme.

Some three quarters of the country’s 7.8m HIV infected residents are on treatment. Another half a million more have taken some kind of PrEP medicine. The rollout has helped slash new infections by nearly two-thirds among the 15 to 49 age group relative to 2000.

However in the province where Abi Dlodlo works, South Africa’s wealthiest province of Gauteng, while HIV infections are falling, infections of other sexually transmitted diseases are rising.

Public health workers believe the two are connected.

“It’s a tale of two contrasts,” says Sithembile Nale, a sexual health counsellor, and former nurse at Leratong Hospital, west of Johannesburg. 

She says the good news is that HIV infections have fallen thanks to condoms, PrEP, PEP, and antiretroviral drugs.

“The ugly news is clinics are treating so many syphilis, and gonorrhoea cases,” she adds.

Out of 66,377 pregnant women who came to the hospital for first-time antenatal care from April to December, 2023, some 1,255 tested positive for syphilis, according to the province’s health ministry.

The proportion of men being treated for Male Urethritis Syndrome (MUS, an inflammation usually caused by gonorrhoea or chlamydia) has jumped from 12 per cent to 15 per cent in only three years.

“We believe that the high uptake of PrEP among women (in Gauteng) has led this group to have unprotected sex resulting in a high incidence of MUS,” said Nomantu Nkomo Ralehoko, the province’s health minister.

PrEP and PEP medications were first rolled out in South Africa in 2016 to vulnerable groups, including sex workers, men having sex with men and intravenous drug users.

The medications are now more widely available, with more than 500,000 sexually active South Africans enrolled on oral PrEP and PEP to date, according to a 2023 study.

‘PrEP has freed them to discard condoms’

Dr Ndiviwe Mphothulo, president of the Southern African HIV Clinicians Society who also doubles as the TB/HIV manager for the City of Johannesburg’s Anova Health Institute said the syphilis rate in the province, at around two percent, was “problematic”.

“We should be worried about the rising numbers of STIs, it tells us that people are not using condoms. It’s a threat,” he warns.

Ms Nale’s experience as a sexual health counsellor in places like Soweto mean she is not surprised by the rising figures, she says.

“They confide to me that PrEP has freed them to discard condoms. It’s mind-boggling,” she says.

Gauteng’s manufacturing, townships, technical colleges and universities all give the province a youthful population.

“That makes Gauteng a perfect hotspot for casual, and transactional sex especially in the key 17 to 30 population band,” she says.

Yet simply blaming young age-groups in Gauteng for fuelling the rise in STIs is simplistic says Pearl Dali, a 23 year old studying a business degree in logistics at the University of Johannesburg.

The reality is more complicated, she says. Safe sex or unprotected sex is linked with race and class in South Africa.

She said most Black South African students like her come from extremely poor households where parents or guardians are jobless. The students could be HIV orphans, and are usually the first in their families to attend university courtesy of tiny government loans.

The financial pressure means young women often resort to transactional sex to keep up with their studies.

She said: “The pressure on us young Black female students to finish varsity is huge. We juggle. Sometimes I dated a mix of young and older men at once to supplement money for rentals, stationery, or food.”

This has created a thriving sub-culture called ‘Blessers’ in South Africa – a phenomenon where young city women, usually varsity students, date and sleep with older, wealthy men in exchange for ‘blessings’ like rentals, cellphones and new clothes, she says.

“Blessers see us as their young, de-facto concubines and demand unprotected sex. We secretly take PrEP at least to guard ourselves from HIV, but are vulnerable to much else like syphilis,” she says.

Dr Mphothulo agrees.

He says: “STIs does not necessarily mean those women are sleeping around. It could be that it’s their partners that are sleeping around.

“So we could be treating these women for stuff like syphilis but not treating their sources”.

He would like to see male partners come in for treatment along with the young women. 

However they are unlikely to be able to spare time from their jobs, he said.

“They are breadwinners. The guy (with gonorrhoea, or MUS could be working at the garage, at the gas station, could be a truck driver, so forth. So they don’t have time to go to the clinics,” he says. 

So men are people at work. Just like with TB in South Africa, unlike women, men cough and go to work until they get sick. “They come to us when they’re about to die,” he says.

As a country, South Africa should have a conversation on how do to get men tested and treated for STIs early, he adds.

It would be tragic to win the battle on HIV and lose the war on syphilis, MUS or chlamydia because there is a strong clinical link between getting STIs and ultimately contracting HPV virus, cervical cancers, or HIV.

He says: “So what do we need to do? We shouldn’t be complacent. We should say, look, people are no longer dying in numbers by HIV. But still, HIV is a threat (in South Africa). If you get STIs, it may cause a lot of problems”.

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