1. 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 Conference
2nd December 2009
Johannesburg, South Africa

2. 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.

3. Why a focus on HIV and urban
Structural and contextual factors
informal settlements?
Housing ? Urban ?
SADC, 2006

4. A focus on the urban:
an increasing urban population

5. By 2030, 50% or more of the African
population will be living in a city
World Urbanization Prospects (2005 Revision), United Nations, Department of
Economic and Social Affairs

6. Ranking of urban HIV epidemics (ESA) among national epidemics
Est. number Adult Est. number Adult
PLHA (2007) PLHA (2007)
1 South Africa 5,400,000 21 Ghana 250,000
2 Nigeria 2,400,000 22 Myanmar 240,000
3 India 2,300,000 Maputo 220,000
Gauteng 1,550,000 23 Carribean 220,000
4 Mozambique 1,400,000 24 Mexico 200,000
5 Kenya 1,400,000 Lusaka 185,000
6 Tanzania 1,300,000 25 Angola 180,000
7 Zimbabwe 1,200,000 26 Chad 180,000
8 USA 1,100,000 Nairobi 180,000
9 Zambia 980,000 Dar Es Salaam 180,000
10 Russian Fed 940,000 27 Swaziland 170,000
11 Ethiopia 890,000 28 Colombia 160,000
12 Malawi 840,000 Port Elisabeth 155,000
13 Uganda 810,000 29 Italy 150,000
Durban 730,000 Addis Abeba 150,000
14 Brazil 710,000 30 France 140,000
15 China 690,000 31 Spain 140,000
16 Thailand 600,000 32 Central African Republic 140,000
17 Cameroon 500,000 33 Rwanda 130,000
18 Ukraine 430,000 34 Argentinia 120,000
19 Cote d'Ivoire 400,000 35 Burkina Faso 120,000
Cape Town 315,000 36 Togo 120,000
21 Vietnam 290,000 Kampala 110,000
22 Botswana 280,000 East London 105,000
23 Indonesie 270,000 …
20 Lesotho 260,000 Pakistan 94,000
Harare 260,000 Bulawayo 90,000
UK 77,000
Luanda 70,000
Henk Van Renterghem, UNAIDS (2009)

7. HIV prevalence in adults aged and49 years by
Why a focus on HIV 15 – urban
locality type, South Africa, 2005
informal settlements?
30
25.8
25
HIV prevalence (%)
20 17.3
13.9 13.9
15
10
5
0
Urban informal Urban formal Rural informal Rural formal
settlements settlement
Locality type
(HSRC, 2005)

8. 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.

10. Sol Plaatjies
informal
settlement
n = 200

11. 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.

12. 24 hours Dietary Diversity Score:
respondents residing informally are more likely to have a
deficient dietary score
70
60
50
Relative frequency
40
In a context of high HIV
Informal
prevalence, urban informal Formal
30
settlements have poor food
20 security.
10
0
Deficient Sufficient Diverse
Score 0 - 3 Score 4 - 6 Score 7 - 9
Chi-square 89.880;
24 hour Dietary Diversity Score
p = <0.0001

13. Perception of risk of HIV
Relative frequency (%) 70
60
50
40
In a context of high HIV Informal
prevalence, urban informal
30 Formal
settlement residents
20
perceive themselves at risk
10
of HIV
0
No Risk Risk
Perception of risk of HIV
Chi-square = 14.221; p = 0.0002

14. 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)

15. Housing

16. Schooling

17. Transit camps

18. Development…..

19. The role of local
government in
responding to HIV
and informal
settlements

20. 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)

21. 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.

22. Key findings

23. 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.

24. 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.

25. 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.

26. 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.

27. 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