Despite expanding health and social services since democracy, South Africa remains among the sickest nations on earth.81 Relative to other middle-income countries, it has worse age-adjusted death rates, years of life lost to premature death and life expectancy at birth.82 The country’s HIV/AIDS epidemic, and the subsequent (though unjustly delayed) roll-out of Anti-Retroviral Therapy, illustrates not only the staggering toll of HIV, but also the radical possibilities of expanding access to affordable, quality healthcare. 3.3.1 The demographic impacts of Anti-Retroviral Therapy Over a period of less than 20 years, post-apartheid South Africa saw a dramatic and unprecedented rise and fall in mortality because of the HIV/AIDS epidemic and subsequent ART roll-out. These effects were not evenly distributed, with those in the poorest municipalities more likely to die of AIDS-related illness and less likely to benefit from subsequent treatment programmes. As a consequence, both mortality and absolute mortality inequality by income spiked (for 18–59-year-olds) in the lead-up to 200683 and dropped rapidly thereafter as South Africa’s ART programme was scaled. By the time the HIV/AIDS epidemic peaked, in 2004, 10 years had been cut from South Africa’s 1990 life expectancy.84 Over the same period, the under-five mortality rate had risen to 79.2 per 100 000 births.85 Many who were dying were doing so at the prime of their lives: homes and communities lost their most economically and biologically productive generation. Often it was close relatives, especially grandmothers, who assumed care for the orphaned children of their dead, bringing emotional and material resources to bear on AIDS illness with little assistance from the state. Indeed, the HIV/AIDS epidemic has contributed to a series of generational anomalies: the elderly have buried their young, small children have nursed their parents, and adolescents have headed households. It has also amplified and necessitated intergenerational reciprocity, as grandmothers and grandchildren step in to complete the work of their ailing children or parents. parents
Figure 15: Life expectancy of South Africans from 1985 to 2020
The HIV epidemic caused a dramatic decline in the life expectancy of South Africans, but since the roll-out of ART, the life expectancy has recovered and now exceeds the pre-HIV epidemic level. Source: MacDonnell and Low, 2019
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INEQUALITY AND DEMOGRAPHY
