The impact of and responses to HIV/AIDS in the private security and legal services industry in South Africa

The impact of and responses to HIV/AIDS in the private security and legal services industry in South Africa Compiled by the Social Aspects of HIV/AIDS and Health Research Programme of the HSRC Funded by and prepared for the Safety and Security Sector Education and Training Authority S A F E T Y & S E C U R I T Y

Funded by and prepared for the Safety and Security Sector Education and Training Authority (SASSETA). Published by HSRC Press Private Bag X9182, Cape Town, 8000, South Africa www.hsrcpress.ac.za First published 2007 ISBN 978-0-7969-2205-2 2007 Human Sciences Research Council Copy-edited by Laurie Rose-Innes Typeset by Simon van Gend Print management by compress Distributed in Africa by Blue Weaver Tel: +27 (0) 21 701 4477; Fax: +27 (0) 21 701 7302 www.oneworldbooks.com Distributed in Europe and the United Kingdom by Eurospan Distribution Services (EDS) Tel: +44 (0) 20 7240 0856; Fax: +44 (0) 20 7379 0609 www.eurospangroup.com/bookstore Distributed in North America by Independent Publishers Group (IPG) Call toll-free: (800) 888 4741; Fax: +1 (312) 337 5985 www.ipgbook.com Suggested citation: Simbayi LC, Rehle T, Vass J, Skinner D, Zuma K, Mbelle MN, Jooste S, Pillay V, Dwadwa- Henda N, Toefy Y, Dana P, Ketye T & Matevha A (2007) The impact of and responses to HIV/AIDS in the private security and legal services industries in South Africa. Cape Town: HSRC Press.

Contents List of tables and figures v Foreword ix Contributors x Acknowledgements xii Abbreviations and acronyms Executive summary xv xiv 1 Introduction 1 1.1 Background 1 1.2 Literature review 1 1.3 Epidemiological model 6 1.4 Objectives 6 1.5 Conceptual framework of the project 7 1.6 Scope 8 1.7 Overview of the report 10 2 Methodology 11 2.1 Introduction 11 2.2 Overall research approaches 11 2.3 Study 1 (HIV prevalence, HIV incidence and KABP survey): the formative research phase 11 2.4 Study 1 (HIV prevalence, HIV incidence and KABP survey): the main study 12 2.5 Study 2 (Business impact and response): the formative research phase 20 2.6 Study 2A (Employer survey of business impact and response): the main study 20 2.7 Study 2B (Employee survey of business impact and response): the main study 21 2.8 Study 2C (Review of HIV/AIDS policies) 21 2.9 Ethical considerations 23 3 Results from Study 1: private security sector 25 3.1 Introduction 25 3.2 Response analysis 25 3.3 HIV prevalence 29 3.4 HIV incidence 31 3.5 Behavioural and social determinants of HIV/AIDS 33 3.6 Voluntary counselling and testing 43 3.7 Substance use 46 3.8 Self-reported behaviour change 47 3.9 Male circumcision 48 3.10 Communication about HIV/AIDS and related issues 48 3.11 Associations between HIV prevalence and sexual behaviour indicators 50 4 Results from Study 1: legal services sector 55 4.1 Introduction 55 4.2 Response analysis 55 4.3 HIV prevalence and HIV incidence 60 4.4 Knowledge, attitudes, perceptions and behaviour 62 4.5 Awareness and use of VCT services 67 4.6 Self-reported behaviour change 68

4.7 Substance use 69 4.8 Communication about HIV/AIDS and related issues 70 4.9 Associations between HIV prevalence and sexual behaviour indicators 72 5 Results from studies 2a and 2b: private security sector 73 5.1 Introduction 73 5.2 Response analysis 73 5.3 Perceptions of general HIV/AIDS impact 78 5.4 Impact on employee profile 78 5.5 Impact on employee costs 80 5.6 Impact on demand and supply of skills 81 5.7 Business response 83 5.8 Employee perceptions of HIV/AIDS impact 85 5.9 Discussion 87 6 Results from Studies 2a and 2b: legal services sector 91 6.1 Introduction 91 6.2 Response analysis 91 6.3 Perceptions of general HIV/AIDS impact 96 6.4 Impact on employee profile 97 6.5 Impact on employee costs 98 6.6 Impact on demand and supply of skills 100 6.7 Business response 101 6.8 Employee perceptions of HIV/AIDS impact 103 6.9 Discussion 105 7 Results from Study 2c: a review of HIV/AIDS policies in both sectors 107 7.1 Introduction 107 7.2 Background 107 7.3 Commentary on policies 108 7.4 Gaps and general problems with the policies 110 7.5 Key issues not included in the policies 114 7.6 Areas requiring improvement 120 8 Conclusions and recommendations 133 8.1 Introduction 133 8.2 Summary of main findings for Study 1: HIV prevalence, HIV incidence and KABP survey 133 8.3 Perceptions of business impact and responses 138 8.4 Recommendations 144 Appendices 153 Appendix 1 Nurses who were trained as fieldworkers 153 Appendix 2 Terms of reference for policy experts 154 References 155

List of tables and figures Tables Table 1.1 Crude and adjusted company-level HIV prevalence in 22 South African workplaces 3 Table 2.1 Overview of employees and companies in the sub-sectors from various sources 12 Table 2.2 Policy reviewers 22 Table 3.1 Individual response rates for interviews and testing by background characteristics 25 Table 3.2 Characteristics among respondents interviewed and tested for HIV 26 Table 3.3 Profile of respondents compared to the national profile of employees in the private security sector 28 Table 3.4 Profile of study participants from the private security firms vs. national profile of employees in the private security sector 28 Table 3.5 HIV prevalence among respondents by demographic characteristics 30 Table 3.6 HIV prevalence among respondents by occupational category 30 Table 3.7 HIV incidence among respondents by demographic characteristics 32 Table 3.8 Responses to individual HIV/AIDS knowledge items by sex 33 Table 3.9 Attitudes towards HIV/AIDS (N = 2 787) 35 Table 3.10 Perceived seriousness of HIV/AIDS by sex and race 36 Table 3.11 Perceptions of personal risk of HIV infection by sex 37 Table 3.12 Reasons for believing that one did not have a high risk of HIV infection 38 Table 3.13 Sexual activity of respondents in the past 12 months by sex and race 39 Table 3.14 Number of sexual partners in the past 12 months by sex and race 39 Table 3.15 Age mixing among sexually active respondents by sex and race 40 Table 3.16 Condom use during last sexual intercourse by demographic characteristics 41 Table 3.17 Condom use during last sexual intercourse in different age groups by marital status and number of partners 42 Table 3.18 Awareness of where to access VCT services 44 Table 3.19 Alcohol use as measured using AUDIT scores by demographic characteristics 46 Table 3.20 Self-reported behaviour change by sex 47 Table 3.21 Communication messages/slogans about HIV/AIDS recalled by respondents by sex 49 Table 3.22 Comfort in communication with others about sex and HIV/AIDS-related issues by sex 49 Table 3.23 HIV prevalence and key sexual behaviour practices 51 Table 3.24 HIV prevalence and age mixing by sex 52 Table 3.25 HIV prevalence and perceived personal risk of HIV infection 52 v

Table 3.26 HIV prevalence and awareness of HIV status 53 Table 3.27 HIV prevalence and recency of HIV test 53 Table 4.1 Individual response rates for interviews and testing by background characteristics 55 Table 4.2 Profile of respondents by demographic characteristics (N = 421) 56 Table 4.3 Profile of respondents by employment category and situation, and household economic situation (N = 421) 57 Table 4.4 Characteristics among respondents interviewed and tested for HIV 58 Table 4.5 HIV prevalence among respondents by demographic characteristics 60 Table 4.6 HIV prevalence among respondents by occupational category 61 Table 4.7 Responses to individual HIV/AIDS knowledge items by sex 62 Table 4.8 Responses to individual attitudinal statements about HIV/AIDS 64 Table 4.9 Perceptions of personal risk of HIV infection by sex 64 Table 4.10 Reasons for believing that one did not have a risk of HIV infection 65 Table 4.11 Age mixing among sexually active respondents by sex 66 Table 4.12 Awareness of where to access VCT services 67 Table 4.13 Self-reported change of behaviour by sex 69 Table 4.14 Alcohol use as measured using AUDIT scores by demographic characteristics 70 Table 4.15 Communication messages/slogans about HIV/AIDS recalled by respondents by sex 71 Table 4.16 Comfort in communication with others about sex and HIV/AIDS-related issues by sex 71 Table 4.17 HIV prevalence and perceived personal risk of HIV infection 72 Table 5.1 Profile of employer respondents 73 Table 5.2 Profile of employees by occupational category, population group and sex (N = 14 105) 75 Table 5.3 Profile of employees by age group, population group and sex (N = 972) 76 Table 5.4 Employment status of employees 77 Table 5.5 Perceptions of past and future impact of HIV/AIDS on operations and profits (N = 13) 78 Table 5.6 Perceptions of the HIV/AIDS impact on employee profile 79 Table 5.7 Reported number of employees (n) who may have died due to AIDS or AIDS-related causes, 2003 2006 79 Table 5.8 Reported number of employees (n) who may have left due to health-related causes, 2003 2006 80 Table 5.9 HIV/AIDS impact on increasing employee benefit costs (N = 12) 81 Table 5.10 Impact on expenditure on HIV/AIDS services (N = 12) 81 vi

Table 5.11 Perceived impact of HIV/AIDS on the demand and supply of skills (N = 12) 82 Table 5.12 HIV/AIDS impact on investment in training by occupation (N = 12) 82 Table 5.13 HIV/AIDS impact on output, service delivery and consumer demand 83 Table 5.14 Awareness and implementation of HIV/AIDS policies 83 Table 5.15 Implementation of HIV/AIDS programmes (N = 12) 84 Table 5.16 Employee perceptions of HIV/AIDS impact on employees and the company 85 Table 5.17 Awareness of HIV/AIDS policies and their implementation 85 Table 5.18 Employee knowledge about content of and gaps in company HIV/AIDS policies 86 Table 5.19 Reported employee access to HIV/AIDS interventions in company 86 Table 5.20 Perceived gaps in company HIV/AIDS interventions (N = 732) 87 Table 6.1 Profile of employer respondents 92 Table 6.2 Profile of employees by occupational category, population group and sex (N = 417) 93 Table 6.3 Profile of employees by age group, population group and sex (N = 417) 94 Table 6.4 Employment status of employees (N = 416) 95 Table 6.5 Perceptions of HIV/AIDS as a business concern and the measurement thereof 96 Table 6.6 Perceptions of past and future impact of HIV/AIDS on operations and profits (N = 20) 97 Table 6.7 Perceptions of the HIV/AIDS impact on employees by occupational category (N = 19) 97 Table 6.8 Reported number of employees who may have died due to AIDS or AIDS-related causes, 2003 2006 (N = 15) 98 Table 6.9 Reported number of employees who may have left due to health-related causes, 2003 2006 (N = 15) 98 Table 6.10 HIV/AIDS impact on increasing employee benefit costs (N = 19) 99 Table 6.11 Impact on expenditure on HIV/AIDS services (N = 18) 99 Table 6.12 Perceived HIV/AIDS impact on the demand and supply of skills (N = 19) 100 Table 6.13 HIV/AIDS impact on investment in training by occupation (N = 18) 100 Table 6.14 Potential HIV/AIDS impact on supply of critical skills and strategies for skills turnover (N = 20) 101 Table 6.15 HIV/AIDS impact on output, service delivery and consumer demand (N = 20) 101 Table 6.16 Awareness and implementation of HIV/AIDS policies 102 Table 6.17 Implementation of HIV/AIDS programmes (N = 20) 102 vii

Table 6.18 Employee perceptions of HIV/AIDS impact on employees and the company 103 Table 6.19 Awareness of HIV/AIDS policies and their implementation 104 Table 6.20 Employee knowledge of contents and gaps in company HIV/AIDS policies (N = 101) 104 Table 6.21 Reported employee access to HIV/AIDS interventions in company 105 Table 6.22 Perceived gaps in company HIV/AIDS interventions (N=134) 105 Table 7.1 Coverage of key issues in the HIV/AIDS policies of SASSETA and private security companies 109 Table 7.2 Coverage of key issues in the HIV/AIDS policies of the legal firms 109 Figures Figure 1.1 Epidemiological model of the impact of HIV/AIDS in a workplace 7 Figure 2.1 HIV testing strategy 17 Figure 3.1 Profile of respondents by employment benefits (N = 2 787) 29 Figure 3.2 HIV test history, participation in VCT and awareness of HIV status 45 Figure 4.1 Profile of respondents by employment benefits (N = 421) 58 Figure 4.2 Sexual activity and number of partners in the past 12 months by sex 66 Figure 4.3 HIV test history, participation in VCT and awareness of HIV status 68 Figure 5.1 Profile of employees by occupational category (N = 14 105) 75 Figure 5.2 Employees by age group (N = 972) 76 Figure 5.3 Number of companies with health-related benefits (N = 11, 8, 8, 11 & 9) 80 Figure 6.1 Profile of employees by occupational category (N = 417) 93 Figure 6.2 Employees by age group (N = 417) 94 Figure 6.3 Number of companies with health-related benefits (N = 16, 10, 12 & 11) 99 viii

Foreword When sector education and training authorities (SETAs) were established in 2000 and we drafted the first sector skills plan, the consultation process with stakeholders contained one constant input: HIV and AIDS may have an impact on our sector and we should be doing something about it. At the time, the Police, Private Security, Legal, Correctional Services and Justice (Poslec) SETA realised that it had an important contribution to make towards the fight against AIDS with a distinct training perspective. However, nobody could give direction in respect of what the SETA should focus on. While the majority of interventions generally seemed to focus on prevention awareness, some employers were raising questions around succession planning and maintaining a healthy workforce. Others were raising questions about the cost to their companies. It was very clear that the scope and impact of the HIV and AIDS problem in the then Poslec sector was not understood, and that interventions from a SETA perspective would be short-sighted if they were not designed and specifically targeted to meet the sector s needs. Thus, the idea of this research project was born. Now, seven years later, SASSETA is proud to present the results of the first survey into the state of HIV and AIDS in two of its constituencies the private security industry and the legal profession. This project, sponsored by SASSETA, was a collaborative effort between the HSRC, SASSETA and stakeholder representatives over one and a half years. While the process was not without stumbling blocks, we believe this to be a major step in the direction of informed and targeted interventions for our sector. Having covered four very important aspects, namely a policy provision analysis, a business impact study, a knowledge, attitudes and practices (KAP) survey, and a prevalence and incidence survey, the findings and recommendations in this report can now be constructively be put to use in the development and implementation of HIV and AIDS management strategies for the private security industry and the legal profession. As is evident from the report, both groups are affected by HIV and AIDS; however, the hesitancy to participate in this survey on the part of so many employers is a clear indicator that the subject-matter has not crossed into the general awareness of businesses in our constituency. We hope that this report will be useful, beyond its original purpose of informing the SETA, in contributing to the general body of knowledge that is being generated on the subject. This publication is presented to the reader with the challenge to take HIV and AIDS seriously as an individual and as a businessperson. Perhaps, if we manage to repeat a similar study in the future, we may be fortunate enough to witness the difference we have made. Temba Mabuya Acting CEO, SASSETA ix

Contributors Authors are listed in order of contribution to the conceptualisation and preparation of the proposal, the development of the questionnaire, preliminary planning, management of the project, data collection, data analysis and report writing. Leickness Chisamu Simbayi, DPhil Research Director Behavioural and Social Aspects of HIV/AIDS Section Social Aspects of HIV/AIDS and Health Research Programme Thomas M Rehle, MD, PhD Research Director Epidemiology, Strategic Research and Health Policy Section Social Aspects of HIV/AIDS and Health Research Programme Jocelyn Vass, MA Senior Research Specialist World of Work Section Education, Science and Skills Development Research Programme Donald Skinner, PhD Chief Research Specialist Behavioural and Social Aspects of HIV/AIDS Section Social Aspects of HIV/AIDS and Health Research Programme Khangelani Zuma, PhD Chief Research Specialist Epidemiology, Strategic Research and Health Policy Section Social Aspects of HIV/AIDS and Health Research Programme Ntombizodwa M Mbelle, MA(ELT), MPH Senior Research Manager (Doctoral Research Trainee) Behavioural and Social Aspects of HIV/AIDS Section Social Aspects of HIV/AIDS and Health Research Programme Sean Jooste, MA Research Specialist (Doctoral Research Trainee) Behavioural and Social Aspects of HIV/AIDS Section Social Aspects of HIV/AIDS and Health Research Programme Victoria Pillay, PhD Research Specialist Epidemiology, Strategic Research and Health Policy Section Social Aspects of HIV/AIDS and Health Research Programme Nomvo Dwadwa-Henda, MA Chief Researcher (Doctoral Research Trainee) Behavioural and Social Aspects of HIV/AIDS Section Social Aspects of HIV/AIDS and Health Research Programme x

Yoesrie Toefy, MA Database Manager (Doctoral Research Trainee) Social Aspects of HIV/AIDS Research Alliance (SAHARA) Pelisa Dana, PhD Research Specialist Epidemiology, Strategic Research and Health Policy Section Social Aspects of HIV/AIDS and Health Research Programme Thabile Ketye, MA Senior Researcher Epidemiology, Strategic Research and Health Policy Section Social Aspects of HIV/AIDS and Health Research Programme Azwihangwisi Matevha, MA Senior Researcher (Doctoral Research Trainee) Behavioural and Social Aspects of HIV/AIDS Section Social Aspects of HIV/AIDS and Health Research Programme Nkululeko Nkomo, MA Senior Researcher (Doctoral Research Trainee) Behavioural and Social Aspects of HIV/AIDS Section Social Aspects of HIV/AIDS and Health Research Programme Yolande Shean Project Administrator Behavioural and Social Aspects of HIV/AIDS Section Social Aspects of HIV/AIDS and Health Research Programme xi

Acknowledgements A project of this magnitude and complexity involves several people in both its planning and execution. Therefore, we wish to thank the following people and organisations for their meaningful contributions to this study: The South African Safety and Security Sector Education and Training Authority (SASSETA) for awarding the tender to the HSRC to conduct this study. We especially wish to acknowledge Ms Yvette Raphael and Mr Jens Gunther from SASSETA for their continuous support throughout the study. Without their passion and strong commitment, this study would not have been successfully completed. The Steering Committee members consisting of senior staff from SASSETA, the HSRC and the various stakeholders from SASSETA for providing ongoing guidance and oversight, which also ensured successful completion of the project. Members of the Technical Task Team from the HSRC, SASSETA and the various stakeholders from SASSETA who tirelessly and regularly met to discuss the progress of the study and to smooth out potential risks to the project whenever there was a need. We would like to thank Mr T Proudfoot and Mr E Boshoff for facilitating communication between the researchers and the large companies in the private security and legal services sectors respectively. The HSRC fieldwork management team and project manager, who managed the fieldwork efficiently and effectively from the beginning to the end of the study. This team included the following: Mr Nkululeko Nkomo and Ms Azwihangwisi Matevha, the PhD research trainees who co-ordinated fieldwork in Gauteng. Mr Sizwe Phakathi of Oxford University and Mrs Pavathy Anthony of the University of KwaZulu-Natal who co-ordinated the fieldwork in KwaZulu-Natal. Dr Victoria Pillay and Mr Sean Jooste who co-ordinated fieldwork in the Western Cape, and who, together with Ms Thabile Ketye, conducted quality control of questionnaire data. Mrs Yolande Shean who efficiently co-ordinated and administered project meetings, data collection material and communication in general. She also helped put the final report together by collating the sections submitted by the various collaborators who prepared the report. Ms Sinelisiwe Ngwenya who assisted with project administration in the project management office. Mrs Linda Ngcwembe who diligently assisted with the project expenditure updates, report and guidance. Ms Alicia Davids for helping with putting together the report. We wish to thank the following people for reviewing the preliminary report (especially the areas indicated) as part of the Experts Panel: Dr Mark Colvin, Epidemiologist, Centre for AIDS Development Research and Evaluation (CADRE), Durban HIV/AIDS epidemiology, especially in workplaces. Ms Cathy Connolly, Biostatistician, South African Medical Research Council (MRC), Durban HIV/AIDS epidemiology, especially in workplaces, and behavioural and social factors driving HIV/AIDS. Professor Kelvin Mwaba, Psychologist, University of the Western Cape (UWC), Cape Town Behavioural and social factors driving HIV/AIDS. Professor Carel van Aardt, Economist, Bureau of Market Research, University of South Africa (UNISA) Impact of HIV/AIDS and response by business. Professor Geoffrey Setswe, Public Health Specialist, Human Sciences Research Council (HSRC) HIV/AIDS policies in workplaces. xii

We thank all the nurses who undertook the fieldwork. We have come to rely on these nurses, most of whom, although recently retired, are willing to further contribute to the development of our country as fieldworkers and supervisors. We especially wish to acknowledge them for their patience when the project was experiencing some problems due to poor response rates from companies in the original sample that was chosen. We also thank all the private security and legal services companies and their employees that participated in the study. We would like to thank the companies for their generosity in allowing the HSRC senior managers to hold meetings and conduct presentations, and for opening doors to fieldworkers to conduct interviews on their premises and among their employees. We wish to thank the staff from the National Institute of Communicable Diseases (NCID) National Health Laboratory Services in Johannesburg and the Global Clinical and Viral Laboratory for undertaking HIV testing during the main study and pilot studies, respectively, and the staff from Maphume for capturing data. We would also like to thank NICD for undertaking, without charge, HIV incidence testing using the BED technique. Finally, we thank our individual families for their support and encouragement during the time when we undertook this study. Prof. Leickness Simbayi Prof. Thomas Rehle Ms Ntombizodwa Mbelle Principal Investigator Principal Investigator Project Manager xiii

Abbreviations and Acronyms AIDS ALP AMS ART ARV CDC CEO DBS GRI HIV ILO KABP LSSA M&E PEP PLWA PLWHA SABCOHA SARS SAS SASSETA SIRA SMMEs SPSS STD STI TTT UCT UNAIDS USA VCT WHO Acquired Immunodeficiency Syndrome AIDS Law Project AIDS Management Standard antiretroviral therapy antiretroviral Centers for Disease Control and Prevention chief executive officer dry blood spot Global Reporting Initiative Human Immunodeficiency Virus International Labour Organisation knowledge, attitudes, beliefs and practices Law Society of South Africa monitoring and evaluation post-exposure prophylaxis people living with AIDS people living with HIV/AIDS South African Business Coalition on HIV/AIDS South African Revenue Services Statistical Analysis Systems Safety and Security Sector Education and Training Authority Security Industry Regulatory Authority small, medium and micro enterprises Statistical Package for Social Scientists sexually transmitted disease sexually transmitted infection technical task team University of Cape Town Joint United Nations Programme on HIV/AIDS United States of America voluntary counselling and testing World Health Organisation xiv

Executive Summary Background The generalised nature of the HIV/AIDS epidemic in South Africa is believed to have uneven impacts on various business organisations operating in the country. Indeed, many companies have responded, in different ways and means, to the challenge posed by the epidemic to their core business. Thus, there is a need to conduct assessments of the impacts of HIV/AIDS and responses thereto by companies. Obtaining such information would inform the concerned organisations about, among other things, the appropriateness of their current responses in terms of prevention and treatment interventions as well as the suitability of their HIV/AIDS policies. This information is critical in mitigating the impact of HIV/AIDS on productivity, economic costs, labour, and demand and supply of skills. Prior to the present project, no such study had been conducted in the private security and legal services industries. In October 2005, the Safety and Security Sector Education and Training Authority (SASSETA) put out a tender to undertake a critical assessment of HIV/AIDS in the private security and legal services industries, in terms of the prevalence rate of HIV, its impact on business and the responses of businesses to the epidemic thus far. Furthermore, the study sought to establish both sufficient and reliable empirical data about the status quo, which would then be the basis for forecasting the possible impact of HIV/AIDS on selected indicators within the sub-sectors. Due to the availability of new laboratory-based HIVincidence methods, the HSRC and SASSETA agreed on the use of the BED technology to measure incidence testing, instead of basing it on modelling. The tender was won by the HSRC, and the contract with SASSETA was signed on 7 March 2006. The intended duration of the project was 12 months. Due to the limited funding that was made available by SASSETA, it was agreed that the sample sizes would be decreased and that the study would take place in only three provinces (namely, KwaZulu- Natal, Gauteng and the Western Cape), instead of in four provinces for each sector, as had been planned. In the original plan, the private security industry study was meant to include Mpumalanga as the fourth province, while the Eastern Cape had been earmarked as the fourth province in the legal services industry study. Although work started immediately, delays were experienced as a result of a strike in the private security industry. In addition, problems were experienced in accessing most companies in the two sectors of SASSETA, which necessitated some changes to the sampling design, prolonging the duration of the project by six months. The project was concluded at the end of August 2007. Objectives The central objective of the present study was to conduct a critical assessment of HIV/ AIDS in the private security and legal services industries, in terms of the prevalence and incidence rates of HIV, business impact, and the responses of businesses to the epidemic thus far. xv

The Impact of HIV/AIDS in the Private Security and Legal Services Industries Methods Two research approaches were followed. Firstly, the study employed a highly participatory approach, which our team had used successfully in similar prior research. This entailed a significant involvement of key stakeholders in the conceptualisation and design of the study as well as its execution. This was effected through a steering committee and a technical task team, consisting of members of our research team and representatives from SASSETA, as well as its stakeholder organisations, the private security companies, legal firms and the unions, which oversaw the implementation of the project from beginning to the end. Secondly, we used a triangulation of several research methods, due to the complexity of the issues that were under investigation simultaneously. This, we believe, allowed for a deeper understanding of the issues than would have been the case if only one method had been used. The original overall project structure is shown in the figure opposite. In order to fulfil the objectives of the study, two parallel sets of studies where conducted within each sector. Study 1, which sought to address Project Outcomes 1 and 2, focused on HIV prevalence and HIV incidence, and knowledge, attitudes, practices and beliefs, while Study 2, which addressed Project Outcomes 3 and 4, investigated the business impact of HIV/AIDS and responses thereto. Both Studies 1 and 2 in each sector were preceded by a formative study involving interviews with managers or key people involved in HIV/AIDS in a few companies and focus groups of employees in all employment categories. The main part of Study 1 consisted of two cross-sectional surveys using the second-generation surveillance approach, which simultaneously collects both biological specimens for HIV testing and behavioural measures that are linked via bar codes. HIV testing was done on dry blood spot (DBS) specimens from a finger prick with a special surgical lancet. In the private security services sector, 2 787 respondents from 15 mainly large firms were interviewed by trained nurses, and 2 224 of them agreed to be tested for HIV. In the legal services sector, 421 respondents from 23 legal services firms agreed to be interviewed, 341 of whom agreed to be tested for HIV. Study 2 consisted of three parts. The first involved surveys of employers or their representatives from the private security and legal services sectors, who completed a questionnaire about the impact of and response to HIV/AIDS on behalf of each company that participated in the project. The second part included modules in the survey conducted as part of Study 1, which asked employees in the private security and legal services sectors about their perspectives regarding the impact of and response to HIV/ AIDS. The third and final part of Study 2 involved the use of a panel consisting of experts who critically reviewed three HIV/AIDS policies from the private security sector, three from the legal services sector, and the SASSETA HIV/AIDS policy. All DBS specimens were first tested on the Genscreen ELISA, and all reactive specimens were subjected to confirmatory tests with a second enzyme immunoassay (Vironostika Uniform 11 + 0). For quality control, a second test was conducted for 10% of cases where the first test was negative. Samples testing positive in enzyme immunoassay 1 and negative in enzyme immunoassay 2 (producing discordant results) were tested further on Western Blot (New LAV BLOT 1) for final interpretation of discordant samples. xvi

Executive summary SASSETA Project Process followed in both sectors Private security sector Study 1 HIV prevalence and incidence (Project outcome 1) Knowledge, attitudes, perceptions and behaviours (Project outcome 2) Phase 1 Formative or elicitation research: focus groups & key informants (Project outcome 2) Phase 2a Pilot study Phase 2b Main survey (2 crosssectional surveys) Phase 3 HIV incidence testing Legal services sector Study 1 HIV prevalence and incidence (Project outcome 1) Knowledge, attitudes, perceptions and behaviours (Project outcome 2) Phase 4 Analysis of test results Study 2 Business impact (Project outcome 3) Business response (Project outcome 4) Phase 5 Recommendations (Project outcome 5) Phase 1 Formative or elicitation research: focus groups & key informants (Project outcome 2) Phase 2a Pilot study (in conjunction with Study 1) Phase 2b Main survey (2 crosssectional surveys, in conjunction with Study 1) Study 2 Business impact (Project outcome 3) Business response (Project outcome 4) Phase 2c Managers survey Phase 3 Expert panel review of HIV/ AIDS policies in 16 companies Phase 4 Synthesis of expert reviews and policy recommendations Phase 5 Recommendations (Project outcome 5) xvii

The Impact of HIV/AIDS in the Private Security and Legal Services Industries The detection of recent infections (incidence) was performed on confirmed HIV-positive samples using the BED capture enzyme immunoassay (CEIA, Calypte HIV-1 BED Incidence EIA, Calypte Biomedical Corporation, Maryland, USA) optimised for DBS specimens. Data from each study was captured and analysed using appropriate methods as described in full in the main report. Finally, ethical approval was obtained from the HSRC s Research Ethics Committee. Main findings from Study 1: The HIV prevalence, HIV incidence and KABP survey Private security sector The following results were obtained: HIV prevalence among the respondents in the private security sector is 15.9%. Other analysis showed that: males had a slightly (although not significantly) higher HIV prevalence (17.3%) than females (12.3%); Africans had a substantially higher prevalence (27.3%) than other race groups (less than 1%); respondents aged 25 49 years had a higher HIV prevalence (17.9%) than respondents aged 50 years and older (7.5%) and respondents aged 24 years and younger (7.3%); widows had the highest HIV prevalence (29.4%), and divorced or separated people had the lowest HIV prevalence (6.8%); KwaZulu-Natal (22.8%) had the highest HIV prevalence, followed by Gauteng (17.8%) and the Western Cape (3.4%); respondents who were labourers, cleaners, porters and messengers had the highest HIV prevalence (24.5%), followed by service workers, clerks and protective service workers (21.8%), while senior officials, professionals, managers and directors had the lowest HIV prevalence (5.1%); HIV incidence was higher among Africans (2.5%) than other race groups; HIV incidence among respondents younger than 25 years of age (3.6%) was higher than among those aged 25 49 years (1.2%); no new infections found among respondents aged 50 years and older; and respondents from KwaZulu-Natal had a higher HIV incidence (3.4%) than those from the Western Cape (1.1%) and Gauteng (2.0%). The respondents in this study were generally very knowledgeable about HIV/AIDS, except for the following few misconceptions or myths: patients with TB also have HIV; once one has started taking antiretroviral treatment for HIV/AIDS one has to take it forever; there is a cure for AIDS; and sharing a cigarette (as well as coughing and sneezing) spreads HIV. Generally positive attitudes towards PLWHA were found on most issues, except for the following two, about which many respondents were either negative or ambivalent: having protected sex with a partner who is living with HIV/AIDS; and disclosing the status of a family member, which most respondents indicated they would want to keep a secret or were unsure about disclosing. xviii

Executive summary The overwhelming majority of participants (95.6%) had started taking the AIDS problem more seriously, and this was equally true for both sexes and the different race groups. Two-thirds of respondents (60%) indicated that it was because of the increased number of deaths due to AIDS, while almost a third (30.1%) viewed the reality of the disease as the second main reason. More males than females believed that they were are risk of HIV infection. Conversely, more females than males believed that they were not at risk. Most believed they were not at risk because they were faithful to one partner/trusted their partner, either always used condoms or were abstaining from sex, did not share used needles or body-piercing instruments, did not have sex with prostitutes, and knew that both they and their partner had tested HIV negative, in that order. Of the four race groups, both males and females of African origin (95.3% and 89.7% respectively) were found to be the most sexually active in the last 12 months, compared with their counterparts from the other race groups, especially white males (90.8%) and coloured females (76.3%). The large majority of respondents (86.7%) reported that they had regular sexual partners, 10.4% had non-regular sexual partners and 0.6% had had sex with commercial sex partners. The breakdown of those who had non-regular partners was as follows: more African and coloured males reported having had two or more sexual partners than did their male white and Indian/Asian counterparts; more coloured females reported having had two sexual partners than did their counterparts from the other race groups; and more importantly, not a single Indian/Asian female reported having had two or more concurrent sexual partners. The large majority of respondents (89%) of both sexes had partners who were within 10 years of their own ages. The breakdown was as follows: more males (10%) than females (3.3%) reported that they had sexual partners who were 10 years younger than themselves; more females (8%) than males (0.5%) reported having had sexual partners who were 10 years older than themselves; and more Africans (10%) had sexual partners who were 10 years younger than themselves, when compared to other groups, with white respondents coming a close second (6.7%). With regard to condom use: nearly a third (32.9%) of all the respondents who agreed to be interviewed had ever used condoms; among those sexually active, 41.9% reported having used condoms with regular partners in the past 12 months, 7.6% with non-regular partners, and 0.5% with sexual partners who engaged in commercial sex; both males and females below 25 years of age reported relatively high levels of condom use (62.4% and 53.6% respectively), compared to their counterparts of 50 years and above (16.4% of males and 9.1% of females respectively); both single males and females reported higher use of condoms (57.1% and 53.0% respectively) than did those of other marital statuses; widowed males reported the highest condom use, after single males, while none of the widows reported having used condoms in the last 12 months; African males and females reported significantly higher use of condoms (46.0% and 49.8% respectively) than did white and coloured males (23.8% and 23.3% respectively) and white and coloured females (22.8% and 22.6% respectively); xix

The Impact of HIV/AIDS in the Private Security and Legal Services Industries both male (63.9%) and female (44.8%) respondents with two partners reported higher condom use than their counterparts with single partners only (37.0% and 31.9% respectively); single respondents across all three age groups reported significantly higher use of condoms in their last sexual intercourse, compared to their married, widowed or divorced counterparts; in particular, respondents below 25 years of age (65.4%) reported higher use of condoms than did respondents in the other two age groups (53.2% for those aged 25 49 years and 50.0% for those older than 50 years); and respondents younger than 50 years old who had more than two partners reported the highest condom use in their last sexual encounters. The large majority of respondents (88%) knew where to obtain VCT services. However, white respondents and those aged 50 years and older were least aware of VCT centres. With regard to VCT use: a slight majority of respondents (53%) had ever had an HIV test, of whom 95% had been told of their test results; the majority of those tested (70.2%) had pre-test counselling before undergoing the test, with more men (73%) than women (64%) having received counselling; fewer, but still a majority of the respondents (60%), had post-test counselling after having had an HIV test; and female respondents (64%) were more likely than males (46%) to report having being aware of their HIV status. Half of the respondents (48.2%) who knew about their HIV status had regular partners, and the large majority (78.8%) of those with non-regular partners indicated that they had used condoms consistently in the past 12 months. One-fifth of the respondents (18.5%) who were found to be HIV-positive in this study had been tested for HIV within the previous two years, while 16.3% had undergone HIV testing more than two years previously. Using a 10-item international Alcohol Use Disorder Identification Test (AUDIT) to assess alcohol use, low-risk drinking was found to be commonest among white respondents, while high-risk alcohol use was most common among coloured respondents and in the Western Cape. A very low level of drug use was found in this study, with dagga (cannabis) being the most commonly used drug (and then amongst only 1.3% of respondents). Two-thirds of the respondents (67%) reported having changed their behaviour in the face of widespread HIV infection, using mainly ABC strategies such as having one partner only or being faithful, always using condoms, abstaining from sex, or reducing their number of sexual partners. Of the 1 582 males who participated in this part of the study, 40.5% reported having been circumcised. No reliable difference was found between the HIV prevalence rates of men who had been circumcised (17.2%, 95% CI = 12.55 23.09) and those who had not (17.4%, 95% CI = 13.05 22.84). The most common message/slogan recalled was on condom use, followed by abstinence tied with fear, and the need for faithfulness. The majority of respondents were generally comfortable communicating about sex, sexuality and HIV/AIDS-related issues, except for females talking with their colleagues, presumably males, about sexual matters. Respondents who reported having been sexually active in the previous year had the highest HIV prevalence (16.7%), followed by those who reported secondary abstinence (10.9%) and those who claimed to be virgins (1.6%). xx

Executive summary The HIV prevalence rate was higher among sexually active respondents who reported having had one sexual partner (16.4%) or multiple concurrent sexual partners (17.0%) than it was among those who practiced secondary abstinence (10.9%). However, there were no significant differences in HIV prevalence among respondents with various types of sexual partnerships. HIV prevalence was found to be higher among respondents who reported that they had used condoms during their last sex act than it was among those who reported not having done so. More HIV-positive respondents reported that they had been using condoms with regular sexual partners consistently over the past year, compared to those who had not. Respondents who perceived themselves to be at high risk of HIV had a higher HIV prevalence (19.9%) than those who considered themselves to be at low risk (9.8%). However, the difference was not significant. Males who had partners 10 years younger than themselves had a higher HIV prevalence (20.2%) than males who had partners 10 years older than themselves (10%). However, females who had partners 10 years older than themselves had an HIV prevalence of 16.3%, compared to a prevalence of 9.3% among those that had partners 10 years younger than themselves. Legal services sector The main findings that emerged from this study were as follows: HIV prevalence among the respondents was 13.8%, with the following breakdown: females had a slightly (but not significantly) higher HIV prevalence of 14.4% than males (12.4%); Africans had an HIV prevalence (20.2%) that was significantly higher than that of the other race groups combined (1.7%); respondents who were 25 49 years old had a higher HIV prevalence (16.0%) than respondents in the other two age groups (5.7% for those aged 50 years and above, and 5.3% for those aged 24 years and younger 5.3%); respondents who had never married had a significantly higher HIV prevalence (18.7%) than married respondents (10.1%); KwaZulu-Natal had the highest HIV prevalence (23.7%), followed by Gauteng (13.6%) and the Western Cape (2.1%); and respondents classified as labourers, cleaners, porters and messengers had the highest HIV prevalence (21.1%), compared to respondents from other occupational categories. Due to the small number of respondents found to have been infected during previous six months, it was not possible to calculate a valid HIV incidence estimate. Respondents were generally very knowledgeable about HIV/AIDS, but had many of the same myths or misconceptions as respondents in the private security industry. The overwhelming majority of respondents generally had very positive attitudes towards HIV/AIDS-related issues including PLWHA, except for 61% of the respondents who were either unsure or said that they would want to keep the HIVpositive status of a family member a secret, and 50% of the respondents who were either unsure or said that they would not have a problem having protected sex with a partner who has HIV/AIDS. The overwhelming majority of respondents, irrespective of gender and race group, indicated that they had started to take the problem of AIDS seriously. This perception varied by race group, with Africans being the most concerned (98.9%) and coloured respondents the least (83.3%). xxi

The Impact of HIV/AIDS in the Private Security and Legal Services Industries A large majority of male respondents believed that they were at risk of HIV infection, while female respondents were divided equally between those who thought they were at risk and those who thought they were not at risk. The majority of those who thought that they were not at risk held this view because they were faithful to their partners (i.e. B of ABC HIV prevention strategies). A large majority of the respondents (86.6%) reported having been sexually active during the previous year, as expected of normal adults, 9.5% of the respondents reported that they had been sexually abstinent, and 3.8% of the respondents indicated that they were virgins. A large majority (86.2%) of the respondents (94.7% of the females and 67.3% of the males) reported that they had one sexual partner. Nearly one-fifth of males reported that they had two partners (18.3%) or more than two partners (3.9%), compared to their female counterparts (4.0% and 1.2% respectively). About a tenth of males (8%) had a partner who was 10 years younger than themselves. The situation was the opposite among females, of whom 6% reported that they had a partner who was 10 years older than themselves. No male respondent had a sexual partner who was 10 years older than himself, while only 0.8% of the females had a partner 10 years younger than themselves. Consistent condom use was higher in relationships involving either one non-regular sexual partner (55%) or more than one non-regular concurrent multiple sexual partner (66%) than it was in regular relationships (16%). Over the previous 12 months, the majority of respondents in casual (non-regular) relationships with one non-regular partner (55%) and two-thirds of those with two or more non-regular partners (66%) reported consistent condom use, compared with 16% and 34% respectively for those in regular sexual relationships. The large majority of respondents (84%) knew where to obtain VCT services, with African (92%) and coloured (80%) respondents having higher awareness of where to access the services than white (71%) and Indian/Asian (63%) respondents. Nearly three-quarters of the respondents (71.1%) had undergone testing, with more females than males having done so; of these, 64% had pre-test counselling and 51% had post-test counselling, with two-thirds (66%) of them of both sexes having been informed of the results of the tests and thus being aware of their status. Overall, nearly two-thirds of the respondents (64%) reported having changed their behaviour in the face of widespread HIV infection. Most had done so mainly though adopting ABC strategies. Overall, 42.1% of the respondents reported that they had used alcohol in the previous 12 months: nearly a third (32.2%) were classified as low-risk drinkers (AUDIT score 1 7), while a tenth (9.9%) were high risk-drinkers (AUDIT score 8+); males (23%) were more likely than females (4%) to be high-risk drinkers; respondents aged 24 years and younger reported the highest levels of high-risk drinking (15%), compared to those older than 50 years (2%); and across the race groups, the majority of white respondents were low-risk drinkers, while no Indian/Asian respondents were high-risk drinkers. Overall, very low substance use was found in this study. Dagga (cannabis) was used more commonly (0.7%) than other substances. The most frequently recalled messages were about the use of condoms (C), fear, abstinence (A), issues of support and care, and the need for faithfulness (B), in that order. A large majority of respondents of both sexes were generally comfortable about talking to family members, colleagues and other people about sex and HIV/AIDS- xxii

Executive summary related issues. As was found in the private security sector, females were not comfortable talking to colleagues about sexual matters, while males were not as comfortable as their female counterparts in talking about sex to at least one family member. Respondents who perceived themselves as being at high personal risk of HIV infection had a higher HIV prevalence (18.4%) than those who perceived themselves to be at low risk of being infected with HIV (8.7%). Main findings from Studies 2A and 2B in the private security sector Employer perceptions of the impact of HIV/AIDS on business The following main findings were obtained from the two studies: Just over half of the employer respondents (53.8%) regarded HIV/AIDS as a business concern. Among these, the majority were large employers with 200 employees and more. Overall, very little was happening in terms of HIV/AIDS activities among participating companies. Nearly half of the respondent companies (46.8%) reported a small impact on company operations. Nearly a third (30.8%) reported that they anticipated a large impact in the next three years, with 7.7% anticipating a large impact on profits, 23.1% a moderate impact and 30.8% a small impact. Most employer respondents reported that HIV/AIDS had no impact on their employee profile. However, a few indicated otherwise, and the impact varied by occupational category, especially among service workers, security guards and labourers. Many AIDS or AIDS-related deaths were reported to have occurred in 2003 and 2004. Turnover was mainly among service workers and security workers, and a fair number was reported among labourers. Most companies provided a company retirement benefit, whereas only half provided either a medical aid or funeral benefit. Very few reported the provision of HIV/AIDS coverage or an occupational health clinic, the latter in lieu of medical coverage. Most companies did not anticipate that HIV/AIDS would have much of an impact on increasing employee benefit costs. On average, 66.7% reported that there would be no impact on benefit costs. Companies spent very little on HIV/AIDS services in the period prior to the survey. However, there does appear to have been some expenditure on HIV/AIDS education and awareness services and VCT. Most companies felt that HIV/AIDS had no impact on skills demand and supply across all occupational categories. Overall, it appears that there had been relative stability in the companies in regard to the demand and supply of skills, irrespective of occupation; consequently, very few companies had strategies in place to deal with potential labour and skills turnover. Most companies felt that HIV/AIDS had no major impact on investment in training. Among those that indicated otherwise, increases had been among labourers (33%), followed by service workers and learners (20% each), the occupational categories reported by companies as being severely impacted on by HIV/AIDS. While some companies reported that there had been no HIV/AIDS impact on output and service delivery, some indicated that there had been increases in sicknessrelated absenteeism and funeral attendance (38.5%) and health-related turnover xxiii