‘SA has made progress but it’s not time to celebrate yet’: HIV experts on World Aids Day

As the world commemorates the 35th World Aids Day on Friday, South Africa is one of the nations that must be applauded for making progress in fighting what scientists had dubbed the “most elusive virus” — but it is not yet time to celebrate.

Instead, the country should "put foot on the accelerator" if it wants to get any closer to the ambitious global targets of ending HIV/Aids by 2030.  

That’s the view of Prof Glenda Gray, president and CEO of the South African Medical Research Council (SAMRC). 

Gray said despite new research by the Human Sciences Research Council (HSRC) released this week showing the prevalence of people living with HIV in South Africa has dropped from 14% (7.9-million people) in 2017 to 12.7% (roughly 7.8-million people) in 2022, there are still far too many people living with the virus and too many gaps that continue to drive new HIV infections.  

The sixth South African National HIV Prevalence Incidence and Behaviour Survey also showed only 81% of South Africans living with HIV who are 15 or older were virally suppressed in 2022, up from 62% in 2017. 

“I think it's very sobering that almost 8-million people in South Africa are HIV-infected. That is a lot of people living with HIV. What is also sobering for me are the low rates of young people who are virally suppressed. That is a big worry because that means if they are sexually active, there’s going to be ongoing transmission. You can’t turn off the tap if people aren't virally suppressed.” 

The survey showed the country has made significant progress towards the UNAids 95-95-95 targets that by 2025 95% of all people living with HIV are aware of their HIV status, 95% of those aware of their status are on antiretroviral treatment (ART), and 95% of those on ART  achieve viral load suppression.  

Among South Africans aged 15 years and older living with HIV in 2022, 90% were aware of their status, 91% of those aware of their status were on ART, and 94% of those on ART were virally suppressed. This is an improvement compared to 2017 when the UNAids target was 90-90-90 but South Africa achieved 85%-71%-87%. 

It also showed girls and young women aged 15 to 24 remain disproportionately affected by HIV. Compared to males of the same age groups, HIV prevalence was about two-fold in females aged 15 to 19 (5.6% vs 3% respectively) and 20 to 24 (8% vs 4%), and three-fold higher in females aged 25 to 29 (20% vs 6%).   

“There’s no time to celebrate yet. We still have a lot of work to do if we want to control HIV by 2030. Instead we are going to have to put the foot on the accelerator,”  said Gray.

“We need treatment as prevention. Everyone who is on antiretrovirals needs to take their treatment. In terms of prevention, we need to increase the number of men who are circumcised and those eligible for PrEP (pre-exposure prophylaxis) to take it as we still have low rates of PrEP.” 

Director of the Desmond Tutu HIV Centre Prof Linda-Gail Bekker said while there is a lot to celebrate about progress the country has made, with South Africa having the largest ART programme in the world, more than 5.5-million on treatment and many having access to PrEP, “we've got niggling areas that we haven't shifted”. 

“First it is the 2-million-odd people who still need to be on treatment. Those are people who don't want to be found. These are largely men who are infecting young women, who are our other niggly problem.

“We have not been able to shift incidence in young women over many years, which continues to be a problem. Like any young person around the world they start to experiment with sex and these young women are becoming infected. We can talk about condoms until the cows come home, but we know it is hard for them to apply a male condom because a male needs to be party to that.”   

The survey, done among 27,000 households between January 2022 and April 2023, showed:

• In 2022 about 81% of people aged 15 and older living with HIV were virally suppressed and could not transmit infection, compared to 62% in 2017.
• Viral suppression was higher (83%) among women compared to men (79%) and lower (70%) among younger adults aged 15 to 24 years.
• The lowest percentage of viral load suppression (66%) was among men aged 25 to 34 years.
• Only half of all young men aged 15 to 24 were medically circumcised, compared to 43% in 2017. This is an important achievement as studies have shown male circumcision can reduce the risk of heterosexual HIV transmission by approximately 60%. 

Bekker said while young women could be protected by PrEP,  access to this “chemical condom” wasn’t always easy.  

While oral PrEP has been proven effective, young people were not always adherent to taking daily pills. Another protective option, the dapivirine vaginal ring approved in South Africa early last year, was in limited supply.

Bekker said while the new injectable PrEP, CAB-LA (short for long-acting cabotegravir) proven to be superior compared to oral PrEP, holds great promise for HIV prevention, the government’s financial barriers in securing this drug could spell disaster for HIV prevention. 

“We know that we've got financial barriers in the health sector. Our health systems aren't thriving and that makes me concerned. That's another reason I don't want for a moment to say the HIV epidemic is done and dusted because then the money will go away, the priority will go away, and we still have a huge amount of work to do.” 

Gray said the latest HIV data showed researchers on HIV vaccine discovery needed to go back to the drawing board.

“We know the virus is a formidable opponent because no-one has been cured naturally from HIV. So far don't we don't know what it takes to cure a person. We know we still have a lot of work to do. We’ve got to go back to the drawing board and find an effective HIV vaccine because it is the only way we're going to eliminate any epidemic and control HIV at a global level.” 

As part of World Aids Day commemoration, Deputy President Paul Mashatile, in his capacity as chairperson of the South African National Aids Council (Sanac), will on Friday launch of the local chapter of the Global Alliance to End Aids in Children in Sundumbili township in the iLembe district in KwaZulu-Natal. This is part of the global initiative by governments to end Aids in children by 2030. 

The 2023 commemorations will take place under the theme “Let Communities Lead”, a call to invest in and strengthen community-led interventions and community-centred approaches in the management of HIV.  

Mashatile will lead the commemoration together with Sanac civil society chairperson Steve Letsike, health minister Joe Phaahla and KwaZulu-Natal premier Nomusa Dube-Ncube.

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