South Africa has the largest number of people living with HIV in the world. It accounts for up to one third of new HIV infections globally. In 2016 there were an estimated 7.1 million people living with HIV In the same year close to 10 million people were tested for HIV.
But huge strides are being made in line with the country adopting the UNAIDS’ 90-90-90 strategy. Under the plan the aim is for:
90% of all HIV positive people to know their HIV status
90% of people who know their HIV status to be on treatment, and
90% of those on treatment to have suppressed viral loads by 2020. Viral suppression is when a person’s viral load – or the amount of virus in an HIV-positive person’s blood – is reduced to an undetectable level.
South Africa has made tremendous progress towards meeting the 90-90-90 targets. In 2016, South Africa’s National Aids Council estimated that 86% of all HIV positive people in the country knew their HIV status, 65% of the those who knew their HIV status were taking antiretroviral therapy and 85% of those taking antiretroviral therapy were virally suppressed.
To complete the last leg South Africa has four important things to do. It must address the gaps in HIV testing; it must start people on antiretroviral treatment and make sure that they remain on it; it must ensure that people maintain virological suppression and, lastly, it must strengthen its strategies around prevention.
All these areas have challenges that may prevent South Africa from taking the last few steps to meet the target.
The HIV testing: the country’s guidelines recommend that all adults are tested for HIV at least once a year. Groups that are at a higher risk of being infected should be tested every three to six months.
But HIV testing programmes show that certain groups are tested much less than this. For example, a significant proportion of men go untested as do adolescents, young people, and men-who-have-sex-with-men.
To narrow this gap and increase access to HIV testing and treatment, community and workplace based HIV testing and counselling should be strengthened and HIV self–tests should be improved.
Antiretroviral treatment: this is the most powerful tool in South Africa’s response to HIV. Treatment has reduced illness and death from a peak of 325 000 in 2005 to 126 000 AIDS related deaths in 2016 as well as the number of new infections at population level in some settings.
And improvements are being implemented all the time. For example, last year amendments to the national treatment programme meant that all HIV positive people could receive ARVs regardless of their CD4 count.
But there are still disparities in starting treatment particularly among men, young people, female sex workers and other key populations. These groups are more likely to start treatment late in the course of HIV infection.
Community based ART initiation as well as high quality client-centred HIV care and treatment services will be essential to address these gaps.
Suppressing the virus: staying on HIV care and maintaining viral suppression is essential if the 90-90-90 targets are going to be met.
But in South Africa there are still high numbers of people who stop taking treatment and attending care. People stop taking their medication for lots of reasons. The reasons range from being pregnant at start of ART or having a low CD4 count at entry into care, a lack of disclosure of HIV status, and inflexible clinic hours.
The national HIV care and treatment programme has recommended various strategies to improve adherence to medication and these are being implemented across the country. These include clinic visits to help monitor people on treatment as well as community based adherence clubs and peer groups. Another has been the recommendation that chronic medicines are delivered through private pharmacies.
What is needed are for programmes to better understand and address the provider, individual and community factors which determine why some people living with HIV can remain in care for a long time and why some cannot.
Prevention: Primary prevention focuses on people who are HIV negative and aims to keep them that way. The weapons in the prevention arsenal are diverse and include:
behavioural change (abstinence, reducing the number of sexual partners as well as correct and consistent condom use),
pre-exposure prophylaxis and post-exposure prophylaxis.
But these interventions vary in effectiveness at population level depending on coverage and for some adherence.
By implementing the 90-90-90 strategy South Africa is expecting to reduce the number of new HIV infections dramatically in the next five years. This will involve scaling up a combination HIV prevention interventions as well as maintain high levels of viral suppression and reduce time spent with unsuppressed viral loads. With all this in place the number of new HIV infections is expected to fall from 270 000 in 2016 to less than 100 000 by 2022.
But ending AIDS as a public health threat will require a sustained focus on health promotion by creating conditions that allows communities and individuals to make informed choices regarding HIV prevention, care and treatment - and empowering of communities and individuals to act on those choices.