HIV in South Africa - High burden districts, key populations, gay men

South Africa has the largest HIV epidemic in the world. More than 19% of adults in South Africa are living with HIV. The burden of HIV in South Africa varies greatly across the country by age and gender, and for different key and vulnerable populations.

HIV in South Africa

HIV in South Africa

By 2016 the very significant achievements in respect of HIV in South Africa were said by the South African government to include that:1South Africa's National Strategic Plan for HIV, TB and STIs 2017-2022 Summary, 2018,

  • Deaths due to HIV had dropped from 681,434 in 2006 to an estimated 150,376 in 2016
  • 3.7 million people were taking ARV treatment for HIV but this was only 53% of those eligible for treatment
  • The number of new HIV infections had fallen and a higher proportion of people living with HIV had been diagnosed and treated
  • but in 2016 an estimated 270,000 people became newly infected with HIV.

By 2018 more than 4.5 million people were taking ARVs.2"South Africa launches campaign to expand access to HIV treatment", 2018, There are some more HIV statistics on the HIV statistics for South Africa page.

This is important progress, but the government acknowledges that more needs to be done and the national response needs to be accelerated if the country is to achieve the goal of ending HIV as a public health threat by 2030.

National Strategic Plan 2017 -2022

The aim is for the National Strategic Plan 2017 - 2022 (NSP) to mark a new approach. There is to be an intensified focus on the geographic areas and populations most severely affected by the epidemic. There is also to be a combination of interventions that have already been proved to deliver a high impact.

A strong focus of this NSP is improving the prevention of HIV infection among adolescent girls and young women because of their extremely high rate of infection. Reaching the national targets for reducing HIV is considered to be unattainable without targeting young women.3South Africa's National Strategic Plan for HIV, TB and STIs 2017-2022 Summary, 2018,

Highest HIV burden

The districts with a particularly high HIV burden are:

  • Gauteng: City of Johannesburg, Ekurhuleni, City of Tshwane, Sedibeng
  • KwaZulu-Natal: Ethekwini, Umgungundlovu, Uthungulu, Zululand, Ugu, uThukela, Harry Gwala
  • Mpumalanga: Ehlanzeni, Nkangala, Gert Sibande
  • Eastern Cape: OR Tambo, Amathole, Alfred NZo, Chris Hani, Buffalo City
  • Free State: Thabo Mofutsanyane, Lejweleeputswa
  • North West: Bojanala, Ngaka Modiri Molema, Dr Kenneth Kaunda
  • Limpopo: Capricorn, Mopane
  • Western Cape: City of Cape Town

Key Populations for HIV in South Africa

The Key Populations for HIV are:

  • Sex Workers
  • Transgender people
  • Men who have sex with men
  • People who use drugs
  • Inmates

Addressing the health needs of Key Populations for HIV

In recent years important progress has already been made in addressing the health needs of key populations for HIV. Examples include the Sex Worker Strategy for HIV, the South African National LGBTI HIV Framework for 2017-2022 and the NDoH Guidelines for the Management of HIV, TB and STIs in Correctional Facilities.

These programmes are to be scaled up and targeted, starting in the HIV high burden districts.

Global priorities for HIV

The UNAIDS 90-90-90 targets for HIV require that by 2020:

  • 90% of all people living with HIV know their status
  • 90% of all people with an HIV diagnosis will receive sustained antiretroviral therapy
  • 90% of all people receiving antiretroviral therapy will achieve viral suppression.

What this means is that 81% of all people living with HIV should be receiving antiretroviral therapy, and 73% of all people living with HIV should be virally supressed.

The World Health Organisation (WHO) guidelines have recommended the provision of antiretroviral therapy to all people when they are diagnosed with HIV, regardless of their CD4 count, when they are willing and ready for treatment. This has become known as the "Universal Test and Treat" (UTT) approach. In September 2016 UTT became the national policy for the provision of antiretroviral therapy in South Africa.

Is South Africa likely to meet the 90-90-90 targets for HIV?

There is some concern about whether South Africa will meet the 90-90-90 targets for HIV. 4"Modelling the impact of HIV in South Africa's provinces: 2018 update", 2018,

According to the Thembisa model the estimates for 2017 suggest that progress towards the first UNAIDS target is good, and progress has been relatively uniform across the provinces. However the model also suggests that progress towards the second target is generally poor with the percentage receiving antiretroviral therapy varying between 54% in Gauteng and North West to 81% in the Northern Cape.

Some provinces are close to reaching the third UNAIDS target, particularly Western Cape and KwaZulu-Natal. Both of these provinces are estimated to have an 82% rate of viral suppression. However, provinces such as Limpopo and Northern Cape appear to have only a 71% rate of viral suppresion.

Overall Northern Cape and KwaZulu-Natal are the provinces that have made the most progress towards the 90-90-90 targets, whilst Gauteng and North West are the provinces that are lagging furthest behind.

Sex Worker Strategy for HIV

The National HIV Sex Worker Plan was launched in South Africa in 2016

The National HIV Sex Worker Plan was launched in South Africa in 2016

The National Sex Worker HIV Plan for 2016-2019 was launched in March 2016.5WHO congratulates South Africa on new strategy for sex workers, 2016, The plan will offer comprehensive HIV services to sex workers who are often marginalized and face barriers to accessing health care. The plan also emphasizes the need to include access to justice and legal protection services, to provide training for health workers, and to support delivery of services through peer, community and clinical settings.

In South Africa all aspects of sex work are criminalised, with both the sex worker and the client committing criminal offences. 6"Say Her Name Report", 2018, In South Africa it is estimated that there are approximately 153,000 sex workers (figures range from 132,000 to 182,000). The majority of sex workers are found in large urban areas, 22 percent in Gauteng, 16 percent in Kwa-Zulu Natal and 11 per cent in the Western Cape.

In the "Say Her Name" report, one death was reported for defaulting on HIV medication. .. Sex workers are vulnerable to HIV/AIDS .. because they engage in penetrative sex with multiple partners over a prolonged period of time, putting them at risk for HIV infection if they do not use condoms.

While access to condoms are freely available, often the mere possession of a condom places sex workers at risk of being abused or arrested. Also there may be discrimination and stigma on the part of health care workers, who may pass judgmental comments or have a negative attitude towards the sex worker, making it difficult for sex workers to access the necessary treatment.

Immediate antiretroviral treatment will be made available to all sex workers with HIV, and daily oral pre-exposure prophylaxis (PrEP) will be offered to HIV negative sex workers to prevent them from acquiring the infection.

Sex work is estimated to account for as much as 20% of new HIV infections in the country. A recent survey showed as many as 70% of sex workers in Johannesburg living with HIV.

South African National LGBTI HIV Framework for 2017-2022

The South African National LGBTI HIV plan for 2017-2022 7South African National LGBTI HIV Plan, 2017, was launched in 2017 by the chairperson of the SANAC Civil Society Forum, Steve Letsike.8World first as SA launches national LGBTI HIV plan, 2017,

Gay flag of South Africa

Gay flag of South Africa

Letsike said that the plan was telling the world that South Africa was starting to be inclusive and that at a local facility level that included schools and courts. It was telling people that the LGBTI community wanted services.

Even when gay men manage to access health services, those provided in the public sector health system in South Africa are often said to be inappropriate, inadequate or insensitive to their particular needs. While the South African constitution does not discriminate against anyone on grounds of sexual orientation, in reality gay men continue to be stigmatised.9"Scared of going to the clinic", 2016,

"They call me a "moffie" some of them will actually curse at me, give me some nasty words that I won't even care to mention ... Especially when you are in the taxis they show by their actions that "I don't want to sit next to him" or "I don't want him to touch me because he might infect me, he's gay and everything" MSM Free State

Human Science Research Council Report

The latest 2017 report on HIV prevalence and incidence in South Africa, has shown a significant decline in HIV new infections in 2017, compared to the similar survey in 2012. But the survey has also shown the extent of the risky behaviour that is still occurring.10"HIV infections down, but still 230,000 new cases in 2017 - HSRC", 2018,

Consistent condom use was low, early sexual debuts before the age of 15 had increased among males, and more than a third of young women had sexual relationships with older men.

"It is concerning to find very little behaviour change seems to have occurred since 2012. This suggests that most of the reduction in new infections was likely due to the impact of the expanded ARV treatment programme". Dr Mpumi Zungu

So what does South Africa need to do?

"We can't treat ourselves out of the epidemic. To get more and more people to come into care and treatment and to reach those who don't want to be treated is going to take more innovation, in both health facilities and at a community level, in terms of support for people who don't want to be tested and treated" Professor Deenan Pillay

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Major Source for HIV in South Africa