South Africa continues to have the largest HIV epidemic in the world. Worldwide twenty per cent of all people living with HIV are in South Africa, and twenty per cent of new HIV infections also occur in South Africa. If the epidemic of HIV in South Africa is not going to continue to grow then more action is needed both by the government and civil society.
HIV in South Africa - the Government Approach
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 HIV 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.1South Africa's National Strategic Plan for HIV, TB and STIs 2017-2022 Summary, 2018, https://sanac.org.za//wp-content/uploads/2018/08/NSP_Summary.pdf As the HIV statistics for South Africa show the prevalence of HIV amongst women aged 35-39 is 39.4%.
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
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 being scaled up and targeted, starting in the HIV high burden districts.
Sex Worker Strategy for HIV
The National Sex Worker HIV Plan for 2016-2019 was launched in March 2016.2WHO congratulates South Africa on new strategy for sex workers, 2016,https://www.who.int/hiv/mediacentre/news/southafrican-strategy-sex-workers/en/ The plan offers 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. 3"Say Her Name Report", 2018, http://www.sweat.org.za/wp-content/uploads/2018/08/Say-Her-Name-Report_HI-RES.pdf 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.
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. Daily oral pre-exposure prophylaxis (PrEP) is being offered to HIV negative sex workers to prevent them from acquiring HIV 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.
National LGBTI HIV Framework for 2017-2022
The LGBTI HIV plan for 2017-2022 4South African National LGBTI HIV Plan, 2017, http://sanac.org.za/wp-content/uploads/2017/06/LGBTI-HIV-Plan-Final.pdf was launched in 2017.
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.5"Scared of going to the clinic", 2016, https://sajhivmed.org.za/index.php/hivmed/article/view/701/1078
"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
HIV in South Africa - the 90-90-90 Targets
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.
Are the 90-90-90 targets for HIV likely to be met?
There is some concern about whether the 90-90-90 targets for HIV will be met. 6"Modelling the impact of HIV in South Africa's provinces: 2018 update", 2018, https://www.thembisa.org/downloads/
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.
Human Science Research Council Report
The latest 2017 report on HIV prevalence and incidence has shown the extent of the risky behaviour that is still occurring.7"HIV infections down, but still 230,000 new cases in 2017 - HSRC", 2018, https://www.health24.com/News/hiv-infections-down-but-still-230-000-new-cases-in-2017-hsrc-20180717 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
Providing HIV treatment
The World Health Organisation (WHO) has recommended the provision of antiretroviral therapy to all people when they are diagnosed with HIV, regardless of their CD4 count. 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 for people with HIV in South Africa. But there is a long way to go before all those living with HIV are on treatment. In 2018 only 62% of people living with HIV were on treatment.
So what does South Africa need to do?
"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