The 9th SA AIDS Conference 2019: Reigniting a sense of urgency
As a South African, the chances that you are living with, or affected by HIV are high. Many of us who are old enough have witnessed first-hand the tragedy the pandemic unleashed over the last 40 years. In the last decade, we have observed great strides in our public-health response to HIV/AIDS. However, recent data show that prevalence in South Africa is still on the rise, with young people bearing the brunt of new infections. Held in June, the 9th SA AIDS conference was a call to action and challenged the growing complacency towards a decades-old pandemic. By Andrea Teagle
In South Africa, 7.9 million people live with HIV, and the number increases daily. Young people between 15 and 24 account for over a third (38%) of new infections: every day, 1000 adolescent girls and young women are infected. These were some of the findings from the recently launched SABSSM 5 report: The 5th South African National HIV, Behaviour and Communication Survey, presented by the HSRC’s Prof Heidi van Rooyen at the 9th SA AIDS conference 2019.
“Without aggressive action to reduce the rate of new infections in young people, HIV will continue to take a tremendous toll on the country for years and generations to come,” warned Van Rooyen, whose research explores the social determinants of HIV vulnerability.
The danger of complacency
Fifteen years ago, being infected with HIV was a death sentence for many South Africans. Despite widespread global scientific consensus on the link between HIV and Aids, the influence of HIV denialists on individuals in government delayed the rollout of antiretroviral therapy (ART).
A stellar civil-society and media response, led by the Treatment Action Campaign, was instrumental in the roll-out of a national ART programme in 2004. Today, South Africa has the biggest antiretroviral programme in the world, with 62.3% of people living with HIV on treatment. This amounts to approximately 4.4 million people, a figure that has doubled since 2012, according to the SABSSM 5 report. With massive national awareness campaigns and outreach testing and counselling programmes, the survey found that two-thirds of South Africans reported having tested for HIV in the previous year.
But these gains in awareness might also have bred complacency. With so many on treatment, it might seem that the worst is behind us. The results of the recent survey paint a different picture.
Also speaking at the conference, Prof Khangelani Zuma, the executive director of the HSRC’s Social Aspects of Public Health research programme, said that between 2012 and 2017 the number of new infections (incidence) declined by 44%. However, he noted that at 0.48%, which translates to 231 000 new infections annually, it remains high enough to sustain HIV prevalence.
More positively, the climbing prevalence also reflects the fact that thanks to ART, fewer people are dying from AIDS-related illness – although the drop in mortality has plateaued in the last five years.
The cycle of transmission: How men between 23 and 35 infect adolescent girls and young women
(15-24), who go on to pass the disease on to partners their own age
Source: Dellar R, Tanser F, Abdool Karim Q et al. Manuscript in preparation, AVAC Report 2016: Big Data, Real People
www.avac.org/report2016/graphics
Breaking the cycle
For men between 15 and 24 years old, the rate of new infections has increased by 11%. Despite this, and the fact that incidence has dropped 26% among young women, young women still face a three times greater risk for infection. By their mid-to-late thirties, almost 4 in 10 women in South Africa are living with HIV.
Researchers and public-health experts have been speaking about the need to focus on adolescent girls and young women for years. What is working, and what isn’t? “Although many organisations and government departments target adolescent girls and young women, action has often been piecemeal, resulting in duplication of effort, funds not allocated strategically and limited impact,” Van Rooyen explained, after the conference.
Interventions that have been shown to be effective at reducing incidence include reaching young women and, critically, their partners, with information and resources to make safer choices, and improving access to youth-friendly reproductive health services.
An effective scale-up of Pre-exposure prophylaxis (PrEP) – a preventative daily medication that reduces the risk of acquiring HIV – could be a critical component of a youth-targeted intervention. In line with a new drive to amplify voices of young people in devising interventions, HSRC researchers are engaging with young people to identify how best to make PrEP accessible.
While prevention options are important, Van Rooyen emphasised that sustained behaviour change will only be achieved by addressing the factors that predispose young women to HIV, including poverty, education insecurity and gender-based violence.
“For young women growing up in such communities with a high HIV prevalence, there is a fatalistic feeling that getting infected with HIV is inevitable. This speaks to the many social determinants of HIV and the need to adopt a holistic approach – a combination effort – when addressing HIV.”
The eThekwini Declaration
A major challenge, raised by the Treatment Action Campaign, is the frequent occurrence of ARV stock-outs at major healthcare facilities. In a 2015 national survey published in the journal PLOS1 this year, 1 in 5 healthcare facilities reported a current stockout of a least one HIV or TB drug; and 1 in 3 reported a stockout in the last 3 months.
Retaining people in care remains a pressing concern: 1 in 4 people who initiate ART are no longer on treatment after a year. In total, 3.5 million people (44%) are not yet receiving treatment. This underscores the importance of engaging with target groups, including young people—among whom viral suppression is worryingly low — in identifying and addressing barriers to initiating and staying on treatment.
Dr Sizulu Moyo, a research director at the HSRC, pointed to the growing challenge of the emergence and spread of HIV mutations. Among HIV-positive individuals who are virally unsuppressed, over a quarter (27%) have drug-resistant strains.
Transgender women are disproportionately affected by HIV, new HSRC research shows, and, while sex work remains criminalised, sex workers face higher risks and reduced access to health services. Finally, funding is declining, threatening to stall the progress South Africa has made towards halting the epidemic.
All of these issues require an ongoing sense of urgency in investigation and response. To this end, delegates at the conference — including local and international scientists, public and private-sector representatives NGOs and faith-based organisations — signed the eThekwini Declaration, received by Deputy President David Mabuza.
The declaration called for a rejuvenated, synergised, community-oriented response that positions young people at the centre of devising interventions to meet their HIV needs, and that addresses inequalities and empowers young women and girls.
To read more and show your support, click here. Millions of South Africans are at risk for infection right now. Millions more are at risk for not receiving the treatment they need. We can’t afford to become complacent.
Author: Andrea Teagle, HSRC science writer
ateagle@hsrc.ac.za