So many successes, but too many new HIV-infections

Dr Fareed Abdullah & Kanya Ndaki

As the global HIV community returns to South Africa for the International AIDS Conference, there is no better time to take stock of the progress the country has made.

South Africa is doing remarkably well in the provision of antiretroviral treatment. Of the estimated 6.8 million people who have contracted HIV, almost half (3.2 million) are receiving treatment. This makes us the country with the largest number of people on ART in the world.

To put this in some sort of global perspective, our programme contributes no less than 20 percent of the 15.8 million people on ART throughout the world. This achievement is due to the unflinching commitment of the Treasury to fund such a rapid rollout and the unique brand of leadership of our Minister of Health, Dr Aaron Motsoaledi.

Are there problems with the implementation of the programme? Of course there are. Drug stock outs, long queues, low staff morale, poor record keeping – are all to be expected in such a large scale programme and, though government is aware of many of the problems, it remains critical for civil society organisations to point out weaknesses and for government to respond to criticism.

All of the problems and even the difficulties within the public sector about carefully tracking each patient (weak patient management systems) do not take away from the staggering demographic and public health benefits that the treatment rollout has heralded. Life expectancy in South Africa has increased from 53 years in 2006 to 61 years in 2012 and mortality has declined by about 50% over a similar period of time. Government spends billions of rand on treatment and the investment is certainly paying off.

Few other economic or safety net interventions yield the population level impact seen through this single intervention. The latest UNAIDS report estimates that South Africa has averted 1.3 million deaths through its ART intervention over the last decade.

The success of our treatment programme, however, brings us to a new crossroads in the epic war against the HI-virus. A successful treatment programme means more South Africans will survive and live longer with HIV. Yet it also means that we are seeing an ever-burgeoning epidemic of HIV as a result of better survival on treatment and a continuing feed of new HIV infections annually.

We estimate there were 330 000 new infections in South Africa in 2014. Using a slightly different methodology, we estimated that there were 469 000 new infections in 2012. The numbers of people living with HIV goes higher and higher. In 2008, it was 5.2 million. In 2012, 6.4 million. Our latest estimates are that we now have 6.8 million people living with HIV in South Africa.

This growing epidemic is unsustainable in the long term from many points of view. Financially, the ever increasing provision of life-long ART to increasing numbers of patients will eventually reach a ceiling, at which point the competition with other needs in the health services will limit the growth of expenditure on the ART programme. The health system’s capacity is already stretched to the limit and there will be consequences of an ever-increasing ill population. At the individual level, with longevity and lifelong treatment there will be missteps in the management of HIV disease that will be cumulative with age and with chronic medication.

This all means that we have to seriously turn our attention to prevention. We have to drastically reduce the number of new infections in the short to medium term. There are two schools of thought on how to approach prevention.

The first takes the view that prevention can be best achieved by a pill as an HIV-positive individual who is virally suppressed on antiretroviral treatment has such a reduced level of infectiousness that the risk of transmission to a HIV-negative sexual partner declines by more than 90%. Combine this with the option of a negative individual who can take a daily pill and reduce his or her risk of infection from sex with an HIV-positive individual in more than 60 percent of the time and you already have the core of an effective prevention programme through the provision of treatment.

This is quite a neat argument and there is modelling work that gives it credibility. The models show that, over time, these ‘treatment’ interventions also have a substantial ‘prevention’ benefit.

The second view is that no amount of pill-popping, gel insertion or foreskin snipping is going to yield the desired result of a rapid reduction in new infections. There are greater forces driving new infections and these have to do with social and economic factors that define sexual relations in South Africa. There is a so called ‘political economy’ of HIV transmission that must be understood before its power is to be broken so that the chain of transmission can be similarly unravelled. What is it that drives the cycle of men having liaisons with young women five to 10 years their junior? What are the social and economic dynamics of transactional sex? What are the gender dynamics that make men in life partnerships take on these other liaisons? How much of it is coercion and how powerless is a young women who is poor, has lost one of her parents to HIV and has just dropped out of school?

Is the breakdown of the family in South Africa as a consequence of a 150 years of circular migration so much worse than other countries in the region to account for the extreme rates of our epidemic?

The holders of this second view are quick to point out that this is not one of those deterministic outlooks that end with a fatalistic ‘nothing will change unless the underlying conditions are removed’ point of view. In fact, the social science research is exciting. We know, for instance, that girls in families that receive child support grants are less likely to become infected with HIV, as are girls who stay in school to the full term. We also know that women who experience gender violence are three times more likely to be infected with HIV than those who don’t share this horrible experience. Pregnancy at a young age, we know, puts a young woman in South Africa on the road to HIV.

Consistent condom use is still the single most effective intervention for the prevention of HIV and it would be fair to say that we have not achieved sufficient consistent condom use to see its full benefits. Now that the South African government has the largest condom procurement and distribution programme in the world at least the commodities exist to get men to put them on their penises.

We also know that medical interventions often fail because of human behaviour. Men with HIV are not seeking treatment although it is universally available (this would help them and their uninfected partners) and we know that men and women struggle to adhere to both prevention and treatment interventions. This is so severe a problem that the famed Tenofovir Gel trial failed not because the preparation was not efficacious but because the women in the trial did not adhere to it.

As a country we need to knock heads to bring these apparently differing perspectives together and to find the magic mix of prevention and treatment interventions to break down the constant stream of new infections that puts a more thorough-going control of the epidemic just out of our reach. Over the next fifteen to twenty years we have to live in a country where the egregious social, economic and cultural factors that drive HIV are no longer commonplace and where the very promising new prevention tools can realise their full potential – not least of these the HIV vaccine. That is the task facing the South African National AIDS Council and its constituents in government, civil society and the private sector.

The conference comes back to Durban after 16 years. AIDS2000 is remembered as the conference that called for the provision of ART to all countries – especially in Africa. Let’s make AIDS2016 the conference that will be remembered for its call to comprehensively tackle prevention.  

Dr Fareed Abdullah is the CEO of the South African National AIDS Council (SANAC).

Kanya Ndaki is the spokesperson of SANAC.

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