Decline in AIDS deaths, but SA missing other HIV targets

While AIDS deaths and the rate of new HIV infections in South Africa are declining, the country seems set to miss crucial UNAIDS and National Strategic Plan targets.

Around 89 000 people in South Africa died of AIDS-related causes in 2017, almost 240 a day. This is according to just-published estimates from the Thembisa model, a leading mathematical model of HIV in South Africa. The 89 000 figure is part of a downward trend from a peak of around 270 000 in 2005. The remarkable decline in AIDS deaths has been driven by the widespread rollout of antiretroviral therapy in South Africa. The estimated 89 000 deaths in 2018 amounts to around 240 AIDS deaths per day – down from a peak of over 700.

The rate of new infections in South Africa is also declining with the model estimating around 275 000 new HIV infections in South Africa in 2017 – around 750 per day. In the period either side of the turn of the century South Africa had more than 500 000 new infections per year. It is estimated that there was around 12 500 cases of mother-to-child transmission of HIV in South Africa in 2017. This is down from highs of around 70 000 in the early 2000s.

There were around 7.35 million peple (13% of the population) living with HIV in South Africa in 2017. This number will keep rising in the coming years since the death rate from AIDS is substantially lower than the rate of new infections. It is also estimated that in 2017 around 335 000 children under the age of 15 were living with HIV.

Around 4.1 million people are estimated to have been receiving antiretroviral therapy in 2017. This means that aproximatley 3.25 million people who were living with HIV in 2017 were not receiving treatment. The World Health Organisation recommends that all people living with HIV should be offered antiretroviral therapy. One encouraging sign is that the rate at which people are being started on treatment is almost double the rate of new infections.

Progress against 90-90-90

The Thembisa model estimates present a mixed picture when it comes to South Africa’s progress against the 90-90-90 targets. These UNAIDS targets have been adopted in South Africa’s National Strategic Plan for HIV, TB and STIs 2017 – 2022 – and as such represents our national targets. The targets are as follows:

  • By 2020, 90% of all people living with HIV will know their HIV status.
  • By 2020, 90% of all people with diagnosed HIV infection will receive sustained antiretroviral therapy.
  • By 2020, 90% of all people receiving antiretroviral therapy will have viral suppression.

The good news is that South Africa appears to have already reached the first 90, with an estimated 90% of people living with HIV knowing their status in 2017.

South Africa is doing much poorer on the second 90, with only around 61.9% of people diagnosed with HIV receiving antiretroviral therapy in 2017. According to the model projections it is unlikely that South Africa will reach the second 90 by 2020.

In terms of the third 90, it is estimated that around 77.8% of HIV positive people who were receiving treatment in 2017 were virally suppressed. Even though this figure is relatively high and may well go up with the introduction of dolutegravir-based antiretroviral therapy in South Africa, it is by no means certain that it will rise to 90 in the coming years and then be maintained above 90.

Maybe of greater importance, is the estimate that of all people living with HIV in South Africa (both on treatment and not), only around 43.3% were virally suppressed in 2017.

About the Thembisa model

The Thembisa model provides arguably the most reliable estimates of the course and state of the HIV epidemic in South Africa. The previous set of model outputs were published in September 2017. Since last year the model has been extended to include modelling of HIV diagnosis in children, which means that the model can now track progress towards the 90-90-90 targets in children as well as adults (as reflected above). The model has also been updated and calibrated with new information, including HIV prevalence data from the 2017 Human Sciences Research Council and antenatal clinic surveys. While the model also contains projections for 2018 and beyond, we have quoted 2017 figures in this article since the model is calibrated with data up to 2017.

The model outputs as well as an Excel version of the model can be downloaded from the Thembisa website. The outputs also include rich provincial estimates and provides confidence intervals for all the key indicators – details that we have not included here in the interest of brevity.

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