HIV in graphs: Latest figures confirm declining rates, but areas of concern remain

Since it's introduction into South Africa's HIV treatment program in 2019, the antiretroviral dolutegravir has been widely rolled out in public healthcare sector.

Around 7.8 million people, or 13.2% of the population, were living with HIV in South Africa in 2022. This is according to recently published estimates from Thembisa, the leading mathematical model of HIV in South Africa.

HIV prevalence was much higher in certain sub-groups. An estimated 31% of women aged 25 to 49 in South Africa were living with HIV in 2022. For female sex workers, prevalence was estimated at 59%, and for men 18 or older who have sex with men 30%. In general, prevalence in men was much lower than in women and children had much lower prevalence than adults.

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Some good news

There is good news in that the rate of new HIV infections continues to fall. In 2022, there was an estimated 164 000 new HIV infections in the country. New infections peaked at around 538 000 in 1999 – more than three times the 2022 estimate.

Deaths due to HIV are also declining. It is estimated there were around 48 000 HIV-related deaths in South Africa in 2022. This is less than a fifth of the peak of around 265 000  in 2005.

Since the number of new HIV infections is much higher than the number of HIV-related deaths (164 000 vs 48 000), the absolute number of people living with HIV in South Africa is still increasing (as shown in the above graph). Though an increase in the absolute number of people living with HIV may at first glance appear to be bad news, there is actually some good news behind it since the increase is partly driven by the fact that people living with HIV are living longer.

Treatment coverage

Of the 7.8 million people living with HIV in 2022, around 5.7 million were taking antiretroviral treatment and around 2.1 million were not. This amounts to treatment coverage of 73.2% – or more than one out of every four people living with HIV not being on treatment – which arguably constitutes the biggest gap in South Africa’s HIV response. Treatment is indicated for everyone living with HIV and most people who are stable on treatment become non-infectious.

On the UNAIDS 90-90-90 targets (recently reframed as 95-95-95) South Africa stood at 94.5-77.4-91.5 in 2022. That is to say, 94.5% of people living with HIV were diagnosed, 77.4% of those diagnosed were on treatment, and 91.5% of those on treatment had viral suppression. (Note that the treatment coverage number in the previous paragraph is lower than the second 90 since the latter refers to only people diagnosed with HIV, while the prior includes all people living with HIV, whether or not they have been diagnosed.)

Recovery from COVID-19

The impact of the COVID-19 pandemic can clearly be seen in many of the new Thembisa estimates. Life expectancy at birth, for example, dropped precipitously from 64.2 in 2019 to 58.5 in 2021 but then recovered to 63.5 in 2022. Despite the COVID-19-related disruption, the longer term trend of life expectancy having dropped due to HIV and then recovered due to the rollout of antiretroviral therapy remains clear.

The number of people newly started on HIV treatment took a hit as COVID-19 disrupted services in 2020. For every year from 2009 to 2019, more than 400 000 people were newly started on HIV treatment. In 2020, that number dropped to just under 260 000. It recovered to around 295 000 in 2021, but dropped back down to 266 000 in 2022. As is clear from the above graph, however, there was already a downward trend prior to COVID-19. In part, such a downward trend is to be expected since year-on-year it has been becoming harder to find people living with HIV who are not yet on treatment as they become fewer.

HIV prevention

Since most people living with HIV who are stable on antiretroviral treatment become non-infectious, increasing treatment coverage is critical not only to the health of individuals living with HIV, but also to wider HIV prevention efforts. Getting the 73.2% treatment coverage level closer to 100% is thus an obvious priority.

But other forms of HIV prevention also have an important role to play. According to the latest Thembisa numbers, as of 2022, 62.5% of men and boys aged 15 to 49 in South Africa had been circumcised. This equates to an increase of over 20 percentage points over the last decade. Medical male circumcision has been shown to substantially reduce the risk of contracting HIV. While the number of circumcisions performed was dramatically down in 2020, it has since recovered, though not quite to pre-pandemic levels.

Condoms also remain a highly effective means of HIV prevention. While the Thembisa model does not contain that much information about condom usage, it does suggest that condom use at last sex for women and girls aged 15 to 24 has been relatively stable in the 35/36% range over recent years.

Finally, there has been an uptick in the use of antiretrovirals to prevent HIV infection (called PrEP or pre-exposure prophylaxis), although from a very low base. In 2022, only an estimated 0.8% of sexually active people were taking PrEP (up from 0.1% in 2018). Among sexually active adolescent girls and young women, the number stood at 4% in 2022 – up from 0.1% in 2018. While these increases are clearly a step in the right direction, and PrEP obviously makes an important difference to every person who does access it, uptake would have to be much higher for it to start making a significant impact on the country’s infection rates.

NOTE: The figures used in this article are from Thembisa version 4.6 released in April 2023. We’ve rounded many of the numbers for accessibility (consult the Thembisa output file for exact estimates). The graphs were made using the R package ggPlot2. This is the first of a series of Spotlight articles on the new Thembisa outputs.