HIV: The day we take stock

2014-11-30 15:00

New infections are down and life expectancy is up, but World Aids Day reminds us there’s still a lot to be done in the fight against the deadly virus

On Monday, the world will again mark World Aids Day and HIV/Aids workers across the globe will be contemplating how far we have come and how much more there is still to do.

At the SA National Aids Council, we have the privilege of hearing a wide and varied set of reflections from stakeholders. We have heard these voices and, having recently published our first report on progress in the fight against HIV, the following are our reflections.

After a disastrous start under the previous administration, we have had accelerated implementation of our antiretroviral treatment programme. The health department’s most recent estimate is that 2.7?million people in South Africa are on HIV treatment this year.

This estimate has been independently verified by a national household survey testing for antiretroviral drugs in the blood of individuals sampled for the survey and corroborated by the impact we have seen on life expectancy, which has increased from 53 years in 2006 to 61 years in 2012.

While much progress has been made, there are still many infected people who will need to be treated in the next few years. The programme will need to at least double in size and there are serious doubts if strained health services will be able to cope with this expansion.

In the current fiscal environment, there is also doubt about how much more money can be extracted from the Treasury for additional scale-up, not only for the expansion of the programme, but for the strengthening of the health system, especially at the primary healthcare level.

Government needs to seriously beef up essential health services or consider private sector and NGO options for delivering services linked to the further expansion of the antiretroviral treatment programme.

Our biggest concern is that there are still too many new infections in South Africa each year (the number of new HIV infections in one year declined marginally in the sexually active population from 1.79% in 2008 to 1.47% in 2012).

Although this number is declining annually, it is still too high. We estimate there were about 400?000 new infections in 2012. The high number of new infections poses several challenges.

First, it fuels our concerns that more South Africans become infected each year and many more will need antiretroviral treatment. At some point in the future, we will not be able to afford HIV treatment in an expanding programme nor will we have the capacity in the health system to match the growing need.

The second challenge is what to do about this high incidence. How do we tackle prevention?

Many in the HIV/Aids fraternity either take the view that there are a sufficient number of proven biomedical interventions or that others will be available in the next few years to turn the tide against new infections.

It is true there have been exciting developments on this front. At the recent HIV Research for Prevention conference in Cape Town, exciting biomedical options were posited as definite possibilities.

We now have the option of using antiretroviral drugs for prevention. They

can be administered to HIV-negative individuals whose partners might be positive. We also now know that an HIV-infected individual on antiretrovirals is 99% less likely to infect a partner.

Besides these two proven interventions, we are optimistic about microbicidal gels, vaginal rings and long-lasting injectables that deliver antiretrovirals in a way that protects negative individuals. Some of these new technologies give us hope for a female-controlled method of prevention that will be widely accepted.

We are also learning that with interventions delivered out of a clinic, there is greater complexity in the dynamics that lead us to expose ourselves to HIV.

It has been found that a quarter of new HIV infections in South Africa occur in females between the ages of 15 and 24.

This is staggering and apart from revealing the growing feminisation of the HIV epidemic, it confirms our experience that HIV targets the most vulnerable members of our population. At 2.83%, the incidence of HIV in young women is the highest across all categories.

A lack of education, low self-esteem, weak social networks, unemployment, poverty, fear, violence, gender inequality and substance abuse merge in a downward spiral of high exposure to HIV.

These are the structural and social drivers of the HIV epidemic. We see young women whose HIV risk is increased through intergenerational and transactional sex.

Young women in informal settlements or rural areas enter into relationships they could otherwise avoid with men who provide food or shelter in exchange for sex.

What is mostly missing is the mental calculation of risk over benefit. This is where a need to survive or the lack of life experience makes for bad decisions that lead to pregnancy, sexually transmitted diseases, or worse, HIV.

Perhaps this is where education has failed or where tightknit families may have protected a young woman, but these do not exist in much of South African society.

South Africa must invest in interventions such as cash incentives to reduce vulnerabilities and schemes to keep girls in school.

Targeted national programmes to change patterns of alcohol consumption where this is linked to HIV risk, to delay sexual debut, and to stick to one partner and use condoms regularly are behaviour-change projects we must invest in or face the dire consequences.

What is our response? First, it’s to wake up to the distressing reality that the battle is far from over and we must accept HIV will be with us for decades to come. Second, we must do what we know works and do it well.

Third, we must continue to encourage further research and innovation, especially in the social and implementation sciences. Fourth, we must elevate the prevention project to the top of our priorities in our response to HIV.

The UN has also come to this conclusion. In its call to action published last week, UNAids proposes two targets for the global response without which, it argues, the world will not be able to bring the epidemic under control.

These are the reduction of new infections in young women and key populations by 75% by 2020.

We should adopt these targets as they have practical meaning for our response. The question is how to achieve this. The answer is that we don’t yet know how, but we draw confidence from the fact that we are learning something new every day.

Dr Abdulla is CEO of the SA National Aids Council

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