Today marks World Aids Day. South Africa has made important progress in addressing Aids, yet we are at a crucial point in this battle. We’ve adopted the 2017-2022 National Strategic Plan that has laudable and ambitious targets, but several critical issues must be addressed or we risk losing the gains we have achieved during the past decade.
South Africans have much to celebrate this World Aids Day. Aids-related mortality and the number of new HIV infections have declined, especially in infants and children. The number of people living with HIV on antiretroviral treatment has significantly increased, resulting in the world’s largest antiretroviral treatment programme. In March, the new HIV, tuberculosis, and sexually transmitted infections national strategic plan for 2017 to 2022 was released, which describes a laudable vision, a credible strategy, and presents objectives that, if achieved, will result in a future where HIV, TB and sexually transmitted infection are no longer public health problems.
The national strategic plan provides a strategy for effectively addressing the HIV, TB, and sexually transmitted infection epidemics in South Africa to meet the UNAids 2020 targets for prevention, treatment and reduction of stigma and discrimination. It includes a target of lowering the number of new HIV infections from 270 000 a year to less than 100 000 a year; ensuring that 90% of the estimated seven million HIV-positive South Africans know their status; 90% of all people who are HIV positive are initiated on antiretroviral treatment; and 90% of all people on antiretroviral treatment achieve viral suppression.
Why, then, are we concerned?
South Africa ranks number one in terms of people living with HIV and is home to nearly one in five people living with HIV despite having less than 1% of the global population. If we do not address several critical challenges identified in the national strategic plan, we are in danger of losing much of the ground that we have gained in the past decade.
What are these challenges?
1. We must increase our focus on preventing new infections and addressing challenges associated with expanding antiretroviral treatment;
2. We need more concerted HIV prevention and treatment efforts in key and priority populations and in high burden health districts; and,
3. We need to develop and implement locally appropriate multisectoral district and provincial implementation plans.
Prevention is key
Goal 1 in the national strategic plan is to “Accelerate HIV prevention to reduce new HIV infections”, recognising that we cannot treat our way out of the epidemic as new infections outnumber the numbers being initiated on treatment. We need to enhance access to the optimal combinations of current available prevention interventions to be responsive to the local epidemics. These interventions include HIV pre-exposure prophylaxis, male and female condoms, and voluntary medical male circumcision. In addition, we must continue to innovate and invest in novel prevention technologies, such as a longer-term prophylaxis delivery mechanisms, as well as in the development of HIV vaccines and cure strategies.
Effective implementation requires a more human-centred approach.
We need to understand and address the behavioural, cultural and social attitudes that prevent people from being tested and using HIV prevention methods, and address the barriers to accessing services.
We have acquired considerable knowledge regarding Aids related treatment and how to reduce infant transmission through science, advocacy, social mobilisation, political will and commitment. We must bring the same energy, if not more, to prevention as the next phase in our response will be even more challenging.
Reaching young people and their sexual partners
Two-thirds of all South Africans are under 35 years of age. In the next seven years 16.7 million people will enter the 15-34 age group in South Africa where most new HIV infections are taking place. Almost a third of all new HIV infections are in young women 15-24 years of age who are being infected 5-7 years earlier than men and have up to 6 times higher infection rates compared to their male peers.
The Dreams and She Conquers initiatives are promising new efforts to reduce vulnerabilities of adolescent girls and young women yet we must also focus on their sexual partners and link them to prevention and treatment services. Successful interventions should also revisit acceptable community norms and values to support prevention and treatment efforts including those relating to gender-power disparities.
Preventing HIV in adolescent girls and young women and other key populations are critical to reaching our national, provincial and local targets.
Local implementation is critical for success
HIV is not distributed equally across South Africa. More than 80% of new HIV infections occur in 27 of the country’s 52 health districts with all 11 districts in KwaZulu-Natal bearing the highest burden of infection. These areas require an increased level of investment and effort and package of HIV prevention and treatment interventions. This “focus for impact” strategy is a critical component of the national strategic plan.
The national strategy requires adaptation and development of local implementation plans. Each province and district must develop a plan for how it intends to achieve its goals using its human and financial resources, and based on the current best evidence. These plans should build on current programs and utilise local data from different sources to develop, costed, and actionable plans to be implemented.
The national strategic plan is the result of research, analysis, prolonged and fruitful discussions, and engagement by many stakeholders committed to ending Aids. The spirit of partnership that went into the national strategic plan gives us reassurance that stakeholders and decision-makers are committed and united in their resolve to end Aids in South Africa. But resolve is not enough. Commitment, focus and local implementation are needed. Never has this been more true than now.
• Dr David Allen is the deputy director of the Bill and Melinda Gates Foundation’s HIV programme in Southern Africa and a member of the South African National Aids Council national strategic plan steering committee.
• Professor Quarraisha Abdool Karim is the associate scientific director at the Centre for the Aids Programme of Research in South Africa, chair of the South African National Aids Council, Prevention Technical Task Team and was recently appointed UNAids special ambassador for adolescents and HIV.