While men account for only a third of South Africa’s roughly 200 000 new HIV infections in the year ending mid-2019, they account for more than half of the approximately 74 000 HIV-related deaths in the same period.
This is according to new HIV estimates released by the SA National Aids Council (Sanac) during an online press conference on Tuesday.
The new numbers from the Thembisa model – a mathematical model of the South African HIV epidemic, designed to answer policy questions relating to HIV prevention and treatment – provide the most up-to-date and arguably most reliable national and provincial-level estimates of HIV in South Africa.
7.6 million people living with HIV
As of 2019, a total of 7.6 million people were living with HIV in South Africa – 4.8 million women, 2.5 million men and 300 000 children, according to University of Cape Town-based Dr Leigh Johnson, who presented the results on behalf of Sanac.
This means that just more than 13% of people in South Africa are living with HIV.
The 7.6 million mark is a substantial increase on the 3.4 million people who were living with HIV in South Africa in 2000.
“This increase may seem like bad news, but the numbers of new infections each year has been steadily declining over the past decade,” explained Johnson.
One reason for the increase in the number of people living with HIV is that fewer people are dying of HIV-related causes due to the widespread availability of antiretroviral treatment.
Between 2010 and 2019 there was a 57% reduction in the rate of new infections. This falls short of the UNAids target of a 75% reduction by 2020.
“We have some way to go before achieving that, but I think it’s important to say that we are doing well compared with most other regions and countries,” said Johnson.
More than half of sex workers living with HIV
The highest prevalence rate was seen in sex workers – 55% of whom are estimated to be living with HIV.
Sex workers were also found to have an exceptionally high HIV incidence – the rate at which new infections occur – eight times the estimate for adult women.
“Interestingly, in all age groups, there are substantially more HIV infections in women than in men … but mortality is higher in men, which is consistent with what one would expect given that treatment coverage is so much higher in women,” said Johnson.
Due to both biological and social factors, women have a much higher HIV risk than men, which in part explains why HIV prevalence in this group is almost double compared with adult men.
The second highest prevalence rates were seen in men who have sex with men – 26%. This group has an incidence rate seven times higher than the estimate for adult men in the country.
Progress against 90-90-90 targets
The new Thembisa estimates also reveal the country’s progress against the UNAids global 90-90-90 targets, which are that by 2020 90% of people living with HIV should know their status, that 90% of those with diagnosed HIV should be on treatment, and that 90% of people on treatment should be virally suppressed.
Viral suppression is when antiretroviral medicines suppresses the amount of virus in the blood to undetectable levels, which makes transmission impossible.
Johnson said the Thembisa model estimates show that, in South Africa in 2019, 92% of people with HIV knew their status, “which is good and means we’ve met the first of the UNAids targets”.
But, he said, “we are unfortunately not doing well on the second target” with only 71% of people diagnosed with HIV on treatment.
This is despite the fact that South Africa is home to the largest HIV treatment programme in the world.
“We exceeded the third target,” said Johnson, noting that 91% of people on treatment were virally suppressed.
“The overall message is that we’ve done well on the first and third of those 90% targets, but we are still quite a long way off from reaching the second,” he said.
Johnson also said the Thembisa model was being expanded to include tuberculosis (TB) and that this work should be completed in the next year.
There is currently no model at the level of Thembisa that provides TB estimates for South Africa.
Insights from new district-level model
While the Thembisa model produces national and provincial-level estimates, it does not produce district-level estimates. That gap is now being filled by a new model called Naomi. Outputs of the Naomi model can be viewed at hivdata.org.za
The district with the highest HIV prevalence was King Cetshwayo district in KwaZulu-Natal (31.6%), while the Western Cape’s Central Karoo district had the lowest prevalence (5.9%).
In terms of incidence, the highest rate was seen in the Eastern Cape’s OR Tambo district with 13.8 new infections per 1 000 people, while the district with the lowest incidence was also Central Karoo with a rate of 1.8 per 1 000.
While the country has not met all its targets, Sanac’s Coceka Noguduka said the estimates show steady progress.
“We’re very excited about launching these estimates,” she said.
“We are all aware that, globally, we are committed to the ambitious UNAids targets that, if not met, [we will not realise] the vision, as a country and globally, to end Aids by 2030.”
According to Noguduka, the estimates are timely, as Sanac will in January start work on the new version of the country’s national strategic plan for HIV, TB and sexually transmitted infections. The current plan expires in 2022.
*This article was produced for Spotlight – health journalism in the public interest.