South Africa aims to reduce the number of new infections from 270,000to under 100,000 by 2022. It has also committed to achieving zero new infections due to mother-to-child transmission.
Prevention of mother-to-child transmission (PMTCT)
Over the past decade, South Africa has made great progress in reducing mother-to-child transmission (MTCT) of HIV, due largely to improvements in the choice of antiretroviral medicines and the widespread accessibility of the PMTCT programme. In 2016, more than 95% of HIV-positive pregnant women received antiretroviral medicine to reduce the risk of MTCT.
As a result, MTCT rates have fallen from 3.6% to 1.5% between 2011 and 2016 – achieving the national target for 2015 of a transmission rate below 2%. The number of children born with HIV has now fallen to below 6,000 in 2015 meaning that the country is on-track to eliminate MTCT. However, to achieve this the goal of zero transmissions the focus must be on getting mothers to adhere to treatment throughout breastfeeding as well as during pregnancy and birth. Maternal mortality is also declining but at a much slower rate. The previous national HIV strategy aimed to reduce maternal mortality by three quarters between 1990 and 2015, from 150 deaths per 100,000 live births to 38 per 100,000. However these targets weren’t met, the maternal mortality rate was reported at 119 per 100,000 in 2015 and 116.9 in 2017. ‘Let our actions count: South Africa’s National Strategic Plan for HIV, TB and STIs 2017-2022’
Condom use and distribution
Between 2007 and 2010, South Africa’s distribution of male condoms increased by 60%, from 308.5 million to 495 million a year. In the most recent National Strategic Plan, the South African National AIDs Council aimed to increase the number of male condoms distributed annually to 850 million by 2018.
South Africa’s female condom programme is also one of the biggest and most established in the world, with over 26 million female condoms (also known as internal condoms) distributed in 2016. By 2022, the South African National AIDS Council hopes to increase this to 40 million.
While condom distribution may have increased in recent years, there is evidence that the use of condoms may be declining. In 2008, 85% of 15-24 year old males reported using a condom during their last sexual encounter, by 2012 this had fallen to 68%. Condom use among men aged 25-49 also decreased, from 44% to 36%. The same survey reported that 53% of participants had never used condoms.
Challenges remain in ensuring that condom programmes are able to serve all groups, particularly those with higher HIV risk. The new strategy will expand condom distribution, making them available at non-traditional outlets such as hair salons, petrol stations, spaza shops, hotels, toll plazas, truck stops, and brothels, as well as secondary schools and non-traditional community settings.
Voluntary medical male circumcision (VMMC)
In 2010, research emerged from sub-Saharan Africa suggesting that voluntary medical male circumcision (VMMC) can reduce the risk of female-to-male HIV transmission by up to 60%. This led the South African government to rapidly roll out a national VMMC programme, which aimed to reach 80% of HIV-negative men (4.3 million) by 2016. In 2016, it was reported that 50-79% of eligible men had been reached by VMMC programming. In 2016 over 491,859 circumcisions were performed in South Africa.
Across the country the VMMC programme has mostly been well received with 78% of women preferring their partner to be circumcised according to the 2011 youth sex survey.
In December 2015 South Africa became the first country in sub-Saharan Africa to fully approve pre-exposure prophylaxis (PrEP), the use of antiretroviral drugs to protect HIV-negative people from infection.
In 2017, it was estimated that between 30,000 and 35,000 individuals were being targeted with PrEP in ongoing and planned projects across South Africa. The 2017-2022 National Strategic Plan aims to expand this, so that PrEP becomes available to all those who are most likely to benefit, including adolescents, sex workers, men who have sex with men and people who inject drugs. They predict that 85858 more people from the most affected groups will be initiated onto PrEP by 2022.
An initial trial of PrEP was conducted amongst South African women, in 2015. Results showed an adherence rate of 76% among the trial population, demonstrating that women in South Africa were both able and willing to use PrEP. These results pave the way for the wider implementation of PrEP.
Recent studies have found that only 59% of young people in South Africa have comprehensive knowledge of ways to prevent HIV (compared to 85% in Swaziland). Only 5% of schools were providing comprehensive sexuality education in South Africa in 2016, but over the next five years the government has committed to increasing this to 50% in high burden areas.
Previous analyses have found that providing comprehensive sexuality education in South African schools led to a 33% reduction in genital herpes (HSV2) incidence in young people, a significant decrease in physical violence or sexual assault perpetrated by young men, and a lower proportion of young men engaging in transactional sex with a casual partner.
Barriers to providing comprehensive sex education in schools include high drop-out rates, a shortage of teacher training, and resistance in schools because of the perceived sensitive nature of the subject matter.
The 2012 National Communication Survey on HIV/AIDS found the country's HIV communication programmes were having a positive effect, particularly on youth (aged 15-24), with an increase in condom usage, uptake of testing services and male circumcision. By contrast, knowledge around safe breastfeeding practices among pregnant mothers living with HIV remains low.
The main HIV awareness campaigns include:
Founded in 1999, loveLife is best known for its 'ABC' billboard campaign, that promoted ‘abstinence, be faithful and condomise’ in the early years of the epidemic. However, the organisation has since turned its attention to breaking down the social and structural drivers of HIV among young people, including poverty and lack of opportunities. They promote the economic empowerment of young people, using a range of different communication techniques, including TV and Radio. Lovelife’s radio programmes reached over 12 million listeners in South Africa with health content in 2015.
The Soul City Institute is another NGO that focuses on health promotion in South Africa, most notably using TV and Radio to provide edutainment programmes. Biggest successes in the past have included the Soul City and Soul Buddyz series, targeting adults and children respectively. Soul City, was able to reach 70% of over 16s, including 65% of rural people and 50% without any formal education, while Soul Buddyz became one of the most successful family television shows produced in South Africa. 67% of 8-12 year olds watched, read or listened to Soul Buddyz (about four million children).
A more recent endeavour, called ‘Untold Stories: In a time of HIV’, has again sought to address drivers of HIV, through edutaining programmes. The series was made in collaboration with nine other countries in southern Africa. Each episode focused on a different context relevant topic. A recent report showed that those who watched the programme often reported having discussed the issues raised with others and there is evidence that it produced behaviour change such as increasing HIV testing.
MTV Shuga is a mass-media behaviour-change campaign that aims to improve the sexual and reproductive health of young people. It began in 2009 and centres around an awarding-winning TV series, supported by radio, digital, social media and mobile elements. Previous series have been set in Kenya and Nigeria.
The most recent series of MTV Shuga was set in Johannesburg. It aired in 2016 and featured the show’s first LGBT character.
Evaluations of previous series have found that viewers of MTV Shuga were more likely to get tested for HIV and the airing of the show was associated with reduced chlamydia infections in young women.
South Africa has the largest ART programme in the world. In 2017, UNAIDS reported that 3.7 million people were receiving treatment in South Africa. This equates to 65% of the people living with HIV in the country.
South Africa’s ART services have undergone dramatic expansion in recent years, in keeping with the World Health Organization’s (WHO) changing guidelines. In 2016, South Africa implemented ‘test and treat’, whereby everyone with a positive diagnosis was eligible to start treatment. This has meant that the number of people eligible for treatment has increased from 3.39 million in the middle of 2015 to 7.1 million in 2016 – more than doubling in just one year.
Initially many were concerned that the dramatic scale-up of ART would result in clinics and services becoming over-stretched and that the quality of care would suffer as a result. However, one year on, studies have shown that the increase in ART provision has had no significant effect on patient outcomes, either in terms of either AIDS-related deaths or illnesses.
Studies have, however, highlighted other issues around treatment provision. They found that men were more likely to start ART at an older age and later stage of infection and had almost double the mortality rate than that of women. This again highlights the need to engage men in testing services and ensure that they are linked to treatment.
In March 2015 it was estimated that there were 136,453 civil society organisations working in the South African HIV response. A new civil society forum was created in 2017, to provide a platform for civil society and government to work together in the HIV response.
One of the most notorious civil societies is the Treatment Action Campaign, formed in 1998. They have been a driving force in the South African response ever since, promoting access to HIV treatment and care for all South Africans. Their first major success came in 2002, with the Constitutional Court ruling that the South African government must provide antiretrovirals to prevent mother-to child-transmission. They are currently campaigning to improve and strengthen the health care system.
Funding is a major issue facing many civil society organisations. Drops in external funding are making civil society organisations more dependent on financing from the government. While domestic funding is a more sustainable model, the shift has increased competition amongst organisations, and is seen by some as undermining their ability to challenge government policy in their work.
Tuberculosis is the leading cause of death in South Africa. The country has the world's sixth largest tuberculosis (TB) epidemic, with a TB incidence rate of 438,000 in 2016.
The HIV epidemic in South Africa fuels the TB epidemic because people living with HIV are at a far higher risk of developing TB due to weakened immune systems. It is estimated that 60% of people living with HIV in South Africa are also co-infected with TB. In 2016 there were 73,000 HIV/TB deaths.
In light of this, the South African National AIDS council, combined the HIV and STI strategy with the national TB strategy, to improve the integration of these two services. One of the aims of this strategy is to get more people living with HIV on isoniazid preventative therapy, a preventative medicine for TB.
The TB treatment success rate has improved in recent years and stood at 83% in 2016. South Africa plans to complete its National TB Prevalence Survey by the end of 2018.
South Africa largely funds its HIV programmes domestically, only receiving 13% of its HIV funding from external sources.
The new National Strategic Plan of the South African National AIDS Council is predicted to cost 207 billion rand over the next five years. In light of this the South African government has increased its budget allocation for HIV and AIDS in 2017, despite general budget reductions across the health sector.
Still the South African National AIDS Council predicts that there will be some funding gaps, however at these early stages it is unclear how severe these will be, especially since there is a level of uncertainty around the availability of international funding for HIV and AIDS in the coming years, particularly from US funding bodies with the new Trump administration.
Treatment and care make up the biggest proportion of the costs, outlined in the National Strategic Plan (NSP). In recent years South Africa has been working hard to negotiate better prices for ARVs, having previously been paying more than most other low and middle income countries despite having the world’s largest procurement programme. In September 2017, UNAIDS announced a breakthrough pricing agreement, which will allow the single pill regime of Dolutegravir to be sold at around $75 per person per year, in south Africa and 90 other low and middle income countries.
The NSP outlines plans to roll-out Dolutegravir. It is thought that the introduction of these medicines will help reduce some of the treatment costs, having been proved to be safer and more effective that the regimens currently being used.
South Africa has made great strides in tackling its HIV epidemic in recent years and now has the biggest HIV treatment programme in the world. Moreover, these efforts are now largely funded from South Africa's own resources.
HIV prevention initiatives are having a significant impact on mother-to-child transmission rates in particular, which are falling dramatically. New HIV infections overall have fallen by half in the last decade, however, there are still too many.
While the short term financing of South Africa's HIV epidemic is secure, in the longer term, the government needs to explore other strategies in order to sustain and expand its progress.
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