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Friday, 8 November, 2024
HomeAnalysisAlmost 40% of the world’s anti-HIV pill users live in South Africa

Almost 40% of the world’s anti-HIV pill users live in South Africa

By the end of August, 1.65m HIV-negative people in South Africa had used an anti-HIV pill at least once, making the country’s HIV prevention pill programme the world’s largest, write
Bhekisisa’s Mia Malan, Linda Pretorius and Zano Kunene, breaking down SA’s latest anti-HIV pill numbers and explaining how they fit into global targets.

South Africa had around 150 000 new HIV infections in 2023, according to the Thembisa project, a mathematical model used by the Health Department to calculate targets, but needs to lower these numbers to 105 000 by 2025 if it wants to reach targets set by the Joint United Nations Programme on HIV and Aids (UNAids).

By 2023, 3.5m people worldwide had used the pill, said the WHO’s Mateo Prochaska, an infectious diseases epidemiologist, at the fifth HIV Research for Prevention Conference in Peru recently. South Africa’s cumulative users by the end of that year stood at 1.34m – 38% of the world’s total number of anti-HIV pill users.

The pill, which contains two types of antiretroviral drugs, was registered in South Africa in 2015, and is now available free in most government clinics and hospitals.

Hasina Subedar, a senior technical adviser for the Health Department, said at the conference that the government’s target for new anti-HIV pill users for the financial year of 2024/5 is 401 430, of whom 79 730, or 20%, should stay on the pill for at least six months.

If taken daily, the oral pre-exposure prophylaxis (PrEP) has to be taken for at least seven days before it fully protects against HIV infection, and must also be taken for seven days after the person was potentially exposed to HIV via sex.

If taken intermittently, two pills should be taken two to 24 hours before sex, one daily for as long as someone needs it, and a pill daily for at least two days after the person potentially has sex with someone with HIV.

The monthly vaginal ring and a two-monthly anti-HIV injection containing a long-acting version of the ARV drug cabotegravir (CAB-LA) have since also become available in South Africa, but are currently available only to people who are part of demonstration studies.

Information from the Health Department at the Peru conference shows South Africa has 87 demonstration sites, 14 of which offer all three forms of PrEP. There, uptake of anti-HIV medication is significantly higher than at sites offering only one or two options.

“Choice,” Subedar said in Peru, “clearly plays a role.”

Numbers and availability

When the anti-HIV pill was rolled out in 2016, only sex workers could get it free from 13 clinics offering health services to them. They were prioritised because their chances of infection are much higher than the general population.

In 2017, the medication was also given to men who have sex with men and at student health clinics at universities and colleges, and in 2018, young women between the ages of 15 and 24 could access it.

In Sub-Saharan Africa, 62% of new HIV infections were among women in this age group in 2023.

From 2019, anyone who needed PrEP could get it from state facilities – if the clinic they visited stocked it. That’s when uptake of oral PrEP jumped markedly: almost three times as many people had asked for it by the end of 2021 than the year before.

Since 2022, about 440 000 new oral PrEP users have been recorded annually, and in the past eight months of 2024, another 305 000. These numbers translate to just more than 37 000 new users every month since 2022.

The goal for new anti-HIV pill users for the financial year of 2024/25 is 401 430, and 79 7302 who started in 2023/24 financial year, or a fifth, should stay on the pill.

Lise Jamieson, a senior researcher at the Health Economics and Epidemiology Research Office, HE2RO, has calculated how many extra infections South Africa would have had if we didn’t have the anti-HIV pill at all.

“Without oral PrEP, we’d see an additional 17 000 new infections over the next five years, equivalent to an average of 3 000 to 4 000 new HIV infections annually,” she says.

“This might not sound like a lot compared with the 150 000 new infections every year at a population level, but this adds up and will have a long-term impact. Also, having an active and well-run oral PrEP programme means the numbers covered, and subsequent impact, will only increase.

“It also increases demand for PrEP, so once we get the more effective, long-acting products, like CAB-LA and lenacapavir (a six-monthly anti-HIV injection), rolled out, then we can hit the ground running in terms of getting people to take them.”

Nearly 30% of the country’s anti-HIV pill users are in KwaZulu-Natal, with Gauteng having the second highest number of users. Combined, these two provinces make up just more than half the total number of PrEP users.

Subedar says the Health Department uses a type of precision-based methodology, with data from the Naomi model, to calculate which age groups, sexes and geographic areas are likely to have higher HIV infection rates, so that they know how many anti-HIV pills to allocate to which clinics and can also work out PrEP targets.

Here’s how they got to the target of 401 430 new PrEP users for the new financial year:

There are 42.8m people 15 and older in SA (about 72% of the total population), of whom 35.3m are HIV negative (the national HIV prevalence among people 15 and older currently sits at 16.3%).

Of the HIV-negative people, 7.7m have a high chance of contracting HIV: of these, at least 7.3m must be tested for HIV to reach 401 430 people with oral PrEP.

More HIV-positive women than men are on treatment, but women, especially those aged 15 to 24, also have a markedly higher chance of infection than men. The data also show HIV-negative women are more likely than men to use the anti-HIV pill.

Moreover, young women who have the highest chance of contracting HIV comprise half the total number of PrEP users.

Subedar says their data show men stay on the pill for longer than women. However, that finding is based on how gay and bisexual men use the pill and isn’t representative of heterosexual men; globally, gay and bisexual men, or men who have sex with men (MSM) adhere relatively well to PrEP.

By August this year, 325 times more clinics stocked anti-HIV pills than in 2016 – and that includes 95% (3 311) of the government’s 3 484 clinics. Studies show the easier it is to access medicine, the more likely people are to use it.

Two ways to make anti-HIV pills easier to get is to give them free, and to make them available close to where people live. Today, 4 225 clinics (government clinics and partner sites at universities, prisons and colleges) now stock the pill at no cost – almost three times more facilities than in 2020, when oral PrEP had become widely available.

The more clinics offering the pill, the higher the chances that a facility is closer to someone’s home. But, Subedar says, more ways to get the pills to people are being tried out, from couriering medication and making it available at private pharmacies, to pop-up clinics at shopping centres.

The Western Cape Health Department mostly outperforms other provinces with important targets like maternal mortality rates, which makes it unexpected that is has the smallest proportion of clinics offering anti-HIV pills.

In KZN, Gauteng, Mpumalanga and the Free State, all government clinics stock anti-HIV pills. But in the Western Cape only 70% of state clinics offer the medication. The province has, however, reached 89% of its oral PrEP initiation targets for April to August 2024 (17 001/19 195 = 89%).

In response, Western Cape Health spokesperson Dwayne Evans, says: “We have a data-driven approach, which can sometimes slow down roll-out, but in the short term we ensure we first reach vulnerable persons who need PrEP the most, and that we make the pills available at the clinics they visit.

“Challenges include the time it takes to train nurses to administer PrEP; expanding to clinics outside cities; and nurses’ workloads. To address this, we’re designing shorter training workshops and sending teams to facilities outside metros to create more awareness of PrEP.”

Five provinces – Mpumalanga, KwaZulu-Natal, the Free State, Gauteng and North West – exceeded their monthly targets for starting new people on oral PrEP between April and August 2024, and the Eastern Cape is only 11 people shy of its goal, so has essentially hit the mark too. The Western Cape is just more than 10% off track, but the Northern Cape and Limpopo are way behind.

UNAids’ goal is to get 21.1m people on the anti-HIV pill by 2025, but by the end of 2023, only 3.5m had used the medication. Of those, 2.6m, or 75%, were from Eastern and Southern Africa. Moreover, SA accounted for 1.34m of these.

To end Aids as a global health threat by 2030, UNAids says the global number of new infections per year should not exceed 370 000 by 2025. But that target, currently, seems unreachable: globally, in 2023, there were 1.3m new HIV infections.

Optimistic

“However, we may see improvements in this field, as other long-acting forms of PrEP, like CAB-LA, taken every other month, and lenacapavir, once every six months and which are easier to adhere to for many people, become available,” says Mitchell Warren, who heads up the New York-based HIV advocacy organisation Avac.

The UNAids targets are calculated based on getting countries to lower their new HIV infections by 70% compared with the number of new infections in 2010.

In 2010, South Africa had about 350 000 new infections, so our goal would be to have only 105 000 in 2025. In 2023, though, the country had 150 000 new cases,  almost 1.5 times more than where it should be be at the end of 2025.

At pregnancy clinics, KZN, Mpumalanga, the Eastern Cape and Gauteng have all exceeded their monthly targets for April to August 2024 of starting HIV-negative women on the anti-HIV pill. Nationally, 43 707 people started using PrEP between April and August – 35% above SA’s target for this period.

PrEP uptake at pregnancy clinics is measured because pregnant and breastfeeding women have more chance of contracting HIV than the general population. Dvora Joseph Davey, an associate epidemiology professor at the University of Cape Town, said pregnant women often don’t use condoms, because there’s no risk of falling pregnant during this time.

“Many women assume condoms are most important to prevent pregnancy,” she says.

There are also biological reasons why pregnant women could be more likely to contract HIV.

“In pregnancy, there are cell changes in the female reproductive system… the body changes how much of certain proteins it makes, which can cause inflammation,” Joseph Davey said. “Inflamed tissue makes it easier for HIV to enter those cells, because it increases the risk of tearing in the vagina during sex.”

On provinces that exceeded targets, Subedar concedes that the Department had set “rather low antenatal clinic targets in the first year [FY2023/24] when PrEP was first offered to pregnant women, using negative tests from the previous year” and also to accommodate understaffed clinics and overworked nurses.

“The targets for the next financial year have been increased substantially.”

In contrast, Limpopo, the Free State and the Western Cape are all less than two-thirds to their goal.

“In these provinces, we’re working on helping with information pamphlets about PrEP for pregnant women, to create more awareness of HIV and how they can protect themselves,“ Subedar says. “We’re also increasing healthcare workers’ capacity to offer PrEP as part of antenatal services through training workshops.”

 

Bhekisisa article – Almost 40% of the world’s anti-HIV pill users live in SA (Creative Commons Licence)

 

See more from MedicalBrief archives:

 

Twice-yearly anti-HIV jab shows total protection – African study

 

Lenacapavir demonstrates efficacy in people with highly resistant HIV

 

One in four HIV+ South Africans not on treatment

 

Nearly 5m South Africans placed on new HIV medicines in four years

 

 

 

 

 

 

 

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