New HIV infections in South Africa have fallen by 44% in the last five years, the country’s latest HIV household survey found. Bhekisisa reports that the Human Sciences Research Council (HSRC) released the study’s preliminary results on Tuesday of this week.
HSRC scientists interviewed over 33,000 South Africans about everything from how many people they’d had sex with in the last year to how much they knew about the spread of HIV. More than 60% of those surveyed also agreed to be tested for HIV.
The study shows about 8m South Africans between the ages of 15 and 64 are infected with HIV and almost three-quarters of those who know their HIV status are on antiretroviral treatment (ARVs). HSRC project director Sean Jooste says the country doubled the number of people on treatment between 2014 and 2018. The country has the largest HIV treatment programme in the world, with more than 4m people with HIV on ARVs, health department figures show.
Jooste says the treatment programme is largely responsible for the decline in new infections.
When taken consistently, ARVs can lower the amount of HIV in a person’s blood to very low levels, that are often undetectable by standard HIV tests. This is known as being “virally suppressed”. Although this doesn’t mean that someone is cured of HIV, scientific studies have shown that HIV-infected people who are virally suppressed are highly unlikely to transmit the virus to another person. About 86% of HIV-positive people between the ages of 15 and 64, who were surveyed and on ARVs, were virally suppressed.
The report says the country has committed to pushing the percentage of HIV-infected people who are on treatment and who are virally suppressed to 90% by 2020, as part of what’s been dubbed the UN’s “90-90-90 targets”. These goals also determine that 90% of people with HIV should know their status. Of those who know their status, 90% should be on ARVs and 90% those who are on treatment should be virally suppressed.
The report says two years before the deadline, the HSRC study shows although 85% of South Africans know their HIV status, only 71% of people infected with the virus are on ARVs. Health Minister Aaron Motsoaledi however argues the results prove South Africa will reach targets. “We are going to win the battle (against HIV),’ he said. “It’s gratifying that some of our hard work is starting to pay off.”
The report says South Africa’s new HIV infections are decreasing at a much slower rate than what the UN’s 2020 targets require: the survey shows the country had 230,000 new infections in 2017 – about two and a half times more than the 88,000 new infections the 2020 goals require it to have in two years-time.
Women between the ages of 15 and 24 make up a third of new infections nationally. A third of adolescent girls surveyed had sexual relationships with older partners, although researchers did not specify how much older these men were.
The report says in 2016, the Centre for the Aids Programme of Research in South Africa (Caprisa) found that 60% of all new HIV infections in young, black South African women and teenage girls could be linked to older men. The men were on average eight years older than their female partners, who were generally in their 20s. The research was presented at the International Aids conference in Durban in 2016.
Young women may not always be able to negotiate condom use with older men, Tlaleng Mofokeng is quoted as saying earlier this year. Mofokeng is the vice-chair of the non-profit Sexual Reproductive Justice Coalition. Caprisa’s research showed that infections among young women often eventually led to infections among men of their same age later in life as people began to look for life-long partners in their late 20s and early 30s.
The report says South Africa’s national HIV plan aims to decrease new infections among young women by 60% and place 81% of HIV-positive people on treatment between 2017 and 2022.
South African National Aids Council deputy chair Steve Letsike warns the country will have to intensify efforts if it hopes to meet its HIV plan targets. “We need to prioritise young, adolescent girls. That’s crucial in our efforts”, she said. “It’s promising, but we need to do better. We are still moving at a snail’s pace.”
The launch of the survey was chaired by HSRC CEO Professor Crain Soudien and co-chair Professor Helen Rees, the executive director of the Wits Reproductive Health and HIV Institute (Wits RHI) of the University of the Witwatersrand, who was the chair of the Review Panel of the survey report.
The 2017 survey is the fifth wave of a series of cross-sectional studies conducted by a consortium of scientists led by the HSRC, including the South African Medical Research Council, National Institute of Communicable Diseases and research agencies. Previous studies were done in 2002, 2005, 2008 and 2012. HSRC’s deputy CEO of research Professor Leickness Simbayi who is the overall principal investigator (PI) of the survey says: “HSRC has a long history of undertaking population-based surveys on HIV/Aids in the country.”
As in previous surveys data were collected on not only the HIV status of individuals, but also information on socio-demographic and behavioural factors that greatly enhanced the analysis and interpretation of the observed trends in HIV prevalence (the proportion of people living with HIV in the country) and HIV incidence (new HIV infections in a given year). The data from the 2017 survey serves as critical benchmark figures for the evaluation of the National Strategic Plan (NSP) 2012-2016 and also the baseline for current one.
The population-based cross-sectional survey of households in South Africa was conducted between January and December 2017. Over 33,000 people were interviewed and almost 24,000 agreed to be tested for HIV.
The survey found that there has been a significant decline in the HIV incidence rate at 0.48%. This translated to an estimated 231,100 new HIV infections in the country in 2017. Although still high, this was a decline of 44% from an incidence rate of 0.85% reported in the 2012 survey. The HIV incidence rate was generally higher among females aged 15 to 24 years old where the number of new infections was three-times that of their male counterparts.
The survey found that over 60% or an estimated 4.4m people living with HIV (PLHIV) were on antiretroviral treatment (ART). It was also found that viral suppression was 87.3% among PLHIV who were on ART, with females generally being more likely to be virally suppressed than males among those aged 15-64 years. “This suggests that progress is being made in increasing ART coverage, however more needs to be done to link those who test HIV positive to care as soon as they are tested in line with the current policy of test and treat” said Dr Sizulu Moyo of the HIV/Aids, STIs and TB (HAST) Research Programme in the HSRC Research Programme and one of the co-PIs of the study. Furthermore, although viral suppression is high among those on ART, not everyone who is living with HIV is on treatment, and consequently only 62.3% of all PLHIV irrespective of treatment were found to be virally suppressed.
The study found that South Africa had made some progress in addressing the HIV epidemic as reflected by some key HIV indicators. In terms of the UNAIDS 90-90-90 targets, the study found that 85% of PLHIV aged 15 to 64-year-olds have tested for HIV and know their HIV positive status, 71% of this sub-group are on ART, and 86% of the group on ART are virally suppressed. “This shows that the country has made significant progress towards reaching the 90-90-90 targets,” says Dr Edmore Marinda of the Research Use and Impact Assessment (RIA) Unit in HSRC, one of the co-PIs of the survey.
As expected there is an upward trend in HIV prevalence which is explained by the reduction in HIV and Aids related deaths and additions of new infections that are still occurring. Approximately 7.9m South Africans were living with HIV in 2017.
The study found that females had higher rates of HIV prevalence than males. HIV prevalence among adults aged 15 to 49 years in South Africa is 20.6%, 26.3% among females and 14.8% among males. The disparity in HIV prevalence by sex was more pronounced among young adults aged 20 to 24 years and was three times higher among females than males.
The study also found that HIV prevalence peaked at 35 to 39 years of age for females and 45 to 49 years of age for males. HIV has risen sharply for women 60 years and older compared to males, where the figures have remained constant.
According to Professor Khangelani Zuma the executive eirector of the HAST Research Programme in the HSRC “This shows the overall aging profile of PLHIV, which is mainly as a result of the successful implementation of ART programme, resulting in fewer deaths and therefore PLHIV living longer.” However, high infection levels (7.9%) among youth aged 15 to 24 years is still concerning. The top three provinces with the highest HIV prevalence were KwaZulu-Natal, followed by the Free State and the Eastern Cape. The bottom three affected provinces were Limpopo, Northern Cape and Western Cape being the least affected. However, compared to 2012 substantial increases in HIV prevalence were observed in the EC and WC.
The study also found an increase in the number of men who are medically circumcised, rising from 18.6% in 2012 to 30.8% in 2017. Simbayi says “Although this is encouraging, this finding highlights a need to continue promoting and creating demand for voluntary medical male circumcision with an immediate target among males in the 15-34-year-old age group.”
In terms of risk behaviours the study found that consistent condom use was low, early sexual debut (sex before the age of 15 years) especially among males increased compared to 2012 and over a third of young women had sexual relationships with older men. “It is concerning to find very little behaviour change seems to have occurred since 2012. This suggests that most of the reduction in new infections was likely due to the impact of the expanded ARV treatment programme” says Dr Mpumi Zungu also of the HSRC’s HAST Research Programme and a co-PI of the survey.
Finally, the survey found that social and behaviour change communication campaigns implemented by Soul City, Centre for Communication Impact (CCI), LoveLife and Community Media Trust campaigns are reaching South Africans. People who were highly exposed to these campaigns reported higher HIV testing, condom use and correct knowledge of HIV compared to those who had lower or no exposure.
In summary, the findings of the report underscores that the country is on the right track with an increase in HIV testing, medical male circumcision and the provision of ART. However, there is a need to increase HIV testing and treatment especially among males as well as among younger age groups. In addition, other biomedical, behavioural, social, and structural prevention interventions are needed to reduce the high rates of new HIV infections.
Surveys of this nature are conducted to inform SANAC, all government departments, civil society, labour, business, donors, traditional leaders and, more importantly, individuals about the current picture of HIV/Aids in the country in order to make informed decisions which involve them. “Government and other stakeholders involved in shaping policy around HIV treatment and prevention programmes will hopefully benefit tremendously from the findings of this survey,” concludes Simbayi.
This survey has been supported by to the Presidents Emergency Plan for AIDS Relief (PEPFAR), whose funding we received through a cooperative agreement (Grant Number 5U2GPS000570) with the US Centers for Disease Control and Prevention, because without their financial support the study would not have been possible. The survey findings are solely the responsibility of the authors and do not necessarily represent the official views of CDC. Additional financial support came from Global Fund to fight AIDS TB and Malaria through the South African National AIDS Council and Right to Care; Soul City; loveLife and the Centre for Communication Impact.
The HSRC is also grateful for the support it receives from the Department of Science and Technology.
“This is an extraordinary response‚” said Rees‚ in a report in The Times.
Researchers expressed concern‚ however‚ that the data showed that condom usage was decreasing and the number of people having sex before the age of 15 was increasing.