The irony of the success of the decades-long focus on HIV/Aids treatment is that the disease is no longer seen as high-risk, especially among young people, but experts warn that HIV is still very much 'unfinished business', writes MedicalBrief.
The availability of antiretrovirals to prevent and control infection means HIV is perceived as a condition that can be controlled and concealed, HIV experts told a webinar on the eve of World Aids Day hosted by the Genital Inflammation Test (Gift) team at the University of Cape Town (UCT).
For this reason, warnings about HIV risks no longer work, they said. Instead, messaging should emphasise the rewards of remaining HIV-negative and healthcare professionals should deliver services more holistically, paying attention to women’s evolving needs and circumstances.
A Spotlight report says with the remarkable success of antiretroviral treatment, South Africans with HIV are generally living much longer than they did two decades ago – with overall life expectancy having shot up by around nine years since the peak of the country’s HIV epidemic in the early 2000s.
But as a result, more people with HIV also have non-communicable diseases (NCDs) like diabetes and hypertension.
The dynamic of an ageing population with HIV is not unique to South Africa, but the size of our HIV epidemic means the scale of the effect here is substantial.
Thembisa, the leading mathematical model of HIV, estimates around 1.7m South Africans aged 50 and older have HIV. This number is projected to rise rapidly in the coming years as those people who are now in their 40s get older.
In addition to ageing, having HIV itself is a risk factor for developing several comorbidities, although these are massively reduced by ARV treatment. People with HIV have an increased risk, for example, of both mental health conditions and heart disease.
It was thus not surprising that the need for a different approach to HIV – one that does a better job of integrating treatment and care for comorbidities – was a hot topic at the 6th Southern African HIV Clinicians Society (SAHCS) conference recently in Cape Town.
‘The new threat’
Speaker Dr Arifa Parker, an infectious disease specialist, said people with HIV are now living longer, which is a positive, “but we now face the new threat of non-communicable disease in this population”.
“We saw mostly patients with advanced HIV (in the past) … but now, in our emergency units, we are seeing patients whose HIV is well-controlled, on ARVs with viral loads suppressed… but the non-communicable diseases are neglected, blood pressure is sky high, and they are presenting with brain bleeds, kidney disease etc.”
“Recent data show that with ageing, the numbers are increasing of people with HIV who also have NCDs and other co-morbidities, adding to the disease burden,” Dr Josephine Otchere-Darko, programme head for Ekurhuleni at Wits RHI’s HIV/TB programme said.
“The prevalence of chronic conditions in people with HIV is reported to be greater than 50% in people over 50, with hypertension, diabetes and depression accounting for the bulk of disease.”
One way to achieve better management of HIV and comorbidities like diabetes and hypertension, she said, was through the integration of healthcare services.
Defining integration is tricky – one WHO document lists six definitions. The essence seems to be that people should ideally receive all of the treatment and care they need from as few healthcare workers and health facilities as possible.
Rather than a simple either/or, most health services will fall somewhere on a continuum from strict silos at one extreme to full integration at the other.
In 2010, activists called on the South African Government to accelerate the integration of HIV and TB services – integration with NCDs takes that a step further.
That the need for better HIV/NCD integration is real has been recognised for some time. For example, in 2008 the WHO produced a technical brief on how to go about integrating HIV and NCD services. The WHO has since published another brief on the matter.
“National responses for both HIV and NCDs require health systems that can deliver effective acute and chronic care and support adherence to treatment. Chronic HIV care also provides an opportunity to assess, monitor and manage NCDs, especially in primary care,” reads the WHO brief.
“Integrating interventions for the prevention and management of major NCDs in people with HIV care can reduce the risks of NCDs and improve HIV treatment outcomes.”
In a TimesLIVE report, Professor Constance Mackworth-Young from the London School of Hygiene and Tropical Medicine, who leads social science research at The Health Research Unit Zimbabwe (ThruZim) said: “Pregnancy is a risk that cannot be hidden and can cause big disruption to women’s life trajectory.”
“In contrast, despite continued stigma, HIV is often viewed as something that can be hidden and controlled through taking pills.”
Professor Nelly Mugo of the Kenya Medical Research Institute said young women at high risk of contracting HIV often have a low perception of that risk, prioritising short-term rewards and assuming they are invulnerable.
“There’s a perception that the consequences of HIV are no longer dire,” Mugo said.
However, while the HIV risk might be seen as low, about 5 000 women between 15 and 24 were infected weekly in eastern and southern Africa in 2022, said Professor Sinead Delany-Moretlwe, director of research at the Wits Reproductive Health Institute.
“And the reasons have to do with a lack of decision-making power about sexual relations, contraceptive use and access to healthcare,” she said.
“HIV continues to be a threat to health for young women and it’s important we continue to recognise that HIV is unfinished business.”
The webinar was the first of a series planned by the Gift team, which recently launched clinical studies of a new device designed to screen for vaginal inflammation that puts women at risk for HIV infections.
The device, a lateral flow test similar to a pregnancy test, detects vaginal inflammation – often caused by sexually transmitted infections (STIs) and bacterial vaginosis. These conditions are typically treatable with antibiotics, but because most women don’t have symptoms, they are often undiagnosed and untreated.
Gift developers believe the test could transform the landscape. The clinical studies involve nearly 700 women in South Africa, Zimbabwe and Madagascar.
But Gift team member and webinar facilitator Dr Ramla Tanko from UCT said diagnostic and therapeutic innovations are only part of the solution.
“We need to understand the concerns of women and their challenges, to design better intervention strategies,” she said.
Mackworth-Young said “incredible public health efforts and successes” mean HIV is often seen as a condition for which effective treatment is readily available.
“A historically singular and successful focus on HIV has meant antiretroviral therapy and increasingly pre-exposure prophylaxis (PrEP) are accessible at public health facilities,” she said.
The risk perception is therefore lower, and “this is the irony of success in terms of HIV”.
In Zimbabwe, Mackworth-Young said her team had seen encouraging outcomes when it aligned its approach to women’s own priorities, rather than simply telling them about the importance of HIV prevention.
Her team at ThruZim recently completed the Chiedza cluster-randomised trial that offered 12 communities an integrated package of sexual and reproductive health services, including HIV and STI testing and treatment, menstrual hygiene products and care, condoms and family planning.
“We found providing free menstrual hygiene products in a context where they are prohibitively expensive to buy was a real draw for young women to attend,” she said.
Mugo said her findings in Kenya were similar.
“Young people tend to be biased towards immediate concern…and rarely think about being at risk.”
Delany-Moretlwe said the uptake of PrEP, with more than 1m South Africans initiated on a daily pill, showed an appeal for this form of HIV prevention.
“But many people who express huge enthusiasm for taking an oral pill daily struggle with that practice in reality. About two out of five will probably stop their PrEP within the first six months of starting. This challenge is probably greater for younger people.”
Risk is also a factor here.
“People self-perceive their risk to be low. Many people articulate concerns about (drug) side-effects particularly. Just taking a pill a day is difficult to remember.”
Researchers had also uncovered interpersonal factors that undermined PrEP adherence.
Often, families are suspicious. ‘Why is this person taking these pills? Do they have HIV?’ And the stigma associated with HIV is still such that many people don’t feel comfortable taking pills in public.
“For young women there are also concerns that come with conversations with partners who might think they are trying to protect themselves from other partners. With the high levels of gender-based violence in our region, this … may prompt people to stop taking their pills.
“Then there are the social and structural factors which are about cost and access to healthcare. And many of these factors that influence PrEP continuation also influence HIV risk, particularly in young people.”
Mackworth-Young emphasised the importance of involving men in their partners’ sexual health rather than placing sole responsibility on women.
“The biggest way men can support women’s health is for men to go to health services… something we see as a constant challenge,” she said.
“We’ve tried offering boxer shorts or haircuts at health services, which has had some impact. But I’d like to go further and meet the need that young men face, which is economic income generation. What can we do to provide something around that which links to health services and will support men to access health services?”
Delany-Moretlwe said she was encouraged by efforts to develop new ways to deliver PrEP.
“We have seen approvals for the vaginal ring and for an eight-weekly injectable PrEP. And there are a number of other studies to evaluate a monthly pill, a six-monthly injection,” she said.
“There is a real desire to increase the options available because we recognise that oral pills are not feasible for everyone. If we have that expanded choice, we really have an opportunity to change the trajectory of the HIV epidemic.”
Meanwhile, while South Africa has done well in its HIV treatment, a top official at the HSRC has cautioned against becoming complacent.
Results from its sixth South African National HIV Prevalence, Incidence and Behaviour survey found that the percentage of all people living with HIV this country had decreased from 14.0% in 2017 to 12.7% in 2022.
This translated to around 7.8m people living with HIV in 2022, compared with 7.9m in 2017.
Professor Khangelani Zuma from the HSRC said the data showed that, from 2010, the level of knowledge of HIV had been decreased, for some reason.
“Also, the percentage of people using condoms from 2010 to now has also been reduced.”
These problems signalled a warning to be cautious “and not find ourselves in a situation where we are complacent about HIV”.
Many homes, he told News24, still dealt with the stigma attached to the virus, whch could hamper getting tested, especially among the youth.
“We need to inform our communities and families that they must understand they have to deal with the stigma.’
The survey had found that lowest percentage of viral load suppression (66%) was among men aged 25-34-years-old, and Zuma noted that men, typically, turned a blind eye to proactively dealing with health problems.
“The challenge is to get men to change their health-seeking behaviours. I think there are efforts from the government on that, but the onus is also on men.”
Spotlight – Integrating HIV and NCD care is critical but not straight-forward, clinicians say
See more from MedicalBrief archives:
HIV cases drop in SA, but so does condom use
Right to Care: South Africa’s women bear the brunt of HIV stigma
Pepfar boss pledges ongoing support to SA in HIV/Aids fight