Ahead of World AIDS Day 2024, Professor Salim Abdool Karim and Dr Nikita Devnarain argue that South Africa needs a concerted effort to reduce new HIV infections in young women and to prepare for the rollout of long-acting forms of HIV prevention alongside a well-functioning HIV treatment programme.
As the global goal of ending AIDS as a public health threat by 2030 nears, we still have much to do. In 2023, nearly 40 million people were living with HIV around the world, 630 000 people with HIV died, and 1.3 million people became newly infected with HIV. Since the beginning of the epidemic, it is estimated that about 88 million people have become infected with HIV.
South Africa is home to one out of every five people living with HIV in the world. Since 2010, new HIV infections have declined by 58%, and AIDS-related deaths are now 66% lower. These declines were driven principally by the rollout of antiretroviral treatment (ART). Though South Africa made a late start with rolling out ART because AIDS-denialists President Thabo Mbeki and his Health Minister Manto Tshabalala-Msimang initially blocked treatment access, the country subsequently made good strides in making treatment available. But we still had 150 000 new HIV infections and 50 000 AIDS-related deaths in South Africa in 2023. AIDS is still a major contributor to our country's burden of disease.
In May 2016, the United Nations (UN) adopted a political declaration on HIV and AIDS titled On the Fast Track to Accelerating the Fight against HIV and to Ending the AIDS Epidemic by 2030. This UN resolution was incorporated into Sustainable Development Goals (SDGs) and set as a target to reduce new cases of HIV by 90% (compared to 2010) by the year 2030.
The path to the 2030 target includes two other intermediate targets. The first goal for 2020 was the 90-90-90 target: 90% of all people with HIV should have known their HIV status, 90% of all people who know that they have HIV infection should have received ART and 90% of all people receiving ART should have been virally suppressed. These 3 targets were raised to 95-95-95 - the aim being to reach these higher targets by 2025.
By the end of 2020, over 20 countries had reportedly reached or exceeded the 90-90-90 target. These were primarily in high-income and upper-middle-income countries with strong healthcare systems like Canada and the UK, and in some lower-middle-income countries in sub-Saharan Africa like Botswana and Eswatini. However, there are still significant gaps in achieving the targets universally, particularly in regions like Eastern Europe, Asia, and parts of Africa, where health systems face greater challenges.
By 2020, South Africa had not reached the 90-90-90 targets.
Since then, South Africa has made good progress in HIV treatment. By the end of 2023, the country had achieved 95-81-91, where 95% of people with HIV knew their HIV status, 81% of those who knew their HIV-positive status were on ART, and 91% of people who were on ART achieved viral suppression. However, only 75% and 64% of all adult HIV-positive women and men, respectively, were virally suppressed.
This means that one in four women and one in three men are still at risk of spreading the virus. South Africa is not on track to achieve the 95-95-95 targets by 2025, with linkage to care being the critical area requiring more effort.
In essence, South Africa needs to further increase HIV screening, diagnosis and treatment initiation while maintaining treatment adherence to keep its viral suppression rates high.
If South Africa does reach the treatment targets of 95-95-95 by 2025, will this be enough to reach the SDG goal of a 90% reduction in new HIV infections by 2030?
At this time, the answer is most likely "No", because, as seen in figure 1 below, the number of new HIV infections is not slowing down sufficiently despite viral suppression rates being close to target levels.
HIV incidence rates are still quite high, especially in sub-groups, such as young women in South Africa. There is a "Cycle of HIV Transmission", seen in figure 2 below, where young women mostly acquire HIV from men about 10 years older. This drives HIV incidence as it has an important gap that treatment on its own cannot remedy - recently infected men who do not know that they are HIV positive and are therefore not on treatment are transmitting the virus to young girls. As a result, South Africa has to continue to improve its treatment strategy to change the current trend in deaths, seen in figure 1 above, so that deaths decline, but it also has to supplement this with a prevention strategy in those at high risk, especially young women.
This requires supplementing the country's overall treatment programme with a prevention priority for adolescent girls and young women. Current prevention programmes focusing on young women have had limited success due to the adherence challenges with a daily HIV prevention tablet. This can now be addressed with long-acting Lenacapavir. This new 6-monthly injection was shown to provide 100% protection to young women in South Africa in a large clinical trial. It is expected to become available in South Africa late in 2025.
This injection is a potential game-changer, provided it has high uptake in high-risk groups of young women. The AIDS control programme in our country will need to develop innovative ways of getting this injection to those at the highest risk of HIV to impact the cycle of HIV transmission. This requires careful planning, research on different ways of implementing Lenacapavir, and a renewed effort on prevention that includes a 6-monthly HIV prevention injection.
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South Africa has gotten tantalisingly close to the 2025 treatment targets. But it still has a long way to go to achieve the 2030 SDG goal for AIDS.
It has six years to achieve the SDG goal of ending AIDS as a public health threat. It will need a concerted effort to reduce new infections in young women and to prepare for the rollout of long-acting HIV prevention therapies alongside a well-functioning AIDS treatment programme to set the country on the path to achieving the 2030 goals.
*Abdool Karim and Devnarain are with the Centre for the AIDS Programme of Research in South Africa (CAPRISA) and the University of KwaZulu-Natal in Durban.
Note: Spotlight aims to deepen public understanding of important health issues by publishing a variety of views on its opinion pages. The views expressed in this article are not necessarily shared by the Spotlight editors.
