Radical plan needed to quell HIV
HIV and Aids researchers are exploring conventional and unusual ways to break SA out of its deadly cycle of infection.
The country is the epicentre of a global pandemic that has killed 32-million people in the past four decades.
Poverty in SA is one of the main reasons behind the transmission of the human immunodeficiency virus (HIV) between young women and older men, a factor at the root of a cycle that makes curtailing the spread so difficult.
HIV attacks the immune system, making people susceptible to illnesses. Tuberculosis (TB), the illness often linked with HIV, makes a deadly combination.
In SA, 7.7-million people out of a population of 57-million are living with HIV, which is the leading cause of death in the country, according to the Medical Research Council.
“We in SA are the capital of the world in HIV and TB. They are out of control. We are the highest in the world by far,” says Prof Glenda Gray, president of the SA Medical Research Council and one of the awardwinning pioneers in stopping HIV spreading from mothers to unborn babies.
Based on figures from UNAids, an estimated 2.8-million South Africans have died from HIV and Aids since 1990.
Fatalities peaked in 2005 and 2006, with 210,000 people dying each year when the disease was a source of political meddling and denialism by the upper echelons of the ANC.
If not treated with drugs as part of an antiretroviral therapy, HIV leads to acquired immunodeficiency syndrome (Aids).
The spread of HIV in SA was worsened by what became known as Aids denialism by then president Thabo Mbeki and his health minister, Manto Tshabalala-Msimang, for nearly a decade from 1999.
Under Mbeki’s government more than 300,000 people died due to policies preventing the supply of antiretroviral drugs to those with the disease and to prevent mother-to-child transmission of the virus.
Subsequent administrations adopted a far more proactive stance, slowing the spread and death toll from HIV. SA has the world’s largest HIV treatment programme.
Antiretroviral therapy is undoubtedly making a huge difference in SA. Deaths from the virus halved to 71,000 in 2018 from 140,000 in 2010, according UNAids data.
New infections among women aged 15 and upward is the highest compared with children and men, making up 140,000 of the 240,000 new HIV infections recorded in 2018, the data shows. This compares with 220,000 women newly infected with HIV in 2010 out of a total 390,000.
Women make up 4.7-million of the total HIV population in SA.
“SA is experiencing downward mortality trends, which could be attributed to the continued expansion of the government antiretroviral programme, with an increased number of HIV-positive people who are taking antiretroviral drugs living longer,” the department of health says in its 2018 annual report.
Life expectancy has increased to 63.8 years from 62.2 years in 2013.
Since 2010, or the end of the Mbeki era, 44-million people have been tested for HIV in SA.
The government spent R18bn on HIV and Aids, TB, maternal, child and women’s health out of a budget of R42bn for various programmes in the 2018/2019 financial year, according to the department of health’s annual report for that period.
But all is not well in SA’s health-care sector. The Treatment Action Campaign, an HIV and Aids activist organisation, says the government’s healthcare system is “often severely dysfunctional”, negatively affecting the implementation of HIV and TB programmes.
“You know your health system is collapsing when women and children are dying. They are our ‘canaries in the coal mine’, the alarm that something is seriously wrong with our healthcare system,” Gray says in an interview, noting the number of neonatal deaths has been unchanged since 1996.
Of the 7.7-million people living with HIV, about 4.5-million are taking treatment to control HIV, but only about two in three are said to be taking their medication properly to drop their viral load to undetectable levels, she says. Once the virus is undetectable it is safe to have unprotected sex without passing the virus on, she says.
Those who do not take the treatment properly do not suppress the virus and continue to pass it on to their sex partners.
In SA, young women are the most susceptible to HIV infection because they are having sex with older men.
Researchers in the field are unanimous about this point, citing SA’s rising level of unemployment with a third of adults unable to find work and poverty as the reasons for young women benefiting from having older, economically active sex partners who give them groceries and other gifts that benefit their families and raise their social standing. “Economically vulnerable people are making decisions that kill them in the end,” says Gray.
As these young women mature, they marry similarly aged men and infect them with HIV. These men go on to have younger mistresses, perpetuating the cycle. Men are unlikely to test for HIV or seek medical attention and this is part of the problem researchers are battling to resolve.
One radical solution to break the cycle proposed by Prof Salim Abdool Karim, director of the Centre for the Aids Programme of Research in SA is to bypass voluntary testing and treatment of those with HIV. Karim wants to implement a pilot study in two communities totalling 56,000 people and give everyone one tablet of antiretroviral medication a day, regardless of whether they have HIV.
The five-year project needs about $50m (R732m) to establish the programme, its staffing and infrastructure, and research work in the two communities with high levels of HIV prevalence.
“If you have HIV, we are treating you. If you don’t have it, we are effectively protecting you,” he says.
“We say this way to mobilise communities to take ownership of HIV and show they can stop it themselves is the way to go,” he says, adding the government is prepared to back the project by supplying the medication.
“It will break the cycle of HIV transmission from men in their 30s to young girls. The minute you do that you break the chain and break the stranglehold HIV has over communities.”
Critics point out antiretroviral drugs have side effects, some of which are not yet fully understood, which means a degree of sacrifice from those who do not have HIV.
Researchers are testing two vaccines in SA and abroad. The results should be known within three years, says Gray.
“The only way to stop an epidemic is with a vaccine to control or eradicate it,” she says.
This is complex, scientific work that relies on an element of luck, says Gray, who pioneered work in the 1990s to break the mother-to-child transmission of HIV that was killing two in three babies early that decade when she was a newly qualified paediatrician.
One trial entails testing a “souped-up” vaccine, which was “moderately successful” in Thailand, and another from pharmaceutical company Johnson & Johnson, one of the few large medicine companies actively involved in trying to solve the riddle of how to destroy the virus, she says.
The results of the tests are reviewed every six months by a panel, which can order an immediate stop to the trials if the drugs are causing adverse effects or if they are ineffective.
Any failure of a vaccine test makes it exponentially more difficult to raise funding and attract experts into scientific research to develop another drug to destroy an incredibly resilient virus, Gray says.
“We sit on the precipice of failure or fame every six months. That’s our lives in HIV vaccine research. This virus is cleverer than us. It’s a formidable foe,” she says.
Addressing the spread of HIV is further complicated by how susceptible a segment of SA’s women are to infection, with vaginal bacteria playing an important role, says Karim.
Normally it takes 1,000 sex acts over four or five years for the virus to be transmitted between infected people and their partners.
That raises the question of why young SA women make up such a high percentage of the country’s HIV population.
It took a decade-long research project studying up to 6,000 types of vaginal bacteria to unlock the mystery.
The preponderance of “bad bacteria” means a vagina is not acidic as it should be and able to naturally fend off HIV in what is essentially a “hostile environment”, Karim says. “About two out of five women in KwaZuluNatal don’t have a naturally acidic vagina. Instead they have a different set of bacteria which have become predominant,” he says, adding that these bacteria contribute to internal inflammation and markedly raised susceptibility to HIV infection.
“I don’t know why there are differences in bacteria in vaginas. There are dozens of researchers who have devoted decades to answering that question and they are no closer to an answer than we are. We just don’t understand it,” Karim says.
“We have to figure out a way to make the vagina healthy again, because a healthy vagina won’t easily be infected with HIV. We haven’t been able to do that,” Karim says.
WE SIT ON THE PRECIPICE OF FAILURE OR FAME EVERY SIX MONTHS. THAT’S OUR LIVES IN HIV VACCINE RESEARCH
YOU KNOW YOUR HEALTH SYSTEM IS COLLAPSING WHEN WOMEN AND CHILDREN ARE DYING