Resuscitating SA’s HIV/Aids response to end the epidemic

UNAIDS wants the disease to be a thing of the past by 2030. To get there, all sectors of our society will have to mobilise. By and

The first cases of HIV were diagnosed in 1981. Forty-one years later the HIV epidemic continues to haunt South African communities. Despite having the world’s largest number of people living with HIV and the world’s largest number of people on life-saving antiretrovirals (ARVs), South Africa still has a long way to go. Of concern is that the response to Covid-19 limited access to essential services during the lockdowns and has also reduced the public’s focus on the twin HIV and TB epidemics in the country, which is aggravated by the emerging pandemic of cardio-metabolic diseases. With HIV/TB co-infection rates of more than 50%, we must treat these diseases as two sides of the same coin.

What are the continuing challenges facing the country? Despite initiating more than five million of the estimated eight million people living with HIV, South Africa did not meet the UNAIDS 90-90-90 targets (90% of people know their HIV status, 90% of these on ARVs, and 90% of those on treatment are virally suppressed) or the prevention targets for 2020. In addition, the number of new annual HIV infections is still around 200,000, and adolescent girls and young women continue to bear the brunt of new infections.

It is currently estimated that, against the 90-90-90 targets, South Africa has reached 93-73-88 for the total population. But, although adult women have reached 95-7789, adult men have only reached 92-6789, and children under 15 fare the worst at 80-66-63, even though their numbers are significantly lower than those of adults.

UNAIDS has put down several markers to be reached by 2025 for countries globally. Arguably the most important of these are to reach a 95-95-95 target by 2025 and end the Aids epidemic by 2030. Less well known among the UNAIDS 2025 targets are the following: 95% of reproductive-age women have their HIV, sexual and reproductive health service needs met; 95% of pregnant and breastfeeding women living with HIV have suppressed viral loads;

95% of HIV-exposed children are tested by 2025;

95% of people at risk of HIV infection use appropriate, prioritised, person-centred and effective combination prevention options; and

90% of people living with HIV and individuals at heightened risk of HIV infection are linked to services for other communicable diseases, noncommunicable diseases, sexual and gender-based violence, mental health and other services they need for their overall wellbeing. In addition to these, the UNAIDS 2025 prevention strategy spells out three social enablers that focus on removing social and legal impediments towards the creation of











an enabling environment to increase access to and utilisation of HIV services.

The 2022 UNAIDS theme for World Aids Day is “Equalise”. The rationale is that inequality in society continues to fuel the HIV epidemic. The same is true of the TB epidemic – long considered a disease of poverty. The theme is particularly pertinent to South Africa with its legacy of apartheid and its continuing high levels of inequality – by race, class, gender and geography.

This means that, to reinvigorate South Africa’s HIV (and TB) responses, the country needs to focus on those being left behind and restructure its

HIV response over the next three years to meet the 2025

UNAIDS targets.

To achieve this, we must also mitigate mental health issues that have a negative impact on people living with HIV and TB. Depression is the most common mental health disorder among people living with HIV and TB, often resulting in nonadherence to treatment.

As people living with HIV live longer as a result of adherence to ARV treatment, there is also an increase in noncommunicable diseases such as diabetes and hypertension, which require management.

We also know that people with diabetes are three times more likely to contract TB, which requires an integrated approach to patient management.

Although the health sector, in particular the public health sector, is primarily responsible for the HIV treatment component, the prevention and management of HIV and TB require a response from the whole of society and government.

In the short to medium term, the government needs to mobilise all sectors of society to respond, with business, communities and organised labour playing a far greater role. We urgently need to reduce sexual and gender-based violence from the ground up, ensure that children are socialised to better understand their gendered and nongendered roles, increase social protection, expand the social welfare net to ensure that we deal more decisively with poverty and hunger, and keep girls in school for as long as possible.

A greater focus on prevention in the health sector is also critical for a reinvigorated response. This will also require a reorientation of the health service delivery platform, retraining of health professions, and additional budgets for prevention.

It is also important that new products for prevention, including long-acting injectables such as CAB-LA, are made affordable and available.

Within the health sector there are innovations that need to be scaled. These include differentiated services to ensure that we have a truly person-centred approach to service provision.

This is not only required for HIV and TB services but for all services. This means a more systematic transformation of the provision and delivery of health services besides optimal use of digital health solutions.

During the height of the Covid-19 pandemic, the centralised chronic medicine dispensing and distribution service enabled many people on ARVs to get their medicines despite the lockdowns. Multi-month scripting was also done. These services need to be expanded to all patients who require chronic medicines.

Technical implementing partners that form the Health Implementing Partners Group have been central to supporting the government’s response to HIV and TB with financial support from a range of bilateral, multilateral and philanthropic organisations.

Many innovations have been developed and lessons learned. But more is needed to end Aids by 2030, as is the global call.

The 2022 World Aids Day commemoration provides South Africans with another opportunity to take our prevention and treatment programmes to new levels.

The cost of illness is much too high not to reinvigorate our responses to both HIV and TB so that we can meet the global targets and reduce the burden of these diseases on our communities.

Although the health sector, in particular the public health sector, is primarily responsible for the HIV treatment component, the prevention and management of HIV and TB requires a response from the whole of society and

government

This article was written on behalf of the Health Implementing Partners Group.