The World’s Largest HIV Epidemic in Crisis: HIV in South Africa

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In some communities of KwaZulu-Natal Province, South Africa, 60 percent of women have HIV. Nearly 4,500 South Africans are newly infected every week; one-third are adolescent girls/young women (AGYW) ages 15-24. These are staggering figures, by any stretch of the imagination. Yet, the HIV epidemic is not being treated like a crisis. In February, we traveled to South Africa, to understand what is happening in these areas with “hyper-endemic” HIV epidemics, where prevalence rates exceed 15 percent among adults. We were alarmed by the complacency toward the rate of new infections at all levels and the absence of an emergency response, especially for young people.

This is no time for business as usual from South Africa or its partners, including the U.S. government through the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR). The epidemic is exacerbated by its concentration in 15-49-year-olds, those of reproductive and working age who are the backbone of South Africa. Without aggressive action to reduce the rate of new infections in young people, HIV will continue to take a tremendous toll on the country for years and generations to come. Collective action is needed to push beyond the complacency and internal barriers to implement policies and interventions that directly target HIV prevention and treatment for young people. PEPFAR should ensure its programs support those efforts.

South Africa remains the epicenter of the HIV pandemic as the largest AIDS epidemic in the world—20 percent of all people living with HIV are in South Africa, and 20 percent of new HIV infections occur there too. The country also faces a high burden of tuberculosis (TB), including multi-drug resistant TB, which amplifies its HIV epidemic. Of particular concern are South Africa’s hyper-epidemics, many in KwaZulu-Natal and Mpumalanga provinces, and the concentration in specific populations like AGYW. Of the estimated 7.2 million South Africans living with HIV, nearly 60 percent are women over the age of 15. HIV prevalence in other key populations—female sex workers, men who have sex with men, transgender women, and people who inject drugs—remains unacceptably high, in some cases double the national prevalence rate of approximately 19 percent.

After the early years of denial, the South African government now finances close to 80 percent of the HIV response, an unparalleled commitment in sub-Saharan Africa, and provides more than 4 million people with life-prolonging anti-retroviral treatment (ART). In 2018, President Cyril Ramaphosa called for an increase of 2 million South Africans on ART by December 2020 through increased testing and treatment.

The problem facing South Africa’s HIV response is that treatment scale-up has stalled, and while new infections have gone down by 42 percent, the rate is not fast enough to bend the curve of the epidemic. New infections in young men and women remain alarmingly high (nearly 87 percent of the total) and viral suppression rates, a key to preventing those living with the virus from passing it on, are under 50 percent for those 15-24 years old. Withapproximately 45 percent of the population under the age of 25, the sheer numbers of those becoming infected and overall prevalence of HIV will stay alarmingly high without a massive decline in the new HIV infection rate.

The central question is how to interrupt HIV transmission in young adults, and where and whom to target. One answer is to target AGYW who are at higher risk for HIV acquisition in South Africa, as they are elsewhere in sub-Saharan Africa. The reasons are both biological and social, including high rates of teenage pregnancy, an epidemic of gender-based and interpersonal violence; lack of quality education; and widespread poverty and unemployment. High rates of sexually transmitted infections (STIs) increase the risk of HIV acquisition, and mental health issues can lead to risky behaviors. Professor Olive Shisana, special adviser on social policy to President Cyril Ramaphosa, emphasized the urgency: “New infections are the highest in adolescent girls/young women. We need to close the tap. If we get to them early, we’ll reduce the load on the nation and globally.”

Addressing the range of social, economic, and health issues that put AGYW at risk is one approach. PEPFAR’s DREAMS program—Determined, Resilient, Empowered, Aids-Free, Mentored, and Safe—includes a package of multisectoral interventions to be “layered” for a comprehensive benefit to the young woman. The importance of this layered approach led to DREAMS being adapted by the Global Fund to Fight AIDS, Tuberculosis, and Malaria and the South African government in its She Conquers campaign. However, tracking the layering of those services has proven to be a challenge, as has widespread scale up.

Another important approach is to reach young men. The Centre for the Aids Programme of Research in South Africa (Caprisa) has demonstrated that a particularly complicated cycle of transmission involves men ages 25-34 infecting adolescent girls/young women ages 15-24, who then go on to infect their longer-term male partners ages 24-35, and the cycle continues. Prevalence among 20-24-year-old women is three times higher than in men their age. Promoting prevention through behavior and voluntary medical male circumcision (VMMC) and getting those men who are already living with HIV on treatment and virally suppressed so they can’t pass the virus to their partners are critical interventions.

The challenge is reaching the men. “Services are not geared for men and young people,” acknowledged Dr. Yogan Pillay, the deputy director general for the National Department of Health. While adult women come to clinics when they are pregnant or for their children, young men rarely interact with the health system unless they have suffered a major injury. In general, men are less likely to know their HIV status than women or to seek care and treatment if they test positive. Health services seen as not “male friendly” and gender norms around masculinity that equate seeking health care with weakness are two factors. As a result, men 25-34 years old have the lowest viral suppression rates (41.5 percent) of any gender/age band in South Africa. Community outreach is one way to reach AGYW and their male partners, especially those out-of-school who have a substantially higher HIV risk and men older than 25 years, by bringing information and services to where they are. “If you think you can intervene by using the current approach to health delivery, it won’t work,” noted professor Quarraisha Abdool Karim, Caprisa associate scientific director.

For many young adults, HIV is often not seen as a crisis because they have bigger worries: extreme poverty, unemployment and lack of jobs, crumbling school infrastructure. When they live in a community with such high HIV rates, there is a fatalistic feeling that getting infected with HIV is inevitable. Girls and women also face an epidemic of rape and gender-based violence; many young women express more concerns about getting raped or getting pregnant than getting HIV. At one site we visited, the girls stated that getting raped was their number one fear.

Pre-exposure prophylaxis (PrEP) offers a tool to help break the transmission cycle. Oral PrEP taken once a day can reduce vulnerability to infection by 99 percent. In areas where there is so much HIV circulating, every sexual encounter is high risk, and widespread PrEP could be a prevention lynchpin. However, PrEP rollout has been slow and inadequate in South Africa since it was approved in national guidelines in 2016. There have been issues with messaging, health worker sensitization and training, and availability. PrEP scale-up will require extensive outreach to create demand, ensure adherence, and negate any stigma to ensure that all those at high risk can have access. Only an estimated 12,000 people are currently on PrEP at approximately 50 clinics nationwide—shy of the national target of more than 18,000. To put that in further perspective, 12,000 equates to only 5 percent of the 231,000 presumed to be at risk for new infections based on the 2017 rates.

Lack of knowledge can impact young adults’ informed prevention and treatment choices. There has been an associated decline in HIV and treatment literacy, which means that young people often don’t understand how the virus affects the body and the impact of lifelong ART. The most recent national survey data from 2017 shows the same low level of condom use among 15-24-year-olds as the last survey in 2012, an increase in sexual debut before the age of 15 for boys, and an increase in multiple sexual partnerships for women under 24.

One barrier is the provision of basic health education and service delivery in schools. While South Africa has a national policy on school-based health education, some provincial officials, school governing boards, and other gatekeepers often prevent services from being provided, even though the age of consent for health services is 12. Schools are an important entry point because there is a high rate of school retention in South Africa and, once out of school, it is difficult to reach young people.

While we met many dedicated HIV champions across South Africa, and there are commitments from national and provincial officials and existing national strategies, the health and education systems are not providing the necessary information and services for young people, and not enough investment is being made to empower communities and civil society organizations to launch more effective and sustainable responses. There is an absence of targeted outreach, media campaigns, and high-profile champions. Young South Africans told us repeatedly that they wanted more leadership and information on HIV and to see role models of healthy living that make HIV prevention and staying negative cool and demonstrate how to live positively with HIV.

The critical gap in South Africa is not between evidence and policy, but between policy and implementation. While the government is committed to supporting the national HIV treatment program and has issued enabling guidelines, it faces significant challenges to effective implementation. It lacks the resources for an overhaul of the public health infrastructure and to scale up and increase coverage of prevention programs like PrEP and broader programs to address the needs of young adults. In addition, health worker shortages and a rising non-communicable disease (NCD) burden are crippling already overstretched health facilities, and the decentralized health system requires political will at the provincial and district levels to implement services effectively.

Many politicians and local government officials are preoccupied with other issues, such as the economic crisis that has gripped the country in recent years, a legacy of corruption that has crippled the energy sector, and upcoming elections in May. The president’s 2019 State of the Nation address called attention to corruption and gender-based violence, but in stark contrast to last year’s treatment pledge, he did not once mention HIV.

South Africa’s HIV epidemic needs to be treated as a public health emergency. After the elections in May, there is an opportunity for the government to re-commit to fighting HIV, at national, provincial, and district levels. Business as usual is not bringing down new infections or getting patients onto treatment. The government should go beyond strategies and push through barriers to actual implementation, get services into school, and re-educate South Africans about HIV. Enabling nationwide scale-up of PrEP for young adults and all who are at high risk would go along way toward protecting South Africa’s future.

For South Africa’s HIV partners, like PEPFAR, the post-election period also provides an opportunity to re-engage with the new government and focus on how to best support targeted interventions toward adolescents and young people. That includes listening to young people and communities, making sure services are available away from clinics in communities and schools, supporting provinces in service provision, and elevating prevention and treatment for young people. Turning the tide on the epidemic will require more than increasing the number of people on treatment; PEPFAR can provide unique support to South Africa to implement a multipronged strategy for young people as an urgent priority.

Sara M. Allinder is executive director and senior fellow and Janet Fleischman is senior associate with the Global Health Policy Center at the Center for Strategic and International Studies in Washington, D.C. This commentary is based on their visit to South Africa in February 2019.