The first cases of HIV were diagnosed in 1981 — 41 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 to end the epidemic. The Covifd-19 epidemic is a concern, as it has received very little attention. Access to the most important 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 emerging pandemic of cardio-metabolic diseases. These diseases must be treated as one entity, with HIV/TB coinfection rates higher than 50%.
What are the country’s ongoing challenges? South Africa failed to meet UNAids 90–90-90 goals (90% of HIV-positive people are aware of their status, 90% of them have ARVs and 90% of HIV-positive people are on treatment) or its 2020 prevention targets. The annual number of HIV infections in South Africa is still about 200,000. Young women and girls continue to suffer the brunt. It is crucial that we can access long-acting, affordable injectables such as CAB-LA As soon as possible, we need to reactivate our HIV prevention program.
South Africa currently stands at 93-73-88%, which is a significant improvement on the country’s 90-90-90-90 population targets. Adult women have reached 9577-89, while adult men have reached 9267-89. Children under 15 are at the lowest, with 80-66-63, despite their being significantly less than adults.
UNAids set several targets for countries to meet by 2025. These are, without doubt, the most important: Reach the 95-95-95-295 target by 2025; and End the Aids Epidemic by 2030. The less well-known are the UNAids, 2025 The following are targets
- 95% of women who are pregnant have their HIV/sexual and reproduction health services met.
- 95% of HIV-positive pregnant and nursing women have suppressed their viral loads.
- 95% HIV-exposed children are tested by 2025. 95% HIV-infected people use the appropriate, prioritized person-centred and efficient combination prevention options.
- People-centred, context-specific, integrated approaches to HIV treatment that supports the achievement of 2025 HIV targets. This will result in at least 90% of HIV-infected people and those at high risk of infection being provided with services for other non-communicable and communicable diseases.
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These are not all. UNAids, 2025 Three social enablers are key to a prevention strategy. They aim to remove legal and social barriers that hinder the creation of an environment that allows HIV services to be more accessible and utilized.
UNAids 2022 theme World Aids Day is ‘Equalise’. The theme of Aids Day is ‘Equalise’ because there is evidence that inequalities in society have and continue 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 refocus on those being left behind and restructure its HIV response over the next three years to meet the 2025 UNAids targets.
We must address the mental health (MH), issues that have a negative impact on HIV/TB patients in order to achieve these goals. Depression is the most common MH disorder among PLHIVs, and TB. It can often lead to non-adherence. HIV patients live longer because they are more likely to be able to start and adhere to ARV treatments. This also means that there is an increase in non-communicable diseases, such as diabetes and high blood pressure. These conditions require treatment by the individual and the health sector. Additionally, we know that people with diabetes are three times more likely to contract TB — this requires an integrated approach to patient management.
Although the primary responsibility for HIV treatment lies with the health sector and the public health sector in particular, it is important that the prevention and management aspects of HIV and TB are addressed by other sectors. Whole of society and entire government response. Government must mobilise all parts of society in the short- and medium-term to address this issue, with organised labour, business, communities, as well as organised labour, playing a much greater role. We need urgently to reduce sexual and gender-based violence, we must ensure that children are socialized to better understand their gendered roles and to help us deal with hunger and poverty more effectively.
For a revigorated response against the epidemic, it is important to place more emphasis on prevention in the healthcare sector. This will also require a reorientation in both the health service delivery platform and retraining of healthcare professionals. It is vital that products such as CABLA, long-acting injectables, are affordable and made available as quickly as possible in order to prevent HIV acquisition.
There are many innovations in the health sector that must be scaled. These include differentiated services — to ensure that we have a truly person-centred approach to service provision. This is required not only for HIV/TB services, but all services. This requires a more systematic transformation of delivery and provision of healthcare services. It also allows for optimal use and optimization of digital health solutions. In addition, many people who were on ARVs could access their medicines without being locked down by the CMDD, the centralised chronic medicine distribution and distribution service (CCMDD). Additionally, multi-month scripting has been done. These services should be extended to all chronic medicine patients.
Technical implementing partners that form the Health Implementing Partners Group (HIP-G) 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 made and many lessons have been learned. It is urgent that we do more to eradicate Aids by 2030. This is the global demand.
We learned a lot from the HIV epidemic, and the Covid-19 pandemic. Patients and the community at the centreThe government and the private sectors will either not reach people in greatest need, or they will provide services that are suitable and acceptable for them.
The 2022 World South Africans have yet another chance to improve their treatment and prevention programmes with Aids Day. Because of the high cost of illness, we must redouble efforts to fight HIV/TB. This will allow us to meet global targets and decrease the burden on our communities. DM
Yogan Pillay is the country director of Clinton Health Access Initiative – SA. Ida Asia is the managing director of JPS Africa. Harry Hausler, CEO of TB/HIV Care. Themba Moeti, Deb Basu (Head of Department of Public Health Medicine at University of Pretoria), Gustaaf Wolfvaardt, CEO of Foundation for Professional Development.