January 22, 2024

Achieving South Africa's HIV Targets: A Strategy

"The pathway to eradicating AIDS is outlined in a recent UNAIDS report, emphasizing that successful HIV responses hinge on robust political leadership, sufficient resources, evidence-based strategies, inclusive and rights-oriented approaches, and a commitment to equity. The report underscores that nations prioritizing their people in policies and programs are already at the forefront of the global effort to eliminate AIDS by 2030.
The goal of terminating AIDS and the HIV epidemic takes on different meanings for various stakeholders. The ambitious language is enshrined in Sustainable Development Goal 3.3, which aims to "end the epidemics of AIDS, tuberculosis, malaria, and neglected tropical diseases and combat hepatitis, water-borne diseases, and other communicable diseases" by 2030. The overarching global target is to reduce the incidence of newly HIV-infected individuals (per 1,000 uninfected population) to 0.05 by 2025 and 0.025 by 2030.
An alternative perspective envisions "ending AIDS as a public health threat by 2030," characterized by the three zeros vision: zero deaths, zero new infections, and zero discrimination. This vision operationalizes a 90% reduction in annual new HIV infections and AIDS-related deaths by 2030 compared to 2010.
Another strategic approach urges countries to achieve the 95-95-95 targets by 2025, where 95% of people living with HIV are diagnosed, 95% of those diagnosed are on antiretroviral treatment, and 95% of those on treatment are virally suppressed.
A more pragmatic fourth approach involves reducing new HIV infections below the number of HIV-related deaths, thereby achieving 'epidemic control' and transitioning to an endemic status beyond 2030."

Irrespective of the interpretation of 'ending AIDS,' what steps should South Africa take to chart its course in diminishing the HIV burden?
To begin, let's examine the anticipated landscape of the HIV epidemic in 2030. While we lack a crystal ball, we possess a well-recognized mathematical model�the Thembisa model, also utilized as the foundation for UNAIDS's HIV estimates in South Africa. The latest Thembisa model outputs, disclosed last year, encompass projections up to 2030.
The model envisions approximately 128,535 new HIV infections in 2030, with the majority, exceeding 54% (70,412), affecting young women aged 15 to 24 years. Utilizing the criterion of a 90% reduction in new infections between 2010 and 2030, South Africa is forecasted to attain a 65.7% reduction.
By 2030, the model predicts around 8.1 million people living with HIV, of whom 6.4 million will be on antiretroviral treatment. The projected total number of AIDS deaths in 2030 is 40,486, marking a 72.9% reduction�slightly below the anticipated 90% reduction according to one of the mentioned definitions.
How well is the country progressing toward the 95-95-95 targets?
According to the Thembisa model, the percentage of individuals ever tested for HIV was 83.7% in 2022 (estimated to reach 86.1% in 2030). The percentage of people living with HIV who received a diagnosis was 94.5% in 2022, projected to reach 96.4% in 2030. In 2022, the percentage of diagnosed individuals on treatment stood at 77.4%, expected to rise to 81.1% in 2030.
The percentage of all people living with HIV who were virally suppressed was 65.4% in 2022, projected to increase to 71.3% in 2030 (slightly higher with a viral load cutoff of 1,000 copies/ml rather than 400). This implies that only one of the 95s (percent diagnosed) is expected to be achieved. If the third 95 is defined as the percentage of people on HIV treatment who are virally suppressed, rather than the percentage of all people living with HIV who are virally suppressed, it will also be met.
A more positive outlook emerges from the Human Sciences Research Council (HSRC) national survey, reporting that 90% of 15-year-olds and older individuals living with HIV knew their status. Of these, 91% were on treatment, and 94% of those on treatment were virally suppressed (at the 1,000 copies/ml threshold).
Despite the Thembisa projections, South Africa is not expected to achieve epidemic control by 2030. What actions are needed to substantially reduce new infections and deaths?
What Action to Take
During his presentation at the 2023 South African AIDS conference, the Minister of Health delineated the Department of Health's perceived imperative actions. He acknowledged that the country has achieved 94:77:92 against the UNAIDS targets�a considerably lower figure than the HSRC survey indicated. According to the Department's data, there are reportedly over two million people living with HIV but not receiving treatment, along with an additional 1.6 million on treatment but not achieving viral suppression. These numbers contrast starkly with the 1.9 million suggested by the HSRC survey as not receiving treatment and not virally suppressed.
Regardless of the accuracy of the data, an urgent need exists to locate these individuals, initiate them on treatment, and support them to achieve viral suppression.
While the Minister did not quantify the number of individuals living with HIV who are not being reached, he outlined the following prioritized interventions:
1. Immediate implementation of the revised and consolidated ART Clinical Guidelines, incorporating an integrated approach to preventing vertical transmission, with a specific focus on TB/HIV due to high coinfection rates, and differentiated service delivery.
2. Focusing on the 100 identified health facilities lagging in reaching the 2nd and 3rd 95s (treatment coverage and viral suppression).
3. Addressing testing and treatment gaps for men and children through HIV self-testing and index testing�an approach notifying exposed contacts of an HIV-positive person and offering them an HIV test.
4. Emphasizing re-engagement of those who have stopped taking treatment and scaling up community treatment, 3-month dispensing of treatment medication, along with employing community health workers for tracking and tracing people living with HIV.
5. Intensifying efforts on combination prevention, utilizing all available prevention methods, including Cab-LA�an antiretroviral HIV prevention injection providing two months of protection per shot.
These interventions, if earnestly embraced by health workers and communities, hold the potential for further reductions in new HIV infections and deaths. However, given that most deaths in people living with HIV are attributed to TB, a heightened focus on testing people living with HIV for TB�given the estimated 59% co-infection rates�and ensuring successful treatment and initiation of those testing negative for TB on TB preventive therapy is paramount.
Alignment with the HIV Investment Case
As Spotlight recently reported, the sole HIV intervention found to be cost-saving for the South African health system was condoms. Nevertheless, the HSRC survey disclosed a decline in reported condom use at the last sexual encounter across all age categories. In 2017, 68% of males aged 15-24 years reported condom use, compared to 50.6% in the latest report. Similarly, condom use among males aged 25-49 years dropped from 53.4% in 2017 to 44% in 2023.
While the Minister acknowledged the availability of Cab-LA for HIV prevention in his speech at the South African AIDS conference, the investment case deemed it an unaffordable option at the current price. The investment case findings suggest that the most cost-effective strategy is to increase HIV self-testing, focus on improving linkage to treatment, and enhance the rate of testing infants for HIV at 10 weeks after birth. Prioritizing HIV interventions becomes crucial, especially considering the reduction in the HIV conditional grant by R1 billion and the incomplete funding of the National Strategic Plan for 2023-2028 by the National Treasury.
In UNAIDS's path to ending AIDS, suggested interventions for countries include political commitment, human rights respect, community engagement, policy and law adjustments, gender equity addressing, stigma and discrimination eradication, and a concentrated prevention approach. Some of the obstacles to ending AIDS listed are insufficient prevention programs, substantial treatment gaps, and insufficient funding.
To sum up, responding to the call to end AIDS by 2030 necessitates:
1. Critical agreement on the definition of ending AIDS.
2. Accurate data collection, particularly at the sub-national level, considering that national averages conceal variability by province and district. District-level data categorized by sex, age, and key populations will enable a more targeted approach to reaching those typically overlooked by the health system.
3. Adapting to a more efficient HIV response in South Africa, with increased precision in targeting and heightened accountability, as the possibility of reduced external funding through PEPFAR and The Global Fund looms in the future. Achieving this transition demands more granular and real-time data.