Between July 18-22 the International Aids Society and South Africa will co-host the 21st biannual Aids conference in Durban, eThekwini. This number is symbolic of the maturity of HIV. It marks another pivotal turning point in the long battle against HIV, the modern infection with its epicentre in Southern Africa.
South Africa has unfortunately been the country that has borne the brunt of the disease and has by far the largest numbers of those infected — a staggering 6.8-million people — more than the total population of Namibia, Botswana and Lesotho combined.
Sixteen years ago in 2000, in Durban, we hosted the 13th International Aids Conference. It was an unlucky moment in the South African history of HIV, as the country’s key leaders were in denial about its cause.
We lagged far behind the rest of the world in our response and although antiretroviral treatment was already available to treat HIV and prevent mother-to-child-transmission, we were not availing ourselves of these medicines.
There was no cohesion between key stakeholders, and renowned scientists and civil society were at odds with the government.
The 2000 conference marked the low-water mark for South Africa. For those infected and affected by HIV there was no light at the end of the tunnel and little hope. People were dying by the tens of thousands and funerals were the weekend social events in hundreds of small towns and rural villages across the country.
From the darkness and into the light
In the intervening 16 years we have achieved much and South Africa is now lauded as being at the forefront of the response to HIV. HIV-positive pregnant women can now look forward to having HIV-free babies, as well as being able to safely breastfeed their babies while taking antiretroviral medication.
In 2000, without any interventions, the mother-to-child transmission rate was close to 30%, representing about 70 000 babies infected annually. Since then, South Africa has caught up and surpassed most countries. In 2015, the newborn infection rate had dropped to about 1.5% — less than 6 000 babies infected annually. This was achieved by South Africa following the latest guidelines of the World Health Organisation and the government providing clear leadership and direction — we got all stakeholders, including academics, civil society, nongovernmental organisations and health services, to contribute to a single plan.
We have massively ramped up the numbers of people taking antiretrovirals; at the end of March, there were 3.4-million HIV-infected people on treatment. This has impacted significantly on the number of deaths in South Africa and on life expectancy. Between 1997 (when the rise of HIV started) and 2005 (when the HIV epidemic was at its peak in terms of infection) the number of deaths virtually doubled. But, as more and more people were put on treatment, deaths steadily declined, and that trend still continues. In 2009 the life expectancy was 57.1; this increased to 62.9 by 2014. This increase of over 10% in a five-year time period is unprecedented in modern times.
In 2010, President Jacob Zuma launched a national HIV counselling and testing campaign for people to know their HIV status. He publicly tested and revealed his own HIV status, which played a significant role in decreasing the stigma attached to HIV. In the following 20 months, around 20-million HIV tests were carried out.
When taking a test, people are counselled about the importance of staying well if HIV negative, and taking up antiretroviral treatment if HIV positive. A household survey conducted in 2012 by the Human Sciences Research Council showed that two-thirds of all South Africans had been tested for HIV.
Randomised clinical trials found that medical male circumcision decreases the risk of HIV infection. Between 2010 and 2015, more than three million men in South Africa were medically circumcised.
One of the most cost-effective interventions to prevent infection is to wear condoms. In 2015, more than 800-million male and 25-million female condoms were distributed. I recently launched a new brand of male condoms called MAX that are coloured and scented to make them more appealing to the youth, who are at the highest risk.
It’s not over yet
While South Africa has achieved a great deal since 2000, we are at another pivotal point: if we don’t maintain the momentum, we run the risk of losing and even reversing the gains we have made.
Every one of the 6.8-million people infected with HIV needs to get onto antiretroviral treatment. This means doubling the current number of people on antiretrovirals. This will require unprecedented effort and co-ordination from multiple stakeholders.
Public health clinics are already straining to provide good quality care for the 3.4-million people receiving treatment. We need to make it simpler for stable patients to receive their medication close to where they live, leaving the clinics and hospitals free to deal with new and medically more complicated cases.
From September, we will begin implementing the “test and start” HIV guidelines. This means as soon as a person tests HIV positive, they can start HIV treatment. We are expecting all stakeholders to work with the health department to make this as successful as the reduction of mother-to-child HIV transmission rates.
Our other problem is that young people, especially adolescent girls and young women between 15 and 24, are still being infected in high numbers: every week, about 2 000 adolescent girls and young women are being infected with HIV. If we do not close this tap we will forever play catch-up on treatment.
Deputy President Cyril Ramaphosa recently launched a national campaign to decrease infections in young women. With support from our development partners, we are putting an additional R3-billion into trying to stem this tide of HIV infection.
In June, we started to roll out pre-exposure prophylaxis (PrEP), programmes among sex workers at 11 sites. PrEP, in the form of a daily antiretroviral pill, can significantly reduce HIV-negative people’s chances of contracting HIV.
HIV is a disease that has presented unique challenges to our young democracy at a time when we’re also faced with many other problems. Aids hits where it hurts most: adults in the prime of their lives. To deal with this challenge requires immense social effort. Although we are only halfway there, I believe South Africa has the energy and creativity to run the second half of this marathon and end the HIV epidemic by 2030.
Dr Aaron Motsoaledi is South Africa’s health minister.