Feb 5, 2014 | News

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The war against HIV has at times seemed more like a battle between David and Goliath. But if history has proved anything it’s that giants can be brought down. Will we one day find our proverbial pebble and slingshot to slay the infectious killer or will it prove to be societal transformation which saves the day? What we do know is that we are making positive advances and now is the time to give the battle everything we’ve got. It’s time we put AIDS on the run, once and for all.

South Africa remains the country with the most cases of AIDS. According to statistics produced by UNAIDS, South Africa accounts for 0.7% of the world’s population yet it is home to 16% of the global HIV population. The Human Sciences Research Council (HSRC) conducted a household survey in 2012 which revealed that 12.3% of our population is living with HIV.

These may seem like formidable statistics – and they are – but when we note just how far we’ve come over the past five years we realise that the picture is far brighter than it first appears. Associate Scientific Director for the Centre for the AIDS Programme of Research in South Africa (CAPRISA), Professor Quarraisha Abdool Karim is extremely optimistic. “Never before have we had such a confluence of information around treating and preventing HIV. Scientifically, we are at a very promising point in time,” she maintains.

“Never before have we had such a confluence of information around treating and preventing HIV.”

Her enthusiasm stems not only from breakthroughs in technology, but also from the incredible commitment to combating the virus which the South African Health Department has demonstrated. Under Dr Motsoaledi’s leadership, South Africa has managed to develop one of the largest treatment programmes in the world – 82% of those in need of antiretroviral treatment (ART) are receiving it. To put it into context, one in every 5 people in the world who are receiving ART live in South Africa.

The current statistics around HIV testing are encouraging: 13 million people were tested for HIV between 2010 and 2011. Programmes rolled out by the Health Department have reflected sound strategy, with the critical first step of encouraging South Africans to test their HIV status having been well executed.  A significant barrier to testing has been the stigma around HIV and the tendency of people to avoid the issue altogether – which is exactly why the current number of individuals receiving treatment is a truly remarkable feat.

“Over two million people are now on antiretrovirals (ARVs), which is 31, 5% of the people who are infected,” informs Director of Health Economics and HIV/AIDS Research Division (HEARD), Professor Alan Whiteside. “It’s an absolutely astonishing achievement.”

Treatment of pregnant women has been a strategic area of focus for governing bodies. CEO of the South African National AIDS Council (SANAC), Dr Fareed Abdullah, reveals that there has been a drastic decrease in the number of children being diagnosed with HIV, largely because of the impressive upscale in ART for pregnant women. “Pregnant women were the first to gain access to the one pill per day ART programme and consequently we’ve seen a 90% reduction in transmission from mother to child,” he provides.

Male medical circumcision is known to reduce the risk of contracting HIV amongst men by 60%. Not surprisingly, it too has been a priority for the national Health Department with one million men in South Africa having already been circumcised and there is a future target of 4.2 million circumcisions in the pipeline.

Antiretrovirals remain the most advanced innovation for the treatment of HIV. Because ARVs are now so prevalent, it’s sometimes too easy to forget just how ground breaking the treatment has been. According to data from the Medical Research Council, the antiretroviral treatment programme in South Africa has led to an increase in life expectancy for all South Africans by six years since the programme was scaled up three years ago. In 2009, the average life expectancy for the average South African was 54 years, but by 2012 this had risen to 60 years. As one of the most common and debilitating infections associated with HIV, the improvement to the general well-being of those living with AIDS has been life-changing.

Abdool Karim notes that not only have ARVs meant that now we are seeing people who were previously bed-ridden with TB normalising as well as women over 30 who were dying in substantial numbers now surviving, but we are also starting to see communities flourish as the knock-on effect takes place throughout the country’s economy.  “ARVs opened up an entirely new era in HIV treatment,” she points out.

Innovations in treatment continue to take place. According to Whiteside, there are huge numbers of people working on ways in which to improve and enhance the drugs currently available, simultaneously seeking out ways to make them cheaper.

Among areas of particular focus is co-formulation. When ARVs were first introduced to the public, patients were required to take a substantial number of pills every day. While at the moment treatment sits at just one pill per day, efforts are being made to increase the intervals between which medication must be administered. Abdool Karim explains that getting people to adhere to long-term prescriptions has been a major challenge and one which future innovations will hopefully address.

The microbicide gel has given South African researchers, and indeed the country as a whole, reason to celebrate.  The fact that most preventative measures on the market are only suitable for men has been a major cause for concern. It’s recently been discovered that ARVs in tablet form can help prevent HIV-free individuals from contracting the virus from their partners, but now scientists have found that by formulating a gel which can be applied directly to the genital tract, the drug’s ability to abort the HIV infection is far greater. “If we can prevent the virus from getting into the blood stream, we can also reduce the side effects,” says

Abdool Karim. What’s more, the drugs become active within 15 minutes.
Health officials are taking steps towards the manufacture of microbicides in South Africa and will also be focusing on the development of alternative preventative measures designed specifically for women. Over the next five or ten years, we may see the introduction of innovations such as implants and injectables geared towards helping prevent women from contracting HIV.

At the moment HIV patients with a CD4 count of 350 or less are put on to ARVs. However, according to Abdullah, research indicates earlier intervention can help to prevent transmission from infected individuals to their partners. As a result, government is now considering placing individuals with counts of 500 or less on treatment, although the cost of such an initiative needs to first be assessed.

Whiteside maintains that while South Africa has performed exceptionally well in managing to provide HIV patients with treatment, there are still major shortcomings to be addressed as far as prevention is concerned. Around half a million people contracted HIV in 2008 – a figure which had decreased considerably to 370 000 in 2012. But as Abdullah asserts, the figure is still far too huge, and considering that 240 000 people died from AIDS in 2012, we are far from where we need to be.

“AIDS has a way of finding us out where we’re weak.”

We may have reached a point in time where we have the technology required to resolve most of the challenges presented by HIV, but all that may prove to be of little use if there aren’t some massive changes in social behaviours.
“South Africa’s response to the HIV epidemic has changed dramatically; we’ve been hugely successful in putting people on treatment, and hundreds of thousands of people are now surviving. My concern is that we have still not cracked the prevention code.

We have to find a way of ensuring that the pool of people who need treatment does not continue to fill,” comments Whiteside, in reference to the need for more responsible behaviours.

The social barriers to achieving this reach across a number of pressing issues; challenges such as gender relations and xenophobia which need to be addressed in order to successfully catalyse large-scale social change. Whiteside captures the complex and destructive nature of the HIV virus well when he says that “AIDS has a way of finding us out where we’re weak”.

Breakthroughs in research and technology have provided us with formidable weapons to wage a brutal battle, but a drastic change in the way that people think and behave is required – and that may ultimately prove key to winning the war.

The rate of infection among young women is a battle ground which requires particular attention. Current statistics in this area are alarming. “Not only do young women contract HIV on average five to seven years before men, but their infection rate is also three times higher,” reveals Abdool Karim.

She says that preventing adolescent women from contracting HIV is the potential Achilles heel in South Africa’s fight against AIDS. “If we can find a way to keep young women uninfected, then we may well be able to say that the end is in sight.”

Pushing for a reduction in HIV transmission among women between the ages of 15 and 24 will require substantial investment in educating the public around inter-generational and transactional sex. Abdullah explains that older men who are already infected with the virus are inclined to have sex with younger women – a scenario which is currently driving the entire epidemic. “We have to make this an area of highest priority,” he maintains.

Other key populations which need urgent attention include those which have previously been marginalised by society. Sex workers, homosexuals, prison inmates and drug users are all groups which require crucial intervention in the form of preventative treatments. “It’s an absolute indictment on our society that we have not looked after these communities,” laments Abdullah. “We all need to learn to suspend our moral judgement in the interest of our nation’s health.”

In line with this, SANAC is working towards launching the first South African National Sex Worker Programme to address HIV and AIDS among sex workers.

An entirely different battleground is the cost of managing HIV, most particularly in conjunction with other lifestyle-related diseases. Organisations such as Aid for AIDS (AfA) are conducting research into the co-management of HIV and other common illnesses. Through enhanced management of multiple conditions, the AfA has been able to reduce hospitalisation costs by up to 71%.

A miraculous cure for HIV continues to elude us and may ultimately prove unreachable in spite of the fact that there have been isolated cases of HIV-infected people who have managed to break free from the virus.

The world was set a twitter with the news that Timothy Brown, otherwise known as “The Berlin Patient” had tested negative for HIV after having been diagnosed with leukaemia and undergoing a stem cell implant. More recently a Mississippi toddler has been confirmed to be HIV-free as well. The child, who was born with HIV and dosed with high doses of antiretroviral drugs just hours after her birth, continues to show no signs of the virus whatsoever.

Cases such as these are greatly inspiring but as Whiteside cautions, there are 34 million people around the world living with HIV and two of them have been cured. Incidents such as these in which circumstances have aligned perfectly to create real miracles are rare in the extreme and can unfortunately not be reproduced on a larger scale.

But do these reports still give us reason to hope? Absolutely – largely because they provide leading researchers with the necessary clues to point them in the right direction. If the global community is ever to reach that elusive cure, these developments will provide the stepping stones.

Equally as remarkable as a cure would undoubtedly be the development of an AIDS vaccine. Imagine a futuristic society in which HIV is referred to in the past tense. In fact, Abdullah is of the opinion that the only way to truly close the door on the dreaded disease forever would be to achieve exactly that. “The end game will have to do with developing a vaccine,” he believes.

While we may be years away from such a game-changing development, research into the production of a vaccine has seen a resurgence. Right now there is more work being done to develop a vaccine in South Africa than anywhere else in the world. “If a vaccine is going to be developed, it will be done in South Africa,” Abdullah asserts, though he cautions that a great deal more time and investment is needed in order for this to happen.

In the meantime, health officials need to launch a full scale attack on all fronts. Not only do they need to continue driving and improving on programmes which have been working well but they also need to institute new drives in critical areas. Abdullah summarises the necessary course of action with the following: “Current steps need to include doubling the number of people we have on treatment, starting treatment earlier and investigating further innovations,” he argues. “But the single biggest thing we need to improve on is behavioural change.”

What does the future hold for HIV in South Africa? At the moment it seems impossible to say. What matters most now is that we throw everything we have at this deadly tyrant. Let’s hope that the answer to our final question is – no future at all.