About six million South Africans are living with HIV. Estimates range between 5.4 and 6.4 million. The estimate of 6.1 million used by SANAC and the NDoH is generated from the UNAIDS sponsored Spectrum Model and uses HIV testing data from the government’s annual HIV survey of pregnant women and the recent household survey conducted by the Human Sciences Research Council.
Six million is a staggering statistic by any measure. Stated differently, 18% of adults between the ages of 15 and 49 – almost one in five – are HIV positive. Although South Africa accounts for 0.7% of the world’s population, we make up 16% of all people living with HIV globally. HIV has been the single largest cause of premature death of adults and children for more than a decade.
The tide, however, is turning and South Africa is finally getting on top of the problem. The most important change has been the government’s decision to provide antiretroviral treatment. More than two million South Africans are now on antiretroviral treatment. It is true we have the largest HIV epidemic in the world, but we can proudly claim that we also have the largest antiretroviral treatment programme in the world. Without treatment almost all two million people on treatment would be dead within two years.
The ART programme is measurably reversing the effects of HIV. Life expectancy has increased from 54 to 60 years between 2009 and 2012 and infant and child mortality has decreased by 25% over the same period. These findings of the Medical Research Council made headlines in medical journals across the world and removed any doubt of the powerful effects of scaling up the treatment programme for adults and pregnant women.
The widespread availability of antiretroviral treatment has given hope to millions of South Africans and it should give hope to the nation that we may yet climb out of a deep dark hole that had the scary potential to bury us all.
World AIDS Day 2013 was an occasion to reflect with gratitude on three counts that have caused us to be in a much better place than we were a decade ago. The first is that we have Aaron Motsoaledi as our Minister of Health. He has provided the clarity of vision and the drive that was essential to unlock the potential that exists within our health system to do remarkable things. Now we know that in many other areas the system is failing, but when it comes to antiretroviral treatment its success is extraordinary.
The unsung hero in the antiretroviral treatment success story is the Treasury. Treasury officials have always been committed to funding antiretroviral treatment – even in the dark days of denialism.
As we commemorated World AIDS Day, we were buoyed by the commitments that the Treasury has made to continue funding the scale up of antiretroviral treatment even in a constrained fiscal environment. Government has provided funding to increase the number of people on antiretroviral treatment by an additional 1.5 million by 2016.
With the right tone from the top and the funding from the holders of the purse strings the scene was set for the doctors, nurses and pharmacists to make the programme work, patient by patient until we arrived at this staggering number of two million people on treatment. These are the real heroes of the struggle against HIV.
Though great progress has been made, we are not out of the woods by any means. We still have a massive problem with new infections. In 2012 alone, there were an estimated 370 000 new infections in South Africa. This means that we have to turn our attention to stemming the tide of new infections. Much of this work is about changing patterns of sexual behaviour and effectively implementing prevention methods that we know work.
The biggest drivers of unsafe sex are structural. Older men with a greater accumulated risk of HIV exposure are infecting younger women. This is a major driver of HIV in South Africa and accounts for a significant proportion of new infections. The age-sex disparity is so marked that we now see that the infection rates in young women between the ages of 15 and 19 are three times higher than their male counterparts. This age-sex disparity is often driven by the poverty of young women and results in what we now call transactional sex. Reversing this trend of intergenerational and transactional sex may be the single biggest change we need to see to turn the tide against new infections.
Gender inequality and gender based violence are key drivers of HIV transmission. At the moment, it would appear that we may even be moving backwards when it comes to this key driver. So much more needs to be done and the AIDS movement in this country has a critical role to lend its weight to the institutions and NGOs doing battle with this scourge. Alcohol, and binge drinking amongst young people, is well described to be associated with HIV infection and SANAC must join forces with those who are taking on this battle.
At SANAC we take the view that we could achieve a great deal more if we did the things that we know work and did them well when it comes to prevention. Promoting the use of condoms in ways that significantly increase their use in a way not seen before is high on our agenda. The two most effective prevention methods available to us at this time are HIV testing and medical male circumcision.
HIV testing is the key to both prevention of HIV and access to antiretroviral treatment. HIV testing has to become common place in a country where the risk of contracting HIV is so high. Every visit to the clinic for someone who does not know their status or who is negative should be associated with a test for HIV. Testing should be available in the community and through all NGOs. Medical male circumcision – and it must be emphasised that this has to be the complete excision of the foreskin (traditional circumcision are often partial) – reduces the risk of HIV transmission in men by up to 60%. The Department of Health has set a target of circumcising 4.2 million men by 2016. These are the reasons that the clarion call for the last World AIDS Day going into 2014 is ‘Get Wise. Get Tested. Get Circumcised.’