Is South Africa Winning the AIDS Battle?

Despites Fewer HIV-Related Deaths, Infection Rate Continues to Soar

Outreach worker in Eschowe, South Africa offering free HIV testing. Photo Credit: Medicins san Frontiere

There has arguably been no bigger turnaround in HIV public health policy than in South Africa, which emerged from the rampant AIDS denialism of former-President Thabo Mbeki to become what is today the world's largest and most ambitious public antiretroviral (ARV) initiative.

So profound has this turnaround been that the perception among some is that the South African HIV epidemic is largely under control or that we, as an international community, are somehow approaching the proverbial "end of the tunnel." And why shouldn't anyone believe this, given that many are now predicting that the end of the epidemic in near?

To be fair, many of the statistics support the argument. Since the start of the ARV roll-out in 2003, South Africa has made some incredible inroads, with the latest CDC data indicating an overall 25% drop in new infections and a 50% reduction in child HIV infections (the latter of which is largely due to highly effective mother-to-child interventions).

But that paints only a part of the picture. The fact is that South Africa remains at a critical crossroads, with not only the largest HIV population in the world (6.4 million) but massive infrastructural obstacles yet to overcome.

Research Shows Steep Rise in New Infections

Chief among these are the rising HIV prevalence rate which, according to the country's Human Science Research Council (HSRC), has increased from 10.6% in 2008 to 12.2% in 2012. While this figure is, in part, due to the increased longevity of those living with HIV, underlying it is the astonishing number of new infections each year.

In 2012 alone, the HSRC reported 470,000 new diagnoses—or nearly 1,100 new infections every day. That's 100,000 more than was seen just one year earlier in 2011.

Driving these statistics is the decreasing, rather than increasing, public knowledge about HIV. According the HSRC report, only 26.8% of the 38,000 people surveyed understood how HIV was transmitted or ways to prevent it.

That's down from 30.3% in 2008, with evidence showing that South Africans under 50 are having an increasing number of sexual partners and lower condom use.

This seems to suggest that the overly optimistic messages shared in the media may, in fact, be filtering down to the South African people.

Low Rate of HIV Treatment Response Undermines Prevention Goals

More concerning, perhaps, is the fact that the rates of optimal treatment response—measured by an undetectable viral load—are extremely low across the entire sub-Saharan continent. According to UNAIDS, only 29% of the treated population in sub-Saharan Africa are able to achieve complete viral suppression needed to reduce the risk of HIV-related illnesses and death.

Many cite low rates of treatment adherence among patients as the primary cause of such failures, as well as drug pipeline problems that continue to plague clinics across the region. These frustratingly low figures further compound the difficulty in achieving the UNAID's 90-90-90 goals, which aim to

  • diagnose 90% of the world's HIV population;
  • place 90% of those diagnosed on treatment, and;
  • achieve undetectable viral loads in 90% of those being treated.

And all by 2020.   

If such numbers are, in fact, attainable, mathematical models suggest that the reduced community viral load would translate to a profound drop in HIV infections across entire populations.

But can Africa—and most specifically South Africa—achieve these targets in less than five years? It's unlikely. But without renewed efforts to do so, the chance of reducing the new infection rates on the southern continent is equally unlikely. 

WHO Policy Put Pressure on South African Health Officials

Meanwhile, the World Health Organization (WHO) and others have now called for a revision of policy, increasing the treatment initiation start point from CD4 counts of under 500 cells/mL to treating HIV at the time of diagnosis irrespective of CD4 count.

This aggressive new policy places greater emphasis on treatment as prevention (TasP) as a means to prevent further spread of infection, particularly in high-prevalence populations.

Unfortunately, what the policy presupposes is a stronger public healthcare infrastructure that currently exists in South Africa, with exasperating shortages of ARVs in many clinics; increasing numbers of patients lost to follow up; still-critical shortages of doctors in the public sector; little in the way of data to quantify the scope and impact of ARV non-adherence, and; still far too many patients presenting with CD4 counts of under 100 (with one study from Soweto showing that 18% started treatment at CD4s below 50).

Professor Francois Venter, former head of the Southern African HIV Clinicians Society (SAHIVCS), stated in 2013: "We first need to fix the system and get the core treatment program right"—something many will agree is simply not happening. With the new WHO guidelines more than doubling the number of people qualified for ARVs, the question is not so much about "when," but "how."

Yet, despite the arguments against the guidelines, it's clear that the current course is not going to effect the reductions needed to ultimately stave and turn back the epidemic. A March 2014 study by the Perinatal HIV Research Unit (PHRU) in Johannesburg confirmed that, in order for TasP to succeed, therapy should be started in all patients irrespective of CD4 count.

How this can be accomplished remains unclear, particularly as the U.S., the world's largest global donor, announced that it would slash funds to South Africa by 50% by 2017 due to compulsory budget cuts. At a time when greater funding is needed to implement new WHO policy, it's ironic that not only the U.S. but other G8 countries have decided to back away—all while suggesting that an "AIDS-free generation" is well within reach.

How South African government will make up the 2.5 billion rand (US$250 million) difference is uncertain at best as the country faces its own economic crisis, with both Standard & Poor's and Moody expected to further downgrade its sovereign rating in the coming year.

So while we should, indeed, laud the South African government on the major advances it has made this past decade, to suggest that the road ahead is any less than dire would be a mistake.


Human Sciences Resource Council (HSRC). "South African National HIV Prevalence, Incidence and Behaviour Survey, 2012." Pretoria, South Africa; December 2014; accessed February 17, 2016.

Levi, J.; Raymond, A.; Pozniak, A.; et al. "Can the UNAIDS 90-90-90 targets be achieved? Analysis of 12 national treatments cascades." IAS 2015: 8th IAS Conference on HIV Pathogenesis, Treatment and Prevention; Vancouver, Canada; 18-22 July 2015.

Associated Press (AP). "Millions More Need Immediate HIV Treatment, Says New WHO Guidelines." Issued September 30, 2015

Cullinan, K. "WHO’s new HIV guidelines may ‘distract’, warns expert." Health E-News; published July 24, 2013.

Govender, S.; Otwombe, K.; Essien, T.; et al. "CD4 Counts and Viral Loads of Newly Diagnosed HIV-Infected Individuals: Implications for Treatment as Prevention." PLoS|One. March 4, 2014; DOI: 10.1371/journal.pone.0090754.

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