New estimates from the Thembisa model (a leading mathematical model of HIV in South Africa) suggest that while KwaZulu-Natal is doing well in its HIV response, North West is struggling.

 90-90-90

One widely endorsed set of measures to track a country or province’s HIV response is UNAIDS’s 90-90-90 targets, which were also adopted in South Africa’s National Strategic Plan for HIV, TB and STIs 2017-2022.

The targets are that by 2020:

1. 90% of people living with HIV must be diagnosed;
2. 90% of those diagnosed must be receiving sustained antiretroviral therapy; and
3. 90% of those diagnosed must achieve viral suppression (there must be so little virus in their blood that standard tests do not pick it up).

How are SA’s provinces doing?

In addition to the 90-90-90 targets we added two extra columns to the right:

• The ART coverage column shows the percentage of all people living with HIV (diagnosed and undiagnosed) who are on treatment – unlike the second 90 which reflects only the percentage of those who are diagnosed and who are on treatment.
• The column on the far right shows the percentage of all people living with HIV who are virally suppressed – unlike the third 90 which reflects only the percentage of people both diagnosed and on treatment who are virally suppressed. This last column tells us the most about the state of a province’s HIV response (technically it is the product of the three 90s).

Key takeaways

• On the 90-90-90 measures, KZN performs better than any of the other provinces. This is particularly impressive given that the province has a large population and much of the province is rural. The Free State does second-best on these indicators.
• The worst-performing province, at least based on these indicators, is North West. This is not surprising given well-documented governance problems in the province’s health department. That Gauteng ranks second-worst may surprise some, especially compared with the more rural KZN. The Eastern Cape also clearly still faces very significant challenges, although that is probably less surprising.
• Across the country, HIV testing efforts have been impressive, with all provinces very close to meeting – and sometimes exceeding – the first of the 90-90-90 targets.
• The one clear shortcoming across provinces is that many people who test positive either stop treatment or never start (the second 90). Helping more people who are living with HIV to start and stay on treatment must therefore be a top priority for provincial health departments.

Note: The numbers quoted in the table are the 2019 mean point estimates from the Thembisa model version 4.3 (confidence intervals are provided in the published outputs on the Thembisa website). Thembisa also includes estimates for 2020, but these are substantially more uncertain than the 2019 estimates. For viral load suppression we used the 1,000 threshold rather than 400 (Thembisa provides both). DM/MC

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