Bhekisisa Centre for Health JournalismIn many areas in South Africa, HIV is spreading faster among those with jobs than people without employment. Yet employers refuse to implement HIV programmes — even when they’re offered for free.

Worsening matters is the fact that the private medical community isn’t responding to HIV in an effective way either.

HIV infection rates among employed adults in uMgungundlovu in the Kwazulu-Natal Midlands are higher than among the unemployed, according to a 2018 household survey that Epicentre conducted.

The study, which is part of the larger HIV Incidence Provincial Surveillance System (Hipss) project, surveyed 10,000 randomly selected adults between the ages of 15 and 49 in Vulindlela and the greater Edendale areas. Those who were employed mostly worked for the government, or privately in the fields of transport, manufacturing and farming, with their salaries ranging between R2,500 and R30,000 per month.

A University of Washington study, which was published in the scientific journal Nature in June, found that uMgungundlovu, which hosts KwaZulu-Natal’s capital city, Pietermaritzburg, is the municipality with the highest proportion of people living with HIV in South Africa.

The country had 7.9 million people who were infected with HIV in 2017, according to the Human Sciences Research Council’s (HSRC) latest household survey — 14% of the population.

Our Epicentre study found that the HIV prevalence rate among employed women, in the parts of uMgungundlovu that we surveyed, was 55.9% — this is 13.2% higher than among those without jobs (42.7%). In the case of men, 30.7% of those who were working was infected with the virus compared to 22.3% of unemployed men.

Why?

Because HIV testing, as well as evidence-based HIV prevention strategies such as medical male circumcision and correctly used antiretroviral treatment (ART), are far more readily available in the public than the private healthcare sector.

ART can prevent HIV transmission, because when people with HIV take the treatment correctly — a three-in-one pill at the same time each day — the amount of HIV in their blood drops to such low levels that it becomes scientifically impossible for them to transmit the virus to others. Researchers refer to such patients as being virally suppressed.

The HSRC’s HIV household survey shows that about 6 out of 10 people with HIV between the ages of 15 and 29, and who were on ART, were virally suppressed in 2017.

But our Epicentre study found that far fewer HIV-positive working (40.8%) men than unemployed men (50.9%) were on ART and virally suppressed. For employed women, there was no significant difference.

One of the reasons for the difference in testing and treatment uptake among men is probably the impact of the health department’s provider-initiated HIV testing policy, where all government patients, regardless of the reason for their visit to a public health facility, are offered HIV counselling and testing, unless they explicitly opt out of it.

This policy has resulted in 13,872,315 people in the public healthcare sector being tested for HIV in the 2017/2018 financial year, exceeding the annual target of 10 million people, according to the health department’s 2017/2018 annual report.

If a patient tests HIV positive in a public health facility, the person is put on HIV treatment as soon as possible.

Although the department’s guidelines also apply to the private sector, it is rarely implemented at private health facilities — at least in my experience: I have never been offered an HIV test by my doctor, have you?

Many workplace wellness screening programmes also don’t link people who test HIV positive to care, leaving it up to the individual to seek treatment. This has probably contributed to a large number of people who know they’re HIV positive, but are not on treatment.

In 2017, only 4.3% of medical aid members — or 380,000 per 8.8 million people — were tested for HIV, according to the Council for Medical Schemes. As a result, only 3.7% of members are on ART. There is no information available on what proportion of HIV-infected medical aid members are virally suppressed, as medical schemes don’t report viral suppression. Assuming that medical aid members’ HIV prevalence reflects the national prevalence for age, race and gender, a crude estimation of prevalence, based on medical aid membership reflected in Stats SA’s 2017 household survey, would be around 8.9% — medical aids are therefore missing at least 5.7% of their members with HIV.

In the case of medical male circumcision — when the entire foreskin is removed — studies have shown that a man’s risk of contracting HIV through vaginal sex is reduced by up to 60%.

South Africa’s HIV household survey found that 43% of men between the ages of 15 and 24 had been medically circumcised by the end of 2017. But, for medical scheme members, the Council for Medical Schemes’ 2017/2018 annual report shows that figure is much lower: less than 1% — 8.6 out of every 1,000 male medical aid members — took up medical male circumcision in 2017.

In our survey, most men who were circumcised were 20 years old or younger. This makes it critical to reach older, employed men to make medical male circumcision an effective prevention strategy.

Even when HIV prevention services are offered for free, employers are extremely reluctant to take these up.

As part of our study, Epicentre identified and approached the 25 largest employers in Ladysmith in uMgungundlovu. We asked them to allow their employees to participate in an HIV testing and voluntary medical male circumcision programme that we offered for free.

To our surprise, 24 out of the 25 employers declined.

Yet our Hipss research, as well as another study Epicentre conducted with the New York-based Population Council, found that employed men around 30 years of age were the most likely to contract and transmit HIV. The study was conducted in Durban.

This failure to appreciate the seriousness of the HIV epidemic, as well as the impact that evidence-based prevention strategies can have on curbing the spread of the virus, is hurting the country’s HIV prevention efforts.

Ironically, it’s also damaging the very same companies that refuse to implement prevention strategies, financially.

In the public sector, it costs R3,899 per year to treat a person with HIV, according to a 2018 study conducted by Wits University’s Health Economics and Epidemiology Research Office. In the private sector, this cost is higher, as the health department is able to negotiate for lower prices of ARVs because it buys these in bulk from pharmaceutical companies. In the private sector, doctors and nurses also charge more for their services than in the public sector.

The refusal of companies to implement HIV prevention strategies means more employees will get infected with the virus, resulting in higher treatment costs for company medical aids, higher rates of absenteeism and reduced worker productivity.

Embracing prevention plans, a 2005 American Journal of Public Health study has shown, can also lower direct costs such as group life insurance premiums and worker’s compensation claims.

And, as South Africa’s 2016 investment case for HIV and TB shows, the cost of addressing the country’s HIV epidemic is largely paid for by taxpayer money — money the companies that refuse to embrace HIV prevention efforts pay each month.

South Africa’s three largest medical schemes, Discovery, Bonitas, and Momentum, have all announced contribution increases well above inflation for 2020. Rather than inflating premiums, medical aids should take some lessons from the health department and look at how they can reduce the prevalence of health conditions such as HIV in order to save costs.

Medical schemes, employers and private healthcare facilities have clearly not adopted the United Nations and department of health’s 90-90-90 targets — to have 90% of people in the country know their status, 90% of those who test positive put on ART, and 90% of those on treatment be virally suppressed by 2020.

The government aimed to have 80% of men between the ages of 10 and 29 circumcised by 2016, but fell behind on this goal: by February 2017 only 55.8% — or 3 million of 4.3 million targeted men — had been circumcised, according to the HSRC’s household survey.

The 90-90-90 and circumcision targets are crucial to end the epidemic by 2030, as the United Nations expects all countries to do.

If we don’t, the cost for South Africa will be enormous – not just to the government, but to each taxpayer and employer. DM

Cherie Cawood is the founder and CEO of Epicentre. This story was produced by the Bhekisisa Centre for Health Journalism. Sign up to their newsletter.