HIV may not be the virus on the block since 2020, but it is going nowhere until a cure is found. It remains common in South Africa, with about 240,000 infections a year, and is especially common among young women. We give you the lowdown on everything – from prevention to treatment and cure. 

1. Current HIV treatment in South Africa is pretty incredible

As long as you swallow your three-in-one antiretroviral (ARV) tablet each day at more or less the same time, and start your treatment relatively early after infection (meaning when you’re healthy), you’re almost certainly going to be okay.  

The combination ARVs currently available in the country are extremely safe, simple to take, and are very well tolerated with very few people experiencing persistent side effects. The government provides treatment for free to anyone with HIV and in the private sector care is similarly easy to access, although you (or your medical scheme) will have to pay for it. 

A monthly supply of first-line generic ARVs in SA costs about R300, based on quotes we got from pharmacies we phoned, but most medical schemes pay for this in full. Serious side effects – such as things that affect your kidneys or bones – seem to be very unusual, and even if kidney issues develop they’re relatively easy to monitor and correct. 

2. You can live a long and healthy life if you are HIV positive on treatment

ARVs stop HIV from making copies of itself. If you use them correctly, they reduce the amount of virus in your body to levels undetectable by standard HIV viral load measurement tests – so low that it’s impossible for you to infect another person.  

If you’ve tested positive for HIV, doctors will do a CD4 test, which measures how strong or weak your immune system is. If you start your treatment when your immune system is fairly strong (a high CD4 count) and when you are relatively healthy, your life expectancy is similar to someone who is HIV negative if you stay on treatment.  

3. A cure and an HIV vaccine are still some time away

Huge resources – time, effort and money – are being poured into research, but the problem is complex and there are no guarantees that we will have a cure or vaccine soon, or even in our lifetime. 

Recent reports of an apparent cure in a patient in Argentina seem to suggest genetics can be harnessed to control the virus, but the case raises more questions than answers. Only a really small number of people have been cured (we think), and mostly it seems due to a combination of luck, genes and very invasive therapies, such as those used to treat cancer. So don’t hold your breath.  

Similarly, researchers are beavering away at a vaccine. Developing an HIV vaccine is much harder than making one for Covid-19 (which in itself is technologically quite tricky). Several candidate HIV vaccines have been tested, and most recently the HVTN 702 one in South Africa. But the trial was stopped because the vaccine didn’t work. 

Developing an HIV vaccine is difficult, partly because the virus hides deep in our DNA, the genetic material that makes us human. HIV also mutates fast, compared with SARS-CoV-2, the virus that causes Covid-19, so new variants emerge relatively fast, which vaccines then need to cater for. 

There are flickers of hope, including from South African researchers, who have been investigating developing a vaccine for decades, trying many different approaches. An exciting development, which the world has become familiar with recently thanks to Covid-19, is using mRNA to make vaccines (Pfizer and Moderna’s Covid jabs are mRNA vaccines). mRNA vaccines use pieces of artificial genetic material to instruct your body to produce proteins that can fight a particular virus (as opposed to the inactivated or harmless “pieces” of viruses that more traditional vaccines use).  

4. New treatments are around the corner

Imagine taking an ARV tablet once a week (or even once a month!) rather than having to take it every day, or needing an injection only every few months. This is almost certainly the future of HIV treatment – there’s considerable research into long-acting treatments on the go –  and a first-generation version of a two-monthly injection is currently under trials in sub-Saharan Africa.  

Although the injections work well, you would need two separate (and slightly sore) jabs by a trained health professional. The injections aren’t available in South Africa yet, but they’ll probably be here within two to three years. And with long-acting oral pills and other, maybe more convenient, injections on the cards, you can expect something of a revolution in HIV therapy. 

5. Exciting HIV-prevention options are on the table

Once-daily tablets to prevent HIV (called “pre-exposure prophylaxis’’, or PrEP) work extremely well for people in high-risk situations, for example, university students who are exploring their sexual freedom. 

HIV-prevention pills can reduce your risk of infection via sex by more than 90% if you take it each day. The tablets consist of two ARVs – the same medication that people with HIV use in South Africa – and you can buy PrEP with a doctor’s prescription from pharmacies for about R300 per month or get it free from the government at more than 2,000 health facilities. (But you must be sure to have a negative HIV test before going on PrEP.) Since 2016, about 400,000 people have received HIV-prevention pills in the public sector. 

Long-acting preventive injections and implants are also being tested, which means that you may be able to take the medication less often and still get the same – or even better – protection. 

This year, results from a study that tested a two-monthly HIV-prevention injection called cabotegravir showed the injection works better than a daily HIV-prevention pill, mainly because adherence is so much easier (and better as a result). The US medicines regulator, the Food and Drug Administration, is currently reviewing cabotegravir and, if approved, the injection could become available in the US early in 2022.  

ViiV Healthcare, the manufacturer, has not yet applied for approval by South Africa’s medicines regulator, but is likely to do so. Whether it will be available in the public sector will depend on the outcome of price negotiations with the pharmaceutical company.   

6. South Africa appears to be making steady progress in preventing new infections

Data showed that the number of new infections almost halved in just five years. (Admittedly, the numbers may be a little dated now, as the data were collected in 2017 already.) 

The decline is probably due to a combination of things, including condom use, a large male circumcision programme and better access to treatment. There may be other factors too, but the main point is that things are improving. 

There’s still plenty to do, though. Lots of new infections still occur in young women (between the ages of 15 and 24) and also in other often-marginalised groups, such as sex workers, men who have sex with men and people who inject drugs.  

7. Getting your care is becoming easier

HIV testing used to be available only through a few sites across the country, and treatment was left in the hands of specialists. Now you can test yourself for HIV at home, and ask your general practitioner (GP) or a nurse to prescribe or monitor your treatment. Both government and medical aids are steadily working to deliver ARVs to convenient collection points, including to people’s homes. 

There are now even programmes looking at whether you can start ARV treatment on recommendation from a pharmacist at your local chemist (so without needing a doctor’s prescription) and also access HIV-prevention pills that way. 

8. Diagnosing and monitoring are now super easy 

We already have highly reliable HIV self-tests for diagnosis and viral load tests that measure whether the drugs are working and are standard these days.  

There are some nifty urine tests that may help health workers to identify people who aren’t taking their medicine often enough, whether for prevention or treatment. This can help them see immediately if someone needs support with sticking to the schedule, rather than having to wait for a blood test and a follow-up appointment. 

Knowing that someone struggles to regularly take their medication is the first step to finding out where the problem lies. 

9. We’re getting better at tackling opportunistic infections 

Opportunistic infections are conditions that you develop as a result of HIV infection; for instance, tuberculosis (TB) or pneumonia. Newer, shorter and safer treatments are now available for cryptococcal meningitis, one of the nastiest Aids diseases we see. (Cryptococcal meningitis is inflammation of the membranes around your brain and spinal cord, caused by a fungus.) 

Previously, treating this condition took at least two weeks, with the medicine given daily, usually through a large drip in your neck or shoulder and which had to be changed every few days. Now, with new developments, it looks like treatment could mean you’d need only a single shot.  

South African researchers have been part of this exciting research, as well as in tackling treatment for TB, which remains a major concern across our population, not only for HIV-positive people. In the case of drug-resistant TB, treatment may be shortened from over two years to just six months in future, using a cocktail of three less toxic drugs and with much higher (90%) success rates.  

10. Keep an eye on living long and well

Gaining weight, sometimes a lot of weight, has emerged as a major concern for people on successful HIV treatment.

It is unclear if this is some strange effect of HIV priming your body to accumulate weight, or a side effect of the treatment, but researchers are working on understanding this.

However, the messages are the same as for HIV-negative people: pay attention to your diet (cut out processed foods and refined sugars), keep active, don’t smoke, go slow on the booze, and nag your healthcare worker to check your blood pressure. You didn’t commit to taking ARVs for life just so diabetes can take you down. 

Is everything rosy? No. People still come in late, or even on their deathbeds, to get tested for HIV and start treatment. New infection rates are still too high. 

Some populations continue to get missed – men are tested later, and fall out of treatment programmes more often than women. Not all pregnant women access ARVs and so pass on HIV to their babies at birth or through breastfeeding. Children with HIV get missed after birth and return to a clinic only when they are ill. 

People with HIV still suffer discrimination and experience stigma. Populations at risk of HIV experience irrational criminalisation, meaning they can’t get the care they need. Men who have sex with men, transgender people, sex workers, prisoners and people who inject drugs often are more vulnerable to getting infected, and usually get a raw deal when it comes to all forms of healthcare, not just HIV prevention and treatment. 

So, there is still plenty of work to do. But we have made a lot of progress. South Africa needs to protect its victories, especially in preventing infections and improving ARV access. The new technologies and approaches, if we get them right, promise fewer infections in the general population, and in those with infection, a long and trouble-free life (at least as far as HIV is concerned). DM/MC

Nomathemba Chandiwana, Bronwyn Bosch and Simiso Sokhela are all research clinicians with extensive experience in clinical trials at Ezintsha. Francois Venter is the head of Ezintsha. Ezintsha is a research and policy unit based at the faculty of health sciences at Wits University. All the authors are involved in research addressing new approaches to preventing and treating HIV, Covid-19, obesity and sleep disorders.

This story was produced by the Bhekisisa Centre for Health Journalism. Sign up for the newsletter.

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