The first cases of HIV were diagnosed in 1981 — 41 years later the HIV epidemic continues to haunt South African communities. Despite having the world’s largest number of people living with HIV and the world’s largest number of people on life-saving antiretrovirals (ARVs), South Africa still has a long way to go to end the epidemic. Of concern as well is that the response to the Covifd-19 pandemic limited access to essential services during the lockdowns and has also reduced the public’s focus on the twin HIV and TB epidemics in the country, which is aggravated by emerging pandemic of cardio-metabolic diseases. With HIV/TB co-infection rates of more than 50% we must treat these diseases as two sides of the same coin. 

What are the continuing challenges facing the country? Despite initiating more than 5 million of the estimated 8 million people living with HIV, South Africa did not meet the UNAids 90-90-90 targets (90% of people know their HIV status, 90% of these on ARVs, and 90% of those on treatment are virally suppressed) or the prevention targets for 2020. In addition, the number of new annual HIV infections is still around 200,000 with adolescent girls and young women continuing to bear the brunt of new infections. It is critical that we are able to get affordable long-acting injectables like CAB-LA as soon as possible to invigorate our HIV prevention programme. 

It is currently estimated that against the 90-90-90 targets South Africa has reached 93-73-88 for the total population. However, whilst adult women have reached 95-77-89, adult men have only reached 92-67-89 with children under 15 fairing the worst at 80-66-63 even though their numbers are significantly lower than those of adults.  

UNAids has put down several markers to be reached by 2025 for countries globally. Arguably the most important of these are: reach the 95-95-95 target by 2025 and end the Aids epidemic by 2030. Less well-known among the UNAids 2025 targets are the following: 

• 95% of women of reproductive age have their HIV and sexual and reproductive health service needs met;
• 95% of pregnant and breastfeeding women living with HIV have suppressed viral loads;
• 95% of HIV-exposed children tested by 2025; 95% of people at risk of HIV infection use appropriate, prioritised person-centred and effective combination prevention options.
• Implementation of people-centred and context-specific integrated approaches that support the achievement of 2025 HIV targets and result in at least 90% of people living with HIV and individuals at heightened risk of HIV infection linked to services for other communicable diseases, non-communicable diseases, sexual and gender-based violence, mental health and other services they need for their overall health and wellbeing.

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In addition to these, the UNAids 2025 prevention strategy spells out three social enablers which focus on removing social and legal impediments towards the creation of an enabling environment to increase access and utilization of HIV services.

The 2022 UNAids theme for World Aids Day is ‘Equalise’. The rationale for the theme is that there is evidence that inequality in society has and continues to fuel the HIV epidemic. The same is true of the TB epidemic — long considered a disease of poverty. The theme is particularly pertinent to South Africa with its legacy of apartheid and its continuing high levels of inequality — by race, class, gender and geography. 

This means that to reinvigorate South Africa’s HIV (and TB) responses the country needs to refocus on those being left behind and restructure its HIV response over the next three years to meet the 2025 UNAids targets. 

To achieve these targets, we must also mitigate mental health (MH) issues that negatively impact on people living with HIV and TB. Depression is the most common MH disorder amongst PLHIV and TB, often resulting in non-adherence to treatment. As people living with HIV live longer as a result of initiation and adherence to ARV treatment, there is also an increase in noncommunicable diseases like diabetes and hypertension which require management by individuals and the health sector. Additionally, we know that people with diabetes are three times more likely to contract TB — this requires an integrated approach to patient management. 

While the health sector, in particular the public health sector, is primarily responsible for the HIV treatment component, the prevention and management of HIV and TB require a whole of society and whole of government response. In the short to medium term, government needs to mobilise all sectors of society to respond, with business, communities and organised labour playing a far greater role. We need to urgently reduce sexual and gender-based violence from the ground up, we need to ensure that children are socialised to better understand their gendered and non-gendered roles, we need to increase social protection, expand the social welfare net to ensure that we deal more decisively with poverty and hunger and we need to keep girls in school for as long as possible. 

A greater focus on prevention in the health sector is also critical for a reinvigorated response to the epidemic. This will also require a reorientation of both the health service delivery platform, retraining of health professions and additional budgets for prevention. It is also critically important that new products for prevention such as long-acting injectables like CAB-LA are made affordable and available as rapidly as possible to prevent HIV acquisition. 

Within the health sector there are innovations that need to be scaled. These include differentiated services — to ensure that we have a truly person-centred approach to service provision. This is not only required for HIV and TB services but for all services. This means a more systematic transformation of the provision and delivery of health services besides optimal use of digital health solutions, In addition, during the height of the Covid-19 pandemic, the centralised chronic medicine dispensing and distribution service (CCMDD) enabled many people on ARVs to get their medicines despite the lockdowns. In addition, multi-month scripting was done. These services need to be expanded to all patients who require chronic medicines. 

Technical implementing partners that form the Health Implementing Partners Group (HIP-G) have been central to supporting the government’s response to HIV and TB with financial support from a range of bilateral, multilateral and philanthropic organisations. Many innovations have been developed and lessons learned. However, much more is needed to end Aids by 2030 as is the global call. 

Most of all the HIV epidemic and the Covid-19 pandemic taught us that unless we put patients and communities at the centre, the services provided by government and the private sector will either not reach those most in need or provide services that are appropriate and acceptable to people.

The 2022 World Aids Day commemoration provides South Africans with yet another opportunity to take our prevention and treatment programmes to new levels. The cost of illness is much too high not to reinvigorate our responses to both HIV and TB so that we can meet the global targets and reduce the burden of these diseases on our communities. DM