Young people, especially young women, account for a huge chunk of the nearly 200,000 new HIV infections in South Africa every year. Preventing HIV infections in this group is thus an obvious priority. Prevention can be achieved through education and access to sexual and reproductive health services such as condoms and PrEP (pre-exposure prophylaxis) among young people. PrEP refers to antiretrovirals being taken to prevent HIV infection.

Young women in South Africa are especially vulnerable to contracting HIV, with an estimated 1,900 new infections reported among young women between the ages of 15 and 24 every week. This number is four times higher than boys their age. The prevalence of HIV in female children between the ages of 0 and 14 has increased consistently between 2008 and 2017. In 2018, HIV-related illnesses were the third-leading natural cause of death of adolescents in South Africa.

Some context

Of the nearly 317 000 children aged 0 to 18 years diagnosed with HIV in 2021, only 215 880 were on treatment, according to estimates from the Thembisa model. While ART is freely available for learners living with HIV but not on treatment, stigma and low demand mean that a shortfall of 100,000 learners went without treatment last year. MEC for health in KwaZulu-Natal Nomagugu Simelane acknowledged in June 2022 that there are serious demand-side issues with the uptake of PrEP in her province, including a lack of knowledge about the benefits of PrEP. 

The dapivirine vaginal ring and PrEP tablets. (Photo: NIH Image Gallery / Spotlight)

It is against this background that SECTION27, where I used to work,  embarked on a Sexual and Reproductive Health Rights Campaign, mainly aimed at young people. The campaign ran in schools from August to November last year and also on community radio stations.

The campaign was, among others, premised on the belief that having non-judgmental and pragmatic conversations with young people, addressing their reservations and answering questions, can drive demand for sexual and reproductive health services like PrEP. 

In the course of this campaign, we found that while stigma often still lace conversations, we had in schools or on air, many young people are curious, outspoken and hungry for information. 

For example, sometimes written surreptitiously on slips of paper in a classroom workshop for anonymity, and other times sent via WhatsApp voice notes on a community radio station – the questions posed to SECTION27 as part of the ongoing public education campaign on SRHR included: 

• Can contraceptives protect you from contracting HIV;
• Should I still use condoms while on PrEP;
• Can I take PrEP if I am not exposed to HIV;
• What happens if a person stops the ARV treatment; and
• What do you mean when you say U=U?

Sex education: gaps and pushbacks

These engagements with school pupils and dialogues on community radio stations in Limpopo and the Eastern Cape showed that young people’s questions aren’t always being answered in schools. The Department of Basic Education (DBE) has admitted that “implementation challenges exist” with the delivery of CSE, with the nationwide roll-out of scripted lesson plans about comprehensive sexuality education delayed by about five years since the project’s inception. For example, while 9,500 educators were trained to deliver CSE in the 2021/22 financial year, not all provinces were able (or willing) to teach CSE in schools. This is sometimes due to a shortage of trained teachers and subject specialists, and sometimes because of pushback from communities based on misconceptions about the content delivered to learners through CSE. 

Read in Daily Maverick: “Open letter to young women: Sex education is everything — so stop shouldering so much of the HIV burden”

While scripted lesson plans for comprehensive sexuality education (CSE) are supposed to provide information about sexual and reproductive health and especially preventative measures such as PrEP, the implementation of CSE has had serious challenges – especially due to budget cuts which meant that the DBE had less money to train teachers and sensitise communities to CSE.

Added to this, the supply of condoms and antiretroviral treatment, including PrEP and post-exposure prophylaxis (PEP), remains a challenge in many areas in South Africa, with 68% of facilities providing PrEP and promises of a wider rollout by government. A report released by the Stop Stockouts Project last year showed that HIV medicines were the third-highest (16%) reported stockout in a survey of public health patients between April and June 2022. In the same survey, nearly 8% of public health facilities reported a stockout of external condoms, and a further 4.8% reported shortages of internal condoms. 

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While the supply of these public health essentials is definitely part of the reason young people continue to contract HIV, the lack of reliable information to answer communities’ SRHR questions can restrict the demand for protective measures like condoms and PrEP.

Questions and answers

It is important to stress that the questions that learners were asking during the campaign are not impossible to answer. It is important, however, that young people get reliable information when they need it so that they can make safe, informed, and empowered decisions about their sexual and reproductive health. While having conversations with young people is not enough to overcome all the structural barriers between youth and sexual and reproductive health services, it is an important step towards building their confidence to claim their sexual and reproductive health rights and contribute to increased demand for SRH services. 

Answers to the questions:

“Can contraceptives protect you from contracting HIV?”

• Condoms can prevent you from getting pregnant and from contracting HIV, while hormonal contraceptives, like injections or oral contraceptive pills, cannot prevent you from contracting HIV although they are effective in preventing pregnancy. It is still important, however, to take hormonal contraceptives in addition to condoms.

“Can I take PrEP if I am not exposed to HIV?”

• You can speak to a healthcare worker to decide whether PrEP suits you and your lifestyle. South Africa’s clinical guidelines for the provision of PrEP identify specific populations who may be at greater risk of contracting HIV, including adolescent girls, boys, young women, and men; men who have sex with men; individuals with more than one sexual partner; people who inject drugs; people with a recent history of STI(s); individuals who recognise their own risk and request PrEP; sero-discordant couples if the HIV-positive partner is not virally suppressed (a sexually active couple where one person is living with HIV and is not virally suppressed, and one partner is HIV negative); sex workers; migrant workers and pregnant and breastfeeding women. All these groups experience different risks for HIV infection and exposure. If you think you may be at risk of being exposed to HIV and want to protect yourself from contracting HIV, you can, in addition to using condoms, get PrEP from a public health facility or ask a private sector GP for a prescription.

“Should I still use condoms while on PrEP?”

• PrEP can take up to 21 days (three weeks) of daily use to reach maximum protection, and it is important to use condoms while the medicine is still becoming effective in your body. Where possible, it is best to use PrEP in combination with condoms because PrEP does not prevent pregnancy or the spread of sexually transmitted infections other than HIV.

“What happens if a person stops the ARV treatment?”

• If you are living with HIV and you stop taking treatment, the virus can start replicating in your system and make you sick. Your case may progress from HIV to Aids (Acquired Immune Deficiency Syndrome). Your immune system may become weaker and vulnerable to opportunistic infections. If you stop and start your ARVs, you can also develop HIV drug resistance, which means that the HIV in your body becomes resistant to the medication used to prevent it from replicating. These medicines are no longer effective at treating the virus. It is important to take your ARVs every day consistently.

“What do you mean when you say U=U?”

• If you are a person living with HIV, and you take your ARVs consistently, the amount or “load” of the virus in your blood becomes lower. Eventually, it can become so low that doctors cannot even see or detect the virus in your blood with standard viral load tests. This is what we mean by “undetectable”. Being undetectable does not mean you are permanently “cured” of HIV (the virus is still hiding away in your body), but you are virally suppressed and the virus is not circulating freely in your body. When you are virally suppressed, you cannot spread or transmit the disease to your partners. This is what we mean by “untransmissible”. So, if your viral load is so low that you are undetectable, you are also untransmissible, which means you cannot spread the virus to other people: U=U.

Read in Daily Maverick: 

“Good sexual and reproductive health services on paper, but implementation gaps remain”

“‘I thought it’s just what fathers do’ – how sex education can tackle child abuse”

The government should now do its part

The finance minister is expected to deliver his budget speech on 22 February. The government again has an opportunity to adequately finance the training and appointment of teachers to deliver comprehensive sex education. A good start is to strengthen the HIV/Aids and life skills education budget which was cut by almost R100-million in 2020.

Treasury also reduced the value of the grant intended for the delivery of life skills training and sexuality education by 6.4% in 2021/22 and is expected to consolidate the grant by a further 8.9% in the 2023/24 financial year. We cannot afford further trimming of the life skills budget, especially comprehensive sexual education, because, as we have seen in the SECTION27 campaign, learners and young people have many questions and there is clearly a great need. DM/MC 

Chaskalson is a former Research and Advocacy Officer at SECTION27.

Note: This article touches on the work of SECTION27. Spotlight is published by SECTION27 but is editorially independent – an independence that the editors guard jealously. The views expressed in this article are not necessarily shared by Spotlight.

This article was published by Spotlight – health journalism in the public interest.