At pregnancy clinics, four provinces — KwaZulu-Natal, Mpumalanga, the Eastern Cape and Gauteng — have exceeded their monthly targets for April to August 2024 of getting HIV-negative women onto the anti-HIV pill. Nationally, 43,707 people have started using PrEP between April and August, which is 35% above the country’s target for this period.
PrEP uptake at pregnancy clinics is measured because pregnant and breastfeeding women have a higher chance to contract HIV than the general population.
Dvora Joseph Davey, an associate epidemiology professor at the University of Cape Town, said pregnant women often don’t use condoms because there’s no risk of falling pregnant when they have sex during their pregnancy.
“Many women assume condoms are most important to prevent pregnancy,” she said.
There are also biological reasons why pregnant women could be more likely to contract HIV.
“When someone is pregnant, there are changes in the cells in the female reproductive system, and the body changes how much of certain proteins it makes, which can cause inflammation,” Joseph Davey explained.
“Inflamed tissue makes it easier for HIV to enter someone’s cells because it increases the risk of tearing in the vagina during sex.”
With regard to provinces that exceeded targets, Subedar said the department, set “rather low antenatal clinic targets in the first year [FY2023/24] when PrEP was first offered to pregnant women, using negative tests from the prior year” and also to accommodate understaffed clinics and overworked nurses.
“The PrEP targets for the next financial year [FY 2025/26] have been increased substantially.”
In contrast, Limpopo, the Free State and Western Cape are all less than two-thirds to their goal.
“In these provinces, we’re working on helping with information pamphlets for pregnant women about PrEP, which will help to make them more aware of HIV and how they can protect themselves against infection,“ Subedar said.
“We’re also increasing the capacity of healthcare workers to offer PrEP as part of antenatal services through training workshops.”
BHEKISISA | Almost 40% of the world’s anti-HIV pill users live in SA
We break down the country’s latest tablet numbers and explain how they fit into global targets
Image: Supplied
By the end of August, 1.65-million HIV-negative people in South Africa had used the anti-HIV pill at least once, making the country’s HIV prevention pill programme the world’s largest. We break down South Africa’s latest anti-HIV pill numbers and explain how they fit into global targets.
South Africa had around 150,000 new HIV infections in 2023, according to the Thembisa project, a mathematical model the health department uses to calculate targets.
The pill, which can either be taken daily or intermittently (if it’s taken in a specific way before and after sex), can lower someone’s chances of contracting HIV through sex to close to 0%.
THE NUMBERS
* By the end of August, 1.65-million HIV-negative people in South Africa had used an anti-HIV pill at least once, making the country’s HIV prevention pill programme the world’s largest.
* By 2023, 3.5-million people around the world had used the pill, the WHO’s Mateo Prochaska, an infectious diseases epidemiologist, said at the fifth HIV Research for Prevention Conference in Peru last week.
* South Africa’s cumulative users by the end of that year were 1.34-million, or 38% of the global number of anti-HIV pill users, according to national health department figures.
South Africa needs to lower its new yearly HIV infections to 105,000 by 2025 if it wants to reach targets set by the Joint UN Programme on HIV and Aids (UNAids).
By 2023, 3.5-million people around the world had used the pill. Wwe don’t know for how long they took it, but the World Health Organisation (WHO) calculates global targets, based on each person taking it for at least six months), the WHO’s Mateo Prochaska, an infectious diseases epidemiologist, said at the fifth HIV Research for Prevention Conference in Peru last week.
South Africa’s cumulative users by the end of that year, according to national health department figures, stood at 1.34-million, which was 38% of the world’s total number of anti-HIV pill users.
The pill, which contains two types of antiretroviral drugs — the same type of medication HIV-infected people use to stop the virus from making copies of itself in their bodies — was registered in South Africa in 2015, and is available for free most l government clinics and hospitals.
Hasina Subedar, a senior technical advisor for the health department, said at the conference the government’s target for new anti-HIV pill users for the financial year 2024/5 is 401,430, of which 79,730, or 20%, should stay on the pill for at least six months.
If it is taken daily, the pill — also called oral pre-exposure prophylaxis (PrEP) — has to be taken for at least seven days before it fully protects someone from getting infected with HIV, and it also needs to be taken for seven days after the person was potentially exposed to HIV via sex.
If it is taken intermittently, the WHO said two pills should be taken two to 24 hours before sex, a pill per day for as long as someone needs it, and a pill a day for at least two days after the person potentially had sex with someone with HIV.
A monthly vaginal ring and a two-monthly anti-HIV injection containing a long-acting version of the antiretroviral drug cabotegravir (CAB-LA) have since also become available in South Africa, but at the moment are available only to people who are part of demonstration studies looking at what works best to roll these out.
Information released by the health department at the conference in Peru shows South Africa has 87 demonstration sites, 14 of which offer all three forms of PrEP. At the 14 sites, uptake of anti-HIV medication is significantly higher than at sites where only one or two options are available.
“Choice,” Subedar said in Peru, “clearly plays a role, as in the case of contraception uptake, in whether people who are offered PrEP decide to use it.”
We break down South Africa’s latest anti-HIV pill numbers and explain how they fit into global targets.
When the anti-HIV pill was rolled out in 2016, only sex workers could get it for free from 13 clinics offering health services to sex workers. They were the first group to receive it because their chances of getting HIV are much higher than the general population. In 2017, the medication was also given to men who have sex with men and at student health clinics at universities and colleges, both high-risk groups, and in 2018, teen girls and young women between the ages of 15 and 24 could access it. In Sub-Saharan Africa, 62% of new HIV infections were among women in this age group in 2023.
From 2019, anyone who needed PrEP could get it from state facilities if the clinic they visited stocked it. That’s when uptake of oral PrEP jumped markedly. Almost three times as many people had asked to use the pill by the end of 2021 as the year before.
Since 2022, about 440,000 new oral PrEP users have been recorded per year, and in the past eight months of 2024, another 305,000. These numbers translate to just over 37,000 new users every month since 2022. Their goal for new anti-HIV pill users for the financial year 2024/25 is 401,430, and 797,302 who started in 2023/24 financial year, or a fifth, should stay on the pill.
Lise Jamieson, a senior researcher at the Health Economics and Epidemiology Research Office, HE²RO, has calculated how many extra infections South Africa would have had if we didn’t have the anti-HIV pill at all.
“In the absence of oral PrEP, we would see an additional 17, 000 new HIV infections over the next five years, between 2025 and 2029, equivalent to an average of 3,000 to 4,000 new HIV infections per year,” she said.
“This might not sound like a lot compared to the 150,000 new infections per year at a population level, but over time this adds up and will have a long-term impact. Also, having an active and well-run oral PrEP programme in place will mean the numbers covered, and subsequent impact, will only increase.”
Jamieson said: “It also increases demand for PrEP so once we get the more effective, long-acting products, such as CAB-LA and lenacapavir (a six-monthly anti-HIV injection), rolled out, then we can hit the ground running in terms of getting people to take them.”
Nearly 30% of South Africa’s anti-HIV pill users are in KwaZulu-Natal, with Gauteng having the second highest numbers. Together the two provinces make up just more than half the total number of PrEP users.
Subedar said the health department uses a type of precision-based methodology, using data from the Naomi model to calculate which age groups, sexes and geographic areas are likely to have higher HIV infection rates so they know how many anti-HIV pills to allocate to which clinics and can also work out PrEP targets.
Here’s how the department got to the target of 401,430 new PrEP users for the 2024/25 financial year: There are 42.8-million people of 15 years and older in South Africa (about 72% of the total population), of whom 35.3-million are HIV-negative (the national HIV prevalence among people 15 years and older sits at 16.3%). Of the HIV-negative people, 7.7-million have a high chance of contracting HIV, and of these at least 7.3-million need to be tested for HIV to reach 401,430 people with oral PrEP.
A larger proportion of HIV-positive women are on treatment than in the case of HIV-infected men, but women, specially those between the ages of 15 and 24, also have a markedly higher chance than their male peers to get infected with the virus. The health department’s data shows HIV-negative women in South Africa are also more likely than their male peers to use the anti-HIV pill. Moreover, young women who have the highest chance to contract HIV make up half the total number of PrEP users.
Subedar said their data shows men stay on the pill longer than women. However, that finding is based on how gay and bisexual men use the pill and isn’t representative of heterosexual men. Globally, gay and bisexual men, also referred to as men who have sex with men, or MSM, adhere relatively well to PrEP.
By August this year, 325 times more clinics stock anti-HIV pills than in 2016, and that includes 95% (3,311) of the government’s 3,484 clinics. Studies show the easier it is for people to access medicine, the more likely they are to use it.
Two ways to make anti-HIV pills easier to get is to give them for free and to make them available close to where people live. That’s why it’s good that 4,225 clinics (government clinics and partner sites at universities, prisons and universities and colleges) in South Africa stock the pill at no cost, almost three times more facilities than in 2020 when oral PrEP had become widely available. The more clinics offering the pill, the higher the chances a facility is closer to someone’s home. However, Subedar said more ways to get the pills to people are being tried, from couriering medication and making it available at private pharmacies to pop-up clinics at shopping centres.
“Waiting times at clinics can also be reduced,” she said.
The Western Cape health department mostly outperforms other provinces with important targets such as maternal mortality rates, which makes it unexpected for the province to have the smallest proportion of clinics offering anti-HIV pills. In KwaZulu-Natal, Gauteng, Mpumalanga and Free State, all government clinics stock anti-HIV pills. But in the Western Cape only 70% of state clinics offer the medication. The province has, however, reached 89% of its oral PrEP initiation targets for April to August 2024 (17,001/19,195 = 89%).
In response, the Western Cape health department’s spokesperson, Dwayne Evans, said: “We have a data-driven approach, which can sometimes slow down roll-out, but in the short term we ensure we reach vulnerable persons who need PrEP the most first, and that we make the pills available at the clinics they visit.
“Some of the challenges we have is the time it takes to train nurses to administer PrEP, expanding to clinics outside of cities and the workload of nurses. To address this, we’re designing shorter training workshops and sending out teams to facilities outside metros to make them more aware of PrEP.” (Read the department’s full response).
Five provinces — Mpumalanga, KwaZulu-Natal, the Free State, Gauteng and the North West — have exceeded their monthly targets for starting new people on oral PrEP between April and August 2024, and the Eastern Cape is only 11 people shy of their goal, so for all practical purposes they’ve also hit the mark. The Western Cape is just over 10% off track, but Northern Cape and Limpopo are far behind on their targets.
UNAids’s goal is to get a total of 21.1-million people on the anti-HIV pill by 2025, but by the end of 2023 only 3.5-million had used the medication. Of those 3.5-million users, 2.6-million, or 75%, were from eastern and southern Africa. Moreover, South Africa accounted for 1.34-million of these.
To end Aids as a global health threat by 2030, UNAids said the global number of new HIV infections per year should not be more than 370,000 by 2025. However that target, at least currently, seems unreachable: in 2023, there were 1.3-million new HIV infections in the world.
“We may, however, see improvements in this field, as other long-acting forms of PrEP, such as CAB-LA, taken every other month, and lenacapavir, taken once every six months, and which are easier to adhere to for many people, become available,” said Mitchell Warren, who heads the New York-based HIV advocacy organisation Avac.
The UNAids targets are calculated based on getting countries to lower their new HIV infections by 70% compared with the number of new infections they had in 2010. In 2010, South Africa had about 350,000 new infections, so our goal would be to have only 105,000 in 2025. In 2023, though, the country had 150,000 new cases — almost 1.5 times more than where we want to be at the end of next year.
At pregnancy clinics, four provinces — KwaZulu-Natal, Mpumalanga, the Eastern Cape and Gauteng — have exceeded their monthly targets for April to August 2024 of getting HIV-negative women onto the anti-HIV pill. Nationally, 43,707 people have started using PrEP between April and August, which is 35% above the country’s target for this period.
PrEP uptake at pregnancy clinics is measured because pregnant and breastfeeding women have a higher chance to contract HIV than the general population.
Dvora Joseph Davey, an associate epidemiology professor at the University of Cape Town, said pregnant women often don’t use condoms because there’s no risk of falling pregnant when they have sex during their pregnancy.
“Many women assume condoms are most important to prevent pregnancy,” she said.
There are also biological reasons why pregnant women could be more likely to contract HIV.
“When someone is pregnant, there are changes in the cells in the female reproductive system, and the body changes how much of certain proteins it makes, which can cause inflammation,” Joseph Davey explained.
“Inflamed tissue makes it easier for HIV to enter someone’s cells because it increases the risk of tearing in the vagina during sex.”
With regard to provinces that exceeded targets, Subedar said the department, set “rather low antenatal clinic targets in the first year [FY2023/24] when PrEP was first offered to pregnant women, using negative tests from the prior year” and also to accommodate understaffed clinics and overworked nurses.
“The PrEP targets for the next financial year [FY 2025/26] have been increased substantially.”
In contrast, Limpopo, the Free State and Western Cape are all less than two-thirds to their goal.
“In these provinces, we’re working on helping with information pamphlets for pregnant women about PrEP, which will help to make them more aware of HIV and how they can protect themselves against infection,“ Subedar said.
“We’re also increasing the capacity of healthcare workers to offer PrEP as part of antenatal services through training workshops.”
This story was produced by the Bhekisisa Centre for Health Journalism. Sign up for the newsletter.
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