As the world commemorates World Aids Day on Thursday, leading HIV expert and head of the South African Medical Research Council Prof Glenda Gray has called on the nation to reflect on and check for blind spots that undermine progress against HIV.
Gray said South Africa has made significant progress in fighting HIV/Aids and is recognised for its large antiretroviral therapy programme. It also was the first African country to approve HIV pre-exposure (PrEP) to those at high risk of infection. But the country still has a long way to go before it can control HIV transmission, let alone eradicate the epidemic in 2030 in line with global targets.
“We have one of the highest incidences of HIV among women in the world, which shows that we are not on top of prevention strategies. So this World Aids Day should be time to reflect that if we are committed to contributing to the control of HIV, we need to up our diagnostic capabilities. We need to increase availability of HIV-testing and make sure that people who have tested positive get into treatment.”
Gray said one in five people were HIV-positive in SA. Of these, two out of five did not know they were infected and this group keeps on transmitting HIV, especially among young women, where the infection rate in the 16-24 age range is about four times that of their male counterparts.
“Until we get 8-million [infected] people on treatment, we are far away from meeting 2030 targets. We need to close that gap and have honest conversations about how good is our medical male circumcision for instance, how is our PrEP programme? We need to have honest conversations with our partners and ensure that anyone who changes a sexual partner gets an HIV test and understands their susceptibility to HIV on an ongoing basis.”
Gray’s concerns were raised by the new UNAids World Aids Day report, which warns that countries are unlikely to meet global HIV targets to eradicate Aids by 2030 if the existing inequalities faced by women, children and key populations such as sex workers, transgender and people injecting drugs continue.
The report, titled “Dangerous Inequalities”, points out that unequal power dynamics between men and women and harmful gender norms remain pervasive and “increase the HIV vulnerability of women and girls, deprive them of their voice and the ability to make decisions regarding their own lives and hamper their ability to mitigate the impact of Aids”.
It encourages world leaders to be courageous in tackling these inequalities.
In Africa the gender divide remains distinct, with adolescent girls and young women more than three times more likely to acquire HIV than their male counterparts.
The report says this divide is clearly seen among sex workers and men who sleep with men, who are not prioritised in the national Aids responses by some countries.
instead of just looking at general HIV numbers and adopting a one-size-fits-all approach to prevention and care, we must focus on the specific communities that have the highest HIV prevalence.
— Nkosi Tshabalala, HIV expert from BroadReach Health Development
It also warns that while new HIV infections have declined significantly in Africa since 2010, including southern Africa, where HIV incidence had gone down by 62%, there has been no conclusive decline among gay men over the same period.
Children are also not spared from inequalities in the treatment of HIV. In 2021 about 800,000 children living with HIV were still not on life-saving treatment. About 60% of children aged five to 14 who are living with HIV are not receiving treatment.
“We know what needs to be done to eliminate the vertical transmission of HIV and meet the treatment needs of children but a failure of leadership has prevented us from doing so, and the disparity in treatment coverage between children and adults is increasing rather than declining.
“Urgent efforts are needed to eliminate these inequalities, including through community-led responses, accelerated scale-up of pre-exposure prophylaxis (PrEP) and immediate action to close access gaps for harm reduction services,” says the report.
UNAids executive director Winnie Byanyima said the latest report shows that the world will not be able to defeat Aids while reinforcing patriarchy. She said harmful masculinities are discouraging men from seeking care. While 80% of women were accessing treatment in 2021, only 70% of men were on treatment.
“The only effective route map to ending Aids and achieving the sustainable development goals is a feminist route map. We can take action now to tackle gender inequalities and promote healthy masculinities to take the place of the harmful behaviours which exacerbate risks for everyone. Gender-based violence is increasing women’s risks of HIV infection and constraining the access of women living with HIV to life-saving services.”
Director of the Desmond Tutu HIV Centre Prof Linda-Gail Bekker remains optimistic because South Africans have access to more effective user controlled prevention methods such as PrEP. She said more needs to be done to ensure that young women and the LGBTQI community are not left out of prevention programmes.
“We definitely lose sleep over the fact that young women and adolescent girls still have very high incidence in South Africa and we haven’t reduced this sufficiently,” she said.
“We need to scale up differentiated prevention services. In our country we have left LGBTQI, and especially transgender people, behind with our treatment and prevention services, which need to be more differentiated and responsive.
“Finally, we must end HIV in children... that we are still seeing children facing vertical transmission and then a lifetime of living with HIV is way past it’s sell-by date. We have all the tools to eliminate vertical transmission.”
Nkosi Tshabalala, an HIV expert from BroadReach Health Development, said while concentrating on priority populations through lifelong treatment, the focus must also be fixed on identifying remaining “last-mile” barriers and the unique needs of vulnerable populations, including teenage girls.
“One of the first things we can do to overcome barriers to HIV care is to move away from the tyranny of the aggregate. That means instead of just looking at general HIV numbers and adopting a one-size-fits-all approach to prevention and care, we must focus on the specific communities that have the highest HIV prevalence.
“We must determine what we can do for them in a human-centric, caring way to address their specific health needs so that they can reach viral suppression. This is the key to stopping further transmission of HIV in society by 2030.”
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