South Africa has the largest HIV epidemic in the world with around 7.1 million people currently living with the disease and hundreds of thousands contracting the disease every year. While former leadership was criticised for their mismanagement of the HIV epidemic, over recent years the government has taken appropriate action by implementing what has become the largest antiretroviral treatment (ART) programme in the world.
In 2004 the South African government launched a national public sector ART programme, which over the last decade has provided lifesaving treatment to people living with HIV/AIDS (PLHIV) across the country. According to the National Department of Health’s (NDoH) Annual Report from 2013/2014, over 35 million South Africans were tested by end of 2013/2014 and over 3 million people of all ages were receiving ART by end of 2014/2015.
The success of the ART programme formed part of a vigorous government-led initiative guided by the National Strategic Plan (NSP) for HIV, STIs and TB for 2012-2016 that aimed to reduce new HIV infections by 50%. As part of the NSP, the NDoH took special measures in ensuring that key populations were targeted in awareness campaigns, including sex workers, men who have sex with men (MSM) and injecting drug users. Other than the scale up of ART, campaigns focused on reducing behavioural risk; providing HIV counselling and testing; condom distribution; Medical Male Circumcision (MMC); prevention of mother to child transmission and the management of sexually transmitted infections (STIs) and TB.
Supressing HIV stigma
The HIV counselling and testing component of the NSP was especially significant in promoting the need to know one’s HIV status and linking HIV positive South Africans to appropriate care and support services. Yet despite the campaign’s success in spreading awareness of how living with HIV is no longer a death sentence, the reality is that PLHIV still face stigma, both internalised and from their communities. This in itself has created another barrier to ridding the country of its HIV epidemic because it can keep people from disclosing their HIV status and prevent them from accessing and adhering to treatment.
In 2015 the Human Sciences Research Council (HSRC) published the world’s largest study into HIV stigma, The People Living With HIV Stigma Index: South Africa 2014. Out of the 10,500 PLHIV surveyed for the study, 36% of the respondents said that they experienced some external stigma, while one-third of them reported experiencing stigma from their communities. Even more worrying was that 40% of participants reported internalised stigma that manifested as shame or inferiority, which in some cases led to them avoiding getting marriage and having sexual partners. Being HIV positive also affected their mental healthcare – 11% of the individuals surveyed reported thoughts of suicide.
One of the only ways to help PLHIV overcome the negative effects of stigma, both internalised and from their communities and other surroundings, is by expanding and developing support systems. This could be in the form of improved provisioning of healthcare facilities, psychological and social support, and access to medical treatment.
In response to the on-going global HIV stigma, health equity initiative, Prevention Access Campaign, set out to end the dual epidemics of HIV and HIV-related stigma by empowering PLHIV and those vulnerable to HIV with accurate and meaningful information about their social, sexual and reproductive health. As part of their campaign, in early 2016 they launched Undetectable = Untransmittable (U=U), a global and fast growing community of HIV advocates, activists and researchers from 58 countries uniting to dismantle HIV stigma, improve the lives of PLHIV and ultimately ending the HIV epidemic.
U=U is based on a Consensus Statement that was drafted with global scientific experts to drive awareness about the largely unknown fact that people living with HIV on effective treatment do not sexually transmit HIV. The Consensus Statement is backed by multiple data sources, including clinical trials and real-world evidence.
The latest clinical trial that affirms U=U followed 548 heterosexual and 340 gay male serodiscordant couples who had regular unprotected sex while the HIV-positive partner had an undetectable viral load. Despite over 58,000 anal and vaginal sex acts, no HIV transmissions occurred between the partners. The findings were shared during the 9th International AIDS Society (IAS) Conference on HIV Science in July 2017.
To date, the Consensus Statement has been signed by over 400 organisations from 58 countries, including many leading HIV advocacy organisations like the Desmond Tutu HIV Foundation. In early September the Janssen Pharmaceutical Companies of Johnson & Johnson (J&J) signed the Consensus Statement, being the first company in the industry to do so.
“Recognising the tremendous importance of this global movement we mobilised quickly to sign the U=U consensus statement on 7th September 2017,” said Janssen/J&J in a statement.
“Despite the many advances in HIV care, the stigma associated with the virus continues to contribute to a fear of getting tested and a hesitation to seek treatment after receiving a positive diagnosis. We support the U=U Consensus Statement and are grateful to the community that has joined together to harness the power of science to shatter the stigma that stands in the way of those living with HIV,” continued Janssen/J&J.
While U=U is an important milestone in combatting HIV stigma, the reality is that many PLHIV, especially those living in low and middle-income countries (LMIC), may be unable to reach an undetectable status. This could be because of factors limiting treatment access, such as inadequate health systems and discrimination, or even HIV drug resistance.
While the U=U acknowledges the above, the campaign believes that they can still help others understand that achieving an undetectable viral load in their blood while receiving ART has a negligible risk of HIV transmission, and can help reduce HIV-related stigma and encourage PLHIV to initiate and adhere to a successful treatment regimen.
The way forward
Last month UNAIDS announced a significant pricing agreement to accelerate the availability of the first affordable, generic, single-pill HIV treatment regimen containing dolutegravir (DTG) to public sector purchasers in LMIC at around US$75 per person, per year. “This agreement will improve the quality of life for millions of people living with HIV,” said UNAIDS Executive Director, Michel Sidibé. “To achieve the 90-90-90 treatment targets, newer, affordable and effective treatment options must be made available—from Baltimore to Bamako—without any delay.”
This new drug agreement is just the latest example of how advances in ART are helping PLHIV live a longer and relatively normal life. Last year the NDoH initiated a programme based on the WHO’s 2015 ‘Test and Treat’ guidelines where all people diagnosed HIV-positive can start ART regardless of their CD4 count. A year before that, in 2015, the Medicines Control Council (MCC) officially registered the use of a combination of two antiretroviral drugs as a form of pre-exposure prophylaxis (PrEP) medication, which has been proven to drastically reduce HIV infection by HIV negative individuals when taken daily.
New research has also further supported the role that voluntary MMC has in reducing HIV transmission in women by 30%. On-going advocacy campaigns, which are backed by local celebrities, have also encouraged more men to opt for the procedure to lessen their HIV risk as well.
On the tech side, over the last couple of years a number of important eHealth platforms have been introduced nationally to support government’s efforts in managing its HIV positive population. During the 2015 SA 7th AIDS Conference the Minister of Health launched the Metropolitan Health HIV Clinical Guidelines App as part of a national campaign to scale up HIV treatment. The app serves as a comprehensive HIV treatment guideline for all levels of healthcare professionals, and includes the latest clinical content to enable more accurate dosage calculations, reduce drug interaction and improve pathology interpretation and interventions.
Aviro Health has also developed another digital reference solution to help HIV clinicians easily consult on ART during patient visits. The information on the Aviro app is based on the South African HIV clinical guidelines. Last year Aviro also released educational videos in partnership with the Desmond Tutu HIV Foundation to train clinicians about the basics of ARVs, ARV adherence and resistance.
On the patient level there have also been a number of social media and mHealth interventions launched to raise HIV awareness and reduce risky sexual behaviour. One such example is loveLife, a youth-orientated site that tackles all teen-life topics from relationships to life transitions through assessments, quizzes, videos and articles. Such platforms are important in facilitating the discussion of HIV to not only raise awareness about prevention methods, but also to talk about treatment and mental health support.
Overall South Africa has come a long way since the HIV epidemic started to unfold and the controversy that stemmed from statements made by former Minister of Health, Manto Tshabalala-Msimang, in the late 1990s about treating the country’s AIDS epidemic with vegetables such as garlic and beetroot, rather than with western ART. Our country’s accomplishment in managing HIV since then can be attributed to a strong legislative and policy environment that has kept up to date with and complied with new local and international evidence-based developments and findings – including adopting the UNAIDS 90-90-90 targets and the ‘Test and Treat’ WHO guidelines. U=U is the next important step to ensure South African PLHIV are able to transgress HIV stigma and live a full and productive life.