It is 40 years since Aids was first identified. Major strides have been made since the spread of the virus reached epidemic proportions in 1995 when 3.3 million people were infected with HIV and just under one million people died.
New HIV infections have reduced by 60% since the peak in 1995 and deaths are down by a third.
In 2023 1.3 million people became newly infected with HIV, while 630,000 people died from Aids-related illnesses.
Aids researchers Nomathemba Chandiwana and Linda-Gail Bekker outline the five key things we should know about HIV as we enter the second quarter of the 21st century.
The epidemic isn’t over
In 2024, 1.3 million people globally and 150,000 South Africans of all ages and walks of life acquired HIV, a sobering reminder that the epidemic isn’t over.
UNAids has set a 95-95-95 target for 2030: that 95% of people living with HIV will know their status; 95% will have access to antiretroviral treatment; and 95% will have achieved viral suppression.
Worldwide in 2023, 86% of all people living with HIV knew their status, 89% were accessing treatment and 93% were virally suppressed.
In South Africa in 2024, progress stood at 95-79-93, with adult females at 96-83-94, adult males at 95-73-94 and children at 82-63-69.
Children under 15 lag on every front – detection, care and ensuring viral suppression. This even though they face a lifetime of living with the virus.
Adolescent girls and young women in Africa continue to account for a significant proportion of new infections, driven by gender inequalities and limited access to tailored health services. Adolescent girls and young women are also twice as likely to be living with HIV than young men of the same age.
Similarly, stigma and inadequate services heighten risks for key populations – men who have sex with men; people who inject drugs; prisoners, sex workers and transgender people.
Tackling all these problems requires innovative strategies, community-led solutions and a commitment to addressing social conditions, such as poverty and gender violence.
Treatment revolution
The first HIV drug, zidovudine, had toxic side effects and the benefits lasted only about a year.
Today, a single daily pill can prevent or treat HIV.
In addition, pre-exposure prophylaxis, or PrEP, offers robust protection against HIV.
Similarly, for people living with HIV, newer antiretroviral treatment drugs can suppress the virus to undetectable levels, meaning it cannot be passed on to sexual partners.
This has revolutionised the global response to HIV, demonstrating the power of treatment as prevention, and reducing stigma among people living with HIV, including pregnant women.
Since 2004, South Africa has built the world’s largest
HIV treatment programme, saving millions of lives and reshaping the course of the epidemic. In 2022, 5.4 million South Africans were on treatment.
Long-acting options are changing the game
While we do not yet have a HIV vaccine, novel long-acting pre-exposure prophylactic and antiviral treatment options are game changers.
Cabenuva is a two-monthly injection administered in the buttock.
Lenacapavir, a six-monthly injection under the skin, is still undergoing trials but with excellent results. It will hopefully soon be available as PrEP, offering more convenient and discreet ways to prevent HIV.
Long-acting options provide choice, reduce stigma and overcome the need for daily adherence. More young women, often too scared to take daily pills for fear of being stigmatised, will be able to.
Testing matters
Too many people remain unaware of their HIV status. For example, a study done from 2015 to 2019 in 13 sub-Saharan Africa countries – including Cameroon, Cote d’Ivoire, Eswatini, Ethiopia, Kenya and Lesotho – found that 34% of men who tested HIV positive during the surveys were unaware of their HIV-positive status.
Testing is central to HIV prevention and care. Regular testing, especially in community settings like schools, workplaces and social spaces, is essential.
For sexually active individuals, those who are pregnant or anyone recently exposed to HIV, testing can be lifesaving.
For people living with HIV, annual testing to ensure their viral level is suppressed and undetectable in laboratory results is equally important.
Early diagnosis and consistent care can make the difference between life and death.
Connecting the dots
The relationship between HIV and non-communicable diseases is increasingly important. As people living with HIV age, they face higher risks of cardiovascular disease, cancer and mental health challenges.
Integrating the prevention of non-communicable diseases into HIV services is essential, with obesity management, mental health support and cancer prevention becoming routine.
Poverty, stress and inadequate healthcare also affect those living with HIV.
Lessons from HIV care, including community engagement and person-centred approaches, can effectively address these overlapping challenges.
Keeping people living with HIV in care and ensuring they age well, while curbing new HIV infections in young people will bring an end to the South African HIV epidemic before another 40 years pass by.
