Optimistic outlook for SA's HIV epidemic

South Africa has reached an important milestone in curbing its HIV epidemic. Preliminary results of the sixth national household survey (SABSSM VI) show that 12.7% of the population was living with HIV in 2022, compared to 14% in 2017 (although the difference was not statistically significant). At 7.8 million people, the plateauing prevalence reflects significant progress towards the 95-95-95 testing and treatment targets.

Speaking at the launch, Principal Investigator Professor Khangelani Zuma from the HSRC confirmed that the prevalence trend indicates a decline in incidence, particularly among young people. "The number of new infections among younger people is actually dropping," he said. "Because if there were more new infections, the HIV prevalence in 2022 would have been higher."

Although the incidence data is yet to be released, prevalence among females aged 15-24 declined from 15.6% in 2017 to 8% in 2022, suggesting a reduction in new infections. This is especially significant because adolescent girls and young women have long borne the brunt of new infections driving South Africa's epidemic. Prevalence among young women remains comparatively high: in the 25-29 age bracket, prevalence was 19.5% for women compared to 6.3% for men of the same age.

Lower mortality is another driver of plateauing national prevalence (counterbalancing the reduction in new infections). Says co-Principal Investigator Professor Sizulu Moyo (HSRC), "With the advent of treatment, people are living longer… So we're going to have more and more people living well into their older ages." Figures 1 and 2 show how peak prevalence among both sexes has shifted into older age groups since 2012, indicating an ageing epidemic.

Progress toward 95-95-95

The positive findings reflect increases in the number of people on treatment as South Africa progresses towards its 2025 target. Ending the epidemic requires that 95% of PLHIV know their status, 95% of those who know their status are on treatment, and 95% of those on treatment are virally suppressed. Viral suppression indicates a viral load too low (<1000 copies HIV/ml blood) for transmission to take place.

In 2022, the treatment cascade figures for PLHIV aged 15 and older were 89.6- 90.7 - 93.9. This is a notable improvement from the 85-71-87 figures for 2017, with the then-target being 90-90-90. However, the study revealed that men continue to lag behind women in the uptake of HIV testing, with 85% of men with HIV aware of their status compared to 92% of women.

The increase in treatment follows South Africa's adoption of the universal test and treat approach in 2016, which extends care to every person who tests positive, regardless of their CD4 count (a measure of how well the immune system is working). A 2019 change in the preferred treatment regimen may also have assisted people in staying on treatment: the percentage of PLHIV who were virally suppressed jumped from 62% in 2017 to 81% in 2022.

Additionally, the survey found an increase in medical circumcision, shown to reduce female-to-male transmission risk by approximately 60%. Half of men aged 15-24 had been circumcised by 2022, compared to 43% in 2017.

Ongoing disparities

Contrary to what might be expected given the lower prevalence among youth, condom use has declined since 2017. Among the 15-24 group, self-reported condom use at last sex was 50.6% for men and 43.5% for women in 2022, compared to 67.7% and 49.8%, respectively, in 2017.

SABSSM VI also showed that women and black South Africans continue to be disproportionately affected by the HIV epidemic. Prevalence among women aged 15 and older was almost double that among men (20.3% compared to 11.5%) in 2022. Geographically, KwaZulu-Natal province was the worst affected province, with an adult prevalence of 21.8%, while the Western Cape had the lowest provincial prevalence at 8.2%. The findings point to the need for targeted interventions to increase treatment coverage.

Reaching the 2025 goals will also require improving uptake of effective prevention measures, including condoms, and getting more men into care, Moyo says.