Latest news with #MarcusLow
News24
11-06-2025
- Health
- News24
Graphs that paint the picture of HIV in SA: Part 3
Eight million people living with HIV. Just over 6 million on treatment. Behind these big numbers lurk a universe of fascinating epidemiological dynamics. In this special briefing, Spotlight editor Marcus Low unpacks what we know about the state of HIV in South Africa. This is part 3 of 3. In Part 1 of this Spotlight special briefing, we looked at some of the big picture dynamics of HIV in South Africa, and in Part 2, we considered some of the vulnerabilities of our HIV programme. Now, in Part 3, we zoom into some nuances relating to HIV prevention, the epidemic in different provinces, gender disparities, and HIV in kids – after which we conclude this special briefing with our take on where all this data suggests we should be focussing next in South Africa's HIV response. Prevention problems A landmark analysis published in 2022 found that the key reasons for the large decline in new infections in South Africa were antiretroviral treatment (since it makes people non-infectious) and the use of condoms. Voluntary medical male circumcision also contributed to reduced infections, more so for men, but also indirectly for women. To some extent, all of these interventions are threatened by the recent aid cuts. Even prior to the cuts there were concerns that both condom distribution and usage has declined. Incidentally, the provision of condoms is probably the area of HIV prevention that has been impacted least by the aid cuts. Last year, we reported extensively on injections that can provide HIV-negative people with six months of protection against HIV per shot. There are big unanswered questions about when these injections will become available and at what price, but experts have described it as a potential game-changer. In the meantime, daily antiretroviral tablets that prevent HIV infection have already been rolled out in the public healthcare system over the last five or so years. The numbers here are tricky to parse since many people start taking the pills and then stop. For example, while 501 000 women started taking the pills from mid-2023 to mid-2024, less than half that number were still taking the tablets in mid-2024 – keep this in mind when considering the above graph. Even so, there has clearly been a dramatic increase in women using HIV prevention pills in recent years. How provinces compare In South Africa, the health system, and most of the HIV programme for that matter, is run by provincial health departments. Apart from demographics differing massively between the country's nine provinces, the capabilities of their health departments also varies. It is thus no surprise that the HIV numbers look very different in different provinces. Part of the difference between provinces is determined by things health departments can do little about, for instance the Eastern Cape quite simply is a more rural province than Gauteng. On the other hand, some provincial departments have been chronically dysfunctional for decades which has no doubt impacted their HIV numbers. Gauteng and KwaZulu-Natal (KZN) are comfortably the country's largest provinces by population, and it is thus no surprise that together they account for over 60% of all the country's HIV cases. But apart from their absolute numbers, they also have particularly high HIV prevalence – roughly 16% of people in KZN are living with HIV, compared to 7% in the Western Cape. In terms of treatment coverage, the three worst performing provinces are the Eastern Cape, Gauteng, and Limpopo – all at around 73%. At 74%, the Western Cape is not much better. KZN leads the pack with 84%. We focus on treatment coverage here since we consider it the single number that tells us most about how well a province is doing. Maybe the most important contrast here is that between KZN and Gauteng. Both provinces have just under two million people living with HIV. Conventional wisdom would have it that delivering treatment would be harder in a more rural province like KZN, yet treatment coverage in KZN is more than ten percentage points higher than it is in Gauteng. It is worth noting though that estimated HIV-related deaths are nevertheless higher in KZN than in Gauteng – possible explanations include much higher TB rates in KZN and worse socio-economic conditions. Differences between men and women One of the most striking aspects about HIV in South Africa is that almost double as many women as men are living with the virus – 5.2 million versus 2.6 million in 2024. The reasons for this are not entirely clear but it is likely due to a combination of biology and social factors that determine who has sex with who. Given these numbers, one might expect that many more women would be dying of HIV-related causes than men, but that is not what is happening. In fact, in 2023/2024, 27 100 men died of HIV-related causes compared to 24 200 women. Men are thus less likely to contract HIV than women, but once they have the virus in their bodies, they are on average much more likely to die of it than women. The numbers suggest that this is at least in part because men are both less likely than women to get tested for HIV and to take treatment once diagnosed. The kids are not quite all right It may come as a surprise to some that, even in the mid-2020s, we still have around 7 000 new HIV-positive babies every year in South Africa. Things have improved massively since two decades ago when the number was more than 10 times higher, but it is worrying that we haven't been able to get it closer to zero. In fact, progress has slowed in recent years. The dynamics here are not obvious. Most pregnant women in South Africa attend antenatal visits where they are routinely offered HIV testing. If the mother tests positive, she is immediately put on antiretroviral treatment that can suppress the virus and protect both her and the baby. Because of such HIV testing in the antenatal period, we have seen dramatically fewer vertical (mother-to-child) transmissions at or during birth. Instead, an increasing proportion of vertical transmissions happen in cases where the mother only contracts HIV in the months after birth and then transmits the virus to her baby during breastfeeding, all before she herself has been diagnosed. Since a person's HIV viral load spikes very high in the first weeks after infection, this can happen very quickly. Apart from ongoing vertical transmissions, another point of concern is the estimate that one in three children living with HIV are not taking antiretroviral treatment. (We have unpacked the dynamics behind this in a previous article.) What is to be done? In a study conducted in KwaZulu-Natal a few years ago, researchers found that people with HIV who only visited the clinic once a year did as well as people who visited the clinic every six months. The nurses at the facilities involved were however convinced that the 12-month group would be worse off – if it was up to them everyone would have to come every six months. Well-intentioned as these nurses were, doing it their way would mean more work for them and more clinic visits and more waiting in line for their clients. Of course, for those people who are ill or struggling, there must be the option of much more regular visits. But for those who are stable on treatment and doing well, we should at most be asking them to visit the clinic once a year and pick up medicines somewhere convenient every six months. ALSO READ | Are children living with HIV being left behind? What the stats tell us South Africa has made tremendous progress against HIV. Yet, as we have shown in this Spotlight special briefing, there are gaps, most notably the fact that one in five people living with the virus are not on treatment. Getting that fifth person on to treatment, might require us doing things differently than before. Quite simply, we need to make it easier and more convenient for people to start and stay on treatment. We have already made several of the right moves. Condom distribution has mostly been a success, it is easy to get an HIV test, allowing nurses to get people started on treatment without the involvement of doctors has worked well, and giving people the option of collecting their ARVs at pick-up points such as private pharmacies has made many people's lives easier. ALSO READ | Francois Venter: Our HIV programme is collapsing and government is nowhere to be seen Though it's come a long way, the medicines distribution system still falls short of providing everyone with a convenient option for collecting their medicines near their home or workplace. Too often people still get only enough tablets for a month or two at a time. For those not keen on visiting clinics, getting an ARV prescription straight from a pharmacy is unfortunately not yet an option. Many people still feel disrespected by the health system meant to support them. Over the last two decades, we have rightfully been somewhat fixated with numbers like treatment coverage. One might argue that to scale up treatment as quickly as we did, we couldn't afford for care to be as personalised as we'd like. But with the world's largest treatment programme in place and a mature epidemic, the context has changed. It is clear where the remaining gaps are – closing those gaps will require that government gets serious about making the health system much, much more friendly to those it is meant to support. *You can find the complete version of this #InTheSpotlight special briefing as a single page on the Spotlight website. Note: All of the above graphs are based on outputs from version 4.8 of the Thembisa model published in March 2025. We thank the Thembisa team for sharing their outputs so freely. Graphs were produced by Spotlight using the R package ggplot2. You are free to reuse and republish the graphs. For ease of use, you can download them as a Microsoft PowerPoint slide deck. Technical note: The Thembisa model outputs include both stock and flow variables. This is why we have at some places written 2024 (for stock variables) and 2023/2024 (for flow variables). 2024 should be read as mid-2024. 2023/2024 should be read as the period from mid-2023 to mid-2024. Reviewed by Dr Leigh Johnson. Spotlight takes sole responsibility for any errors. Show Comments ()
News24
10-06-2025
- Health
- News24
Graphs that paint the picture of HIV in SA: Part 2
Eight million people living with HIV. Just over 6 million on treatment. Behind these big numbers lurk a universe of fascinating epidemiological dynamics. In this special briefing, Spotlight editor Marcus Low unpacks what we know about the state of HIV in South Africa. This is part 2 of 3. In Part 1 of this Spotlight special briefing, we looked at some of the big picture dynamics of HIV in South Africa. Most of the news there was good. In Part 2, however, we look at why making progress is getting harder and consider some key vulnerabilities of our HIV programme. The final 10% or 20% will be the hardest Spotlight The above graph shows the number of people starting treatment by year. As you can see, around a decade ago, this number was often higher than 500 000. Since 2021, it has been below 300 000. Government could no doubt do a better job at helping people start and stay on treatment, but there are also good epidemiological reasons for the slow-down. In short, those who were sicker or more eager to start treatment - and for whom taking treatment is relatively easy - are mostly already on treatment. Those who are not on treatment are likely less motivated to take treatment or may have challenges in their lives that make it hard for them to start and stay on treatment. Convincing and supporting this latter group to start and stay on treatment is quite simply harder than it is for the prior group, but it is where the focus will have to be if we are to get our numbers higher. It is one reason why many are so concerned about recent aid cuts that have disproportionately impacted HIV services for marginalised groups like sex workers, people who use drugs, and men who have sex with men. These groups of people often feel unwelcome at public sector clinics. One key thing to keep in mind when looking at HIV numbers is that people cycle in and out of HIV treatment a lot. A misleading impression can, for example, be created if one looks at the number of people starting or restarting treatment without subtracting the number of people who have stopped taking treatment over the same period. It is for this reason that it is best to focus mainly on the total number of people on treatment and how that number changes from year to year (you can see a graph of this in Part 1 of this series). Finally, another important nuance in the numbers is how much damage has been done to people's immune systems by the time they start treatment – the earlier you start, the better your long-term prognosis. It is concerning that, of the 241 000 people who started treatment in 2023/2024, 54 000 had CD4 counts below 200 cells per cubic millimetre, an indication that their immune systems had already been hit hard. Bigger programme, bigger vulnerabilities? Much of how an epidemic grows or wanes depends on how many people are infectious at a specific point in time. Generally, the more infectious people there are in a population, the more other people will get infected. It follows that, if you can't cure people, the next best thing from an epidemiological control perspective, is to make people non-infectious. (See our recent Special Briefing on the search for an HIV cure.) Fortunately, apart from keeping people healthy, consistently taking antiretroviral medicines also make the vast majority of people living with HIV non-infectious. Thus, while all eight million people living with HIV in South Africa could potentially become infectious, antiretroviral treatment means that only around two million of them actually are. Spotlight It is very unlikely that we will drop from 6.2 million people on treatment to 5.2, or even 5.5, but even just dropping by 100 000 or 200 000, will mean 100 000 or 200 000 more people become infectious. That would give our HIV epidemic a blast of oxygen it wouldn't have had otherwise. There are real vulnerabilities here. According to preliminary modelling that the Department of Health commissioned in response to US funding cuts, failure to replace the HIV services that were funded by the US in South Africa could result in an additional 150 000 to 295 000 additional infections by 2028. It will take a year or two before we see the actual impact of the aid cuts in data sources such as Thembisa, but, as reported by Daily Maverick, there have been some early indications from the country's public lab service that important numbers are down. *Check back tomorrow for Part 3 of this series. You can also find the complete version of this #InTheSpotlight special briefing as a single page on the Spotlight website. Note: All of the above graphs are based on outputs from version 4.8 of the Thembisa model published in March 2025. We thank the Thembisa team for sharing their outputs so freely. Graphs were produced by Spotlight using the R package ggplot2. You are free to reuse and republish the graphs. For ease of use, you can download them as a Microsoft PowerPoint slide deck. Technical note: The Thembisa model outputs include both stock and flow variables. This is why we have at some places written 2024 (for stock variables) and 2023/2024 (for flow variables). 2024 should be read as mid-2024. 2023/2024 should be read as the period from mid-2023 to mid-2024. Show Comments ()
News24
08-06-2025
- Health
- News24
Graphs that paint the picture of HIV in SA
Eight million people are living with HIV with more than six million being on treatment. Behind these big numbers lurk a universe of fascinating epidemiological dynamics. In this special briefing, Spotlight editor Marcus Low unpacks what we know about the state of HIV in South Africa. This is part 1 of 3. Four decades ago, hardly anyone in South Africa had HIV. Today, roughly one in eight people here are living with the virus. HIV has quite simply become a routine part of life in South Africa. But thanks to the fact that antiretroviral treatment is keeping several million people alive, HIV is no longer the crisis it was at the turn of the century. For many, the virus is still an all-too-real part of their lives. It still ranks among the country's top killers. As we will see in this Spotlight special briefing, there is good and bad news. We have made massive progress in our collective fight against HIV, especially since around 2008. But, as positive as the big picture may be, there are also reasons to be worried. In the 10 sections of this special briefing, we have used lots of graphs and an interactive table to liven things up. We have drawn almost entirely on estimates from Thembisa, the leading mathematical model of HIV in South Africa and also the basis for UNAIDS' country numbers. The big picture Total PLHIV in SA Graphic: Spotlight South Africa has the world's biggest HIV epidemic. Eight million people, or 12.8% of the population, lived with the virus in 2024. Despite the massive progress we've made in the last 20 years, this absolute number has kept increasing, and, at least by this measure, the epidemic has kept getting bigger. But while more people are living with HIV, dramatically fewer people are dying of HIV-related causes than two decades ago - we've gone from 281 000 HIV-related deaths in 2005/06 to 53 000 in 2023/24. This is mainly because antiretroviral medicines have kept several million people alive who would otherwise now be dead. The rate of new infections has also declined a lot, as shown in the above graph. South Africa's HIV epidemic is closely entwined with our tuberculosis (TB) epidemic. This is because untreated HIV breaks down the immune system, which then makes people vulnerable to falling ill with TB. Accordingly, TB is the top cause of HIV-related deaths in South Africa. Recovering life expectancy Just what a big deal HIV has been in South Africa is clear from estimates of life expectancy in the country. As HIV killed more and more people through the nineties and early 2000s, life expectancy dropped precipitously from 63.2 in 1990 to 53.2 in 2004. But then, as antiretroviral treatment started keeping more and more people alive, it increased again. It stood at 66.1 in 2024. Graphic: Spotlight There is much history that is not captured in this graph. Perhaps most notably, the introduction of antiretroviral treatment in South Africa's public sector was intentionally delayed by the state's policy of Aids denialism under then-president Thabo Mbeki. While the dramatic improvement from 2005 onward is impressive, life expectancy didn't have to drop as low as it did in the first place. The blip you can see on the right of the graph is a result of the Covid-19 pandemic. While significant, the broader trend is driven by HIV and the recovery from HIV. A massive treatment programme Of the eight million people living with HIV in South Africa, about 6.2 million or roughly four in five, were on treatment in 2024. This means South Africa has the world's most extensive HIV treatment programme by some distance. We take it somewhat for granted these days, but to treat so many people is a tremendous success story for which many healthcare workers, activists, government officials, donors, and others deserve great credit. That said, it is concerning that about one in five people with the virus are not on treatment. Treatment is recommended for everyone living with the virus. Though we focus on treatment coverage here, these numbers are often split further into the UNAIDS 95-95-95 targets. READ | Trump's HIV funding cuts will hit diabetes and cervical cancer treatment hard. Here's why In 2024, 95% of people living with HIV had been diagnosed, 81.5% of those diagnosed were on treatment, and 92% of those on treatment were virally suppressed - meaning the amount of virus in their blood was below a low threshold. The key takeaway from these numbers is that the most significant gap in South Africa's HIV response is in helping people who have already been diagnosed to start and stay on treatment. *Check back tomorrow for part 2 of this series. You can also find the complete version of this #InTheSpotlight special briefing as a single page on the Spotlight website. Note: All of the above graphs are based on outputs from version 4.8 of the Thembisa model published in March 2025. We thank the Thembisa team for sharing their outputs so freely. Graphs were produced by Spotlight using the R package ggplot2. You are free to reuse and republish the graphs. For ease of use, you can download them as a Microsoft PowerPoint slide deck. Technical note: The Thembisa model outputs include both stock and flow variables. This is why we have at some places written 2024 (for stock variables) and 2023/2024 (for flow variables). 2024 should be read as mid-2024. 2023/2024 should be read as the period from mid-2023 to mid-2024.
