The country has made progress with its plans to prevent, treat and monitor HIV but still has a long way to go.
The 90-90-90 targets arithmetically translate to 90%, 81%, 73% of a 100 people who are HIV positive if one multiplies the first 90 by the second 90 and the result by 90.
The three 90s need to be achieved by 2020, the United Nations says: 90% of people need to know their HIV status, of those diagnosed with HIV infection, 90% would need to be on antiretroviral treatment, and of those on treatment 90% need to be virologically suppressed.
These 90s are called the HIV cascade. Cascades are useful for monitoring progress and finding and fixing leakages in the treatment pathway.
Will South Africa reach these targets by 2020?
This is where we are currently:
• 76% of adults know their HIV status;
• 65% of adults who are HIV positive are on antiretroviral treatment; and
• 84% of those on antiretroviral treatment and whose viral loads are recorded are virologically suppressed.
This information comes from a system called Tier.net, which has been implemented in most public-sector health facilities in the country. Recordings of laboratory results are incomplete, but a study conducted by the National Health Laboratory Service (NHLS) found high levels of viral suppression in patients when they took into account duplicate requests for viral load tests. In the case of those with known viral load testing results (53% of people on treatment), viral suppression levels are high – upwards of 80%.
Given the results of the cascade analysis, notwithstanding the data challenges, what should we do to achieve the targets?
To get 90% of people tested for HIV, we need to identify those most likely to be living with HIV and test them. These include testing all pregnant women using public health facilities and their partners. Government data show that 30% of pregnant women are HIV positive. We should encourage pregnant women to bring their partners with them to antenatal clinics. That way they also can get tested and access treatment if needed.
We need to reach men in communities and workplaces, as they typically do not utilise health services as often as women and children.
To get 90% of those who are HIV positive on to treatment, the health department implemented a test and treat policy in September. Everyone who tests HIV positive in South Africa receives immediate access to antiretroviral treatment, regardless of the strength of their immune systems. But not everyone who tests positive would necessarily accept immediate treatment, so we need to improve our counselling services and public health campaigns. This will help people to understand why it’s important to test and treat: to stay healthy and reduce the risk of transmission.
To get 90% of those on antiretroviral treatment virologically suppressed – in other words, to reduce the amount of HIV in their bodies to such an extent that they become unlikely to infect others – we need to remove barriers to adherence. We can do this by reducing waiting times in clinics, providing help through adherence clubs and making it easier to stay on treatment by couriering medication to patients.
We need to rapidly expand the use of the unique identifier, a national identification number for patients, so that we keep track of patients between health facilities and the NHLS, and ensure that the results of viral load tests are recorded in a patient’s folder and used in patient management. While not yet available, long-acting injectable antiretrovirals will substantially increase adherence as it will make the need to take oral medication redundant.
An unusually high number of people in South Africa, seven million, are infected with HIV. To achieve the three 90s and move towards ending the HIV epidemic by 2030 will require effort from all of society. This means individuals reducing their risk through safer sexual behaviour and communities making it easier for people to take their treatment without fear of stigma.
We have climbed more than halfway up the mountain and can see the peak, but the final ascent is the steepest part that still needs to be climbed.
Yogan Pillay is the director for HIV and TB delivery at the Bill & Melinda Gates Foundation. Prior to this he was the South Africa country director of the Clinton Health Access Initiative before which he spent more than 20 years in the national health department in various management positions.