The state of the epidemic

South Africa is still in the grips of a devastating HIV epidemic. An estimated 7.5 million South Africans are living with HIV. This means that one in every eight people in the general population and almost one in five people between the ages of 15 and 49 years have been infected. It is sobering to consider that our country is home to 20% of the global population living with the virus.

South African women continue to be disproportionately affected. In 2021, women aged 15 years and older made up 64% of people living with HIV and 62% of new infections. The disparity is even more pronounced in women of child-bearing age (15 – 49 years) who have double the prevalence rate of men (24.5% versus 12.1%). Among adolescent girls and young women (15 – 24 years) the picture is even more dire: they are three times as likely to be living with HIV (9% versus 3%) than their male counterparts. Forty years after the discovery of the virus, AIDS-related causes remain a leading cause of death among 15 – 49-year-old women in the region.

This picture resonates throughout Sub-Saharan Africa. In 2021, an estimated 250 000 adolescent girls and young women were newly infected with HIV; five out of six of these infections occurred in women living in Sub-Saharan Africa. This is one new infection every three minutes; five times more than the 2025 global target. This is in contrast to the rest of the world where the majority of new infections occur in so-called “key populations”, such as sex workers, men who have sex with men, transgender people, and people who inject drugs. While these groups are certainly also vulnerable to HIV in South Africa, their numbers (albeit derived from crude estimates) are relatively small. For instance, there are an estimated 146 000 sex workers; 309 700 men who have sex with men; 179 300 transgender people; and 82 500 people who inject drugs in the country of whom 62%, 29.7%, 58%, and 21.8%, respectively, are living with the virus. These groups deserve special consideration, however, since they tend to face multiple structural inequalities that often exclude them from mainstream healthcare.       

Antiretroviral treatment has undoubtedly saved millions of lives. Seven million (94%) of the 7.5 million people living with HIV in South Africa know their status and 5.5 million (74%) are on treatment. While an estimated 5.1 million people have had a good response on treatment and manage to suppress the virus circulating in their blood to undetectable levels, this means that only 67% of people living with HIV have a suppressed viral load. We are also still struggling to reach “key populations” and only 69.5% of sex workers, 44% of men who have sex with men, and 40.5% of people who inject drugs are on treatment. Given the principle that “undetectable = untransmittable”, this means that one third of people living with HIV are able to transmit HIV to their partners. This is evident in the number of new infections estimated to have occurred in the country in the past year: 210 000, or almost one person newly infected every two minutes!

Why are we not winning?

The COVID-19 pandemic has, of course, derailed multiple gains that have been made over the last decade. The latest UNAIDS report paints a gloomy picture: “progress has been faltering, resources have been shrinking and inequalities have been widening”. An estimated 1.5 million new infections occurred globally last year; only 3.6% fewer than in 2020 – the smallest decrease since 2016. Alarmingly, this is 1 million more infections than the global target. The number of people newly started on antiretroviral therapy has also slowed down to the smallest increase since 2009.

In 2021, one person in the world died of HIV every minute. The increasing number of people living with HIV together with non-communicable diseases, such as cardiovascular disease, depression, diabetes, and cancer is contributing to this mortality. For instance, cervical cancer, the leading cause of cancer death for women in Sub-Saharan Africa (killing 66% of those who develop it), is six times more likely to develop in women living with HIV. Cervical cancer is a preventable and curable disease, but services are inequitably spread and integrated, and the implementation of vaccination against the human papilloma virus (the cause of cervical cancer) has been slow and erratic.

Social inequalities, within and between countries, lie at the heart of vulnerability. Young women in particular face multiple vulnerabilities, especially those stemming from harmful social norms and practices, hypermasculinity, gender inequality, and poverty, which makes them vulnerable to exploitation and abuse.   

The impact of gender-based violence, which greatly intensified during COVID-19, should be acknowledged. Data from 156 countries indicate that an estimated 245 million women (aged 15 years and older) who have ever been married or partnered experienced physical or sexual intimate partner violence in 2021. In 20 of the 26 countries with data available for 2017-2021, this equated to more than 10% of ever-married or partnered women, with the highest rate (47.6%) reported in Papua New Guinea, and Sierra Leone, Liberia, and South Africa following closely behind. The numbers in South Africa are staggering with 30.3% of women aged 15 – 49 years and 30.1% of adolescent girls (15 – 19 years) having experienced recent intimae partner violence. It is an indictment on societies around the world that the World Health Organisation had to set a target of reducing physical or sexual violence from an intimate partner to below 10% by 2025.

Violence is exacerbated by harmful patriarchal norms. For instance, in 46 countries surveyed, a median of 28.3% of women and 23.9% of men (aged 15 to 49 years) believed that a husband is justified in hitting or beating his wife for a specific reason. All violence stems from relations of inequality that are deeply rooted in the distribution of resources as well as privileges and power in the home, the state, and communities. Unless women are respected as equal citizens, in the most comprehensive sense of the word, violence will continue.

Violence is also driven by prevailing discriminatory attitudes towards people living with HIV. Despite a myriad of education and advocacy campaigns, 59.1% of people across 55 countries reported discriminatory attitudes and, in 11 countries, the proportion exceeded 75%. Important contexts where people experience stigma is in the community and healthcare settings. In South African communities, 12.6% of people would not buy fresh produce from a person living with HIV; 7.5% believed children living with HIV should not be allowed to attend school with children not so infected; and 16.9% agreed with both statements. 

Discriminatory attitudes in healthcare settings especially affect adolescents and “key populations”. In fact, stigma and discrimination are seen as among the key barriers for access to quality health-care services. In more than a third of countries with recent survey data, more than 10% of “key populations” avoided health care due to stigma and discrimination. Self-stigma (i.e., reporting that one feels ashamed of being HIV-positive) also remains high and in 9 of 21 countries, more than half of people living with HIV surveyed reported feeling ashamed of having HIV. Self-stigma prevents early and consistent use of treatment    

What can be done?

In any epidemic, prevention is key. However, less than half (45.8%) of young South Africans (15 – 24 years) have adequate knowledge about prevention of HIV infection, and only 61.4% of women and 73.1% of men (15 – 49 years) used a condom during their last high-risk sexual encounter. Availability, uptake, and persistence of pre- exposure prophylaxis (PrEP) have been low with only an estimated 100 000 PrEP users in the country. While it is expected that the imminent introduction of long-acting injectable or implantable PrEP solutions will increase uptake, a single solution will not overcome an infection that is so deeply embedded in inequality.   

It is a wicked problem[1]. Much like homelessness and poverty, the HIV epidemic is intertwined in existing systems – economic, political, social, cultural, legal, etc – and this interconnectedness defies simplistic solutions. Just as climate change has challenged us to reimagine our way of being in the world, HIV demands that we reconsider the structural inequalities that have been introduced and keep being perpetuated between the global North and South, rich and poor, mainstream and alternative, men and women. Surely, a world in which injustice thrives should be firmly opposed?    

As part of this process, it is essential that people are given the knowledge and means to take care of themselves. We know that knowledge and empowerment are crucial for protecting the vulnerable from abuse and infectious diseases such as HIV. Quality education is not negotiable. It reduces poverty, improves health outcomes, and leads to social and economic development. In girls, education increases their lifetime earnings, reduces inequalities, strengthens social inclusion, and reduces their risk of acquiring HIV and other sexually transmitted diseases. Sadly, the COVID-19 pandemic left an estimated 20 million more secondary school-aged girls out of school in developing countries (most of them in Africa).

It is also critical to address the structural conditions underlying violence. As recently argued in The Conversation (Amanda Gouws, 30 November 2022), the origins of violence appear to be ontological and are related to a long history of men’s treatment of women. Here, the connections between the economic, social, and political realm cannot be ignored. It has been repeatedly demonstrated that equality lessens sexual violence while inequality and conflict worsen it.

Will we be brave enough to reconsider the inequalities imposed by the prevailing macroeconomic environment, the politics of exclusion, lack of political will to make real changes, and the toxic heritage determining the place of people in society along gendered lines?   

Professor Theresa Rossouw is a professor in the Department of Immunology at the University of Pretoria.