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HIV in South Africa – Epidemic, strategic plans, TB/HIV

Current HIV epidemic in South Africa

An expanding graveyard shows the impact of the HIV epidemic on a South African township

An expanding graveyard shows the impact of the HIV epidemic on a South African township

South Africa has an extremely serious generalised HIV epidemic. It is estimated that 6.4 million people were living with HIV in 2015, the highest number of any country in the world. This is an increase from an estimated 4.02 million living with HIV in 2002.

In 2015 an estimated 11.2 % of the population was HIV positive. Also, an estimated 2.5 million South Africans were taking HIV antiretroviral treatment in 2013.

It is also estimated that 162,445 people died of HIV related illnesses in South Africa in 2015. This is an estimated 30.5% of all deaths in South Africa. There are some more HIV statistics for South Africa.

The Start of the HIV & AIDS epidemic in South Africa

The HIV epidemic in South Africa started in the 1980s, and was initially an HIV and AIDS epidemic among gay men. Antiretrovirals for the treatment of HIV came to South Africa soon after the 1996 Vancouver AIDS conference. This was however followed by a period of “AIDS denialism” led by President Mbeki and Minister¬† Manto Tshabalala-Msimang. It was only in 2003 that a national HIV antiretroviral treatment programme was started in South Africa.

Eligibility criteria for receiving antiretroviral treatment in South Africa

From the start of the HIV antiretroviral treatment programme in 2003 until early 2010 adults were eligible to start antiretroviral therapy when their CD4 count dropped below 200 cells per mm3. HIV positive adults in South Africa were also eligible for HIV antiretroviral treatment (ART) if they had an AIDS defining illness other than extra pulmonary TB.

In 2010 the South African Antiretroviral Treatment Guidelines were launched which prioritised HIV antiretrovirals for a much wider group of HIV positive people. But one of the main challenges for the government was the implementation of the programme. In early 2010 pregnant women and patients co-infected with TB and HIV became eligible for ART when their CD4 counts dropped below 350 cells/mm3. In late 2011 all HIV positive adults became eligible when their CD4 counts dropped below 350 cell/mm3.

Initially the South African treatment guidelines had provided for HIV antiretroviral treatment to be started at a lower level than that recommended by the WHO. But in 2011 the guidelines were brought in line with the 2010 WHO recommendations for the first time. By early 2012 the guidance was that all patients should be initiated on ART if their CD4 count was less than 350cells/mm3.

South African HIV Antiretroviral Treatment Guidelines 2013

The new South African HIV Antiretroviral Treatment Guidelines 2013 had specific objectives which included prioritising ARVs for:

  • Patients with CD4 counts < 350cells/mm3 or with severe HIV disease (WHO stage 3 or 4) irrespective of CD4
  • Patients co-infected with drug sensitive or drug resistant TB who should be initiated with ART irrespective of CD4 count
  • Pregnant women with CD4 < 350cells/mm3 for lifelong ART and CD4>350cells/mm3 for prophylaxis

In addition all HIV exposed children under one year old were to be tested and treated if infected with HIV. Also all first and second line therapy was to be standardised and the use of stavudine was to be reduced.

These new guidelines meant that there was a large increase in the number of people living with HIV who were eligible for antiretroviral treatment. At the same time HIV prevention efforts, although in many cases high profile, had been somewhat ineffective. This meant that an additional 300,000 to 500,000 people were becoming infected annually and increasing the number of people needing treatment.

HIV and TB co-infection

Children orphaned by HIV in South Africa

Children orphaned by HIV in South Africa

HIV has caused the severe TB epidemic in South Africa to rapidly escalate. This has had a severe effect on both individuals and communities. It had also resulted in almost 2 million children becoming orphans.

One of the major issues for the HIV programme has been the added morbidity and mortality of undiagnosed and untreated TB. There has also been a major logistical challenge of having two such major health programs. One of the solutions has been to make sure that both programs can manage both diseases.

Lower antiretroviral drug costs

As recently as 2010 South Africa had been paying substantially more for HIV antiretroviral medication than many other low and middle income countries.

So having expanded access to antiretroviral therapy, South Africa was determined to increase the competitiveness of its antiretroviral medicine purchases. This started with a major antiretroviral medicine tender in 2011 – 2012.

South Africa announced in November 2012 that it had achieved a massive 53% overall reduction in the cost of antiretroviral medicines, with projected two year savings of US$ 640.

National Strategic Plan for HIV, TB and STIs (2012 -2016)

In 2011, and following on two previous National Strategic Plans (NSP) (2000 – 2005) and NSP ( 2006 – 2011) a new NSP was launched. It provided guidance for a five year period of response. Its main goals, which were quite demanding, were that in relation to HIV the aim was to:

  • reduce new HIV infections by at least 50%, using combination prevention approaches
  • initiate at least 80% of eligible patients on antiretroviral treatment (ART) with 70% alive and on treatment 5 years after initiation
  • ensure an enabling and accessible legal framework that protects and promotes human rights in order to support implementation of the NSP
  • reduce self-reported stigma related to HIV by at least 50%

There was in addition an objective set to reduce mother to child transmission (MTCT) to 2% at six weeks after birth and less than 5% at 18 months.

Progress with the NSP (2012 – 2106)

Reduce new infections by at least 50%

There has been a decline in new infections, that is HIV incidence, over time. However, this has not met the 50% required by the NSP. Much more needs to be done to improve prevention efforts in South Africa, especially among young women, in order to halt the spread of HIV.

Start at least 80% of eligible patients on antiretroviral treatment with 70% alive and on treatment five years after ART was started

It has proved difficult to find a satisfactory way of defining the number of patients eligible for antiretroviral treatment. This is partially because the criteria of eligibility for treatment has changed. People who were not eligible a few years ago have now become eligible for HIV treatment. So as the epidemic continues there is not only a need to estimate the number of newly infected people needing treatment. There is in addition a need to measure the number of people previously infected with HIV who now need treatment because of changing criteria.

In the 2011/12 financial year it is known that 558,085 patients started ART in the public sector. In the next few years South Africa will need to enroll in excess of 500,000 new patients onto ART per year to progress to an ever increasing proportion of the overall HIV infected population being on ART. At the same time the health program aims to still have alive and in care 70% of those people initiated on ART some five years earlier.

HIV patients initiating ART and retention in Care in South Africa for adults and children reaching between 1 and 5 years on ART, by financial year of outcome reporting
Adults Children
Year of starting


FY 2008/09

Year of starting


FY 2012/13

Year of starting


FY 2008/09

Year of starting


FY 2012/13

No. patients reaching this time on ART
1 year 61,731 177,301 4,462 7,681
2 years 40,206 114,973 3,104 7,3322
3 years 26,695 70,958 2,360 4,957
4 years 14,997 54,460 1,352 3,930
5 years 6,019 34,929 489 2,581
Retention in care
1 year 74.9% 71.7% 83.7 79.3%
2 years 67.6% 58.1% 82.1% 71.6%
3 years 64% 50.6% 84% 67.7%
4 years 64.5% 46.6% 86.2% 65.7%
5 years 64.1% 42.2% 83.5% 68.2%

So this table shows that the largest number of adults retained in care were those people who had been on antiretrovirals (ARVs) for 1 year in 2008/09 and 74.9% were still in care one year later. The smallest number were those people who had been on ARVs for 5 years in 2012/13 with just 42.2% in care five years later.

The 40% still in care and not taking antiretrovirals are unlikely to be obtaining antiretrovirals elsewhere. So either they have already died, or their chances of becoming ill and dying over the next few years, are quite high.

So it would seem to be a priority for the national HIV programme that adherence is improved over the next few years.

Sources for HIV in South Africa

Report: South African National AIDS Council (SANAC) Progress Report on the National Strategic Plan for HIV, TB and STIs (2013 – 2106) http://sanac.org.za/news/item/219-progress-report-national-strategic-plan-on-hiv-stis-and-tb-2012-2016
Mid-Year Population Estimates July 2015 Statistics South Africa Statistical Release P0302 www.statssa.gov.za