Aids in south africa research paper
Furthermore, focusing on high transmission areas and key populations, together with the implementation of evidence-based combination prevention strategies has the ability to substantially reduce HIV transmissions and achieve epidemic control, potentially transforming the pandemic to low level endemic epidemics [ 11 ]. Notwithstanding the major advances in the delivery of HIV prevention and treatment to attain epidemic control, initiatives to prevent sexual transmission of HIV, indeed the major mode of transmission in sub-Saharan Africa remains a challenge to the possibility of an AIDS free generation.
HIV/AIDS denialism in South Africa
In an estimated Ten countries, mostly in southern and eastern Africa, viz. The epidemics in Botswana, Namibia and Zambia appear to be declining, whilst the epidemics in Lesotho, Mozambique and Swaziland seem to be plateauing [ 12 ]. In sub-Saharan Africa, the main mode of HIV transmission is through heterosexual sex with a concomitant epidemic in children through vertical transmission. Not only do young women aged years have HIV rates higher than their male peers, they acquire HIV infection years earlier than their male peers. Adapted from [ 12 , 24 ].
The disproportionately high HIV prevalence throughout the region suggest the lack of appropriate interventions to protect young women and to meet their sexual and reproductive health needs as they prepare for adulthood [ 12 ]. In the region, there is a paucity of research in marginalized groups such as men who have sex with men, people who inject drugs and sex workers, however, emerging data suggests that HIV prevalence is significantly higher in these groups than in the general population [ 32 ].
Studies from South Africa and Kenya show that HIV prevalence was almost three fold higher in men who had sex with men than in men who had sex with women only [ 33 , 34 ]. Similarly, HIV incidence rates have also been three to four fold higher at Injecting drug use is a growing concern across the region compounded by reports of high risk sexual behaviors in these individuals.
The absence of harm reduction programs and persistent high risk behaviors has implications for transmission of HIV. Sex work has been the key driver of the epidemic in the region and the burden of HIV remains disproportionately high amongst female sex workers.
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Even in countries with generalized epidemics, HIV prevalence is at least two fold higher in this group than in the general population and the pooled HIV prevalence among female sex workers in sub-Saharan Africa was Whilst the number of life time sex partners, risky sex acts or behavioral practices impact on HIV acquisition, sex workers within sexual networks play a role in sustaining transmission.
Despite the impact of combination prevention interventions that target high risk marginalized populations, the major challenges in the region are the discriminatory environments and in-country legislation that not only sustain, but fuel the epidemics resulting in extraordinarily high prevalence [ 38 ].
Major challenges exist in maintaining the declining rates of HIV infections. It is imperative that structural, behavioral and biomedical interventions are evidence and rights based, are non-discriminatory and gender transformative [ 38 ]. Furthermore, the programs should aim to decriminalize sex work, men who have sex with men and reduce intimate partner violence [ 39 , 40 ] as these impact on HIV prevention efforts.
Ideally, access to comprehensive sexual reproductive health services for HIV prevention should focus on maximizing on coverage of interventions [ 12 ]. Intensifying prevention activities requires a thorough understanding of the HIV epidemic typologies, modes of transmission and populations affected as these inform the extent to which evidence based modalities can be customized and combined to substantially reduce HIV transmission which is critical in continuing the path to altering epidemic trajectory [ 41 - 43 ].
The evolving epidemic has been characterized into several typologies to capture the dominant characteristic at regional and or country level.
However, a key feature of the epidemic is variation in disease burden not only across population and countries but across districts and sub districts. Countries characterized as having low-level epidemics , where adult HIV prevalence has not spread to significant levels in the general population nationally, nor in any sub-population, suggests that sexual networks of risk are diffuse and driven by low levels of partner change or concurrent sexual relationships or that the virus may have been recently introduced.
In such settings, information on the most vulnerable and at risk populations is needed to understand risk behaviors, social sexual networks and factors such as rates of sexually transmitted infections STIs that could potentially impact on the spread of HIV. Many West African countries such as Benin 1. Thus, prevention planning should track the epidemic and entail knowledge of HIV trends. In concentrated epidemic settings, HIV has spread rapidly in one or more populations but is not well established in the general population.
Adult HIV prevalence is high enough in one or more sub-populations, such as men who have sex with men MSM , people who inject drugs PWID or sex workers and their clients who maintain the epidemic in this sub-population, but the virus has not spread in the general population. In several countries, HIV prevalence is nearly 20 times higher amongst high risk sub-populations such as MSM and sex workers compared to adult HIV prevalence in the general population.
In Burundi, HIV prevalence in sex workers is To prevent epidemics expanding to the general population, HIV prevention efforts should focus on understanding the dynamics of HIV transmission, tracking the size and course of the epidemic and prioritizing and intensifying interventions in affected sub-populations.
In generalized epidemic settings , HIV prevalence is well established in pregnant women attending antenatal clinics, indicating that the presence of HIV among the general population is sufficient for sexual networking to drive the epidemic. Multiple partner relationships giving rise to sexual networks intensify HIV transmission and account for majority of infections. Importantly, the behaviors of most at risk populations through longer term multiple concurrent relationships sustain HIV transmission in the general population [ 42 ].
In countries such as Kenya 6. Thus, prevention efforts must focus on broad social movements that contribute to safer sex behaviors and extend to those in the general population with increased vulnerability to HIV, especially young people. In such settings, high levels of HIV related stigma, gender based violence and sexual coercion fuel the spread of HIV in the general population, leading to excessively high prevalence [ 45 , 46 ].
Countries such as Botswana These groups are at an increased risk of infection, yet are less likely to access HIV prevention and treatment services because of the pervasive stigma and discrimination against these groups [ 38 , 46 ]. A more recent concern has been the role of HIV super infection, which occurs when an infected individual is infected again, by another variant.
Super infection leads to a spike in viral load and individuals can transmit either variant or a recombinant form to partners [ 47 , 48 ]. Understanding HIV epidemic typologies has been central to the design of prevention programs, however a more in-depth and nuanced understanding of HIV transmission is needed to direct interventions. Recent efforts to reduce sexual transmission of HIV have made progress and strategies from recent evidence based interventions are promising and should incrementally be tested and evaluated in populations at risk for HIV.
UNICEF South Africa - HIV and AIDS - Introduction
To prevent the further spread of HIV, focus on combination strategies and reaching the majority of sex workers, their clients, MSM and other high risk individuals is key to altering epidemic trajectory [ 43 ]. Whilst these have been useful as a national response and scaled up towards attaining universal access to prevention and treatment including care and support for all, these have failed to address social and economic factors and power in relationships.
However, country level HIV data masks diverse, complex and heterogeneous epidemics at sub-national, regional and district level. Furthermore, as new HIV infections continue one or more sub-populations of virus emerge [ 47 , 48 ] resulting in the spread of HIV viral variants.
Geospatial mapping is a novel approach that is being used to map HIV infections [ 51 , 55 ] in order to understand geographic variation of the HIV epidemic, its drivers, and for increasing the efficiency of targeted interventions in high HIV burden, resource poor settings. Adding to this novel approach, phylogenetic analyses of HIV-1 viral sequences are increasingly being applied to map HIV transmission links. The transmission links are important to understand dyadic relationships, and to identify clusters or networks in communities.
A combination of HIV phylogenetic analyses with the relevant socio demographic and behavioral data provide powerful knowledge on patterns and dynamics of HIV transmission networks across communities, which could guide HIV prevention and intervention strategies [ 56 - 58 ]. In the village of Mochudi, Botswana, a high proportion of Mochudi unique clusters were identified among sequences suggesting that the HIV epidemic in this community is dominated by locally circulating viral variants [ 56 ]. These data provide empirical evidence to understand the dynamic heterogeneity of HIV which to a significant degree is often masked at a country level [ 49 ].
The HIV prevention field has evolved rapidly over the last five years. Numerous interventions to prevent HIV acquisition are available; however, these have not been implemented and utilized in relation to the magnitude of HIV burden. Comprehensive and effective public health strategies include programming for behavior change, condom use, HIV testing and knowledge of HIV status, harm reduction efforts for injecting substance use, medical male circumcision and provision of post exposure prophylaxis.
For example condom use is generally highest in commercial sex work and lower and inconsistent in non commercial and regular partnerships [ 61 ]. Studies indicate that the majority of women are generally unable to negotiate consistent male or female condom use which is largely dependent on male partner co-operation. Although increases in male condom distribution and use played a key role in declining HIV incidence during the period [ 62 ], the major challenge has been sustaining consistent condom use [ 63 ] so men can protect themselves and their partners.
Mapping HIV prevalence in sub-Saharan Africa between 2000 and 2017
Similarly HIV counselling and testing HCT has been tested through several models [ 64 - 68 ] to enhance knowledge of HIV status, access HIV prevention and treatment programs and minimize stigma and discrimination in association with HIV Although these innovative approaches and expansion of services have been fundamental in promoting knowledge of HIV status to access treatment and promoting preventing onward transmission, knowledge of HIV status remains low. Results from three randomized controlled trials RCTs and modelling data have paved the way for large scale roll-out of voluntary medical male circumcision VMMC as an important intervention by engaging men and reducing heterosexually acquired HIV [ 4 - 6 , 69 ].
These data suggest that for any benefit of VMMC to be realized, coverage must be scaled up. Improving surgical procedures and using novel approaches for recruitment for the safe delivery of high quality VMMC services would contribute to rapidly achieving targets for public health benefit [ 70 - 73 ]. Several RCTs of cervical barrier, diaphragm and non antiretroviral ARV based microbicides when applied vaginally have failed to show any significant benefit in preventing HIV acquisition [ 74 - 80 ]. Randomised clinical trial evidence for preventing sexual transmission of HIV adapted from [ 93 ].
Whilst these trials had no safety concerns, the major drawback was the lack of adherence and therefore the failure to demonstrate the effectiveness of the study products. In this trial the dapivirine vaginal ring reduced the risk of HIV-1 infection by These results provide renewed hope for women initiated methods, whilst clinical trials on newer ARVs with alternate delivery mechanisms are currently underway and the role of potent broadly neutralizing monoclonal antibodies are being explored as newer HIV prevention interventions [ 24 , 91 ].
These interventions would fill an important gap as HIV prevention options for young women and impact on new HIV infections [ 24 ].
The major challenge of these promising interventions is that they are not yet licensed in sub-Saharan Africa for public sector use. Whilst vaginal microbicides and oral PrEP are urgently needed as behaviors are difficult to modify, effect and sustain, their effectiveness is largely dependent on risk perception, uptake of interventions and adherence to interventions [ 10 ], further complicated by genital inflammation with increased concentrations of HIV target cell recruiting chemokines and a genital inflammatory profile contributing to HIV acquisition [ 92 ].
These findings provide compelling evidence to the importance of viral load as a key predictor of HIV transmission. Furthermore, adding VMMC, behaviour change communication, early ART and preexposure prophylaxis could achieve greater effect in reaching the goals of epidemic control. Although high coverage of early or universal ART with VMMC, behaviour change communication and pre-exposure prophylaxis could achieve greater effect to reach the goal of epidemic control and virtually eliminate HIV transmission [ 9 , 11 ], population-based RCTs are currently ongoing to determine the effectiveness of these regimens in reducing the HIV incidence [ 97 ].
Effective ART first introduced in , led to dramatic reductions in morbidity and mortality [ 20 ]. There has been a parallel increase in the number of pregnant women receiving ART for the prevention of mother to child transmission of HIV and significantly more women and children are receiving ART [ 98 ].
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Most countries have progressed with scaling-up ART provision and with a commitment to increase the numbers over the next several years. In South Africa alone over 2. Notwithstanding the success of the region as a whole in scaling up ART, this masks significant in country variability with some countries e. The variability in treatment access remains a challenge and may potentially reverse the gains made thus far. The major milestones of ART provision aiming for maximum coverage through early or universal ART is rapidly advancing in many countries [ ]. However, some countries have not met their targets highlighting the complex challenges of patient populations that remain under-served and undermining the parallel prevention efforts.
It is hoped that strengthening of health systems, reducing costs, improving and simplifying treatment are more likely to improve adherence to drug regimens with better chances for long term survival. New ART formulations can also help address some of the current challenges including funding constraints. This approach has been successful for individual benefit in reducing morbidity and mortality. Whilst a few individuals with HIV are aware of their infection, the majority have never tested to know if they are infected. Comprehensive HIV testing programs with either community centered or innovative approaches which include self-testing would improve knowledge of HIV status.
Furthermore, of the many individuals with HIV, less than half receive adequate and ongoing treatment and less than a quarter of those on ART successfully maintain viral suppression.
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Therefore undiagnosed HIV infection and inadequate viral suppression remain significant factors fueling the epidemic and threatening epidemic control in sub-Saharan Africa. It provides hope for controlling the virus at the individual level decreasing mortality and importantly and at the public health level decreasing HIV transmission.
Thus, populations that are currently underserved would benefit from large scale HIV testing, knowledge of HIV status, expediting early access to and adherence to treatment, mitigate stigma and discrimination and realization of prevention benefits from early treatment initiation [ 97 , - ]. Notwithstanding success in a growing number of countries with stabilized epidemics and or reductions in new HIV infections, the continued high burden of new HIV infections in South Africa, Swaziland, Lesotho, Zimbabwe, Botswana, Mozambique, Namibia and Zambia contribute to new infections globally.
It is imperative that innovative models of delivery, together with information and education on HCT, male and female condoms and VMMC are expanded to maximize on the coverage of these existing cost effective interventions. The rapid scale-up of targeted primary prevention and testing and treatment services for high risk individuals such MSMs, PWID and sex workers are needed to prevent further transmission. A better understanding of structural, biological and behavioral factors, including the chains of transmission by applying molecular methods and phylogenetic analysis of HIV-1 sequences could improve the efficient targeting of HIV prevention efforts.
A group that has not yet benefitted from these global and regional HIV trends is young women. Adolescent girls and young women acquire HIV infection years before men.