South Africa Perspective: HIV/AIDS

Background

HIV infection remains a major problem for the world. Globally, there were over 35 million HIV-positive people in 2012, with 1.6 million people dying from the infection. South Africa has the highest number of HIV infections in the world: 6.3 million in 2013. Of these, 360,000 were children under 15, and 59% of the infected adults were women. About 200,000 people died of AIDS (the end-stage of HIV infection) and there were about 2.4 million under-18s orphaned due to HIV.

Effective treatment is possible, but maintaining current levels of prevention and treatment activities would mean that there would be significantly more sufferers by 2030. However, scaling up of interventions would put the epidemic into permanent, long-term decline. Taking into account future gains in income and economic productivity plus savings in healthcare spending, scaling up efforts globally could give benefits worth 15 times the investment by 2030.

There are two recommended targets to strengthen the fight against AIDS, and both are highly relevant to South Africa.

The first target is to increase the number of people treated with anti-retroviral therapy (ART), concentrating at first on those who are sickest (having the weakest immune systems). The normal measure of immune system strength is the CD4-cell count, and the aim is to treat 90% of people with CD4 count below 350 cells/µL (cells per microliter) with ART, before extending treatment to people with higher CD4 counts.

South Africa is currently implementing the most recent WHO (World Health Organization) guidelines on AIDS, which recommends extending ART to people with a cell count below 500 cells/µL. But coverage of those with weaker immune systems is still only about 61% and there is a strong case for concentrating on these patients first. The improvement to their health is greater and, since these individuals are significantly more infectious, treatment would help prevent further transmission.

There is also evidence of ‘crowding out’ of the sickest patients if medicine is available more widely, because these are the people who may be too ill to visit clinics or not be able to afford the travel costs.

Achieving 90% coverage of the target group of patients would give health benefits worth nine Rand for each Rand spent. This does not take account of economic benefits, which would make this treatment even more cost-effective.

A second target is to expand circumcision to include 90% of HIV-uninfected men. This has two main benefits, the first being to reduce HIV infection of men through heterosexual intercourse by 60%. After some delay, this also reduces rates of infection among women. One of the big advantages of circumcision is that it is a relatively cheap intervention which lasts a lifetime, unlike ART which means taking medicine for life.

Currently, fewer than a third of South African men are circumcised.  However, over two thirds of uncircumcised men are willing to accept circumcision if it protects from HIV infection and other sexually transmitted infections. About the same proportion of mothers and fathers are also willing to circumcise their sons for the same reason.

Because the costs of circumcision are lower than extending ART, every Rand spent would pay back 24 Rand, not including indirect economic benefits. Extending ART would cost an additional $11 billion, while scaling up circumcision would cost only $356 million. But both targets are very important and worthwhile. As for any large-scale public health program, there are significant challenges to implementation, but the results would certainly make this justified.