Young people still face significant gaps in treatment, testing and prevention efforts, with only 62.8% on antiretroviral therapy
While there has been a decline in the overall prevalence of those living with HIV in KwaZulu-Natal, there are worrying gaps in treatment and prevention efforts, particularly among young people.
According to the sixth South African national HIV prevalence, incidence and behaviour survey for the province, KwaZulu-Natal had the second-highest HIV numbers in the country at 16.0% in 2022 — behind Mpumalanga at 17.4% — although it was down from 18.0% in 2017.
Nearly two million people in the province remain HIV-positive.
“HIV prevalence is still high among individuals aged 25 to 49, peaking at 44.5% in those aged 45 to 49,” said principal study investigator Professor Khangelani Zuma.
The Human Sciences Research Council conducted the survey in partnership with the US Centers for Disease Control and Prevention, the South African Medical Research Council, the University of Cape Town and the National Institute for Communicable Diseases.
The findings of the survey, conducted between 2022 and 2023, were presented in Durban on Monday, and will be used for planning and implementation at a provincial level.
This was the first time in the history of the survey, which is conducted every three years, that the researchers had “drilled down the data to the lowest level possible”, said Zuma.
Overall, the number of people who are virally suppressed had been improving in the province and South Africa, and while 88% of those aged 0 to 14 years old in KwaZulu-Natal were virally suppressed (possibly because their mothers were on treatment during pregnancy), the 15 to 24-year-old age group was least likely to be virally suppressed.
“So we have our work cut out to put more effort into young people. We have to educate them about HIV, get them linked to care, and work with parents, because the issue of stigma is still a challenge,” Zuma said.
“We have to empower the parents to assist and disclose their HIV status to their children and assist the parents [with how to] assist a child that is now living with HIV. That is our responsibility as members of society and healthcare workers.”
The virus continued to disproportionately affect those living in rural areas, where prevalence rates reached 20%, he said.
Antiretroviral treatment (ART) coverage in KwaZulu-Natal rose to 87.3% in 2022 from 71.2% in 2017. But ART uptake among adolescents and young adults remained significantly lower, with only 62.8% of those aged 15 to 24 receiving treatment.
This age group was also least likely to know their HIV status, Zuma said. Males, in particular, lagged behind in testing and treatment, with only 58.8% of young men on ART.
Among females of the same age group, 19.8% had never tested, while 25.5% of males had never tested.
By district, eThekwini and King Cetshwayo had the lowest ART coverage, at 83.4% and 85.5%, respectively. Zuma said there was a need for targeted interventions, particularly in urban areas, where treatment uptake continued to fall short.
UNAIDS targets
The survey also assessed KwaZulu-Natal’s progress toward the UN programme on HIV/Aids (Unaids) 95-95-95 target, which aims for 95% of people living with HIV to know their status, 95% of those diagnosed to be on ART, and 95% of those on treatment to achieve viral suppression.
KwaZulu-Natal was largely on track, said Zuma, with 94% aware of their status, 93.4% on treatment and 95.3% virally suppressed. But significant gaps remained, again among adolescents and youths, with only 73.9% of those aged 15 to 24 aware of their status.
The survey also revealed concerning trends in sexual behaviour.
Condom use with the most recent sexual partner dropped from 44.9% in 2017 to 32.8% in 2022.
In contrast, self-reported male circumcision — which has been shown to reduce HIV transmission — increased to 54.6% in 2022 from 38.3% five years earlier.
KwaZulu-Natal has the highest rate of medical circumcision in the country, at 87.6%.
Despite the improvements in treatment coverage and male circumcision, the survey showed the urgent need for targeted interventions.
“Young people, particularly adolescent girls and young women, are still at significant risk,” said Zuma. “There is also a pressing need to address gaps in the treatment cascade, especially in urban areas where many are not receiving the care they need.”
The key recommendations from the survey emphasised the need for targeted interventions to address age-specific HIV challenges, particularly for adolescent girls and young women who face higher HIV risks.
Prevention efforts should be intensified for these groups, alongside a long-term care strategy for an ageing population living with HIV. Tailored interventions were also recommended to address gaps in the clinical care cascade, focusing on the specific districts, localities and subpopulations which were most affected.
The survey also calls for enhanced public awareness and demand for medical male circumcision among those aged 15 and older. In addition, it highlighted the importance of increasing the uptake of HIV prevention measures, including regular testing, condom use and pre-exposure prophylaxis.
These efforts were critical to meeting the 2030 targets for reducing HIV as a public health threat.
The council is continuing its provincial dialogue roadshow to disseminate the results, with events scheduled in the Free State, Western Cape and Northern Cape.