December 1, 2023

Ending HIV: How far have we come?

Clinical HIV Research Unit

The antiretroviral therapy that is available today allows people living with HIV to live long, healthy lives. Previously, patients needed to take several pills, with side-effects so unpleasant that many couldn’t tolerate the treatment. Today, there is a single once-daily pill that effectively treats the vast majority of people living with HIV.

Jaclyn Ann Bennet, Principal Investigator at the Clinical HIV Research Unit (CHRU) says, “There is much research that has taken place and is currently underway into all aspects of the HIV treatment pathway, from prevention to treatment and finally cure. In South Africa, we have excellent tools to use for prevention such as pre-exposure prophylaxis (PrEP), post-exposure prophylaxis (PEP), voluntary medical male circumcision and condom use, yet stronger implementation is required to reduce the incidence of HIV infections.”

Dr Tom Boyles, CHRU agrees. “We have seen notable progress in prevention, with longer and longer active agents becoming available. However, we still need to make treatment easier for patients to achieve viral suppression in 95% of all people on HIV treatment. We are struggling with both adherence to medications for those with HIV and prevention for those without.”

Treatment interruption

Treatment interruption is a real challenge. A person might stop taking their antiretroviral treatment for different reasons – migrant workers in SA go back home to countries beyond our borders for holidays and don’t take up multi-month dispensing that facilities offer; a person may move away from a rural area to an urban centre for employment and then not find a new facility; and stigma may also prevent continuing treatment. Despite efforts to contact patients and remind them to collect their treatment and attend facility appointments, these patients become lost to follow up, ultimately compromising their health outcomes.

Yet, when it comes to treatment interruption studies, scientists have mixed views. On the one hand, treatment interruption studies are considered an important step to achieve an HIV cure. If they are performed in an ethical and controlled manner, they can be safe for participants and minimise the risk of mutations inside a participant’s body. On the other hand, some researchers believe that interruption studies are harmful and should therefore not take place.

New HIV infections in SA

So why are South Africans at the highest risk for new HIV infections? Bennet says, “Many factors are increasing South Africans' risk of contracting HIV. Many of these factors are socioeconomically-driven or relate to delayed health-seeking behaviour – men especially delay going to their closest health facility for testing and treatment.”

Boyles says that nobody knows for sure why new infections in SA are not abating. “There are essentially two camps among researchers: those who believe it is a genetic predisposition, and others who believe it’s all about sexual networks. Both are important to consider. What is clear is that the need for people to migrate away from their families for work has led to larger sexual networks than would otherwise be the case. This is a significant factor in the ongoing spread of HIV.”

How to reduce HIV prevalence?

To reduce the HIV prevalence rate in South Africa, Bennet says that, “HIV self-testing programmes with strong linkage to care for access to treatment, PrEP and other preventative services need to be enhanced.” Boyles agrees, adding that, “The development of an ultra-long acting PrEP that can be combined with a contraceptive for adolescent girls and young women will be a game changer.”