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Going back to basics to fight Aids

South Africa and the world have won many battles in the fight against HIV/Aids, but the race for a cure and the war against the epidemic with its epicentre still in KwaZulu-Natal, are not yet over, writes Lyse Comins

South Africa’s activists, NGOs, government officials and departments seem to have laid down their swords and stopped communicating constant messages of HIV/Aids prevention in taxis, on billboards and radio, in print media and in schools. This has rolled back some of th gains against stigma and behaviour changes in the fight against the disease in recent years.

But the slow-down in communication is only part of the problem which has contributed to an unacceptably high new infection rate among young people, with young women still most at risk of contracting the disease according to Professor Olive Shisana, local co-chairwoman of the upcoming International Aids Conference planned for this year.

Shisana, a leading public health expert who was the first director-general of the Department of Health in post-apartheid South Africa has expertise spanning from epidemiological studies of communicable diseases and HIV/Aids to health systems, quality and financing. Shisana highlighted the challenges in the fight against the disease and the victories of the country’s ARV treatment roll-out campaign which has led to a decline in the number of HIV/Aids related deaths since 2002.

But this could, in her view, also be contributing to new infections related to behaviour changes, as well as scientific breakthroughs in the search for further preventative measures like female condoms and a cure, which she believes she may see in her lifetime.

According to a report released by Statistics SA in July 2015, it was estimated that about 11.2% of South Africans - 6.19 million people out of a total population of 54.95 million - are living with HIV/Aids. But prevalence among the 15- to 49-year-old-age group is higher, estimated at 16.6%.

The report also indicated a decline in the number of HIV/Aids-related deaths to 30.5% with 162 445 of 531 965 estimated deaths last year attributed to the disease, a figure which peaked at 50.7% in 2005.

But Shisana said the decline in infection rates which dropped, for the 15- to 24-year olds, from 6.75% in 2002 to 5.59% in 2015, still fell short of health experts’ expectations and she blames a lull in communicating the prevention message and an erroneous change of mindset among people that HIV/Aids is not life-threatening.

There has been a decline but we still had more than 300 000 new infections in 2012.

According to the South African National HIV Prevalence, Incidence and Behaviour Survey released by the Human Sciences Research Council in 2014 there were 400 000 new infections in 2012 and almost 28% of people infected with HIV/Aids live in KwaZulu-Natal, while the Western Cape had the lowest prevalence at almost 8%.

Other provinces with a prevalence above 20% were the Free State, Mpumalanga and North West. The study found the country still ranks first in the world in HIV incidence and that it has the largest antiretroviral treatment (ART) programme.

“KwaZulu-Natal is still the epicentre of the global epidemic and most infections are still in Africa in places like Nigeria, Tanzania, Zimbabwe, Swaziland and Botswana,” she said.

Shisana said until people’s living conditions and standard of living were raised HIV/Aids and TB would be diseases which would not disappear.

“HIV thrives in a place where there is a lot of poverty. KwaZulu-Natal has a lot of people who are poor and there are informal settlements and challenges getting service to them,” she said.

“When you have a large pool of people living with the disease there is a much higher probability of passing it on to someone,” she said.

But just how was the prevention message silenced in recent years?

“Young people aged 15 to 24 have been using condoms in very high rates and it was only between 2008 and 2012 that we actually saw a decline in the use of condoms which spells trouble for all of us.

“New people who are coming into the age group are not as informed because prevention programmes in the country have declined and people are not communicating enough,” Shisana said.

“Government and NGOs are not saying and doing much - there was a lull in terms of new communication programmes. We used to have signs in taxis and on buses saying “condomise”. Why did they slack off? I think we have not done enough in terms of interrogating this issue. We let our guard down all around and it wasn’t just government; it was everybody involved.”

Shisana said many citizens seemed to have “lost” their knowledge about how the disease is contracted and the high number of new infections could also partly be due to the availability of treatment.

“Since people knew ARVs were possible and that you could prevent mortality and live longer, people thought, well I could take one pill and I will be all right’,” she said.

But Shisana said the Department of Health had recently employed a new communication company to revive the HIV/Aids campaigns, while the roll-out of Nurse Initiated Management Anti-Retroviral Therapy was a victory that was making an impact with 40% of people living with HIV/Aids now on treatment despite limited human and financial resources.

But she said a lack of financial and human resources to get the other 60% of infected people on treatment was a problem, which could be fixed by the implementation of National Health Insurance (NHI), which would redistribute medical schemes' resources.

“In so far as treatment we have done well and are winning the battle in terms of keeping people living longer because life expectancy has gone up,” Shisana said.

“We have really cut down in infections in babies because our Mother-to-Child transmission programme has been really effective and we have also taken steps to introduce medical male circumcisions especially in KwaZulu-Natal, so it is important to see we are averting new infections from men as well as women.”

Shisana said another challenge around communication was a culture that parents should not speak to their child-ren about sex and the disease and parents wanted this value extended to schools.

Shisana said the infection rate among 15- to 49-year-olds based on direct testing was worrying at 1.72% and roughly 396 000 new infections occurred in this age group out of a total of 469 000 new infections in 2012.

“HIV is staying with us and we have to not let our guard down in terms of education,” she said.

Shisana said young women aged 15 to 24 were most at risk of contracting the disease as the prevalence among the population group was 2.5%, accounting for 113 000 of 139 000 infected in the age group.

“HIV is affecting young people so much and at the conference one of the big groups we will be focusing on is young women,” she said.

Shisana said young women needed to be aware they were at high risk and should prevent infection by consistently using a condom, while women participating in microbicide gel prevention studies should follow instructions for use to the letter.

“If they don’t, we have no way of testing the efficacy of this prevention tool which means for years and years we won’t have women prevention control methods.”

Shisana said abstinence was not a message she was bothered with because young people were going to have sex and it should be safe sex and they should also be educated about the availability of the pre-exposure prophylaxis, Truvada, which could thwart the disease's ability to infect a healthy person.

Shisana added that South Africa was one of only four countries, France, Kenya, and the US, where the drug had been approved.

But she said people were still dying in this country because of stigma.

“We have made progress where people can say I have a sibling who is HIV-positive but for people to say I am HIV-positive, they fear stigmatisation and discrimination,” she said.

She said the country was leading the way in terms of treatment roll-out and scientific research such as the Centre for the Aids Programme of Research’s Tenovfovir microbicidal gel discovery, which had been shown to reduce the infection in women by between 39% and 54%.

“There are some great scientists in Durban who are doing some really great work and we encourage them to continue. It could be that because of their hard work, the medical intervention may come from them.

“I do think we are going to see a cure in our lifetime.

“One of the plenaries at the conference will be focusing on this and will tell us the state of cure research, how far we are, what is promising and what the potential is, so that is exciting,” Shisana said.

Professor Olive Shisana says she is optimistic about the chances of a cure for HIV/Aids being developed during her lifetime.

Professor Olive Shisana at the 20th International Aids Conference (Aids 2014) held at the Melbourne Convention and Exhibition Centre in Melbourne, Australia.

Stigma, risky social behaviour and a slow-down in prevention messages are some of the challenges facing those at the forefront of the battle where scientists are working hard to develop a cure, leading health expert and local co-chairwoman of the International Aids Conference 2016, Professor Olive Shisana, told Lyse Comins ahead of the event which takes place in Durban in July.

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