AIDS in South Africa

by Edward C. Green & Allison Ruark
Treating HIV/AIDS is important, but more important is preventing its spread.

A recent article in the New York Times (“AIDS Progress in South Africa Is in Peril,” by Donald McNeil Jr., August 25) argues that the impressive treatment rates achieved in South Africa are imperiled as U.S. government assistance dwindles, while implying that U.S. government-funded treatment programs have also been responsible for significant prevention success in that country.

The article assumes that success in bringing down HIV prevalence has been due mostly to greater access to AIDS drugs. The widespread availability of ARV (antiretroviral) drugs has certainly brought down death rates (which paradoxically increases HIV prevalence — that is, the number of people living with HIV), and some research has indicated that the higher the percentage of infected people in a community who are receiving treatment, the lower the risk of HIV infection for everyone else.

At the 2013 South African AIDS Conference, attendees debated the meaning of preliminary data from South Africa’s most recent national survey on HIV prevalence, incidence, and behavior, carried out in 2012. While HIV prevalence had declined among children and young people (below the age of 24), more adults ages 25 and above were living with HIV than ever before. Was this increase in HIV prevalence due to South Africa’s success in keeping people with HIV alive, or was the number of new infections (incidence) perhaps on the rise? When the final report on the 2012 national survey was released this year, we had an answer. In 2012, 396,000 South African adults — 1.7 percent of the adult population — were newly infected with HIV. (There had been virtually no change in HIV incidence among adults over the previous decade, although significant declines in new infections were seen among youth ages 15 to 24.) This evidence does not square with the claim made by Mr. McNeil that new HIV infections in South Africa have declined by a third.

Success in getting South Africans on drug treatment and thus lowering death rates should not be confused with prevention success. Such confusion is widespread, and does not involve only South Africa. Organizations treating HIV/AIDS want to be able to show prospective donors that their approach is working, and the greatest investment of resources in dealing with AIDS globally is going to the purchase and distribution of drugs. Another assumption in the Times article — namely, that condoms cause or are related to the decline of HIV infection rates in South Africa — is also questionable. A decade’s worth of national surveys has shown that condom use in South Africa increased from 2002 to 2008 but then declined significantly between 2008 and 2012.

In Africa as a whole, HIV incidence peaked in the late 1990s, soon followed by a decline in prevalence. These rates came down before ARVs were widely available. In Africa’s first and greatest AIDS success story, Uganda, HIV-infection rates declined even before condoms were much available outside the capital city of Kampala. Uganda is not doing so well now, probably because Western donors pressured its leaders to take the emphasis off discouraging risky behavior – principally, multiple, concurrent sexual partners — and to rely instead on drugs, testing, and condoms.

But back to the HIV epidemics of Africa more broadly: Why did HIV-infection rates decline? We and our colleagues believe that natural fear of the threat of HIV provoked the commonsense response of men and women to stop having multiple, concurrent sexual partners. Indeed, “partner reduction” has been shown to quickly bring down HIV-infection rates. It seems probable that the preaching and exhortations that have always come from the grass roots, notably from churches and mosques, initially reinforced the natural reaction to become more cautious in one’s sexual behavior. The expansion of medical male circumcision has also contributed to declining HIV rates, as circumcision significantly decreases men’s risk of acquiring HIV and transmitting the virus to their female partners. On the partner-reduction count, there is further bad news from South Africa: National behavioral surveys show that the percentage of South Africans reporting multiple sexual partners (two or more in the past year) has been increasing for a decade. Paradoxically, the greatly increased availability of HIV treatment in recent years may be leading to less caution when it comes to the risky behaviors that spread HIV, as people realize that AIDS is no longer a death sentence.

South Africa has stood out among African countries in that (1) its HIV incidence and prevalence rates have remained stubbornly high even as rates elsewhere in Africa have declined significantly and (2) South Africa was late in making ARVs available, because, as Mr. McNeil explained in his Times article, the Mbeki administration’s health minister, “who claimed garlic, beetroot and lemons could cure AIDS, forbade public hospitals” to give out the drugs. This reflected Mr. Mbeki’s own “denialist” view of the role of HIV in causing AIDS.  

And now the U.S. funding provided to South Africa under the President’s Emergency Plan for AIDS Relief (PEPFAR) is being cut, with the limited funds being sent instead to poorer countries. While the South African government is attempting to fund AIDS treatment at levels comparable to those provided under PEPFAR, we believe that no amount of funding will allow South Africa to treat its way out of the HIV pandemic. South Africa’s experience to date shows that even when impressively high treatment levels are achieved, HIV incidence may remain essentially unchanged. What is urgently needed are strategies to reduce risky behaviors, principally multiple and concurrent sexual partners. When one of the present authors, Dr. Edward C. Green, was a member of the Presidential Advisory Council on HIV/AIDS, from 2003 to 2007 — the early PEPFAR years — all 27 of us on the council pretty much agreed that “treating our way out” was a pipe dream. Even the then-CEO of Pfizer, Hank McKinnell, frequently reminded us of this, and he co-wrote a book with the rest of the advisory council describing the need for promoting changes in sexual behavior, encouraging male circumcision (at least in Africa), and taking the other steps need for sound AIDS prevention.

Regarding trends in U.S.-government spending under PEPFAR, what little funding (perhaps not emphasis, but actual funding) behavioral interventions enjoyed under PEPFAR during the Bush years seems to have largely disappeared under the Obama administration. As PEPFAR has targeted its resources at buying and distributing drugs, this has not addressed the actual drivers of HIV epidemics: risky behaviors such as multiple and concurrent sexual partners and, in some parts of the world, sharing needles for nonmedical drug use. The dominant paradigm in the world of HIV/AIDS has been to offer interventions aimed at reducing risk only, in the usually unchallenged belief that we cannot — and perhaps should not — even try to change risky behaviors.

In our view, the real challenge facing South Africa is not how to pay for treatment for its millions of HIV-infected citizens, but rather how to get HIV prevention right.

— Edward C. Green is formerly of the Harvard School of Public Health. Allison Ruark is a Ph.D. candidate at the Johns Hopkins Bloomberg School of Public Health and lives and conducts research in Swaziland, which is contiguous to South Africa. Green and Ruark  are the authors of AIDS, Behavior, and Culture: Understanding Evidence-Based Prevention (Left Coast Press, 2011).

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