The introduction of a new HIV drug, as part of the new antiretroviral treatment guidelines, has been greeted with widespread positivity. The three-in-one pill is more efficacious and may help to tackle the growing problem of drug-resistant HIV strains. However, HSRC experts emphasise the roll-out must be accompanied by continued efforts to tackle HIV stigma.
In South Africa, over 5 million people living with HIV (PLHIV), or 62%, are receiving treatment, according to UN estimates. This is up from about 4.4 million people in 2017.
“We are indeed as a country making progress in terms of putting people on antiretroviral treatment,” says Prof Khangalani Zuma, an executive director of the HSRC. However, he says, among children of school-going age (10-19), just half are receiving treatment, underscoring an important gap in ART coverage.
This is particularly significant since the 15-24 age group has the highest rate of new infections.
Reasons for poor retention in care among youth include lack of access to food and running water, side effects associated with the medication, long distances to clinics and stigma.
A need to tackle stigma
Zuma underscores that stigma remains a major barrier to achieving universal ART coverage and HIV prevention.
For those children who were born with HIV/AIDS, he notes, many are not aware of their status, despite being on antiretroviral treatment. In such cases, parents have not disclosed to them that they were born with HIV, or that they themselves are HIV positive.
“It speaks to the challenges that we face as a society around stigma issues, especially within families,” Zuma says.
In 2014, an HSRC study sought to measure internalised stigma, or self-stigma – how PLHIV felt about themselves – and external stigma – how they believed that others perceived them because of their HIV positive status.
The Stigma Index Survey found that self-stigma was highest among the 15-24 age group.
To investigate how HIV related stigma has shifted over time, the HSRC is repeating the study in three provinces in which people experienced the most stigma in 2014: KwaZulu-Natal (KZN), Mpumalanga and Free State. KZN and Mpumalanga are also the provinces with the highest HIV/AIDS rates.
Dr Jacqueline Mthembu, an HIV researcher at the HSRC, says that the 2020 survey will be administered by data collectors who themselves are living with HIV/AIDS. LGBTI+ organisations and sex worker organisations will also be involved in the study.
Previously, respondents in the three provinces indicated that they felt that their medical records were not kept confidential. In some instances, PLHIV travelled long distances to receive treatment outside of their communities, or dropped out of treatment altogether.
“SANAC and other organisations have done a lot of work in terms of decreasing stigma post the 2014 study,” Mthembu says. “However, people are still experiencing it”. Interventions include NGO support groups at hospitals, and programmes targeting young women and girls. Support for PLHIV has been expanded to include mental health components.
Mthembu notes that stigma is often intersectional: in addition to HIV, people are dealing with stigma around adolescent pregnancy, tuberculosis, depression etc. “I think we are looking at HIV stigma more comprehensively,” she says.
The hope is that the study will find that experiences of stigma and discrimination have decreased in these three provinces.
A recent HSRC study looking to improve treatment outcomes among young pregnant women in KwaZulu-Natal, found that the involvement of men helped to reduce experiences of stigma.
The 2017 national HIV prevalence survey showed that approximately 1 in 4 people who initiate ART are no longer on treatment after a year.
New ART medication
This World AIDS day is marked by the much-anticipated introduction of the new TLD pill, which is more effective at suppressing viral load and reduces a person’s risk for developing resistance.
Dr Sizulu Moyo, a research director at the HSRC, says that the pill is very important for South Africa in light of drug-resistant strains of HIV and other infections.
According to the last HIV prevalence survey, over a quarter (27%) of people on treatment had some kind of resistance to one or more of the HIV combination drugs.
The three-in-one pill combines the commonly used ARVs, tenofovir and lamivudine with a new drug, dolutegravir (DTG).
Moyo emphasises the importance of staying on treatment if you are living with HIV, even if you are virally suppressed. The virus rebounds very quickly in the absence of ongoing treatment, she says.
In addition, while TLD is hoped to bring down levels of resistance, taking your medication inconsistently still puts you at risk for developing resistance.
The new pill does have some side effects. One of the concerns for women of childbearing age is a possible increased risk of birth defects.
However, Sizulu says that women’s groups have advocated for the right to be given the relevant information and be allowed to make informed choices. The treatment remains the primary recommendation of the WHO for all PLHIV.
In addition to its efficacy, an advantage of the new drug is that it makes taking treatment much easier – the single pill can be taken on an empty stomach. That taking ART medication previously required access to food and water was one of the challenges for adolescents in low-income areas.
