The HSRC’s latest provincial HIV data revealed that in Mpumalanga, HIV prevalence among young men aged 15–24 was 1.5 times higher than among their female peers. The finding is striking, considering that adolescent girls and young women (AGYW) have long accounted for a disproportionate share of HIV infections in South Africa. At the Mpumalanga launch of findings from the HSRC’s 2022 national household HIV survey, stakeholders argued that successful AGYW interventions should be fully extended to boys in the same age group. Increasing uptake of HIV testing also emerged as a priority in the province. By Andrea Teagle
HIV prevalence in Mpumalanga is the highest among the provincial prevalence rates, at 17.4% in 2022. This is a decline from 19.4% in 2017. At the same time, however, antiretroviral treatment (ART) coverage improved significantly from 65.4% to 81.8% of people living with HIV (PLHIV) in 2022. Mpumalanga also had among the highest viral load suppression rates, at 82.5%.
At a recent provincial dialogue, the HSRC’s Professor Khangelani Zuma presented the key findings from the Sixth South African National HIV Prevalence, Incidence, Behaviour and Communication Survey (SABSSM VI).
A SABSSM VI fieldworker visiting a household in Mpumalanga, March 2022 , Photo: HSRC
The data revealed an ageing epidemic. Between 2017 and 2022, Mpumalanga’s prevalence peak shifted from the 35–39 to the 45–49 age group, indicating longer lifespans for those on treatment. At the same time, prevalence declined from 18.8% to 8.8% among those aged 20–24, indicating a possibility of fewer new infections among young people (Figure 1).
The new campaign, U=U (Undetectable = Untransmittable), emphasises that PLHIV who are virally suppressed – with undetectable amounts of HIV in the blood – cannot transmit HIV to anyone else.
“Those who are on treatment and virally suppressed should be loudly celebrated,” said Dr Heather Paulin of the United States Centers for Disease Control and Prevention.
However, Zuma, who is the overall principal investigator for SABSSM VI, highlighted a worrying gap between actual and target HIV status awareness.
In 2022, 85% of PLHIV knew their status, against a target of 95%. Of those who knew their status, 94.5% were on treatment, and, of those on treatment, 94% were virally suppressed. However, to improve the overall number of PLHIV with viral suppression, the province needed to boost HIV testing uptake.
“We are actually achieving the second 95 [target], but remember, it’s conditional on having a good first 95,” Zuma emphasised.
Figure 1. Overall HIV prevalence by age group, Mpumalanga Province, 2017 and 2022
Source: HSRC
Including adolescent boys and young men
While the decline in prevalence among those aged 15–19 and 20–24 was encouraging, the numbers remained too high, Zuma said. Concerningly, although they accounted for only 9.4% of all PLHIV, young people (aged 15–24) made up 16.9% of PLHIV who did not know their status and 16.7% of PLHIV who were not virally suppressed.
Unlike in other parts of the country, where young girls continued to face an elevated risk for HIV, in Mpumalanga, prevalence among adolescent boys and young men (15–24) was 9.8%, compared to 6.3% among adolescent girls and young women.
The finding suggests that while interventions for adolescent girls and young women have been somewhat successful, there is an urgent need to intensify them and extend similar efforts to young men and boys.
“Whatever [interventions] that you are doing among young girls, we need to continue doing, but it should not be at the expense of young boys,” said Zuma.
Participants suggested that the province should focus on enhancing and scaling up the HIV programmes that have already gained support and proven to be effective. They noted that effective interventions sometimes fell away in favour of “shiny” upgrades, leading to community disengagement.
Social-behavioural youth programmes deemed to have been effective included You Only Live Once, or YOLO (aimed at young people aged 15–24), ChommY (ages 9–14 years), and Boys Championing Change (ages 13–19 years). These programmes, supported by developmental partner USAID, aimed to instil young people with a sense of self-worth, equipping them with knowledge and skills to make informed choices about HIV risk.
Participants identified a need for greater collaboration between government departments and developmental partners to increase the reach of HIV prevention initiatives. However, they cautioned against chasing numbers, which could lead to interventions reaching the same people repeatedly, or failing to translate into more people on treatment and who are virally suppressed.
Overcoming stigma
According to community members, stigma remained a barrier to HIV testing uptake among young people. Small-group discussions revealed that young people did not want to be seen to be visiting clinics known to offer HIV services. Discreet testing services, in conjunction with myth-dispelling information campaigns, could help to increase uptake.
School-based sexuality education and HIV testing were important ways to encourage young people to know their status. However, argued Busi Mabuza from the Department of Education, schools needed to create enabling environments for HIV-testing programmes to attract adolescents.
“We cannot do HIV testing without counselling [or] without having a private area,” she said.
Beyond school-based efforts, participants highlighted the need to revive parent-focused programmes to encourage open conversations about HIV at home.
Selective PrEP use
Uptake of the HIV prevention treatment, pre-exposure prophylaxis (PrEP), faced challenges in Mpumalanga. Only 3.2% of the respondents were currently taking PrEP, and only 34% had heard of it. After receiving information about the treatment, 51% indicated they would take it.
Ronald Sibuyi of the Institute of Health Programs and Systems highlighted the need for carefully framed PrEP messaging targeting men.
“[Mpumalanga men] have that information, but the challenge is that they are not using that information correctly,” he said.
He recounted instances of men taking PrEP only in anticipation of sexual encounters, arguing that event-driven campaigns – for instance, around Valentine’s Day – inadvertently promoted this selective use.
Dr Tendani Matoro, from Right to Care in the Ehlanzeni district, pointed out stigma as another barrier to PrEP uptake, with some young people associating it with sex work. To address these challenges, participants proposed clear, consistent PrEP campaigns alongside enhanced promotion of consistent condom use.
Promoting condom use
The survey showed that Mpumalanga had the highest rate of condom use of all provinces, with 46.1% of adults reporting that they had used a condom during their last sexual encounter. The national figure was 31.8%. However, only 24.6% of participants in Mpumalanga said they always used condoms, and 32.4% said they never used them with their most recent sexual partners (Figure 2). Participants suggested that male and female condoms were not always available in schools, and that they should be widely distributed.
Figure 2. Consistency of condom use with the most recent sexual partner among people aged 15+ years, Mpumalanga Province, 2022
Source: HSRC
In addition to increasing ART coverage and access to preventive tools, addressing the root causes of the epidemic – such as poverty and lack of opportunities – was considered crucial to reducing new infections.
Research contact:
Yolande Shean for SABSSM research enquiries at the HSRC’s Public Health, Societies and Belonging Division
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