The prevalence of HIV among children and teenagers in the Western Cape has increased. While more children with HIV may be surviving into their teenage years, the increase could also be the result of new infections. New data show more young people started having sex during adolescence. They have multiple sexual partners, and most still do not use condoms. These and other challenges were discussed at the recent launch of the Western Cape findings from the HSRC’s 2022 national household HIV survey. By Antoinette Oosthuizen
The Western Cape has seen a significant increase in HIV prevalence among children, teenagers and people 50 years and older, in the period between 2017 and 2022. This points to a need to scrutinise prevention of mother-to-child transmission programmes, and to understand the drivers of early sexual debut, HIV risk behaviour and people’s uptake and adherence to antiretroviral treatment (ART) in the province.
These were among the views expressed at the HSRC’s launch of the Western Cape results from the Sixth South African National HIV Prevalence, Incidence, Behaviour and Communication Survey (SABSSM VI).
The overall HIV prevalence in the Western Cape decreased from 8.6% in 2017 to 7.4% in 2022. However, it increased significantly among children (Figure 1). In the age group 0–14 years, HIV prevalence increased from 2.9% (2017) to 4.3% (2022), and, among those aged 15–19 years, it almost doubled, from 3.5% (2017) to 6.7% (2022). Among those 50 years and older, prevalence increased from 7% (2017) to 8.4% (2022).
Figure 1. Overall HIV prevalence by age group, Western Cape Province, 2017 and 2022
Source: HSRC
The higher prevalence among children and older adults could be the result of survival, but delegates warned that it also could be due to new infections. The increase among children could have been driven by issues with the quality or consistency of prevention-of-mother-to-child transmission programmes and early sexual debut, while HIV risk behaviour and the reluctance to be tested and treated may have increased HIV transmission among all sexually active groups.
Early sexual debut
The Western Cape saw an increase in the proportion of adolescents and youth aged 15–24 years who reported having had their sexual debut before the age of 15 years, up from 14% (2017) to 16.3% (2022).
The province also had the highest proportion of people reporting early sexual debut in the country in 2022, moving up from third-highest after Gauteng and the Eastern Cape in 2017. More than a fifth (21.5%) of young men in the Western Cape reported having sex before the age of 15, compared to just over one in ten (11.3%) females.
Dr Erin von der Heyden,a medical officer for Khayelitsha Eastern Substructure, was concerned that sexual education programmes reached school-going children too late, suggesting that difficult conversations about sex needed to be introduced before and during early adolescence.
During a table discussion,Dr Nelis Grobbelaar, programme manager at Anova Health Institute, questioned if concepts around sex were sufficiently grappled with.
“What do we and the children understand about sex? The thinking tends to be black and white – [that sex] is either good or bad. And have we simplified sex to penetration? Because during adolescence, children [are supposed to] discover their bodies. How does this unfold and how do we approach conversations about what is ‘allowed’ and what is not?” he asked.
Delegates during group discussions at the launch of the SABSSM VI findings for the Western Cape in Cape Town, September 2024. Photo: HSRC
Multiple partners and no condoms
Almost one in five (19.1%) adolescents and youth aged 15–24 reported that they had had multiple sexual partners in the 12 months before the 2022 survey, with 39.9% having used a condom with their most recent partner (Table 1). In contrast, only 5.3% of people aged 50+ reported using a condom with their most recent partner.
Overall condom use was the lowest in the Western Cape, at 22.1% in 2022, compared to 31.8% nationally. Age group data was not available for the 2017 survey, so researchers do not know if the relatively higher condom use among adolescents and young people in the Western Cape has been improving or not.
Table 1. Condom use with the most recent sexual partner among people aged 15+ years by sex and age group, Western Cape Province, 2022
Source: HSRC
Barriers to accessing school-going children
Many participants were concerned about a lack of access to schools for sexual education and health programme interventions, blaming “gatekeepers” such as governing bodies, parent groups, teachers and principals. They suggested engaging with school governing bodies to sensitise them about the SABSSM VI results. Joe Tayag, a provincial advisor from the United States Agency for International Development (USAID), said this may require high-level leadership.
Luzuko Melapi of the Treatment Action Campaign suggested that signing the Basic Education Laws Amendment (BELA) Bill might help to “open up” schools for sexual education programmes.
ART uptake and viral load suppression
ART reduces the amount of HIV in the body (viral load) in those who test positive for HIV. In this survey, having less than 1 000 copies of HIV/mL blood meant viral load suppression (VLS) had been achieved. Once HIV is undetectable in the body, it becomes untransmissible. Proven by research, this has become the foundation of the latest U=U (undetectable=untransmissible) campaigns to encourage ART uptake.
ART coverage of all people living with HIV in the Western Cape increased to 76.8% in 2022, from 54.4% in 2017. VLS increased from 54.6% to 78.4%. However, the researchers could not produce robust statistics on ART uptake and VLS among children and young people aged 0–24 (as indicated by the dashes in Tables 2 and 3). The HSRC’s Professor Sizulu Moyo attributed the lack of granular data to small sample sizes due to insufficient survey participation.
Table 2. Antiretroviral treatment among all people living with HIV by age group, Western Cape Province, 2022
Source: HSRC
Table 3. Viral load suppression by age group, Western Cape Province, 2022
Source: HSRC
In terms of progress towards the 95-95-95 UNAIDS targets, SABSSM VI revealed that, in the Western Cape, 85.6% of people living with HIV aged 15 years and older were aware of their HIV status. Of this group, 91% were on ART and, of those on ART, 92% were virally suppressed.
Only 79% of men were aware of their HIV status, compared to 88.4% of women. However, once they knew their status, men (97.7%) were significantly more likely than women (88.5%) to initiate treatment.
Only a third (33.5%) of the Western Cape participants had heard of pre-exposure prophylaxis (PrEP) to prevent HIV infection. Yet, 61.9% were willing to use PrEP, indicating a window of opportunity.
Calls were made for the U=U campaign to be intensified as research conducted in Cape Town showed U=U messaging led to a significant improvement in HIV testing uptake.
They also called for the “rebranding’’ of condoms to move messaging beyond HIV prevention to include an emphasis on protection against other sexually transmitted infections and pregnancy.
Voluntary male circumcision at a younger age?
In 2022, about half of men aged 15 years and older reported being circumcised, with 46.3% of this group opting for voluntary medical male circumcision (VMMC), which reduces a man’s chances of acquiring HIV. Considering that a fifth of men reported having their sexual debut before the age of 15, attendees suggested advocating for VMMC and traditional circumcision at a younger age.
Dr Inneke Laenen from the Khayelitsha Eastern Substructure said that in some sub-districts like Mitchells Plain, VMMC campaigns have been successful, exceeding their targets for boys aged 10 to 14. Having community ambassadors who created a demand for this service was key.
This finding and other successful case studies prompted calls for more youth ambassadors to be involved in HIV awareness campaigns in the province.
Research contacts
Yolande Shean for SABSSM research enquiries and Lesiba Molopa, SABSSM VI provincial coordinator for the Western Cape and researcher in the HSRC Public Health, Society and Belonging Division
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