Despite notable progress in antiretroviral treatment uptake and viral load suppression, the Northern Cape has experienced a rise in HIV prevalence. These findings were recently discussed at the provincial launch of the HSRC’s 2022 national household HIV survey. Attendees at the launch noted limited access and insufficient provision of HIV services in what is South Africa’s largest but most sparsely populated region. By Jessie-Lee Smith
SABSSM VI researchers during fieldwork in the Northern Cape, January 2022. Photo: HSRC
The Northern Cape recently stood out as the only province in which HIV prevalence rose in South Africa, with prevalence decreasing nationally overall between 2017 and 2022. The Northern Cape also saw a significant increase in antiretroviral treatment (ART) uptake and viral load suppression (VLS) during this time.
This is according to findings from the HSRC’s Sixth South African National HIV Prevalence, Incidence, Behaviour and Communication Survey (SABSSM VI), released in the Northern Cape.
Professor Khangelani Zuma, the study’s principal investigator, described how HIV prevalence in the province rose from 8.2% (99,000 people) in 2017 to 8.9% (120,000 people) in 2022 (Figure 1). This meant that at least 21,000 people were infected in the five years, a significant increase when considering the province’s small population.
Figure 1. Overall HIV prevalence by age group, Northern Cape Province, 2017 and 2022
Source: HSRC
Treatment strides
Overall, the province made great strides, going from having the second-lowest ART coverage (54.9%) in 2017 to the second-highest (86.2%) in 2022.
In terms of 95-95-95 targets, in 2022, 91.5% of people living with HIV in the Northern Cape knew their HIV status, 94.7% who knew that they had HIV were on ART, and 97.4% of those on ART were virally suppressed.
Service access
According to Paula Makatesi, head of the Northern Cape Provincial Council on AIDS Secretariat, the Northern Cape is the largest province in South Africa but also one of the poorest. She said that social determinants of health played a significant role in access to, and uptake of, HIV care and services. For instance, many attendees noted that the Northern Cape’s relatively small population, dispersed settlements, poverty and lack of infrastructure present both logistical and systemic obstacles to effective HIV management and prevention.
“Resources are always sent to the places with the most people, leaving the rural areas underserved,” she said. The results showed these disparities. For example, Figure 2 shows that urban areas had a circumcision rate of 36.6%, rural tribal areas had a circumcision rate of 41.3%, and rural farm areas had the lowest prevalence of 19.8%.
Figure 2. Self-reported circumcision rates of males over 15 based on location, Northern Cape Province, 2022
Source: HSRC
According to Sheila Lute from the Northern Cape Department of Health, few service providers and partners in the Northern Cape provided services outside of working hours and away from health facilities.
Lute argued that the support of the US President’s Emergency Plan for AIDS Relief (PEPFAR) in other provinces had influenced the expansion of healthcare services. She said that advocating for these resources in the Northern Cape would increase service access opportunities.
Barriers to service delivery
SABSSM VI also found that the Northern Cape had the lowest circumcision rate among males aged over 15 in the country. This rate decreased from 39.2% in 2017 to 35.6% in 2022.
Tebogo Olifant, the coordinator of the medical male circumcision (MMC) programme in the province, said MMC was accepted and in demand in many Northern Cape communities, but the issue was the lack of service access points.
He argued that service providers saw MMC as a seasonal service and should be encouraged to provide it year-round. “We should also create a demand for MMC in institutions of higher learning,” he said.
Participants also identified challenges in implementing educational and awareness campaigns. One attendee noted that communication barriers, intensified by cultural and linguistic diversity, hindered the effectiveness of these initiatives in the province. She argued that stakeholders should tailor campaigns to different groups based on their language, culture and experiences to achieve the best outcomes.
For example, MMC is considered a more trusted method for preventing HIV infection than traditional circumcision. However, to encourage its adoption, stakeholders should remain sensitive to cultural practices and traditions.
Another significant gap in service delivery in the province was pre-exposure prophylaxis (PrEP) provision. Figure 3 shows only 22.7% of individuals had heard of PrEP, less than 1% of individuals had ever used it, and at the time of the survey, none of the participants were on it. However, the survey revealed that 86.3% of participants would take PrEP.
“This highlights an opportunity to optimise PrEP as a prevention strategy,” said Dr Rachel Joseph from the US Centers for Disease Control and Prevention.
Figure 3. Awareness and uptake of PrEP among those aged 15 and older, Northern Cape Province, 2022
Source: HSRC
Testing
Joseph also noted concerning gaps in HIV testing seen among individuals between 15 and 24 years. Figure 4 shows that 39.1% of females and over 50% of males in this age group had never tested for HIV.
Figure 4. HIV testing among people 15 years and older, Northern Cape Province, 2022 (%)
Source: HSRC
HSRC PhD intern Thembelihle Ginyana said that in small communities, people avoided clinics because the healthcare workers there knew their families.
“They mention that stigma still exists, making them hesitant to visit clinics,” she explained.
Ginyana also suggested the use of HIV vending machines on college campuses to increase access.
“We should develop and distribute testing kits in these machines,” she said. “People may be more likely to test themselves rather than be tested by someone else in fear of stigma.”
Parental engagement
According to an attendee, some projects in the Northern Cape fostered dialogues between parents and children. She argued that these should be strengthened and expanded, and emphasised educating parents on sexual reproductive health.
Makatesi also cited the importance of parental influence, stating that this was where children got their information first and foremost.
“The power of parents is an intervention we should never underestimate,” she said.
Lessons from other epidemics
Attendees urged a reevaluation of HIV intervention measures, drawing on the successes of recent epidemics. One delegate spoke about the success of South Africa’s human papillomavirus (HPV) vaccination campaign, which succeeded in vaccinating many young girls in the drive to prevent cervical cancer. These vaccines were rolled out to schools across the country in 2014, and aimed to vaccinate Grade Four girls against certain HPV strains that cause cervical cancer.
The National Department of Health led this process, which involved government agencies, schools, healthcare workers, international organisations, pharmaceutical companies, NGOs, community leaders, parents and the media.
She argued that by applying this unified strategy, and with the same ferocity, the Northern Cape could engage the same stakeholders in coordinated HIV education and intervention programmes.
Lute compared the success of COVID-19 measures to those currently ongoing for HIV. “We contained the COVID-19 pandemic with political will and resources,” she said. “We need to invest the same amount in ending this epidemic.”
Research contacts
Yolande Shean for SABSSM research enquiries and Adlai Davids, a senior research manager, in the HSRC’s Public Health, Societies and Belonging Division
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