Between 2017 and 2022, HIV prevalence among young people in the Free State increased. This was a worrying caveat to the overall gains made in tackling the HIV epidemic in the province, as reported in the HSRC’s 2022 national household HIV survey. Progress was also uneven at the district level, with the lowest antiretroviral treatment coverage occurring in the district with the highest prevalence. At a provincial dialogue following the launch of these findings, stakeholders highlighted the need to channel resources into PEPFAR-unsupported areas. They also discussed providing more men-friendly services at more diverse locations. By Andrea Teagle
SABSSM VI researchers at Marakong Clinic in the Free State in February 2022. Photo: HSRC
The peak of HIV prevalence in the Free State was seen in an older cohort in 2022, compared to 2017, echoing the national narrative of an ageing epidemic. However, prevalence among those aged 15–19 years more than doubled, from 3.2% to 7.4%. By contrast, total prevalence declined from 17% to 15.6%.
The HSRC’s Professor Khangelani Zuma discussed these findings (see Figure 1) at the launch of the Free State key findings from the HSRC’s Sixth South African National HIV Prevalence, Incidence, Behaviour and Communication Survey (SABSSM VI) in September 2024.
“[15–19 years olds living with HIV] are the young ones who were most likely born HIV negative, but got infected between 2017 and 2022,” said Zuma, who is the overall principal investigator of SABSSM VI.
“The prevalence among young people is roughly synonymous with HIV incidence because it tells us about recent infections. We see a similar pattern among those who are 20 to 24 years old, so we’ve got our work cut out to deal with the HIV epidemic among those younger than 25 years.”
To ensure that the epidemic curve continues to shift towards older age groups, it was critical that the province bridge gaps in HIV testing and antiretroviral treatment (ART). For instance, young people aged 15–24 years accounted for more than a quarter (27.5%) of people living with HIV (PLHIV) unaware of their status, even though they made up just 10.0% of PLHIV.
Status awareness was high among men at 86.2%. However, it remained lower than among women (88.8%) and, for both sexes (88.1%), notably lower than the 95% testing target.
Overall, the Free State achieved a substantial increase in ART coverage, from 64.7% in 2017 to 81.3% in 2022. However, partly due to testing gaps, that left 84,000 out of 450,000 PLHIV not on treatment, which poses a risk for transmission.
Figure 1. Overall HIV prevalence, Free State Province, 2017 and 2022
Source: HSRC
Geographical gaps
Of the three districts where enough people were surveyed to provide representative results, Mangaung had the highest prevalence (18.7%) and, despite this higher need for treatment, it had the lowest overall ART coverage (76.4%) (Figure 2). This was mainly due to testing gaps: 78.4% of adults in Mangaung knew their status, compared to 96.5% in the Lejweleputswa district and 89.7% in Thabo Mofutsanyane.
Although prevalence was highest in rural areas, urban areas contributed to a disproportionate percentage of PLHIV who did not know their status.
What accounted for the significant district difference in testing uptake? According to community representatives, higher testing rates regionally corresponded to development partner support. Specifically, the United States President’s Emergency Plan For AIDS Relief (PEPFAR) partners with the government to provide HIV services in priority districts identified as having a particular need.
On-target testing rates in Lejweleputswa, a PEPFAR priority district, indicated the effectiveness of partner-supported programmes. These include family strengthening, voluntary medical male circumcision (VMMC) services and school-based HIV education programmes such as DREAMS (Determined, Resilient, Empowered, AIDS-free, Mentored and Safe).
Participants argued that coordinated efforts were needed to extend resources to neighbouring districts like Mangaung. Adolescents and young people aged 15–24 could also be reached outside school through HIV messaging on social media platforms such as Instagram and TikTok.
Figure 2. Overall HIV prevalence (a) and antiretroviral treatment (b), by selected districts, Free State Province, 2022
Source: HSRC
VMMC and integrated services
The survey indicated that peak HIV prevalence was among individuals aged 55–59, underscoring the importance of treatment coverage and viral suppression in this group. Participants argued that interventions aimed at adolescent girls and young women should also target men – particularly young professionals more likely to have younger sexual partners.
Music and sports events were considered effective areas for HIV campaigns. However, participants suggested that healthcare workers be present to offer HIV testing and treatment initiation on site.
According to the survey findings, overall viral suppression lagged among men at 75.9% compared to 83.4% among women. Speakers argued that men-friendly services would help to increase HIV testing and retain men in care. Suggestions included increasing the number of male clinicians, expanding hours, and offering them HIV services at more diverse, men-chosen locations.
Rosey Yaso, from the Department of Health, suggested that integrating multiple services at a single men-friendly site could increase uptake. She described a pilot site that initially only offered VMMC but now provides a broader range of HIV services to men.
“We have started with one team and our metro, which was exclusively a VMMC site, but … we are looking into increasing the package of interventions that are being provided for males, and the plan is to expand to other districts once this one is sufficiently budgeted and staffed,” said Yaso.
Although circumcision prevalence among males 15 years and older increased to 59.2% in 2022 from 57.2% in 2017, it was below the national average of 63.7%. Mangaung had relatively low circumcision rates, particularly among young men aged 15–24: 37.1% of males were circumcised compared to 65.7% and 64.2% in Lejweleputswa and Thabo Mofutsanyana, respectively.
The finding calls for geographically targeted VMMC campaigns. Teboho Motseti, from Mangaung’s Men’s Forum, noted that traditional men’s parliaments offered an avenue for promoting VMMC and debunking myths surrounding HIV.
Prof Khangelani Zuma (middle) and other delegates at the Free State SABSSM VI provincial dialogue in September. Source: HSRC
Increasing testing and PrEP uptake
According to Yaso, the Free State’s introduction of lay counsellors for HIV testing in 2021 significantly increased testing uptake.
“[Before then], we were focusing on professional nurses and other categories of nurses in terms of testing,” she said. “The uptake of testing appeared to be low. Between 2020 and 2021, during the [COVID-19] pandemic, we appointed lay counsellors. Since then, our uptake of testing has improved.”
Stakeholders agreed that HIV testing campaigns should be augmented with widespread pre-exposure prophylaxis (PrEP) awareness. According to the survey, 60.5% of people aged 15 and older said they would take PrEP after receiving information about it. Despite this relatively high interest, actual use remained low, with only 4.8% reporting having ever taken it.
Healthcare workers noted that some young people hesitate to take PrEP once they realise it is an antiretroviral medication, fearing that it will lead to stigma and assumptions about their HIV status. This highlights the need for enhanced awareness campaigns to improve the understanding of PrEP and dispel the ongoing stigma surrounding HIV in the province.
Research contact
Yolande Shean for SABSSM research enquiries at the HSRC’s Public Health, Societies and Belonging Division
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