Reducing new infections among young people, and increasing antiretroviral treatment coverage and viral suppression among men, is critical to maintain momentum towards controlling the HIV epidemic in South Africa’s North West Province. This was one of the takeaways from an HSRC dialogue around the results of the latest national household HIV survey. Encouragingly, the survey revealed widespread interest in the preventative treatment known as pre-exposure prophylaxis (PrEP), suggesting that with enhanced awareness, PrEP could prove to be a game changer in North West. By Andrea Teagle
A delegate views an exhibition at the SABSSM VI provincial launch dialogue in September 2024. Photo: HSRC
The HIV epidemic is stabilising in North West Province, but the prevalence among adolescents and young adults, aged 15–19 and 19–24 years, remains worryingly high. The HSRC’s Sixth South African National HIV Prevalence, Incidence, Behaviour and Communication Survey (SABSSM VI) revealed a provincial HIV prevalence of 12.3% in 2022, down from 14.8% in 2017. This translates into 465,000 people living with HIV (PLHIV) at the time of the survey.
Consistent with a country-wide trend, the North West data showed that HIV prevalence had increased among older age groups from 2017 to 2022 (Figure 1).
“That is actually an indication of an ageing epidemic,” said principal investigator Professor Khangelani Zuma of the HSRC. He was addressing a gathering of local healthcare experts, activists, development partners and policymakers at the launch of the SABSSM VI key findings for North West Province.
The shift in the epidemic indicated that PLHIV were living longer thanks to antiretroviral therapy (ART), Zuma said, which was good news. However, the simultaneous reduction in new infections among young people (15-19 years) nationally was not seen in North West. Instead, prevalence increased slightly from 3.2% to 4.5%. The difference was not statistically significant but remains a concern, he said.
“One would expect fewer infections in 2022 compared to 2017 because of the messages [around] condom use, and knowledge about HIV,” Zuma said. However, prevalence had not decreased as expected among young people and “that is a concern”.
Figure 1. Overall HIV prevalence by age group, North West Province, 2017 and 2022
Source: HSRC
Dual focus
The higher prevalence among women aged 15–24 (8.3%) compared to men (3.3%) pointed to age-disparate relationships as one of the ongoing drivers of new infections in this age group. The province had among the lowest ART coverage (78.9%), with 69.9% of men living with HIV on treatment.
Within the province, ART coverage was lowest in Bojanala (81.5%), the district with the highest prevalence. North West Province was one of two provinces with the lowest viral load suppression, at 58.7% in 2017 and 77% in 2022. Having less than 1,000 copies of HIV/ml blood means viral load suppression has been achieved, and the person’s chance of becoming ill or transmitting HIV is greatly reduced.
“We have a group of men out there who are living with HIV but are not on treatment, and they don’t even want to participate in the studies,” said Zuma, referring to the lower SABSSM VI survey participation rate among men (85.5%) than women (91.9%) in the province.
Among men, viral load suppression was just 62.5% compared to 84.9% among women. This translated to a large pool of men able to transmit HIV to their sexual partners, including young girls and women.
Participants in the dialogue agreed that reducing new infections in the province would require a dual focus on empowering young people with prevention and treatment strategies, and improving HIV messaging aimed at men. With HIV prevalence and ART coverage varying by district, strategies also needed to consider localised challenges.
Men-to-men groups
Creating safe spaces for open dialogue emerged as a critical strategy to engage with men.
“We need to start having conversations with men … about many issues, including issues around HIV, issues around GBV [gender-based violence], and issues around VMMC [voluntary medical male circumcision],” urged Bonolo Motlhomi from the sexual and reproductive health group Shout-It-Now.
The success of Shout-It-Now’s Man-to-Man programme is evidence of the effectiveness of this approach. The programme provides a safe space for men to talk about gender norms and sexual health, to share information on HIV prevention and to test for HIV. However, such development partner initiatives are limited in scope and require state collaboration to upscale.
An important component of HIV messaging, particularly in the context of men, was the U=U (Undetectable = Untransmittable) campaign, launched nationally in 2023. The campaign aims to raise awareness that PLHIV on treatment and who are virally suppressed cannot transmit HIV.
However, Neo Moepi of the North West Provincial Council on AIDS suggested that U=U had been “poorly introduced” in the province, with some individuals using it as an excuse to stop using condoms. Participants agreed that while the U=U campaign could reduce stigma and encourage treatment adherence, it should be accompanied by widespread messaging around the importance of consistent condom use.
In North West, only 21.4% of those aged 15 and older reported that they wore condoms consistently during sexual encounters, and only 3.6% almost every time (Figure 2).
Figure 2. Consistency of condom use with the most recent sexual partner among people aged 15+, North West Province, 2022
Source: HSRC
Going digital
Although only 6.4% of PLHIV were between the ages of 15 and 24, young people accounted for 15.8% and 15.5% of those not on treatment and not virally suppressed, respectively (Figure 3). Participants agreed that reaching young people required channelling the limited available funding into innovative, youth-led campaigns.
“We need to think how they are thinking,” said Puseletso Mohapi from PEPFAR (the US President’s Emergency Plan for AIDS Relief). “We need to go digital.”
Participants suggested that HIV messaging be designed by young people and delivered on popular social media platforms such as TikTok and Instagram.
Recognising that some outreach methods, such as church-based campaigns, may be missing the mark, participants suggested targeting youth where they spent time. Community events, festivals and schools in particular were identified as key areas for HIV messaging and condom distribution.
Educational interventions like the PEPFAR-funded DREAMS (Determined, Resilient, Empowered, AIDS-free, Mentored and Safe) have been shown to reduce risky sexual behaviour among adolescent girls and young women. The participants suggested that such programmes be intensified and extended to adolescent boys and young men for a broader, lasting impact. Reintroducing family interventions that engage parents around HIV could catalyse conversations in the home.
Figure 3. Gaps in 95-95-95 targets for people aged 15+ years living with HIV, by age groups, North West, 2022
Source: HSRC
Youth- and men-friendly HIV services
Stakeholders also highlighted the importance of making health facilities that offer HIV testing and treatment services more youth- and men-friendly. In addition to making clinics feel safe and private, the province could consider drawing young people to these spaces through other offerings that reflected the socioeconomic drivers of the epidemic. Ideas ranged from gardening training to providing free internet access.
“If we have internet where youth can source available opportunities, they know where they can apply for employment,” Motlhomi suggested, underscoring the link between HIV risk and socioeconomic factors such as unemployment. Participants also proposed initiatives to restore youth clubs and recreational centres.
Suggested strategies to draw more men into care included investing in more male clinicians and bringing services to remote areas – particularly in Bojanala – to cater for migrant farm workers and truck drivers. Existing strategies that worked included the “Happy Hour” at clinics – dedicated timeslots for young people and men to access HIV services.
Biomedical strategies such as pre-exposure prophylaxis (PrEP) also have an important role to play in helping those at high risk for HIV to protect themselves. Available in some healthcare facilities in South Africa, PrEP refers to medication that prevents HIV acquisition.
The SABSSM VI team found that only 30% of all survey participants in North West had heard of PrEP. However, on receiving information about the preventative treatment, 79.5% said they would like to take it. Participants agreed that the province needed to focus on raising awareness of PrEP among young people. Said Paula Morgan, deputy country director at the Centers for Disease Control and Prevention, “It could be a gamechanger.”
Research contact:
Yolande Shean for SABSSM research enquiries at the HSRC’s Public Health, Society and Belonging: yshean@hsrc.ac.za
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