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World AIDS Day has been commemorated on 1 December every year since 1988. On this day, people around the world unite to show support for people living with HIV and also to remember those who have lost their lives due to AIDS-related illnesses. The red ribbon has become the universal symbol of HIV awareness and symbolises support for and solidarity with people living with HIV. World AIDS Day was the first-ever global health day, and the iconic red ribbon led the way for many other coloured ribbon awareness campaigns, like the pink ribbon for breast cancer.

COVID-19 brought challenges for HIV/AIDS

Each World AIDS Day has a specific theme with this year’s theme being Global solidarity, shared responsibility. Like many other public health issues, the COVID-19 pandemic has brought additional challenges to the HIV/AIDS programme. Disruption of service delivery at primary health-care level – including HIV prevention, testing, treatment and care – will undoubtedly haunt us for years to come. The call to solidarity is made to re-focus efforts to reach the goal of ending the HIV/AIDS epidemic by 2030.  In the short-term, this means restoring and maintaining essential HIV services that were disrupted during the COVID-19 pandemic. In the medium term, this means intensified efforts to prevent new infections, while awaiting a breakthrough in the area of developing a vaccine.

Having an HIV-free generation is an attainable goal: it has been proven that when an HIV-infected person’s viral load is undetectable, they cannot transmit the virus via unprotected sex. HIV viral load refers to the amount of HIV in your blood. Antiretroviral Treatment (ART) suppresses viral replication and if taken regularly, results in the amount of virus in the blood being undetectable. The message that undetectable equals untransmittable (U=U) has given people living with HIV (PLHIV) new hope.

Success story of the SA HIV/AIDS programme

Especially women living with HIV can now be almost certain of not transmitting HIV to their unborn child if their viral load is undetectable. One of the great success stories of the HIV/AIDS programme in South Africa is the Prevention of Mother To Child Transmission (PMTCT) programme. Vertical transmission (meaning from mother to child) of HIV can happen during pregnancy, during labour or after birth via breastfeeding. In 2010 the rate of vertical transmissions in South Africa was 16%. This decreased to 3% in 2019, but renewed efforts are now being made to Eliminate Mother to Child Transmission of HIV. The current South African Consolidated ART guidelines allow access to treatment for all HIV-infected people. The latest UNAIDS data revealed that 97% of pregnant HIV-positive women are accessing HIV treatment. (2). In order to eliminate vertical transmission, we need to ensure these women attain and maintain full virological suppression, but more importantly, we need to prevent new infections in women.

National prevention strategies

National prevention strategies include public health-education programmes, Post-Exposure Prophylaxis (PEP), Pre-exposure Prophylaxis (PrEP) and voluntary male medical circumcision (VMMC). Education on prevention of HIV includes HIV risk reduction counselling and education on the correct use of condoms and lubricants. Despite all these measures, there were 200 000 new infections recorded in South Africa in 2019 (2). With complacency setting in, demonstrated by this rise in new HIV infections, it is critical to continue education and awareness programmes.

PEP is offered to individuals after a high-risk exposure with the potential transmission of HIV, e.g. after rape or to health-care workers sustaining an injury on duty. Effectiveness of PEP is reliant on early presentation and good adherence. Due to the advances made in ART, PEP is now also as simple as taking one tablet once a day with minimal side-effects, improving compliance and outcomes.

PrEP is defined by the WHO as the use of ARVs by HIV-negative people who are at substantial risk of acquiring HIV before potential exposure to HIV to prevent HIV acquisition. Specific populations considered to be at significant risk of HIV infection include, among other, adolescent girls and young women, men who have sex with men, people with more than one sexual partner and sex workers. (3). South Africa was the first country in sub-Saharan Africa to fully approve PrEP. The preferred regimen is also a fixed-drug combination (FDC) containing two ARV drugs in a single tablet taken once daily.

Still no cure

Although we have very effective preventive strategies as well as excellent treatment available for PLHIV, a cure still has to be found. A cure is either defined as “sterilising” or “functional”. A sterilising cure would remove HIV from the body altogether. A functional cure means that HIV is not entirely eradicated from the body, but the virus is no longer increasing; thus, treatment is not needed.

So far, two people have been cured of HIV. Both of these patients received bone marrow transplants as part of blood cancer treatment. In both cases, the donor cells were naturally resistant to HIV. The cancer treatment eliminated the already HIV-infected cells from the body, and because the new cells were not susceptible to HIV, no more new viruses were produced. Unfortunately, the first patient, Timothy Ray Brown, passed away this year due to a recurrence of cancer. A sterilising cure of this nature is clearly not the answer, and therefore, intensive research in this area is ongoing.

Despite the enormous scientific strides made since the identification of HIV in 1984, HIV remains a significant public health concern. Globally, millions of lives are still lost every year due to AIDS-related illnesses. In South Africa, 72 000 deaths were recorded during 2019 (2). This number is substantially higher than the deaths due to COVID-19 in 2020.  World AIDS Day remains as relevant today as always, reminding people and governments that HIV has not gone away.  It is a public responsibility to continue to fight the epidemic together as a society.

Opinion article by Dr Riana van Zyl, Senior Lecturer and Medical Specialist: Paediatrics and Child Health