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Ten years ago Nomvula*, a 20-year old mother of two living with HIV, would have been extremely ill but with a CD4 count of over 400, she would not have been eligible for treatment. It is likely that at least one of Nomvula’s children would have contracted HIV from her because she mix-fed her babies (breast and bottle feeding). Nomvula’s partner might also have contracted HIV from her and her quality and length of life would be severely compromised.

Today, the picture is very different for Nomvula and millions of South Africans like her. Research on prevention and treatment has accelerated the pace of change in the HIV and AIDS response, leading to new policy and strategic directions such as the introduction of test and treat, which immediately puts people on treatment when they test HIV positive. We are now in an entirely different era. Increases in treatment access in South Africa is a marked success story. The more than four million people currently on antiretroviral treatment (ART) represent a 44% increase since 2012. As a result, AIDS-related deaths have sharply declined and life expectancy has increased from 60 years in 2012 to 64 years in 2017. The mother-to-child transmission rate is less than 3%.

But with an estimated 260,000 new infections annually, South Africa’s HIV epidemic is not only the largest in the world (with 7.9 million people living with HIV), it is also the fastest growing. Women face a disproportionate HIV burden, particularly adolescent girls and young women (AGYW) aged 15-24 years. Also at greatest risk are key populations: sex workers, men who have sex with men, people who inject drugs and transgender people. The latest strategies to prevent these new infections and care for those affected are very different to the approaches of 10 years ago.

Treatment as prevention

A recent landmark study published in the Lancet has confirmed what scientists have long suspected: that people whose HIV infection is fully suppressed by antiretroviral drugs have no chance of infecting their sexual partners. Undetectable is un-transmittable. This means that getting people tested and onto immediate treatment is now the cornerstone of HIV prevention efforts. UNAIDS’ 2030 fast track targets of 95% of people living with HIV knowing their status, 95% of these people being on treatment and 95% of these being virally suppressed has become the driving force behind the AIDS response.


Pre- and post-exposure prophylaxis (PrEP and PEP) are courses of antiretroviral medication provided to people who are HIV-negative to prevent transmission. PEP is provided to rape survivors and other people who have been exposed to HIV and PrEP is offered to men who have sex with men, sex workers and, most recently, adolescent girls and young women. While the provision of PEP is not new, we are learning more about driving demand and supporting rape survivors to adhere to the full course to improve their chances of avoiding HIV – if started within 72 hours after exposure and taken for 28 days, PEP can reduce the risk of HIV infection by over 80%.

The roll-out of PrEP is expected to yield results for South Africa’s new infections rate but creating demand for PrEP and supporting people who choose to take it will be critical to its success.


There are an estimated 280,000 children, ages 0-14 living with HIV in South Africa, with 13,000 newly infected per year. Only half of children living with HIV under 15 in South Africa who need ART are receiving it. South Africa is home to 15% of all adolescents living with HIV globally, with an estimated 320,000 10-19-year-olds who are HIV-positive. While vulnerable children and adolescents receive health and social services, they are not routinely tested for HIV. And while such services are being made available to schools, there is still work to be done with school leadership bodies to change their hearts and minds to allow such services to be offered.

Girls aged 15 to 19 are becoming HIV-infected at eight times the rate of their male peers, but often only access testing, care and treatment services if pregnant. Poor rates of testing of children and adolescents and a lack of child and adolescent-friendly health services underpins the higher rates of HIV-related illness and death in young people. Finding HIV positive children and adolescents, linking them to appropriate care and supporting them and their families through the treatment cascade is therefore a critical component of today’s AIDS response.

Community systems

As the response to HIV has developed, the role of communities and community systems has become increasingly important. Demand creation for testing, treatment, PrEP and HIV self-screening (or self-testing) is now a core component of many interventions and community engagement is vital in encouraging people to seek the services they need. The de-centralisation of HIV testing, treatment and support services means that civil society organisations are now more integrally involved than ever before – reaching into communities and populations that health systems simply cannot reach. According to UNAIDS:

“Civil society should play a role at every level in order to ensure that services are designed and delivered equitably.”

On target

Another key shift has been the geographic implementation approach of targeting high-burden and transmission areas and saturating them with services to ensure maximum impact. This is the result of a much more focused and data-driven strategy and has made service mapping at a granular level a necessity.

As a society, we have become much more sophisticated in our response to the AIDS epidemic but we still have a long way to go to in dismantling stigma and discrimination to reach the global target of ending AIDS by 2030. Let’s work harder together to get there.

Find out more about how NACOSA’s programmes are working towards this target.

* Not her real name

Sources: UNAIDS, HSRC, WHO, The Lancet