The state of HIV in Sub Saharan Africa:
A decade of progress and the challenges and opportunities that lie ahead
The Sub-Saharan region of Africa has been the hardest hit by HIV. Despite having approximately six percent of the world’s population, this region is home to more than half the global number of people living with HIV (20.6 million people).1
Here, while the HIV epidemic is considered generalised, populations with an increased vulnerability to infection include: young women, men who have sex with men, transgender people, sex workers, prisoners and people who inject drugs. Although laws and cultural traditions vary between African countries, a number of ingrained cultural, structural and legal barriers to HIV prevention remain, including stigma and discrimination, social exclusion, uninterrupted access to treatment and access to new technologies.
In Sub-Saharan Africa, gender-related factors fuelling the epidemic are especially stark, as women and girls often face discrimination and less access to education, employment and healthcare. In fact, adolescent girls and young women in this region were more than twice as likely to acquire HIV than their male peers, according to a Joint United Nations Programme on HIV/AIDS (UNAIDS) estimate — accounting for about 59% of all new HIV infections in 2019.2,3
While work remains to improve these numbers, great strides have been made towards meeting the UNAIDS 90-90-90 targets of reaching the majority of people living with HIV by 2020, including increasing their access to antiretroviral treatments and expanding the availability of HIV testing services.4 Some countries in Sub-Saharan Africa, specifically Botswana, Eswatini and Namibia, have achieved or exceeded the targets set for 2020.5 Yet, many more countries lag behind. For example, in Madagascar, Mauritius and South Sudan, fewer than 25 percent of the people living with HIV are aware of their status.5
Many factors come into play to ensure a continued comprehensive and effective response. Here, we will discuss the challenges facing this region, including the COVID-19 pandemic’s impact and opportunities for the decade ahead.
Global pandemic disruption to HIV/AIDS-related treatments
The rapid spread of the SARS-CoV-2 virus caused some setbacks to the progress made on the treatment and diagnosis of HIV. Due to measures to prevent the spread of the COVID-19 pandemic, populations at risk for, or living with, HIV may experience reduced access to pre-exposure prophylaxis (PrEP) and other preventive measures such as condoms.6 Additional barriers include interruptions in the antiretroviral drug supply, effects of lower quality clinical care due to overstretched health facilities, an interruption of the supply of other drugs (for example, co-trimoxazole, which is taken to prevent protozoal, bacterial and fungal infections), and the suspension of HIV testing because of a reluctance among patients to start or continue treatment over concerns about being exposed to COVID-19.6
Early modelling from UNAIDS indicated that a severe disruption in HIV treatment could result in additional AIDS-related deaths in Sub-Saharan Africa.4 As a result of the of the COVID-19 pandemic, some countries have reported:
- An approximate 20 percent reduction in the collection of medicine in certain areas
- People living with HIV lacking an adequate supply of antiretroviral treatment for a lockdown of more than 60 days
- People abandoning their HIV treatment due to a lack of food.4
During the COVID-19 pandemic, to avoid additional HIV-related deaths, governments, healthcare companies and communities should focus on maintaining uninterrupted supplies of treatments and prevention measures for people at risk for, or living with, HIV.
A promising vaccine research outlook
It is widely acknowledged that only a vaccine will end AIDS. With more than 20 HIV vaccine clinical trials ongoing and some very recent learnings from innovative vaccine approaches in the quest for a SARS-CoV-2 vaccine (e.g. mRNA technology), the HIV vaccine environment looks promising.
Over the past decade, early failures and new advances in scientific knowledge have led to some successes and have helped frame the research agenda around HIV vaccine research. Early on, the RV144 study was the first time an HIV vaccine showed some level of protection, offering the promise that a preventive vaccine was possible7 and providing the basis for researchers to create other vaccines.
Other approaches include the Imbokodo trial (2017), a Phase IIb proof-of-concept study designed to evaluate “mosaic”-based vaccine regimens using mosaic immunogens delivered through a viral vector comprised of an inactivated common cold virus.8 These immunogens are molecules capable of inducing an immune response to a wide variety of strains of HIV.8 The study is currently enrolling women, between the ages of 18 to 35, in five countries across Sub-Saharan Africa.9
Other vaccine trials, such as PrEPVacc (to be launched in 2021 in Mozambique, South Africa, Tanzania and Uganda), will be a combination efficacy study comparing two experimental vaccine regimens with placebo, with a concurrent open-label randomised PrEP arm.10
Within the context of HIV clinical trials, digital health technologies are being used to measure adherence to antiretroviral therapies. Some examples include programmes in South African and other Sub-Saharan countries to engage women in HIV prevention treatment using text messaging for interventions.10
New targets for 2025
Globally, we’ve made great progress in the prevention of new HIV infections and AIDs-related illnesses. Since 2010, new HIV infections and AIDS-related mortality have declined by 23 percent and 39 percent respectively.11
At the end of 2020, UNAIDS released a proposal for new HIV targets for 2025 to ending AIDS as a public health threat by 2030.11 The proposal replaces the 90-90-90 with more ambitious 95–95–95 testing and treatment targets, focusing on a high coverage of HIV and reproductive and sexual health services and on reducing stigma and discrimination.12
While the COVID-19 pandemic disrupted health systems and other public services, and halted HIV services and supply chains for key commodities across Sub-Saharan Africa, the approval of mRNA vaccines to combat viral transmission brings scientific advances, holding promise for a future HIV vaccine. Running HIV trials requires new and creative approaches to combat discrimination and stigmas, and reflects the diverse cultural, lifestyle and biological circumstances that influence individual decision-making around the use of HIV prevention strategies.
References
- HIV and AIDS in East and Southern Africa regional overview. (2019). Avert. https://www.avert.org/professionals/hiv-around-world/sub-saharan-africa/overview#footnote1_5rg566p
- Adolescent girls and young women in sub-Saharan Africa more than twice as likely to acquire HIV. (2020). UNAIDS. https://www.unaids.org/en/resources/presscentre/featurestories/2020/march/resources/presscentre/featurestories/2020/march/20200309_adolescent-girls-young-women-sub-saharan-africa
- Fact Sheet - Latest global and regional statistics on the status of the AIDS epidemic. (2020). UNAIDS. https://www.unaids.org/sites/default/files/media_asset/UNAIDS_FactSheet_en.pdf
- 90–90–90: good progress, but the world is off-track for hitting the 2020 targets. (2020). UNAIDS.https://www.unaids.org/en/resources/presscentre/featurestories/2020/september/20200921_90-90-90#
- AIDSinfo. UNAIDS. http://aidsinfo.unaids.org/
- Jewell, BL, et al. Potential effects of disruption to HIV programmes in sub-Saharan Africa caused by COVID-19: results from multiple mathematical models. (2020). The Lancet. 7:9: E629-640. DOI: https://doi.org/10.1016/S2352-3018(20)30211-3
- Uhambo. (2020). http://uhambo.org.za/
- Imbokodo. (2020). https://imbokodo.org.za/
- Seizing the moment: Tackling entrenched inequalities to end epidemics. (2020). UNAIDS.https://www.unaids.org/sites/default/files/media_asset/2020_global-aids-report_en.pdf
- Vaccines for poverty-related diseases: Project: Weber A combination efficacy study in Africa of two DNA-MVA- or DNA- Env protein HIV-1 vaccine regimens with pre-exposure prophylaxis (PrEP). (2020). ERA- LEARN. https://www.era-learn.eu/network-information/networks/edctp-ii/vaccines-for-poverty-related-diseases-prds/weber-a-combination-efficacy-study-in-africa-of-two-dna-mva-or-dna-env-protein-hiv-1-vaccine-regimens-with-pre-exposure-prophylaxis-prep
- Global HIV & AIDS statistics — 2020 fact sheet. (2020). UNAIDS. https://www.unaids.org/en/resources/fact-sheet
- 2025 AIDS Targets. (2020). https://aidstargets2025.unaids.org/#