CUBAN revolutionary leader Fidel Castro once remarked: “A revolution is not a bed of roses. A revolution is a struggle to the death between the future and the past.” I have often argued that the introduction of the National Health Insurance (NHI) is not an attempt at tinkering with the health care system but a complete change, a revolution. As Castro rightly, observed, this is a struggle between the future and the past.
Clearly, while many of us want a future in which the provision of health care will be based on a mandatory pre-payment system whereby patients would not be required to pay at the point of service, in all facilities - both public and private - regardless of the patient’s economic status or social standing, there are those who are clinging to the past characterised by inequality in the provision of health care. We have no option but to press ahead with the implementation of the NHI to deliver on the mandate imposed to us by our Constitution that states that the provision of health care is a right.
A decade ago, those who were against the use of antiretrovirals (ARVs) to deal with the HIV/Aids pandemic argued the treatment was unaffordable. Today, those against the implementation of the NHI also argue that the plan is too expensive. Our response, as it was then when we were rolling out a massive ART (Antiretroviral Therapy) programme, is that the real question should be: can we afford not to?
A decade later, study after study shows that we were right to press ahead with the massive ART programme despite calls to the contrary. Now South Africans are living longer, thanks to the ART programme.
There are now fewer children born with HIV. And because people are living longer, there are fewer orphans. The economic spin-offs of the ART are massive.
As we honour the founding father of our democracy, Nelson Mandela, we have to reflect on how we are making his vision of a better life for all a reality. Madiba was a great campaigner for the provision of Antiretroviral Therapy.
It is indeed significant that the South African national HIV Prevalence, Incidence, Behaviour and Communication Survey 2017 was launched just a day before Madiba’s 100th birthday, given that it was our beloved president who commissioned the first survey in 2002. Madiba was very concerned about the impact of the HIV epidemic on South Africans, and it is in his honour that we launch these results this week.
These results come at the right time, ahead of the International Aids Society Conference to be held in Amsterdam next week. South Africa can, therefore, showcase our response to the HIV epidemic globally at this conference using the latest data. It is indeed gratifying to know that some of our hard work since 2012 is beginning to pay off.
The researchers estimated the number of new HIV infections in 2012 in people older than 2 years of age was 378 700 or 0.85%. Incidence in 2017 is reported to be 231 100. This group represents 38% of all new infections (88 400 of the 231 100) in 2017 and justifies our focus on this group when President Ramaphosa launched the She Conquers Campaign in 2016!
South Africa adopted the UNAIDS 90-90-90 targets to be reached by December 2020. This study has helped to determine our progress towards these targets and to provide a 2017 benchmark against these targets. According to our researchers, we are currently at 85-71-86. This means that we are very close to the first 90 - which is the percentage of those that are HIV positive who know their status.
The second 90 refers to those that are on treatment. Although we have 4.4 million people on treatment, we still have some way to go to ensure that those that are HIV positive are on treatment. That is, we need to strengthen linkage to care.
The third 90 refers to the percent of those that are on treatment and virally suppressed. Here, we are very close to the target. As reported by the researchers, we need to focus on getting more men and young people who are HIV positive on treatment. We therefore need to find creative ways of getting more men and young people between the ages of 15 and 24 tested for HIV and initiating them on treatment.
The campaign to test and initiate 2 million people in HIV treatment announced by the president in his 2018 State of the Nation address will indeed include a focus on men and young people. We will be launching this campaign within the next few months. As the researchers reported the key reason for the declines in new HIV infections across all age ranges is that large numbers of people are on ARVs and are virally suppressed. Our plans are to increase the number of people on ARVs to over 6million by the end of 2020. This is a tall order, and the support of all our partners will be critical in achieving this.
Given the large number of people with HIV on ARVs and virally suppressed, it is not surprising that prevalence has increased between 2012 and 2017. Indeed, this is to be expected. This report makes clear that the increase in prevalence is not due to increasing incidence. There is therefore only one explanation - prevalence is increasing because people on ARVs are living longer. This is corroborated by data on life expectancy from Stats SA which estimated that life expectancy in 2008 was 56.1 years, rising to 61.1 years in 2012 and 64 years in 2017.
However, let’s be clear. We must also ensure that our prevention campaign is strengthened to ensure that we are able to close the tap more rapidly. This means that people who are sexually active must use condoms consistently - as the 2017 data suggests young people especially are having sex at a younger age but not using condoms consistently. We need to work harder to ensure that young people delay sexual debut, but if they are having sex, they must use condoms consistently.
In this regard, an issue of concern is the perception of the risk of acquiring HIV. It is clear from the study that a large percentage of respondents did not consider themselves to be at risk. We need to think about how to change this because unless people do think about the risks, they will continue to participate in risky sexual behaviour.
It is gratifying to see that the number of medical circumcisions is rising. We need to increase the rate of circumcisions, especially among those between 15 and 35 years of age. With our partners, we will increase our focus on this age cohort. We know that multiple concurrent partnerships increase the risk of HIV acquisition. It is gratifying to see that the proportion of men who reported multiple sexual partners has declined.
However, it is clear that we need to focus on providing more information on HIV and how it is transmitted as well as the importance of being on treatment as soon as one is diagnosed HIV positive. This report provides us with much data. I am sure that the researchers together with implementing partners will spend many hours, days and months analysing the data. As government, we will do everything possible to not only reach the 90-90-90 targets by December 2020 but also to reduce new HIV infections.