South Africa’s HIV infection rates could be slashed significantly when the twice-a-month HIV vaccine, among new treatments offering hope in reducing the massive global burden of HIV, is rolled out by the end of the year.
Health experts and world leaders at the International Aids Conference in Germany in the past week, marked significant advancements in the treatment of the disease – which has infected nearly 89m people worldwide – and killed about 42.3m, notes MedicalBrief.
It comes as a seventh person – a German man – has been declared HIV-free after a stem cell transplant.
Contraception in its various forms, the growing use of pre-exposure prophylaxis (or PrEP), and multi-faceted education programmes, have all helped reduce the number of infections, although globally, 39.9m people were still living with HIV at the end of 2023.
New ARV therapies are also contributing to declining numbers, as are preventative therapies (the six-monthly lenacapavir is considered highly effective but is not yet available here), while the two-monthly CAB-LA HIV-prevention jab is also creating international excitement and in South Africa, where roll-out begins later this year.
Before the end of this year, 867 public health facilities will start rolling out the HIV preventative CAB-LA injection, using 96 000 doses donated by the US Government, drawing South Africa closer to its goal of ending the spread of Aids as a public health threat by 2030 as promised by Deputy Health Minister Dr Joe Phaahla
At the 25th International Aids Society Conference in Germany this week, Phaahla said that this did not mean there would be no cases of HIV/Aids by then, but rather, that the spread would be “completely under control”.
It is widely hoped that the roll-out of the CAB-LA jab will go some way to achieving that goal.
Eliminate chances
Studies show that CAB-LA, which gradually releases the antiretroviral drug cabotegravir into the body over two months, can virtually eliminate the chances of contracting HIV through sex, write Mia Malan and Linda Pretorius for Bhekisisa.
Through the jab, 52 000 new HIV infections can be stopped every year, found a 2022 modelling study published in The Lancet HIV. In that year, about 150 000 adults –15 and older – in South Africa contracted HIV, which means making the shot available as an HIV prevention option can slash the country’s infections by a third.
Early results of five demonstration studies released at the International Aids Conference showed that when offered choice between taking a daily HIV prevention pill, using the monthly vaginal ring or getting a CAB-LA shot, which only has to be taken every other month, up to three-quarters of women went for the jab.
Researchers from the Desmond Tutu Health Foundation in Cape Town found that among 1 084 women aged between 19 and 28, 74% chose the injection.
The jab, made by British manufacturer ViiV Healthcare, has been added to HIV prevention options at 16 research sites between February and June, Hasina Subedar, a senior technical adviser for the national Health Department, told Bhekisisa at the conference.
Although it’s too early to comment on trends from these studies, or draw clear conclusions, Subedar said the long-acting cabotegravir injection is gaining momentum as a popular choice among both young men and women.
Donation of doses
The government accepted the 96 000 CAB-LA doses – to arrive between October and December this year – as part of a larger donation of 231 000 doses that Pepfar is releasing over two years, said the Health Department’s director-general Sandile Buthelezi.
Buthelezi, who signed South Africa’s acceptance of the donation on 27 June, said the department accepted the donation on the basis that cheaper generic versions are likely to become available in early 2027, which will help the country to sustain supplies.
Other donors, such as the Global Fund for Aids, TB and Malaria, have “also shown appetite” to donate CAB-LA, and people started on this medicine will be able to switch to another injection, lenacapavir, which only has to be taken once every six months, if they choose to and if it becomes available in South Africa.
A recent study showed that none of 2 134 women who received lenacapavir contracted HIV, but the drug is not yet registered with the SA Health Products Regulatory Authority (SAHPRA). CAB-LA was registered in December 2022.
The 96 000 CAB-LA doses are enough to protect 13 728 people against HIV infection for one year, Subedar said.
The remainder of the 231 000 doses will arrive in this country from October 2025, the beginning of the financial year in the US.
South Africa will be the fourth African country, after Zambia (which started roll-out in February this year), Zimbabwe (in April) and Malawi (April), to offer CAB-LA free in state clinics and hospitals as part of its health programmes.
At a session at the Aids conference, Ashneil Jain of the US Department of State said Pepfar planned to sponsor CAB-LA in at least 12 countries before the end of the year.
Four times more expensive
Research shows CAB-LA works better than the daily HIV prevention pill, which, by the end of April, was available free in 93% (3 241 out of 3 484) of primary health clinics.
The pill contains two antiretroviral drugs (ARVs), emtricitabine and tenofovir disoproxil fumarate. Once there is enough of these two in an HIV-negative person’s vaginal or anal tissues, their white blood cells are shielded against HIV.
If the pill is used consistently (daily), it can lower the chances of contracting HIV by at least 90%, but many people struggle with adherence.
CAB-LA, on the other hand, only has to be taken every other month. But it is four times more expensive than the daily pill.
The department buys a month’s supply of the pill for R64.50. The injection, however, costs £23.50 a shot, the price ViiV Healthcare said in November 2023 it would charge for the medicine in 90 countries classified as having low- and middle-income status, including SA.
The 867 clinics that were chosen to stock Pepfar-sponsored CAB-LA have been selected because they’ve had a high uptake of oral PrEP – at least 20 new clients had to be given the pill in the past financial year, which started in March, said Subedar.
The department also had to ensure the donations are given to at least one facility in each municipality.
“If we run out of donations, and if there are no cheaper generic formulations or the department has not been successful in securing CAB-LA at a lower price,” she added,” we at least have oral PrEP that is effective.”
Under control
Phaahla said the aim was to reach a stage, in 2030, where “everybody will test and know their status, and everyone who is positive HIV-positive will be on treatment, and everybody who is on treatment will be virally suppressed … and we will achieve the target of making sure young people are HIV-free. In other words, there should be no new infections”.
However, he conceded that mother-to-child transmission is not decreasing as quickly as it had before, and the numbers of HIV+ children were still high, reports The Citizen.
“The numbers are not huge, it’s the coverage that’s the problem,” he added. “More difficult is the issue of stopping new infections, especially among young people … young girls and adolescent women.”
New social mobilisation and biomedical preventative initiatives – like the CAB-LA roll -ut – will tackle this, he said.
South Africa does not lack the political will to see this through, and in fact had been commended by international experts for having a specific budget for dealing with HIV/Aids, he pointed out.
Additionally, for the first time in the history of the HIV pandemic, more new infections are occurring outside sub-Saharan Africa than in sub-Saharan Africa, “reflecting both the prevention achievements in much of the region and the lack of comparable progress in the rest of the world, where people from key populations and their sex partners continue to be neglected in most HIV programmes.
This is according to a UNAids report released this week, which said that midway to the 2025 milestone set by the UN General Assembly, the global fight to end Aids by 2030 is making strides.
Entitled The Urgency of Now: Aids at a Crossroads, the report indicates, however, that while major progress is being made against the pandemic worldwide, there are still challenges.
The report highlights a decrease in new HIV infections, with fewer people being diagnosed with HIV in 2023 than at any time since the late 1980 – and notably, a decline in new infections among key populations in South Africa and Southern Africa from 2010 to 2022.
For example, reports News24, new infections among sex workers decreased by 51%, and among gay men and other men who have sex with men by 40%.
Last year, almost 31m people were receiving lifesaving ARV therapy, which contributed to the lowest number of Aids-related deaths since the peak in 2004.
Yet while South Africa provided ARVs to 5.9m people in 2023, covering 77% of the HIV+ population, 1.7m are still not receiving any treatment.
A major challenge, said the report, is re-engaging 1m people who have discontinued treatment due to long distances to clinics, inefficient services and stigma from healthcare workers.
“Despite the impressively high HIV testing coverage, substantial numbers of people with HIV are not receiving ARVs or are starting treatment late. Of the almost 240 000 people who started on antiretroviral therapy in 2023, close to one-fifth did so with compromised immune systems, with their CD4 counts below 200 cells/mm.”
The role of PrEP
The report touched on the importance of wider access to PrEP to reduce new infections, stating that the number of people using oral PrEP rose from just more than 200 000 in 2017 to about 3.5m in 2023, still far from the global target of 21.2m by 2025.
The report noted that CAB-LA has shown extremely high efficacy in preventing HIV among adolescent girls and women in Africa, and “if made available rapidly and affordably to potential users, could herald a breakthrough for HIV prevention”.
Decline in condom use
Condom use, a critical method for preventing HIV transmission, has seen a decline, noted the report, with the South African Government distributing 45% fewer male condoms in the 2022-2023 financial year than in 2018-2019, due to supply chain disruptions from the pandemic.
Condom use among sexually active young women in Eastern and Southern Africa has dropped from about 45% to 30% over recent years, and remains low in Western and Central Africa.
