The United Nations has set targets to end the AIDS epidemic by 2030. To do this the aim is to ensure that by next year, all countries will have achieved what the UN calls 90-90-90 targets. That is that 90% of those with HIV should know their status; 90% of those who know their status should be on antiretroviral treatment; and 90% of those on treatment should be virally suppressed (meaning the levels of the virus in their blood are undetectable).

Many countries have made substantial progress towards achieving these goals. But many have not. In particular, there are important groups of people at high risk, such as adolescents, whose progress is below the national average. These populations contribute the most to the ongoing transmission of HIV.

Adolescents – aged between 10 and 19 – especially female adolescents, continue to show high infection rates. Worldwide, 25% of all new infections are in adolescent girls and young women aged between 15 and 24. And unlike most age groups, adolescent mortality is increasing, with HIV being the leading cause of adolescent death in Africa.

Adolescents are also less likely to seek HIV services, or stay on treatment. HIV treatment outcomes, including retention, are worse for this age group than for adults.

This is true for South Africa too.

The country’s HIV treatment programme is expanding and the number of adolescents receiving care is growing. But our recent study shows that many adolescents who tested for HIV and had a blood test to measure the stage of HIV disease don’t start antiretroviral therapy.

This is a missed opportunity to engage adolescents already at a facility and link them to treatment successfully. By 2016, two thirds of young South Africans living with HIV were on antiretroviral therapy. This is encouraging but it’s still far off the UN’s 90% target.

Evidence from other work suggests that current models of HIV care aren’t meeting the unique needs of this group. This shows that South Africa’s health system needs to be adapted to deliver effective HIV care to adolescents.

What we found

We used routinely collected laboratory data from South Africa’s national HIV programme to estimate the total number of children and adolescents (aged 1-19 years) entering HIV care. The key finding was a 10-fold increase in the number of adolescents aged 15-19 years on antiretroviral therapy between 2013 and 2016 compared with 2005-2008.

Despite this growth there are still large gaps in successful linkage to treatment. Only 50% of those aged 15-19 successfully initiated antiretroviral therapy through to viral load testing. This is a test that measures the effectiveness of the treatment and usually takes place at six months, one year and then annually after treatment is started.

We didn’t look at long-term retention, so our research doesn’t speak to whether they are still on treatment now or even alive. We looked specifically at uptake of antiretroviral therapy after entering into HIV care.

This is an important finding because adolescence is a critical developmental transition stage from childhood to adulthood. We suggest that there are a number of factors that contribute to the lower rates of uptake of HIV treatment at this stage of life.

The first is that adolescents with HIV can be caught between paediatric and adult services that are unable to address their special needs. These include disclosure of HIV status, stigma, discrimination, sexual health and social support and other factors that impact their ability to move successfully through the HIV care cascade. This refers to the steps that people with HIV go through from diagnosis to viral suppression. It also shows the proportion of people accessing services at each stage of care.

Another factor affecting the rate of treatment among adolescents is that they are dealing with changes in parental versus personal responsibility for maintaining their health. They may be taking more risks, relying more on their peers for support and becoming more interested in serious sexual relationships. They may drop out from treatment to avoid disclosing their activities.

Research has shown that adolescents are at increased risk of infection and have lower rates of entry into care than adults. They also have higher rates of loss from care. But, until now, no national description of the stages in the adolescent HIV care cascade has been available to guide the way resources are targeted.

Our research provides this national perspective of the early stages of the care cascade. It gives a better idea of which young people are in need and when they are at risk of dropping out of care. It’s also important to track how they move from adolescent to adult care and how to keep them in care.

Next steps

Several factors will have an impact on the numbers of adolescents accessing HIV care in the coming years.

One is the success of programmes addressing prevention of mother-to-child transmission of HIV. Another is the extent to which adolescents get tested for HIV, how many go on treatment, and how many stay on it.

If these gaps were closed and antiretroviral treatment uptake increased to the 90% targets, the adolescent population on treatment in South Africa could nearly double in the next five years.

This expansion could have a powerful impact in breaking HIV transmission chains among adolescents. It also highlights why it’s important for the country’s health systems to understand and meet the needs of this group.

For example, traditional ways of getting care – having to go to a clinic or hospital to get tested and treated – don’t seem well-suited to the needs of many adolescents. They may be put off by the operating hours, poor relationships with staff, perceived stigma and loss of confidentiality.

South Africa is already trying to find more flexible ways to address some of these challenges. Adherence clubs – where HIV treatment and support is offered at times and locations convenient for specific groups of people – are one way of getting health care without having to visit a clinic. Mobile app-based technology could also offer awareness and education services that appeal to adolescents.

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PARIS: The number of young people in South Africa receiving treatment for HIV has increased 10-fold within a decade, a major new study has found.

South Africa has the largest number of HIV-positive people in the world, with around 7.2 million carrying the virus, which causes AIDS.

Researchers studied more than 700,000 young people receiving treatment for the infection and found 10 times the number of adolescents aged between 15-19 being treated compared with 2010.

Authors of the study, published in The Lancet HIV journal attributed the rise partly due to the success of AIDS prevention programmes that result in better detection and treatment rates.

However they found that fewer than 50 per cent of young South Africans who present for HIV care go on to initiate antiretroviral therapy, which can prevent transmission and stops a patient developing AIDS.

“Despite the upswing in numbers initiating therapy, barriers persist that prevent many adolescents from starting treatment,” said Mhairi Maskew from the University of Witwatersrand and the report’s lead author.

These include concerns about stigma, a pervasive sense that clinics cannot guarantee patient confidentiality and increased domestic responsibilities for young people, especially in families where children have lost parents to HIV and AIDS.

The study found that while those diagnosed with HIV were roughly split by gender, nine in 10 people actively receiving treatment were girls.

The authors said this was consistent with far higher rates of sexually-transmitted HIV infection in young women compared to young men.

AIDS deaths have declined globally since the peak of the epidemic in the early 2000s, but an international AIDS commission warned last year of a resurgence if the world’s booming adolescent population weren’t protected.

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Remember the landmark RV144 study in Thailand a decade ago that was the first clinical trial to show any efficacy of a vaccine for preventing HIV infection? Now, a team of scientists led by the Fred Hutchinson Cancer Research Center and the University of the Witwatersrand in Johannesburg has found the same regimen can also induce promising immune responses in South Africans, suggesting the vaccine may have the potential to protect against multiple strains of HIV.

In Thailand, the predominant HIV strain is clade B, while clade C is the most common subtype in South Africa. In the new trial, scientists found the RV144 vaccine—containing constructs of HIV clades B and E inserts—showed even higher cellular and humoral immune responses in healthy people in South Africa than in RV144’s Thailand vaccines, according to results published in Science Translational Medicine.

HIV is notorious for its diversity and tendency to mutate, which already makes treating the virus difficult. The same challenge holds true for vaccine development. That’s why the Fred Hutchinson-led team set out to test the RV144 regimen in South Africa and compared immunogenicity data to those from the Thailand study.

One hundred healthy adults participated in the trial, and 91 received all four vaccinations. The researchers evaluated the magnitude and frequency of several immune responses that correlate to infection risk.

Specifically, the vaccine induced strong CD4+ T cells directed at HIV envelope proteins in 51.9% of South Africans, significantly higher than the 36.4% seen in the Thailand trial. And the South Africans’ T cells also scored better on a functionality assay that evaluates how good the cells are at producing cytokines.

They looked at the immunoglobulin G (IgG) antibody responses, and participants in the current trial performed better across the board than those from the original RV144 study. They also examined the antibody-dependent cellular cytotoxicity (ADCC), in which immune cells rupture the target cell. Previously, the efficacy of RV144 was correlated with ADCC. Turns out, 72.6% of the trial participants in South Africa responded in the current trial, versus 58.5% of those in Thailand

Back in 2009, RV144 showed just 31.2% effectiveness by month 42. Since then, a variety of research teams have been trying to achieve better protection against as many strains of HIV virus as possible. Scientists led by Duke University previously built on the regimen by adding three more targets to the vaccine construct, making it a pentavalent vaccine. In a study in monkeys, the vaccine achieved 55% protection. Johnson & Johnson recently started testing a different HIV vaccine in a 3,800-person late-stage clinical trial.

The newly reported trial was a precursor to a trial that tested an adapted regimen including subtype C antigens and an adjuvant from GlaxoSmithKline in 252 South African participants. Based on positive interim results from HVTN 100, the National Institutes of Health pushed the new regimen into a large-scale trial that aims to enroll 5,400 men and women, also in South Africa.

The Fred Hutchinson and Johannesburg team did report that the T-cell and antibody responses dropped over time during the trial, “suggesting the utility of additional boosts,” they argued in the study.

But the vaccine’s ability to provide protection against multiple strains of HIV was key, they added. “Our data suggest that the breadth of immune responses elicited by this vaccine regimen may allow for vaccine protection that could extend beyond the clade used for immunogen development, and potentially function as a more global vaccine,” they wrote in the study.

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Significantly better health outcomes are reported for both infants and mothers living with HIV when male partners are co-enrolled in antenatal care with the mother. In this clinic-randomised control trial, infants were 4.55 times less likely to become infected with HIV when male partners were actively involved in prevention of mother-to-child transmission (PMTCT) programmes during pregnancy.

The study took place across 12 randomly selected community health centres in Gert Sibande and Nkangala districts in Mpumalanga province, South Africa.

Researchers compared standard of care PMTCT programs with a new intervention which used group sessions and individual counselling to encourage adherence to treatment, HIV testing of family members, disclosure and partner communication alongside other outcomes.

In the first phase women were enrolled in the intervention or the standard of care alone, while in the second phase they were invited to enrol with their male partners.

The primary outcomes of the trial were infant HIV status, assessed at 12 months by DNA polymerase chain reaction (PCR) test, and infant survival, defined as miscarriage or death by 12 months postpartum. They also collected data on socioeconomic status, knowledge of HIV status, depressive symptoms, HIV stigma, family planning knowledge and intimate partner violence.

A total of 1,399 participants were included in the analysis at baseline. The average (mean) age of the women in the study was 28 and 48% had completed 10 to 11 years of education. Just over half (54%) of the women were unmarried and living separately from their partner and 64% had a monthly income of at least 1,000 ZAR (~70USD). Just over half (55%) of the women had been diagnosed with HIV in this present pregnancy and 50% reported that their pregnancy was unplanned.

The analysis found that more infants became HIV-positive in Phase 1 over Phase 2, and infants whose mothers were enrolled alone had a 1.98% increased likelihood of death or becoming infected with HIV. Moreover, rates of attrition and loss to follow-up were much lower when male partners were involved.

Researchers found that on average, across both phases, women had been diagnosed with HIV 24 months prior to baseline and had been on treatment for 15 months. Male involvement and family planning knowledge were moderate, and HIV-related stigma was low. Depression rates were high, with 45% of women showing clinically significant symptoms of depression. In addition to this, approximately 15% of women reported having more than two alcoholic drinks in the past month, and 61% reported having disclosed their HIV status to their partner. However, of these demographic findings, only depressive symptoms were significantly associated with infant HIV infection at 12 months.

The study found male participation was by far the most significant factor in determining health outcomes of both mother and child, outperforming the ‘protect your family intervention’, which had no significant impact on health outcomes of mother and child compared to standard of care, when women were enrolled alone.

In discussing these findings researchers comment that “male participation in the intervention may have promoted greater male partner involvement overall, including in PMTCT and child nurturing, leading to decreased risk of infant HIV infection and mortality. Male involvement, therefore, should be emphasized in areas with high rates of HIV transmission during or after pregnancy to enhance infant outcomes among HIV-exposed infants.”

Previous programmes primarily focus on mother and child, with little emphasis on the role of the father in pre- and postpartum care. These study results support the shift in thinking and programming that looks at male partner involvement as a critical component of PMTCT.

In this study, depressive symptoms are highlighted as high-risk poor HIV-related outcomes, and interventions should focus on screening for depression in order to improve treatment adherence and decrease infant HIV infection and mortality.

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