Twenty years ago, treatment for HIV was a rare luxury in South Africa. Exorbitant cost and government opposition to providing antiretroviral treatment (ART) kept it from the public sector.

Those were terrible days. Many lives were lost.

The environment has changed drastically since then. The turning point came in 2004, when, after a four-year struggle led by the Treatment Action Campaign, the government begrudgingly agreed to start providing ART.

Antiretroviral coverage of people with HIV in South Africa had increased from 0% in 2000 to 71% in 2019. The South African antiretroviral program is now the largest in the world, with more than 5 million people on treatment with the number continuing to grow. 

HIV-linked deaths rose from 150,000 in 2000 to a peak of around 300,000 in 2006, but dropped to 72,000 in 2019.

But deaths have not decreased as much as was hoped. HIV remains a leading cause of death in South Africa. Indeed, AIDS remains a major contributor to hospitalization and deaths in Africa, while the global death toll was 690,000 in 2019.

Doctors Without Borders (MSF) supports hospitals in South Africa, Guinea, the Democratic Republic of Congo (DRC), Malawi and the Central African Republic that continue to treat large numbers of AIDS patients. Of those with very advanced HIV disease, up to one in three dies during their hospital stay.

One of the main challenges remains that diagnostics and drugs aren’t readily available for sufferers with advanced HIV. This group is very vulnerable to deadly opportunistic infections such as tuberculosis (TB), meningitis and severe bacterial infections.

This all goes to show the world is very far from seeing the end of AIDS.

In the last decade, the focus has been on achieving earlier diagnosis and beginning treatment. Efforts in test-and-treat focus on the UNAIDS 90-90-90 targets: 90% of people with HIV to know their status; 90% of those whose status is known to be on antiretroviral therapy; and 90% of those on antiretrovirals to have an undetectable viral load.

This is necessary but not enough to address HIV-related mortality. Life-long treatment requires life-long support. Some people will interrupt treatment; some will struggle to take their tablets every day, risking developing drug resistance and treatment failure.

Today, most people with advanced HIV either are failing or have interrupted treatment. In two MSF-supported studies in the DRC and Kenya, only 20%-35% of inpatients with advanced HIV were ART-naïve (had never accessed treatment) and over half of those on ART had treatment failure, requiring a new approach.

Thus, MSF piloted Welcome Back Services in Khayelitsha, Cape Town. The services focus on the needs of patients returning to care and those failing treatment. Stigmatization and blaming patients for interrupting or failing treatment is common. This leads to delays in seeking care, and patients retesting for HIV while hiding the fact they were previously on treatment.

This is one reason HIV still claims too many lives. Patients turning up very late often have severe immune suppression, multiple concurrent life-threatening illnesses and significant organ damage due to HIV itself. 

Treatment is complicated by the need for many different medicines, with a higher risk of drug interactions and severe side effects. 

TB is the leading cause of death among people with HIV in resource-limited settings. It is estimated that TB is responsible for around 50% of deaths. Two other leading causes are cryptococcal meningitis (one in five HIV deaths), and severe bacterial infections.

Together, these infectious diseases cause more than two thirds of HIV-related deaths, yet are preventable and treatable if detected early enough.

New evidence shows that shorter regimens of rifapentine and isoniazid, weekly for three months or daily for one month, are equally effective at treating latent TB and decreasing deaths compared to the older regimen of isoniazid for six to 36 months. And a recent trial demonstrated that a four-month treatment with a new regimen was as efficacious as the current six-month regimen to treat active TB disease.

When left untreated, the odds of surviving cryptococcal meningitis are zero. However, it can be prevented and there have been advances in treatment. Daily fluconazole is recommended in some countries for prevention of a first episode, and everywhere as secondary prophylaxis to prevent recurrent disease. Treatment with flucytosine and amphotericin B reduces mortality by 40%. Yet these medicines are still missing in many – if not most – health structures in Africa.

Steps can be taken to prevent death from advanced HIV. These include earlier detection at the primary care level – before patients develop disease so severe that they seek hospital admission. The longer the delay to diagnosis and treatment, the lower the chances of survival.

This is where CD4 tests and rapid tests for TB and cryptococcal meningitis are life-saving.

What is needed urgently to save lives is accelerated access to a package of care for the prevention, diagnosis and treatment of advanced HIV at the primary care and hospital level, along with strategies with clear targets to decrease AIDS mortality.

Dr. Gilles Van Cutsem is Senior HIV and TB Advisor, MSF Southern Africa Medical Unit.

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