HIV treatment reaches millions in South Africa, but critical gaps threaten progress

IOL News

27-05-2025

Despite South Africa making world-leading strides for HIV testing rates, new data reveals that tens of thousands of people still begin treatment dangerously late
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Despite South Africa making world-leading strides for HIV testing rates, new data reveals that tens of thousands of people still begin treatment dangerously late — and over a million have stopped taking their life-saving medication altogether.
This is according to the latest estimates from Thembisa 4.7, South Africa's most sophisticated HIV modelling tool.
Thembisa 4.7 synthesises multiple data sources including Stats SA's 2022 Census and the HSRC's latest national HIV survey.
To understand the numbers, we need to understand what viral suppression is and what it means for South Africans. What is viral suppression?
When someone living with HIV takes their medication regularly, the amount of virus in their blood can drop so low that it's undetectable. This is known as 'viral suppression.' This is a good thing, as it keeps people healthy and prevents the virus from spreading to others.
Are South Africans on ART reaching viral suppression?
According to the data, in South Africa, viral suppression varies by province and by person.
Researchers used patient data from a global HIV research network called IeDEA, as well as South Africa's own TIER health system, to understand how well antiretroviral therapy (ART) is working in different provinces.
However, not everyone had their viral load (amount of virus in the blood) measured and recorded. So scientists used a method called Bayesian analysis to fill in the blanks based on patterns they saw in the data they did have.
Scientists found that viral suppression rates dropped after 2009, but have been improving since 2013.
According to the data, women tend to have better suppression rates than men and older adults (age 50 and above) are doing better than younger people.
They also found that those who started treatment earlier — when their immune systems were still strong — had better outcomes.
The study indicates that the Western Cape and Free State are performing better than average, while other provinces, like Limpopo and Eastern Cape, are lagging behind.
For example, in Limpopo, patients had 46% lower odds of viral suppression compared to the reference group. Meanwhile, the Western Cape had 22% higher odds than average.
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What about missing data?
As mentioned previously, not everyone had their viral load measured and recorded, which could make the official numbers look better or worse than they really are.
To deal with this, the researchers estimated what might be happening with patients who didn't have test results. On average, people without a recorded viral load were slightly less likely to be virally suppressed — but not always by much. Alarming statistics
In 2023, an estimated 7.8 million people — or 12.6% of the population — were living with HIV in South Africa. Of those, 5.9 million were on ART, leaving roughly 2 million untreated. Worryingly, about 1 million of the untreated population had previously started treatment but later disengaged, signalling deep cracks in the country's treatment retention strategy.
Over 46,000 adults only started ART in 2023 after their CD4 counts had fallen below 200, a level that reflects advanced immune suppression and significantly increases the risk of life-threatening illnesses like tuberculosis. SA's progress on global 95-95-95 HIV targets
South Africa has made notable progress toward the global 95-95-95 HIV targets. The targets aim to ensure that by 2025, 95% of people living with HIV know their status, 95% of those diagnosed are on treatment, and 95% of those on treatment are virally suppressed. The country has already met the first goal, with 95.4% of people living with HIV diagnosed.
However, only 78.7% of diagnosed individuals are currently on ART — far short of the second goal.
Of those on treatment, 91.3% have achieved viral suppression, indicating strong medication efficacy — but when assessed across all people living with HIV, only 68.6% are virally suppressed. New infections are outpacing deaths
There were 149,000 new HIV infections in 2023, down from over 500,000 annually in the early 2000s. Yet, with only 50,000 HIV-related deaths, the overall number of people living with HIV continues to climb — and is expected to rise for several years.
On a positive note, more people are starting treatment than becoming newly infected. In 2023, 237,000 individuals began ART, creating a 1.6:1 ratio of treatment starts to new infections. But this ratio has declined from over 2:1 in the 2010s, suggesting momentum is slowing.
Life expectancy continues to rise. After dropping to 53.6 years in 2004 at the height of the AIDS crisis, it has now climbed to 65.9 years in 2023 — 62.3 for men and 69.7 for women — largely due to ART scale-up.
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