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Daily Maverick
6 days ago
- Health
- Daily Maverick
Are children living with HIV being left behind? Here's what the stats tell us
Huge gains have been made in reducing new HIV infections and deaths in children. Yet, many of the statistics for children still look worse than those for adults. Spotlight asked experts why this is the case and what factors prevent children living with HIV from starting and staying on the treatment that can keep them healthy. Of the 157,000 children living with HIV in South Africa, about one in three is not getting the medicines they need to stay healthy. That is according to recent estimates from Thembisa, the leading mathematical model of HIV in South Africa. At first glance, the contrast with adults seems stark. While only 65% of children with HIV are on treatment, the figure for everyone in the country who is living with the virus stands 13% higher at 78%. For these numbers, children are defined as people younger than 15. The differences hold across much of the cascade of HIV care. While 95% of all people with HIV have been diagnosed, only 85.5% of kids with the virus have been diagnosed; 81% of all diagnosed people are on treatment, but only 76% of diagnosed kids are. And of all people on treatment, 92% have viral suppression, but only 77% of kids on treatment are virally suppressed. There is substantial variation in these figures across South Africa's provinces. For example, while more than 70% of kids living with HIV in the Western Cape and Northern Cape are on treatment, fewer than 60% are on treatment in each of the other seven provinces. What to make of the numbers The reality is more nuanced than a cursory look at the above data would suggest. For one, there is some uncertainty about the exact numbers. Compared with the Thembisa estimates, two national surveys on HIV prevalence conducted in 2017 and 2022 found higher levels of HIV prevalence in children. In one recent analysis of the 2017 data, it is estimated that only 40% of children living with HIV had been diagnosed. 'The paediatric HIV data sources aren't as consistent with one another as the adult data sources are,' Dr Leigh Johnson, an expert in HIV and TB modelling from the University of Cape Town and key developer of the Thembisa model, tells Spotlight. '[T]here's more uncertainty around our estimates of HIV prevalence in children than there is in adults, which is important because the HIV prevalence estimate is the denominator in the ART coverage estimate.' ART stands for antiretroviral therapy. Apart from some uncertainty over the data, Johnson also cautions that while treatment coverage in children is lower than in adults at 65% compared with 78%, this doesn't necessarily mean the rates of treatment initiation and retention are poorer in children than in adults. As he explains: 'This is because coverage is a cross-sectional measure (measured at a point in time), whereas the rates we're talking about are measured over a period of time. Two groups can have the same rates of ART initiation and retention but have different levels of coverage (cross-sectionally) if they are followed for different average durations (longer duration of follow-up typically means higher coverage).' Put another way, a child of four who became infected at the age of one would only have had about three years to get diagnosed, while an adult aged 40 who became HIV positive at 20 would have had 20 years to get diagnosed. Because of this effect, you'd expect a higher proportion of 40-year-olds to have been diagnosed than four-year-olds, even if everyone tested at the same rate. 'The rates are difficult to measure directly, but our model suggests that the ratio of ART initiations to new infections (a crude proxy for the ART initiation rate) have been a bit lower in kids than in adults in recent years,' Johnson says. HIV often progresses faster in children While a crude proxy, it is a concerning trend if the rates of ART initiation in children are lower than in adults, since HIV tends to make children much sicker and faster than adults. 'Young children have immature immune systems, so when HIV is acquired at a young age… children tend to have a more rapid HIV disease progression than adults. Children can progress to having advanced HIV disease within months, whereas in adults this process usually takes several years,' says Dr Kim Anderson, a clinical epidemiologist and doctor with expertise in treating children and adolescents living with HIV. However, she explains, it is estimated that up to 10% of all children living with HIV are 'slow progressors' and don't get sick as quickly. Because their immune systems are not fully developed, it is vital to diagnose children as early as possible, Dr Moherndran Archary, a professor of paediatric infectious diseases based at the KwaZulu-Natal health department and researcher at the Africa Health Research Institute, tells Spotlight. '[U]ltimately, we do want to make sure, in children, we diagnose them early, start them on antiretroviral treatment… and keep them virologically suppressed throughout the treatment, especially in the childhood and adolescent phase,' he says. Delaying HIV treatment is likely to lead to children developing high levels of viremia (virus in the blood), which can negatively affect the brain, kidneys, lungs and other organs. Progress has stabilised Overall, the data paints a picture of huge progress when it comes to HIV in children, which in recent years has slowed. 'Over time, there has been a general trend towards declining numbers of children acquiring HIV and declining Aids deaths in children,' Johnson says. 'However, the proportion of children living with HIV who have been diagnosed has stabilised at about 85% to 86% in recent years. 'Also, levels of ART coverage in children have stabilised at relatively low levels in recent years (about 65%),' he adds. ART coverage here means the percentage of all children with HIV who are on treatment. This is not the same as the second 95 from the UNAIDS 95-95-95 targets, which looks only at the percentage of already diagnosed children who are on treatment. Johnson says the UNAIDS target indicators 'are not always a good reflection of progress in reducing HIV incidence and Aids mortality, which are arguably more important'. Between the start of 2005 and the start of 2024, says Johnson, there has been a 97% reduction in HIV/Aids-related deaths in children, compared with a 78% reduction in adults. In that same period, there's been an 87% reduction in children acquiring HIV, compared with 69% in adults. He says the decline in children getting HIV to be 'largely a reflection of success in reducing adult HIV incidence rates and getting more women onto ART', as ART drastically reduced HIV transmissions from mothers to their children. This, in addition to earlier diagnosis of more infants with HIV and them starting treatment before they get really sick, are behind the decline in HIV-related deaths in children. Vertical transmission remains a concern While experts Spotlight spoke to agree that the rates of vertical transmission have gone down significantly, it remains a big driver of new HIV infections. If the mother's HIV is not under control – either because they don't know they have HIV, or the treatment hasn't had a chance to work yet – then the virus can be transmitted to their child during pregnancy, birth or while breastfeeding. 'In South Africa, we achieve good ART coverage among pregnant women and the number of new infections in children has declined as a result; infections in children make up around 5% of all new infections,' says Anderson. 'Although rates of vertical transmission in South Africa are relatively low (2% to 3%), maternal HIV prevalence is high, therefore the number of new infections in children each year, around 6,500, still remains a concern.' The reasons for this, she says, are complex, ranging 'from children being missed because of limitations in routine testing, challenges in ART adherence, and a need for optimised treatment regimens'. Routine testing might be missing children Children living with HIV tend to be diagnosed through routine postnatal testing or when they visit a healthcare facility with symptoms suggestive of HIV. 'All babies born to mothers living with HIV will have an HIV test, a PCR test (a blood-borne test) that is done at delivery and then at multiple time points in the first year of life,' Archary says. A PCR test is used for babies under the age of two instead of a rapid test because rapid tests look for viral antibodies, which could have been passed to an infant from their mother. The turnaround time for the PCR test is about 72 hours, which could pose a further challenge since the result can only be communicated to the caregivers if they come back to the healthcare facility. 'Our routine testing is geared towards picking up children much earlier and starting them on antiretroviral treatment – and I think that's completely an appropriate response. The problem is really if someone falls between the gaps of that initial net, then unless they present to a healthcare facility, there's very little opportunity for them to get picked up,' he adds. Johnson flags the same issue. 'My biggest concern is that HIV testing efforts have focused very heavily on testing infants/the first 18 months of life, and there hasn't been enough attention paid to testing in older kids. A large proportion of undiagnosed paediatric HIV is in older children… We need to focus on innovative testing strategies to reach older children living with HIV,' he says. Difficulties with achieving virologic suppression Anderson says that, once diagnosed, the rates of linkage to care – going from getting an HIV test to getting care from a healthcare facility – and receiving initial HIV treatment are good for children. The challenge is keeping those children on treatment since high levels of treatment adherence is needed to keep the virus under control. 'Prolonged gaps in care (more than six months) are common among children starting ART, with up to a third experiencing interruptions within the first year, highlighting significant challenges with retaining children in care,' she says. Archary explains that another complication is that children rely on adults to give them their treatment. Some of these children move between different caregivers so they might not get their treatment regularly or from the same person. He adds that stigma also plays a role. Some mothers might be scared to tell other caregivers that their child is living with HIV, and this might result in the child not getting their treatment when they are not with their mother. In the past, HIV treatment itself also posed challenges. Anderson says older, less-suitable treatment regimens led to fewer children keeping the virus under control. These include regimens that were bitter tasting, or pills meant for adults that had to be crushed and were difficult to dose correctly, side-effects, and at times 'insufficient market incentives' for child-friendly formulations. Today, a child-friendly formulation that contains the drug dolutegravir is recommended as part of the preferred first line treatment for children from four weeks of age. Results from a recent Cape Town study, reported on by Spotlight, showed that two new formulations of dolutegravir were also safe to use in newborns. Anderson describes the introduction of cheap, child-friendly dolutegravir as a significant breakthrough that could transform paediatric outcomes. 'It is hoped that transitioning all children on ART to dolutegravir-based regimens may significantly improve paediatric viral suppression rates.' This is because dolutegravir-based regimens, she says, have several advantages, including better palatability and once-daily dosing and fewer side-effects. 'We don't have much recent data yet to show if these expected improvements are being realised… but watch this space!' What needs to be done? Despite the progress, Archary says there is still a long way to go. One priority is providing better support for mothers or caregivers. A lot of the counselling he and his team provide to caregivers of children living with HIV is to help them get a strong support structure around themselves and the child. This, he says, serves as a type of safety net to ensure the child is always given their treatment, no matter what happens. Anderson also weighed in on this. 'Family-centred approaches and better attention to broader social support for the most vulnerable mothers are needed for more successful HIV prevention and treatment,' she says. Family-centred approaches include 'structuring the healthcare services/visits so that mothers and children are seen together at the same visit, ideally by the same provider'. Anderson says this type of integrated service, which does exist in some healthcare facilities, will reduce the burden of having to do multiple clinic visits and helps to manage their healthcare in a more holistic way. 'It would be ideal for mothers to have postnatal access to support from psychologists, social workers, counsellors and peer support groups. Such services are not always available, and if they are, they are overburdened,' she adds. Another approach, says Anderson, is having community health workers provide home-based support. This could include checking that the child is getting their treatment, offering advice to caregivers, assessing food security and assisting with social grant access if needed. 'Small financial incentives or support (like paying for transport or giving food vouchers) might help vulnerable families overcome economic barriers that lead to treatment interruptions,' she reckons. Important research derailed Long-acting HIV treatments for children could potentially help them stick to treatment better because caregivers wouldn't have to give medicine every day. However, some research efforts along these lines have been derailed by the funding cuts and new funding policies for research grants from the US government. 'I am hopeful that long-acting injectables could be the game changer we've long awaited, both in further reducing vertical transmission, and in improving viral suppression rates among mothers and children,' Anderson says. 'At the same time, I am worried that cuts to future HIV research funding could undermine the hard-won progress we have made.' This is a reality for Archary. He was involved in a study set to look at the use of long-acting cabotegravir and rilpivirine injections for HIV treatment in adolescents, paired with peer support interventions. But this was halted because funding through a grant from the US National Institutes of Health, which is the largest public funder of biomedical research globally, was cancelled. 'I think it's a wake-up call for research in South Africa because we've been quite highly dependent on external funding… [M]uch of the innovative research that's happened in HIV, TB and other infectious diseases has happened from South Africa, so we've got the intellectual capital, but we do need to now find the money in order to cover that gap,' he says. DM
News24
26-05-2025
- Health
- News24
Are children living with HIV being left behind? What the stats tell us
Massive gains have been made in reducing new HIV infections and deaths in children. Yet, many of the statistics for children still look worse than those for adults. Spotlight asked experts why this is the case and what factors prevent children living with HIV from starting and staying on the treatment that can keep them healthy. Of the 157 000 children living with HIV in South Africa, around one in three are not getting the medicines they need to stay healthy. That is according to recent estimates from Thembisa, the leading mathematical model of HIV in South Africa. At first glance, the contrast with adults seems stark. While only 65% of children with HIV are on treatment, the figure for everyone in the country who is living with the virus stands 13 percentage points higher at 78%. For these numbers, children are defined as people younger than 15. The differences hold across much of the cascade of HIV care. While 95% of all people with HIV have been diagnosed, only 85.5% of kids with the virus have been diagnosed and while 81% of all diagnosed people are on treatment, only 76% of diagnosed kids are. And of all people on treatment, 92% have viral suppression, but only 77% of kids on treatment are virally suppressed. There is substantial variation in these figures across South Africa's provinces. For example, while over 70% of kids living with HIV in the Western Cape and Northern Cape are on treatment, fewer than 60% are on treatment in each of the other seven provinces. What to make of the numbers The reality is more nuanced than a cursory look at the above data would suggest. For one, there is some uncertainty about the exact numbers. Compared to the Thembisa estimates, two national surveys on HIV prevalence conducted in 2017 and 2022 found higher levels of HIV prevalence in children. In one recent analysis of the 2017 data, it is estimated that only 40% of children living with HIV had been diagnosed. 'The paediatric HIV data sources aren't as consistent with one another as the adult data sources are,' Dr Leigh Johnson, an expert in HIV and TB modelling from the University of Cape Town and key developer of the Thembisa model, tells Spotlight. '[T]here's more uncertainty around our estimates of HIV prevalence in children than there is in adults, which is important because the HIV prevalence estimate is the denominator in the ART (antiretroviral therapy) coverage estimate.' Apart from some uncertainty over the data, Johnson also cautions that while treatment coverage in children is lower than in adults at 65% compared to 78%, this doesn't necessarily mean the rates of treatment initiation and retention are poorer in children than in adults. As he explains: 'This is because coverage is a cross-sectional measure (measured at a point in time), whereas the rates we're talking about are measured over a period of time. Two groups can have the same rates of ART initiation and retention but have different levels of coverage (cross-sectionally) if they are followed for different average durations (longer duration of follow-up typically means higher coverage).' Put another way, a child of four who became infected at the age of one would only have had about three years to get diagnosed, while an adult aged 40 who became HIV positive at 20 would have had 20 years to get diagnosed. Because of this effect, you'd expect a higher proportion of 40-year-olds to have been diagnosed than 4-year-olds, even if everyone tested at the same rate. 'The rates are difficult to measure directly, but our model suggests that the ratio of ART initiations to new infections (a crude proxy for the ART initiation rate) have been a bit lower in kids than in adults in recent years,' Johnson says. HIV often progresses faster in children While a crude proxy, it is a concerning trend if the rates of ART initiation in children are lower than in adults, as HIV tends to make children much sicker, and faster than adults. 'Young children have immature immune systems, so when HIV is acquired at a young age … children tend to have a more rapid HIV disease progression than adults. Children can progress to having advanced HIV disease within months, whereas in adults this process usually takes several years,' says Dr Kim Anderson, a clinical epidemiologist and doctor with expertise in treating children and adolescents living with HIV. However, she explains, it is estimated that up to 10% of all children living with HIV are 'slow-progressors' and don't get sick as quickly. As their immune systems are not fully developed, it is vital to diagnose children as early as possible, Dr Moherndran Archary, a professor of pediatric infectious diseases based at the KwaZulu-Natal health department and researcher at the Africa Health Research Institute, tells Spotlight. 'Ultimately, we do want to make sure, in children, we diagnose them early, start them on antiretroviral treatment … and keep them virologically suppressed throughout the treatment, especially in the childhood and adolescent phase,' he says. Delaying HIV treatment will likely lead to children developing high levels of viremia (virus in the blood), which can negatively affect the brain, kidneys, lungs and other organs. Progress has stabilised Overall, the data paints a picture of massive progress when it comes to HIV in children, which in recent years has slowed. 'Over time, there has been a general trend towards declining numbers of children acquiring HIV and declining AIDS deaths in children,' Johnson says. 'However, the proportion of children living with HIV who have been diagnosed has stabilised at around 85-86% in recent years. 'Also, levels of ART coverage in children have stabilised at relatively low levels in recent years (around 65%),' he adds. ART coverage here means the percentage of all children with HIV who are on treatment. This is not the same as the second 95 from the UNAIDS 95-95-95 targets, which looks only at the percentage of already diagnosed children who are on treatment. Johnson says the UNAIDS target indicators 'are not always a good reflection of progress in reducing HIV incidence and AIDS mortality, which are arguably more important'. Between the start of 2005 and start of 2024, says Johnson, there has been a 97% reduction in HIV/AIDS related deaths in children, compared to a 78% reduction in adults. In that same period, there's been an 87% reduction in children acquiring HIV, compared to 69% in adults. He credits the decline in children getting HIV to be 'largely a reflection of success in reducing adult HIV incidence rates and getting more women onto ART', as ART drastically reduced HIV transmissions from mothers to their children. This, in addition to earlier diagnosis of more infants with HIV and them starting treatment before they get really sick, are behind the decline in HIV-related deaths in children. Vertical transmission remains a concern While experts Spotlight spoke to agree that the rates of vertical transmission have gone down significantly, it remains a big driver of new HIV infections. If the mother's HIV is not under control - either because they don't know they have HIV, or the treatment hasn't had a chance to work yet - then the virus can be transmitted to their child during pregnancy, birth or while breastfeeding. 'In South Africa, we achieve good ART coverage among pregnant women and the number of new infections in children has declined as a result; infections in children make up around 5% of all new infections,' says Anderson. 'Although rates of vertical transmission in South Africa are relatively low (2-3%), maternal HIV prevalence is high, therefore the number of new infections in children each year, around 6 500, still remains a concern.' The reason for this, she says, are complex, ranging 'from children being missed because of limitations in routine testing, challenges in ART adherence, and a need for optimised treatment regimens'. Routine testing might be missing children Children living with HIV tend to be diagnosed through routine postnatal testing or when they visit a healthcare facility with symptoms suggestive of HIV. 'All babies born to mothers living with HIV will have an HIV test, a PCR test - which is a blood borne test - that is done at delivery and then at multiple time points in the first year of life,' Archary says. A PCR test is used for babies under the age of two instead of a rapid test because rapid tests look for viral antibodies, which could have been passed to an infant from their mother. The turnaround time for the PCR test is about 72 hours, which could pose a further challenge since the result can only be communicated to the caregivers if they come back to the healthcare facility. READ | Aids programmes grind to a halt as government drags its feet 'Our routine testing is geared towards picking up children much earlier and starting them on antiretroviral treatment - and I think that's completely an appropriate response. The problem is really if someone falls between the gaps of that initial net, then unless they present to a healthcare facility, there's very little opportunity for them to get picked up,' he adds. Johnson flags the same issue. 'My biggest concern is that HIV testing efforts have focused very heavily on testing infants/the first 18 months of life, and there hasn't been enough attention paid to testing in older kids. A large proportion of undiagnosed paediatric HIV is in older children… We need to focus on innovative testing strategies to reach older children living with HIV,' he says. Difficulties with achieving virologic suppression Anderson says once diagnosed, the rates of linkage to care - which is going from getting an HIV test to getting care from a healthcare facility - and receiving initial HIV treatment are good for children. The challenge is keeping those children on treatment since high levels of treatment adherence is needed to keep the virus under control. 'Prolonged gaps in care (over 6 months) are common among children starting ART, with up to a third experiencing interruptions within the first year, highlighting significant challenges with retaining children in care,' she says. Archary explains that another complication is that children rely on adults to give them their treatment. Some of these children move between different caregivers so they might not get their treatment regularly or from the same person. He adds that stigma also plays a role. Some mothers might be scared to tell other caregivers that their child is living with HIV, and this might result in the child not getting their treatment when they are not with their mother. ALSO READ | Motsoaledi urges unity, assures HIV/Aids programme stability amid US Pepfar funding pullout In the past, HIV treatment itself also posed challenges. Anderson says older, less suitable treatment regimens led to fewer children keeping the virus under control. These include regimens that were bitter tasting, or pills meant for adults that had to be crushed and were difficult to dose correctly, side-effects, and at times 'insufficient market incentives' for child-friendly formulations. Today, a child-friendly formulation that contains the drug dolutegravir is recommended as part of the preferred first line treatment for children from four weeks of age. Results from a recent Cape Town study, reported on by Spotlight, showed that two new formulations of dolutegravir was also safe to use in newborns. Anderson describes the introduction of cheap, child-friendly dolutegravir as a significant breakthrough that could transform paediatric outcomes. 'It is hoped that transitioning all children on ART to dolutegravir-based regimens may significantly improve paediatric viral suppression rates.' This is because dolutegravir-based regimens, she says, have several advantages, including better palatability and once-daily dosing and fewer side effects. 'We don't have much recent data yet to show if these expected improvements are being realised... but watch this space!' What needs to be done? Despite the progress, Archary says there is still a long way to go. One priority is providing better support for mothers or caregivers. A lot of the counselling he and his team provide to caregivers of children living with HIV is to help them get a strong support structure around themselves and the child. This, he says, serves as a type of safety net to ensure the child is always given their treatment no matter what happens. Anderson also weighed in on this. 'Family-centred approaches and better attention to broader social support for the most vulnerable mothers are needed for more successful HIV prevention and treatment,' she says. Family-centred approaches to her include 'structuring the healthcare services/visits so that mothers and children are seen together at the same visit, ideally by the same provider'. Anderson says this type of integrated services, which do exist in some healthcare facilities, will reduce the burden of having to do multiple clinic visits and helps to manage their healthcare in a more holistic way. She added: It would be ideal for mothers to have postnatal access to support from psychologists, social workers, counsellors and peer support groups. Such services are not always available, and if they are, they are overburdened. Another approach, says Anderson, is having community health workers provide home-based support. This could include checking that the child is getting their treatment, offering advice to caregivers, assessing food security, and assisting with social grant access if needed. 'Small financial incentives or support (like paying for transport or giving food vouchers) might help vulnerable families overcome economic barriers that lead to treatment interruptions,' she reckons. Important research derailed Long-acting HIV treatments for children could potentially help them stick to treatment better because caregivers wouldn't have to give medicine every day. However, some research efforts along these lines have been derailed by the funding cuts and new funding policies for research grants from the United States government. 'I am hopeful that long-acting injectables could be the game changer we've long awaited, both in further reducing vertical transmission, and in improving viral suppression rates among mothers and children,' Anderson says. READ | Cape Town study brings hope to newborns left behind in HIV treatment advances This is a reality for Archary. He was involved in a study set to look at the use of long-acting cabotegravir and rilpivirine injections for HIV treatment in adolescents, paired with peer support interventions. But this was halted because funding through a grant from the US National Institutes of Health, which is the largest public funder of biomedical research globally, was cancelled. 'I think it's a wakeup call for research in South Africa because we've been quite highly dependent on external funding… Much of the innovative research that's happened both in HIV, TB and other infectious diseases have happened from South Africa so we've got the intellectual capital, but we do need to now find the money in order to cover that gap,' he says.
News24
22-05-2025
- Entertainment
- News24
‘I set very strong boundaries for myself' - Lady Zamar channels life lessons into powerful music
Despite any controversy that may have followed her she remains unshaken. She's best known for her smile and soothing voice - with a career spanning multiple hit singles and albums that have earned her a loyal fan base. Yamikani Janet Banda a.k.a Lady Zamar is a South African singer-songwriter and house vocalist, she hails from Thembisa and grew up in Mamelodi, Pretoria. Lady Zamar rose to fame in 2011 when she was still a duo with Junior Taurus, their debut album 'Cotton Candy' was released in 2015. This album garnered the spotlight ultimately laying the foundation for Lady Zamar's solo career. Her first solo album 'King Zamar,' debuted in 2017, solidifying her status as a solo artist and swiftly earned gold and double platinum certification. Following this accomplishment, her second album 'Monarch,' further showcased her musical ability and flexibility. And she has been releasing more hit songs and albums since then, including her latest single 'Russian Roulette.' Read more | Amalanga Awafani star Fanele Zulu on balancing family life and rising TV career In a conversation with DRUM, Lady Zamar described this chapter of her life as creative and embracing whatever's in store for her. 'I think I'm focused on global appeal right now, and I'm focused on repositioning myself as a storyteller, that tells stories that are relevant to people right now. This new chapter is about me being a visionary as well, in terms of taking risks in the music and taking risks in the type of stories that I'm telling as well.' Speaking on new music she says that her new sound is a result of having learnt to trust her voice and storytelling 'My first single, Russian Roulette, really encapsulates that I am in a more playful spirit, but it's still a place of speaking, writing and creating music from a place of understanding, reflection, and I'm just in a place where I'm willing to embrace what's coming,' she explained. Read more | EXCLUSIVE | Emtee celebrates rising like a phoenix after Metro FM award win - 'I have no regrets' Lady Zamar also shared some valuable lessons she's learned from her past relationships and how they've influenced her music and personal growth. 'I've become more aware of who I am. I no longer just give people the space to just come in and out of my life as they will, and that has translated into music the same way, I don't allow people to tell me how I should live my life, in terms of how I should write the kind of stories I put out. I'm not allowing anyone to shape my narrative for me. I'm doing it myself and I'm allowing myself the freedom and the grace that I expect other people to give me, and I give them that grace as well.' Read more | WATCH | A demure international collab between SA's Lady Zamar, Nigeria's Timicrox and America's Elle B She says that in order to bring balance into her life, she separates her true self from the brand that she has created. 'The most effective way of doing it for me is to switch off. I switch off anything and everything. I treat my work as work. I treat my brand as work. As much as it's a very big part of who I am as a person, it is a part that I don't live 24-7. I allow myself to spend time with family, with friends. I do stuff that makes me happy. I'm very quick with enjoying my life, basically. I also don't allow myself to be too concerned about people's opinions of me. 'There's a saying that I recently learned, 'if you can't take advice from someone, don't take criticism from them.' If a person can't give me any valuable advice and any valuable insight into something that I'm busy with or doing, I don't usually pay attention to them. I respect everyone's opinion. However, I don't allow them to penetrate into the innermost parts of me and affect my work. I set very strong boundaries for myself, my team, my family, and also the people that I consider family, which are my fans.' View this post on Instagram A post shared by Lady Zamar (@lady_zamar) 'Honestly, if it doesn't make me feel good whether it's something that requires a lot of concentration or a lot of pressure, or something that requires for me to indulge or to engage in it more, I will still apply myself without allowing myself to get overrun by that activity itself.' Read more | Meet Nhoza Sitsholwana, a traditional African fusion genre singer Lady Zamar has also shared some of her fondest milestones with us. 'What I'm most proud of, is the brand that I have. I'm very proud of the work that has been put into it. I think a lot of people have contributed to who I am and where I am today. Even those whose relationships I no longer have or whose favour I no longer have, and those who do not have my favour either, everything for me has been monumental. You lose some, you win some, but if you look at everything as a lesson and if you allow yourself to see the good in what someone has brought, even if it's not nice, you get to appreciate the whole of you. The reputation that I have as a performer, I'm very, very proud of that and I'm grateful for it,' she giggled. The process of creating her latest single, 'Russian Roulette' was tedious and fun she says. 'Russian Roulette is a single from an upcoming album. It's going to be out later on in the year. The process of creating it was kind of simple; I wanted to create a song that was fun and simple. I wanted to be able to dance to it first, you know? I like to be the first person to experiment with my own sound.' She is excited about the album she will be releasing. 'I've been recording this particular album for over a year now in terms of recording, mixing, and mastering. So, this is the first of a beautiful body of work that I hope you guys will enjoy later on in the year,' she smiled.
Daily Maverick
15-05-2025
- Health
- Daily Maverick
New strategies required to protect mothers and infants who are still getting HIV
Over the past two decades, South Africa made massive progress in reducing transmission of HIV from mothers to their babies. Even so, about 7,000 babies still contract the virus every year. Experts put this down to having the right puzzle pieces for prevention but failing to integrate them optimally. About 7,000 infants in South Africa still contract HIV from their mothers every year — a stark reminder that, while significant progress has been made in preventing mother-to-child transmission (MTCT), that progress has somewhat plateaued. Twenty years ago, there were 10 times as many — about 70,000 — new infections per year in babies. Today, the MTCT rate has dropped from a peak of over 30% at the turn of the century to about 2.7%. The story is mainly one of antiretroviral medicines helping suppress the virus in the bodies of mothers living with HIV, thus protecting tens of thousands of babies over the years. But the story is also one of progress that has slowed in recent years — while South Africa's MTCT rate lingers well above 2%, it is at or below 1% in several developed countries. About a decade ago, South Africa was making great progress towards reducing new HIV infections among children and keeping their mothers alive, but that has been followed by some complacency, says Professor Linda-Gail Bekker, CEO of the Desmond Tutu Health Foundation and Director of the Desmond Tutu HIV Centre. As pointed out by Professor Adrian Puren, Executive Director of the National Institute for Communicable Diseases and the the head of its Centre for HIV and Sexually Transmitted Infections, 'although the vertical transmission (another term for MTCT) rate is low, because of the high burden of maternal HIV, the absolute number of vertical transmissions remains high'. As pointed out by Dr Glenda Gray, a Distinguished Professor at the University of the Witwatersrand: 'We have very high rates of HIV in pregnant women in South Africa. About a third of all women in our country who are pregnant are HIV infected, and it's even higher in some parts of KwaZulu-Natal and particularly in young women.' An evolving problem The progress of the past two decades is largely due to increased access to antiretroviral therapy and how well the medicines suppress the virus in a person's body. If a mother living with HIV is stable on treatment, the chances are very close to zero that the virus will be transmitted to her baby. In the public sector, pregnant women are routinely tested for HIV and offered antiretroviral therapy if positive. A complication, however, emerges when a woman contracts HIV late in pregnancy or in the months after birth and the virus is then transmitted to her baby via breastfeeding before she is diagnosed and can start the treatment that will suppress the virus. The latest estimates from Thembisa, the leading mathematical model of HIV in South Africa, suggest that this dynamic is indeed driving much of the MTCT in the country. Of the approximately 7,200 babies who contracted HIV in South Africa from mid-2023 to mid-2024, only 2,500 became positive before or at birth. The rest of the transmissions occurred during breastfeeding in the months after birth. While a portion of these mothers were on antiretroviral therapy, the majority had not been diagnosed with HIV yet. HIV-exposed infants are at particularly high risk if the mother was recently infected. As Bekker explains, this is because a person who has just acquired HIV has a very high amount of the virus in their body, since their immune system hasn't had time to fight it yet, making it easier to pass the virus on. 'So, you get very high viral loads, and this is therefore a very dangerous time for vertical transmission,' she says. Dvora Joseph Davey, an associate professor of epidemiology at the University of California, Los Angeles, and the University of Cape Town, concurs. 'We know that in South Africa, over a third of HIV in infants is due to getting HIV from their mothers who were HIV-negative at their first antenatal visit, and they acquired HIV at some point during pregnancy or lactation,' she says. She explains that MTCT is in part due to inequity in healthcare. Mother-to-child transmissions often occur in certain pockets, such as in rural areas, because of limited access to prevention methods, late diagnosis, not starting treatment on time, and coming into antenatal care late. 'This points to missed opportunities in sustaining maternal antiretroviral therapy adherence and viral suppression throughout the breastfeeding window — an area where we urgently need more targeted and consistent support,' says Olwethu Mlanzeli, who leads Communications and Advocacy for the youth HIV-focused initiative Africa Reach. What to do? South Africa's 2023 guidelines for preventing vertical transmission (of several infectious diseases) does cover several of the issues experts raised in interviews with Spotlight. Among others, the guidelines recommend that pregnant women or new mothers who are newly diagnosed with HIV should be started on a dolutegravir-based antiretroviral regimen, since dolutegravir is particularly effective at rapidly suppressing the virus. The guidelines prescribe testing babies for HIV at birth, 10 weeks, and at six and 18 months. But in South Africa, good guidelines are not always followed by universal implementation. In line with this, several experts firstly suggest simply strengthening existing HIV treatment and prevention services, particularly those aimed at women before, during and in the months after pregnancy. It is suggested that women should continually be offered HIV testing during all stages of pregnancy and after birth. Joseph Davey says this needs to be integrated better, so that the same nurse offers contraceptives, HIV testing and HIV prevention medicines, proactively. Her research has shown that, at least on a small scale, training clinics to integrate the services can work well. Puren notes that the integration of MTCT care could also be done by joining HIV testing with infant immunisation programmes. 'There doesn't need to be a major overhaul,' adds Joseph Davey. 'These are simple steps related to data collection and targets around HIV testing that can be implemented within existing standards of care.' Experts also suggest that it is crucial to put women and babies on HIV treatment and HIV-prevention treatment as widely as possible during the postnatal phase. Joseph Davey cautions that these interventions are not the same across the country. The Western Cape, for instance, has explicit guidelines around HIV prevention medicines and pregnancy that have been updated every few years, while this does not seem to be the case for other provinces. Joseph Davey says that expanding this could be helpful. But even with good guidelines, there are barriers to adherence. Bekker notes that a daily HIV prevention regimen may be difficult to take for a pregnant woman experiencing morning sickness, or while she is a new parent. 'So here comes the perfect opportunity for long-acting injectable pre-exposure prophylaxis, such as cabotegravir or hopefully, in the future, lenacapavir,' she says. Not widely available Cabotegravir injections provide two months of protection against HIV infection per shot and lenacapavir six months per shot. Neither is yet widely available in South Africa. Cabotegravir is registered here, and lenacapavir's registration is expected in the next six months or so. There are other potential advances, according to Gray, that could make a significant difference. 'Antiretrovirals can mop up and control a lot, but to eradicate breast milk transmission we need other monoclonal antibodies or an HIV vaccine. And so, if we really are committed to eradicating paediatric HIV, then we need more tools besides antiretroviral therapies in the toolbox.' For now, these alternatives to antiretrovirals remain experimental and none have been proven to work or been approved for use by regulatory authorities. Lastly, Mlanzeli notes that patient awareness is a key part of the challenge, especially during the postnatal period. 'There's a need for greater investment and visibility around prevention of MTCT programmes, particularly in the postnatal period,' she says. 'While many governments allocate substantial resources to HIV programmes overall, these resources don't always translate into strengthened support for mothers and infants.' Brodie Daniels, Specialist Scientist at the HIV and other Infectious Diseases Research Unit at the South African Medical Research Council, agrees. 'What we need to focus on now is educating women on the increased risks during pregnancy and breastfeeding if they are HIV-uninfected during their antenatal visits,' she says. 'Women need to be encouraged to test more often during these periods, so that if they do seroconvert, both they and their infant can be placed on prophylaxis.' Impact of aid cuts In recent months, large and abrupt cuts to HIV funding from the United States government have severely disrupted HIV services in South Africa and neighbouring countries. While some limited funds are still flowing, it is a small fraction of what there was previously and there is little hope that funding will be restored. Several researchers Spotlight spoke to are very worried that the cuts will negatively impact MTCT rates. The cutting of some services, specifically those aimed at marginal groups, will probably lead to many not being able to access HIV counselling, prevention and testing services in a timely manner. Thus, the number of women contracting HIV while pregnant or breastfeeding and not being virally controlled may increase. But the silver lining is that change is within reach, if the resources are available and implementation is done right. As Bekker puts it: 'We know exactly what we need to do, and it's not like we don't have the tools. We need to just do it!' DM
Daily Maverick
29-04-2025
- Health
- Daily Maverick
Surprising new study reveals alarming HIV death rates, challenging official statistics in South Africa
It is widely acknowledged among health and demographic experts that relying solely on what is written on death certificates does not paint an accurate picture of what people in South Africa are actually dying of. Now, an SAMRC study has provided evidence that the undercounting of deaths due to HIV might be even greater than previously thought. Many in health circles were surprised by a recent South African Medical Research Council (SAMRC) study that found that 23% of deaths in a nationally representative sample drawn from 2017/2018 were due to HIV. By comparison, Stats SA data for roughly the same period puts the figure at only 5.7%. That Stats SA's HIV mortality figure differs from other sources is not new and not in itself surprising. This is because Stats SA reports a relatively straightforward count of what is written on death certificates — where it is known HIV is often not indicated, even if it is the underlying cause of death. By contrast, the new SAMRC study looked at autopsy reports, death certificates, medical records, and interviews with next of kin to come up with its much higher estimate. The thing that did come as a surprise, is just how much higher the SAMRC figures were than anticipated. Previously, the real number of HIV deaths were thought to be around double the Stats SA number, rather than four times as much. For example, according to Thembisa, the leading model of HIV in South Africa and the basis for UNAids' estimates for the country, about 12% of deaths in the country in 2018 were due to HIV. 'Accurate mortality data are essential for informed public health policies and targeted interventions; however, this study highlights critical gaps in our cause-of-death data, particularly in the underreporting of HIV/Aids and suicides,' says Professor Debbie Bradshaw, study co-author and Chief Specialist Scientist at the SAMRC Burden of Disease Research Unit, in a media statement. (The study also found substantial under-reporting of suicide on death certificates.) Multiple data sources The study was conducted in three phases, examining deaths that were registered in 27 randomly selected health sub-districts between 1 September 2017 and 13 April 2018. In addition to the examination of autopsy reports, death certificates, and medical records, trained fieldworkers interviewed next of kin to conduct verbal autopsies using a World Health Organization (WHO) questionnaire that had been translated into the country's nine official languages. Based on these various sources of data, the cause of each death was categorised into one or more of 44 categories and then compared to the cause of death indicated on the person's death certificate. (The process for ensuring accuracy, including a review shared by a team of 49 medical doctors, is described in detail in this report.) The researchers collected data for more than 26,000 deaths, although not all types of data were available for each death. Medical records were available for more than 17,600 cases, forensic pathology (autopsy) records for 5,700, and about 5,400 verbal autopsies were conducted. In the end, 'to save costs', not all medical records were reviewed. Overall, for just over 15,000 deaths, the researchers could link and compare their assessment of why a person died to what was written on death certificates. 'Poor agreement' The researchers found that 'there was poor agreement between the underlying cause of death obtained from the study and the official cause of death data'. The cause of death was the same in only 37% of cases. In addition to the under-reporting of HIV, the researchers also identified 'severe under-reporting' of suicide as a cause of death. Some question marks As noted earlier, the new numbers are substantially higher than estimates from the highly respected Thembisa model. According to their data only 12% of deaths from mid-2017 to mid-2018 were due to HIV-related causes, with a further 9% of deaths occurring in persons with HIV but due to other causes. Dr Pam Groenewald, a co-author of the new study and also with the SAMRC, describes Thembisa as 'an excellent source'. She tells Spotlight they had a long discussion with the Thembisa researchers, 'but we weren't able to fully explain the differences'. The study authors cite several factors that might contribute to a higher proportion of HIV deaths in their study. Firstly, the weighted national causes of death validation sample aimed to represent the registered deaths in the country, and it was known that deaths in rural areas and child deaths were under-represented. Secondly, deaths that occurred in private sector hospitals were not represented. Groenewald says the HIV-linked deaths in private hospitals are 'definitely lower', but doubts they would have had a significant impact on their findings. One thing in favour of the study numbers is the fact that the cases they identified with HIV/Aids as the underlying cause of death were independently reviewed by clinicians. As Groenewald points out, they looked at medical records of people admitted to and who died in hospital, including CD4 cell counts and HIV viral loads. The suggestion is that if someone had a very low CD4 count and a very high HIV viral load at the time of death, then it is very likely HIV played a role in their death, unless of course they died of a clearly non-associated cause like injuries from a car accident. On the other hand, it might be argued that since HIV is very widely tested for in South Africa, it is more likely to appear on medical records than other less tested for diseases. Another interesting wrinkle is that the proportion of deaths from HIV/Aids from this study was higher than anticipated based on observed declines in adult mortality. It is widely accepted that the decline in adult mortality and the increase in life expectancy over the past two decades was driven by antiretroviral therapy keeping more people with HIV alive. While the new findings do not challenge this narrative, it does suggest the effect may be less pronounced than previously thought. What to do? The researchers suggest their study has immediate implications for the country's response to HIV and TB. 'The study recommends strengthening case finding, follow-up, prevention, and treatment for HIV, Aids and TB to reduce mortality rates, and underlines the importance of the government's rapid response to counter the recent abrupt withdrawal of Pepfar (American) funding,' Bradshaw commented in the media release. But more broadly, the findings put the spotlight on major problems in the country's death certification systems. 'Our findings highlight the need for improved record quality and adherence to testing guidelines within the medical community. Poor record keeping included incomplete documentation of clinical findings and results,' the study authors write. 'A lot of doctors' report HIV as 'retroviral disease', for example, and it's not coded as HIV,' Groenewald said. Urging doctors to record the actual underlying cause of death when writing up death certificates, she also called for improved training in death certification at medical schools. Doctors' reluctance to report HIV on death certificates probably has various reasons, including stigma related to HIV and the fact that some medical insurance policies used to exclude HIV, though policies now treat HIV like any other chronic condition. Overall, Groenewald said, we needed to step back and probe the rationale of compiling underlying cause of death statistics. 'The public health aim of the medical certificate of cause of death is to prevent premature deaths. We therefore need to record the cascade of events or causal sequence of medical conditions leading to death and target our interventions at the underlying cause of death. The coding rules focus on the underlying cause of death to compile the mortality statistics,' she said. Groenewald stressed that the law required doctors to provide accurate information on death causation. The Health Professions Council of SA's ethical rules also recognised that a statute requiring disclosure about a deceased person's health must be complied with and was not considered unethical. Contrary to common physician misconception, Groenewald said all this combined to show 'it is completely ethical to disclose on a death certificate that a person has died from an Aids-related illness'. In the meantime, routine mortality data from Stats SA should clearly be taken with a pinch of salt. As Groenewald pointed out, vital registration data should not be accepted at face value but should be interrogated and cross-checked with other data sources to get coherent and consistent estimates that fit within an envelope of all causes of mortality. DM
