10-fold increase in South African adolescents entering HIV care
The number of adolescents in HIV care in South Africa has increased 10-fold since 2005, and could double again by 2021.
An analysis of records relating to around 730,880 one to 19-year-olds entering South Africa's public HIV treatment programme between 2005 and 2016 found a significant increase in the number of 15 to 19 year-olds coming into contact with HIV care services. However, only 66% of 15 to 19-year-olds were found to initiate antiretroviral treatment (ART), compared to 87% of those aged 15 and under.
By 2016, 55% of the 1 to 19-year-olds entering HIV care were between 15 and 19, compared to 32% in 2005. The rise was attributed to the ageing of a large group of young people who had acquired HIV at birth and had entered care between 2002 and 2006, before prevention of mother-to-child transmission (PMTCT) services had been fully rolled out. But it was also associated with an increasing number of 15 to 19-year-olds who were seeking care for the first time, presumably after becoming HIV-positive through sexual transmission.
Around 88% of the 15 to 19 year olds entering HIV care between 2005 and 2016 were female. Across all age groups, more females than males entered care. But the particularly sharp contrast betwaeen females and males in the late adolescent age group is likely to reflect that those entering into care at this age acquired HIV through sexual rather than vertical transmission. It also provides further evidence of the urgent need to address the inequalities in education, sexual and reproductive health, poverty and food security that exacerbate adolescent women’s vulnerability to HIV infection.
This study has two important limitations. Firstly, because 15 was assumed to be the right age to distinguish between sexual and vertical modes of transmission, any young person acquiring HIV sexually before this age would be misclassified in the analysis. Secondly, some groups are not included in the data, including infants younger than 1 year, clients accessing care in the private sector or in other places, and, importantly, those who do not test and do not enter the treatment programme.
The study suggests that, should uptake of ART increase to 90% among people living with HIV, as is South Africa’s stated goal, the number of 15 to 19-year-olds on ART is likely to nearly double between 2016 and 2021. However, as adolescents are currently the least likely age group in South Africa to start ART promptly, unless HIV programmes urgently address their needs, transmission cycles involving this age group are likely to continue, and the ability of South Africa to reach the UNAIDS 90-90-90 targets, and ultimately control its HIV epidemic, will be compromised.
Commenting on the findings in The Lancet, Audrey Pettifor, Associate Professor of Epidemiology at the University of North Carolina, said: “The point of this study is clear, adolescents are being left behind by treatment programmes in significant numbers. With an expanding global adolescent population, the high HIV incidence among adolescents, and the gap in HIV treatment services, the findings here emphasise the need to not only strengthen care programmes but to also prevent new HIV infections if programmes are to care for all people living with HIV.
“Few evidence-based interventions exist to improve linkage to and retention in care for adolescents, and even fewer have been taken to scale; this must change if we want to see reductions in new infections and alter the course of the HIV epidemic.”