South Africa’s HIV epidemic is driven by people who face obstacles in obtaining treatment and struggle to adhere to their daily oral medication or remain in care – and the lack of access to long-acting injectables for HIV treatments compounds this challenge.
This alarming reality was underscored by University of Cape Town (UCT) Professor Catherine Orrell during her recent inaugural lecture – “Toward effective HIV treatment in South Africa – injustice, clinical pharmacology and adherence.”
Professor Orrell is an HIV clinician, clinical pharmacologist, and clinical trial specialist. Since 2004, she has been a principal investigator on more than 20 antiretroviral clinical trials including a range of efficacy, toxicity, pharmacokinetic, drug interaction, and dosing studies. She has in-depth experience conducting research in state-of-the-art research facilities at UCT, community settings, and primary healthcare clinic environments.
“By increasing our understanding of Professor Orrell’s work, we also build our understanding of how HIV is currently treated in South Africa and what it will take to make treatment more effective,” says deputy vice-chancellor for Transformation, Student Affairs and Social Responsiveness, Professor Elelwani Ramugondo.
According to South African History Online, southern Africa became the epicentre of what is now a global pandemic in 2000.
“After more than two decades, this region still has the highest global HIV rate – with South Africa in third place behind Eswatini and Lesotho,” says Prof Ramugondo. “South Africa’s HIV prevalence among adults is just under 18%.”
Statistics from 2002 revealed that of the 7,6-million South Africans who have tested positive for HIV, only 5,7-million are on antiretroviral treatment (ART). This, says Professor Ramugondo, means around 2-million people with HIV are still not receiving the lifesaving treatment they need.
“In 2022 we had 160 000 new HIV infections and 45 000 AIDS-related deaths,” Prof Ramugodon says. “According to the same report, despite huge improvements in getting people to test for HIV, men are far less likely than women to do so. In 2022, only 68% of men with HIV were estimated to be on ART compared to 80% of women – and this is helping to drive new infections, particularly among young women. In 2022, around one-third of all new infections were among young people.
“With her focused research into novel methods to monitor and improve ART adherence, as well as her exploration into the use of long-acting antiretroviral therapy in adolescents and young people living with HIV, Professor Orrell is developing practical ways to address HIV prevalence and, we hope, to bring the rate of new infections down,” adds Prof Ramugondo.
Since the early 1990s, a sense of injustice has driven Professor Orrell’s interest in HIV – from the era of AIDS denialism – when access to treatment was limited to small clinical trials – to today, when ongoing global inequity once again denies people living with HIV in Africa access to new formulations.
South Africa’s growing HIV epidemic was ignored for many years, says Professor Orrell.
“It was plagued by political interference and the varying costs of treatments – and too expensive for people in South Africa to afford for a very long time.”
She says that the harm done by AIDS denialism cannot be ignored.
“We still have people who don’t come for HIV treatment because they’re nervous about side-effects,” she says. “Medications used have long since been improved, but much stigma remains because of the exaggeration of bad medication effects during the period of AIDS denialism. We still live with this today and continue to have to educate people about accessing treatment.”
Long-acting injectable HIV treatments were approved by the South African Health Products Regulatory Authority in March 2023, but have not yet been launched, creating a gap in HIV treatment options.
“We hear that, a year and a half after registration, the company has chosen not to launch these long-acting treatments for a number of reasons including ‘lack of demand’ and the concern we can’t do cold chain in Africa. These drugs are also extremely expensive,” says Prof Orrell.
As well as the inequity of not making these drug available to people in Africa, she says that it’s short-sighted that researchers cannot access these drugs for research purposes as “we need to work out who might best benefit from these products in a resource-limited setting.
“For example, we are trying to study these drugs in women in the postpartum and breastfeeding period which is a really vulnerable period with high viral loads – and where people struggle to disclose while they are trying to come to terms with new motherhood,” she says.