Being diagnosed and living with HIV now is not what it looked like just ten to twenty years ago. What was once seen as a virus that would “destroy” your life can now safely be described as a manageable chronic condition (just like any other) that not one person ever has to lose their life to again.
A quick look at the HIV statistics for South Africa would give anyone a rush of anxiety. Apart from the fact that we have the biggest HIV epidemic in the world, with over seven million people living with the disease, South Africa also accounts for a third of all new HIV infections in southern Africa.
But, and it’s a big one, we also have the largest antiretroviral treatment programme in the world and we were the first country in sub-Saharan Africa to wholly approve PrEP (which we’ll get into in a minute). So things are looking up.
UNAIDS set a treatment target to help end the AIDS epidemic called “90-90-90”. With this they hoped that by 2020: 90% of all people living with HIV will know their status; 90% of all people diagnosed with HIV infection will receive sustained antiretroviral treatment; 90% of all people receiving antiretroviral therapy will have viral suppression. To this end, UNAIDS had not met their goal, in part owing to the Covid-19 pandemic. During the pandemic, many people in lockdown had limited access to their life-saving medication.
Still, according to HIV/AIDS organisation Avert, 90 per cent of South Africans are at least aware of their status, of which 68 per cent are on antiretroviral treatment, of which 87 per cent are virally suppressed. So we’ve met the target for at least one of the goals.
The work now lies in getting people to take treatment and, most importantly, building awareness around how the treatment has evolved over the years. This involves breaking through the stereotypes that exist around it and highlighting, through vigorous awareness initiatives, the life-changing benefits it has for an HIV-positive person today.
The good news is that there are a lot more ways for you to be protected from contracting the virus and there is a lot less to be sad about if you do get diagnosed with HIV right now because you can live a full, vibrant and ‘normal’ life with HIV (like an HIV negative person). This includes your sex life, conception, pregnancy, breastfeeding and and and and!
What exactly has improved, you ask? Well, let’s take a look…
How U=U has revolutionised sex for HIV+ people
The biggest game changer, and probably the most ground-breaking discovery, for HIV-positive persons in the last couple of years is U=U, which stands for undetectable equals untransmittable.
“There’s a stubborn belief that when you are HIV positive, you will always transmit the virus if you have unprotected sex, even if you are on treatment, and this is no longer true,” explains Dr Marlin McKay, owner of the Goldman Medical Centre in Johannesburg.
“We now know for a fact that if someone is taking treatment and their viral load (the amount of HIV in your blood) is suppressed (is at an undetectable level), then that person can’t transmit HIV when engaging in any unprotected sexual activity. That is U=U.”
So, if you are diagnosed with HIV today, your doctor will put you on treatment immediately and after 12 weeks, your viral load should become undetectable. Thereafter, you will do blood tests every six months to a year (depending on your doctor’s recommendation) to make sure that your viral load is still suppressed.
Because of the stigma and fear built up around the virus over the decades, this discovery has often been taken as something too good to be true by many. But whether you’re sceptical about it or not, the science and the overwhelming evidence is there. As you will see, U=U has become the bedrock of most advancements within the HIV treatment space.
PrEP has become somewhat of a buzzword and for good reason. It stands for pre-exposure prophylaxis and it is a two-in-one antiretroviral drug specifically formulated for HIV-negative individuals to protect themselves from contracting the virus. It does this by blocking the replication of the virus in human cells and, by doing so, stops the infection.
If you don’t know your partner’s HIV status; if your partner is HIV positive without an undetectable viral load; if you have multiple sexual partners; if you’re not a big fan of condoms; if you’re a sex worker and/or have a recurrent history of sex while under the influence of alcohol or drugs – you should definitely be on PrEP. But if you also just want to generally feel safe in your sexual interactions, then you should be on PrEP too.
One of the biggest misconceptions about PrEP is that you can pop one pill today and it will be effective by tomorrow, but this is not the case. It is a commitment and you have to wait a number of days before it starts working. “PrEP has to be taken every single day for it to work,” says Dr Sindi van Zyl, a general practitioner and HIV clinician. “If you’re engaging in vaginal sex, it will take about 20 days for PrEP to be effective after you start taking it. And it will take about seven days if you’re engaging in anal sex.”
“One of the conditions of PrEP is that you have to come in for a blood test and check-up every four months to make sure that you’re still HIV negative,” she says.
Right now, researchers are working on long-acting PrEP in the form of an injection that provides up to six months protection from HIV and Aids. It will take a while for this to be released, but is an encouraging sign of progress.
Serodiscordant couples who want to conceive
A serodiscordant couple is a couple where one partner is HIV positive and the other one isn’t. There are a lot of questions about how a serodiscordant couple can navigate conception, but the answer is a lot more straightforward now than it was years ago. Back in the day, most couples had to look at assisted conception treatments which were, and continue to be, quite expensive. These included things like artificial insemination, in vitro fertilisation and donor sperm.
Many couples who couldn’t afford these high-end fertility treatments would self-inseminate (if the male partner was HIV-negative). This involved a woman removing the sperm in the condom with a syringe after sex, lying on her back and injecting the semen as high up into her vagina as she could. But with the discovery of U=U, these treatments are no longer necessary (unless there’s an already existing fertility issue in the relationship).
“U=U has changed everything for serodiscordant couples,” van Zyl says. “The first thing to do is to make sure that the HIV-positive partner is taking their treatment as they should and that the viral load is undetectable. Once that is achieved, the couple can have unprotected sex without worrying about HIV infection and conceive in the same way an HIV-negative couple would.”
When you’re HIV+ and pregnant
A lot of pregnant HIV-positive women are anxious during their pregnancies because of the fear they might transmit the virus to their babies. But this will not happen if the proper steps are taken. Van Zyl highlights the effectiveness of the prevention of mother-to-child transmission (PMTCT) of HIV and regards it as the most important HIV-related programme in the country. Again, the solution is straightforward:
“If the mother is on treatment and her viral load is undetectable, she won’t transmit the virus to the baby,” she explains.
Contracting HIV during your pregnancy
But what happens if a woman contracts HIV during her pregnancy? Every pregnant woman in South Africa has to go through antenatal screening and one of the compulsory tests is an HIV test. This test will ideally be conducted every trimester of the pregnancy (sometimes it will only be done again in your final trimester) – so a woman will know her status throughout her pregnancy.
If at some point during the pregnancy the results come back positive, it’s not the end of the world. Dr Margaret Mojapelo, a doctor and the founder and CEO of Mediwell Holdings, does however warn that it might not be the easiest of times.
“As part of the process, we will introduce psychological therapy because the woman might be devastated about her new diagnosis, which could put the unborn baby at risk,” she says. “We also make sure to start HIV treatment immediately so that we can get the viral load to an undetectable state before the baby is born to prevent transmission.”
She goes on to explain that seroconverting (transitioning from being HIV negative to being HIV positive) during pregnancy can result in a higher likelihood of getting sick – sometimes intensely and sometimes not. “Pregnancy in itself is a very fragile condition and when you seroconvert in that time, you could be hit with an avalanche of viruses, from the common flu to something as intense as pneumonia,” she says. “This is why a woman will have to be monitored quite intensely during her pregnancy.”
But the recurring message still stands: the baby can and will still be protected from the virus if the treatment schedule is adhered to.
Natural birth vs C-section
Once upon a time, HIV-positive women were offered no other option but to give birth via a Caesarean delivery (C-section), but this is no longer the case. Because of U=U, now pregnant HIV-positive women also have the option of giving birth naturally if their viral load is undetectable. But it’s still important to speak to your healthcare provider about which option will suit you best, particularly because different healthcare providers have opposing views on this.
On the one hand, a healthcare practitioner might not recommend natural birth by arguing that there’s more control during the delivery when it’s a C-section – like Mojapelo. On the other, a healthcare practitioner might highlight the benefits of giving birth naturally – such as the minimisation of allergies, early illnesses and the risk of use of antibiotics – like McKay, and will recommend a natural birth.
Unless there’s a medical emergency that requires that a woman give birth via a C-section, the decision will ultimately lie with the patient based on what they have discussed with their doctor.
Similar to the debate on birthing options, doctors often have opposing views on whether an HIV-positive mother should breastfeed or not. The science and data are there to support the fact that exclusive breastfeeding is safe for the baby and McKay is an advocate for this. “I’m of the view that breast is best,” he says. “It’s just important to know that if you’re HIV-positive and breastfeeding, the baby must only have breast milk and nothing else – not even water.”
He explains that exclusive breastfeeding should ideally go on for at least six months. Not losing sight of the reality faced by most women (six months’ maternity leave is hardly ever on the cards), he does say that it can also only go on for three months if there is no other way around it.
However, Mojapelo is not of the same view. Not because she doesn’t believe in the idea of exclusive breastfeeding, but because the strict exclusivity of it makes her uncomfortable and ‘leaves too much room for error’. “I’m not an advocate for breastfeeding for HIV-positive mothers because I see it as a risk,” she says. “As a doctor, I won’t be able to monitor whether a mother is sticking to the exclusivity and I have witnessed babies becoming HIV positive because the mother didn’t stick to the rule. That’s the only thing that makes me uneasy about it.”
Again, it’s a choice that a mother has to make based on her conversations with her doctor and what she believes will be feasible and right for her.
It’s clear to see that HIV treatment has come a long way and it’s going to continue reaching new heights until a cure for the virus is found. Gone are the days when patients had to take a handful of pills a day and still suffer severe side effects that sometimes caused changes in their body shape.
Now, you only have to take one combination tablet with minimal side effects and it’s only going to get better. “The most exciting development at the moment is the injection that will replace antiretroviral pills,” van Zyl says enthusiastically. “How it’s set to work is that a patient will only need to get an injection every two to three months versus taking the pill every day.”
Another new development is the introduction of a strawberry-flavoured pill that replaces the syrup children used to take as a treatment for HIV. Now, children are able to take medication that’s more palatable.
McKay adds that there’s also the development of long-acting implants in the works. These will release an anti-HIV drug into the body at a controlled rate for continuous protection from the virus (replacing PrEP). “I always say to my patients: ‘Take your treatment so that you can be alive when the cure arrives,’” says van Zyl.
Let us all take a moment to appreciate the strides South Africa and the world have made in the HIV space and the hope that this has created for millions of people.