Breaking the Cycle: Intergenerational HIV Transmission

“In Africa, the group with the highest incidence rate of HIV is young women. Young women bear the brunt of the HIV epidemic, and if we are going to have a global impact on HIV, we have to turn the fortunes of that group.” With nine in 10 children in the world living with HIV in sub-Saharan Africa, MOSIBUDI RATLEBJANE spoke to epidemiologist and infectious diseases expert, Professor Salim S Abdool Karim, about the new generation of HIV infections in Southern Africa, and why young women are most at risk.

What strides have been made in the last few years regarding the HIV and Aids epidemic?

Throughout recent years we have seen many efforts to understand why young women are acquiring HIV at a young age. There have been several important studies done globally, and in certain countries in Africa,- some with positive outcomes that have given us ideas and tools on how to deal with the HIV epidemic going forward, and some with disappointing results in terms of what we had hoped to see.

What have been your biggest concerns relating to the rate of new HIV infections?

The first concern is that the HIV epidemic has been in steady decline, in terms of the number of new infections over the last 5 to 10 years, however we have seen a tremendous slowing down in that decline, and in fact we are now starting to see a reversal of that decline in several countries, which is deeply concerning. We had hoped that, as we increase treatment coverage, we would start seeing the numbers of new infections going down, but we have not seen declines in HIV. Instead, when looking at the global HIV epidemic, we are seeing 1.8 billion new infections, which means 5,000 new infections every day.

So, to people who say that HIV is not a problem anymore, “we’ve sorted it out”, you can’t consider any epidemic conquered if it has 5,000 new cases every day. So, there is a need to double down and do even more, if we are going to defeat HIV.

According to the United Nations Children’s Fund (UNICEF), every two minutes an adolescent aged between 15 and 19, is infected with HIV, which means 700 adolescents are infected every day.

We need to understand that one in five HIV positive people in the world is found right here in Southern Africa. We contribute about 18 to 19% percent to the global HIV epidemic. Which means the global HIV epidemic will not be beaten if we cannot win the battle here in Southern Africa. If you look beyond Southern Africa, Africa as a whole accounts for 70% of the global HIV epidemic. Therefore, if we are not seeing declines in the number of new cases of HIV, it’s because Africa is not seeing the kind of progress we would like to see.

Who is most impacted, and what are the reasons for the new cycle of HIV infections?

The group that is severely impacted, with the highest incidence rate of HIV, is young women, and this applies across the African continent. Young women have such high infection rates, while young boys have low infection rates.

We know that there are two key factors that drive the high rates of HIV in women. Firstly, the societal norms and beliefs found in communities where young women live, which lead to them acquiring HIV because they have sexual partners who are substantially older. We have seen this by looking at the sequence of the virus, where we were able to track the cycle of HIV transmission, and found that teenage girls were being infected by men in their late twenties to early thirties, with the average age difference being 8 to 10 years.

In the KwaZulu-Natal (KZN) communities where we did our research, over half of the women are HIV positive by the time they reach their thirties. Those women in their thirties become the main source of HIV for men in their thirties, where the age difference between the women who are the source the virus and the men that are acquiring it, is one year. Of the men in their thirties, with a partner in the same age group, we found that 40% of them are also linked to another young teenage girl, who has the same virus.

So, the cycle relates to young women with high rates of HIV reaching their thirties, and then being the main source of infection for the “older” men they are in relationships with, who in turn infect the young girls in their teen years, who will grow up and infect the next group of men, and so the cycle goes on. That is the fundamental basis of why the epidemic is so severe in much of Southern Africa.

Is there a biological explanation as to why young women are more susceptible to being infected?

Young women have a subclinical lesion, called genital inflammation. We know this from looking at little proteins, that indicate inflammatory responses. Due to young women having genital inflammation, they have a higher number of CD4 positive cells in their vagina. When CD4 cell are activated, this makes them prone to acquiring HIV. So not only are young women having sexual encounters with older men, they have a vaginal environment that predisposes them to acquiring HIV rapidly. That is why they get infected while they are still very young.

When you have such large numbers of young girls getting infected, you have to ask the question, how will this affect their lives? Will they drop out of school? Will they fall pregnant? What about the risk of transmitting it to their babies? We can see that the effect of the epidemic is very serious in its impact on our society.

What strategies are in place to address the persistent gaps in testing, treatment and prevention, affecting children and adolescents? And how effective are these strategies?

Due to societal norms and belief systems, we have found that many adolescent women face socio-economic circumstances that may lead to transactional relationships with older men. At times older partners provide financial relief to families and young women struggling with basic amenities. So, we have found that we are going against the grain by telling young women not to sleep with older men.

The alternative has been, firstly, to capture as many men as we can to go on treatment, as they will not be infectious to partners once they’re on treatment. However most men who are HIV positive don’t know they are HIV positive. Secondly, because women have more interaction with the health services, we thought we could focus on protecting the women.

However, ensuring that people who are not HIV positive take pre-exposure prophylaxis (PrEP) has proven challenging, as people need to accept that they are at high risk of acquiring HIV, and then decide to take on the responsibility of taking pills every day. As you can imagine, that’s difficult for an adult, let alone young teens and youth, who are preoccupied with many other things.

We have offered several thousand women PrEP within the KZN region in South Africa, and found two thirds rejected taking PrEP as a preventative measure to protect themselves against acquiring HIV. Only one third were willing to take PrEP, however only two thirds of those willing participants are able to stay on PrEP indefinitely.

In order to encourage the use of PrEP, particularly for individuals seeking discretion, or who are unable to negotiate safer sex, the Tenofovir Alafenamide (TAF) Implant is currently still under development, which will relieve the burden of pill intake. TAF is a combination of a highly potent antiretroviral pro-drug and PrEP, released from an implant. Although still being developed, the aim of this implant is to be inserted into the arm, and slowly release the treatment over time. Currently being tested on animals, there’s hope that in the next few years tests on people will be conducted, which will enable an effective form of prevention of new infections, particularly for the next generation.

UNICEF launched the global statistical update on HIV/AIDS in Johannesburg. Watch the event on UNICEF Africa’s Facebook page.

Mosibudi Ratlebjane is a writer based in Johannesburg.