Current HIV/AIDS Reports

, Volume 11, Issue 2, pp 99–108

The HIV Epidemic in Southern Africa – Is an AIDS-Free Generation Possible?

The Global Epidemic (S Vermund, Section Editor)


Southern Africa, home to about 20 % of the global burden of infection continues to experience high rates of new HIV infection despite substantial programmatic scale-up of treatment and prevention interventions. While several countries in the region have had substantial reductions in HIV infection, almost half a million new infections occurred in this region in 2012. Sexual transmission remains the dominant mode of transmission. A recent national household survey in Swaziland revealed an HIV prevalence of 14.3 % among 18–19 year old girls, compared to 0.8 % among their male peers. Expanded ART programmes in Southern Africa have resulted in dramatically decreased HIV incidence and HIV mortality rates. In South Africa alone, it is estimated that more than 2.1 million of the 6.1 million HIV-positive people were receiving ART by the end of 2012, and that this resulted in more than 2.7 million life-years saved, and hundreds of thousands of HIV infections averted. Biological, behavioural and structural factors all contribute to the ongoing high rates of new HIV infection; however, as the epidemic matures and mortality is reduced from increased ART coverage, epidemiological trends become hard to quantify. What is clear is that a key driver of the Southern African epidemic is the high incidence rate of infection in young women, a vulnerable population with limited prevention options. Moreover, whilst ongoing trials of combination prevention, microbicides and behavioural economics hold promise for further epidemic control, an AIDS-free generation will not be realised unless incident infections in key populations are reduced.


South Africa AIDS Global epidemic Southern Africa AIDS-free generation Infection Microbicides Combination prevention HIV-positive ART Review 


Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. 1.
    UNAIDS. In: AIDSinfo. 2013. Last accessed on 30 Dec 2013.
  2. 2.
    Mayosi BM, Lawn JE, van Niekerk A, et al. Health in South Africa: changes and challenges since 2009. Lancet. 2012;380(9858):2029–43.PubMedCrossRefGoogle Scholar
  3. 3.••
    UNAIDS. Global report: UNAIDS report on the global AIDS epidemic 2013. 2013. Available at: Last accessed on 30 Dec 2013. The UN Report is the most comprehensive source of up-to-date epidemiological information regarding the state of the epidemic.
  4. 4.••
    Cohen MS, Chen YQ, McCauley M, et al. Prevention of HIV-1 infection with early antiretroviral therapy. N Engl J Med. 2011;365(6):493–505. Describes the results of the seminal study which demonstrated a significant reduction of HIV transmission in HIV+ patients on antiretroviral therapy.PubMedCentralPubMedCrossRefGoogle Scholar
  5. 5.
    Abdool Karim SS, Abdool Karim Q. Antiretroviral prophylaxis: a defining moment in HIV control. Lancet. 2011;378(9809):e23–5.PubMedCentralCrossRefGoogle Scholar
  6. 6.
    Fauci AS, Folkers GK, Dieffenbach CW. HIV-AIDS: much accomplished, much to do. Nat Immunol. 2013;14(11):1104–7.PubMedCrossRefGoogle Scholar
  7. 7.
    Shisana O. HIV/AIDS in South Africa: at last the glass is half full. In: 6th South African AIDS Conference. Durban, South Africa. 2013. Available at
  8. 8.•
    Cremin I, Alsallaq R, Dybul M, Piot P, Garnett G, Hallett TB. The new role of antiretrovirals in combination HIV prevention: a mathematical modelling analysis. AIDS. 2013;27(3):447–58. An important modelling analysis which highlights the potential impact of treatment as prevention on epidemiologic trajectories.PubMedCrossRefGoogle Scholar
  9. 9.
    Abdool Karim SS, Churchyard GJ, Abdool Karim Q, Lawn SD. HIV infection and tuberculosis in South Africa: an urgent need to escalate the public health response. Lancet. 2009;374(9693):921–33.PubMedCentralPubMedCrossRefGoogle Scholar
  10. 10.
    Novitsky V, Ndung’u T, Wang R, Bussmann H, Chonco F, Makhema J, et al. Extended high viremics: a substantial fraction of individuals maintain high plasma viral RNA levels after acute HIV-1 subtype C infection. AIDS. 2011;25(12):1515–22. doi:10.1097/QAD.0b013e3283471eb2.PubMedCentralPubMedCrossRefGoogle Scholar
  11. 11.
    Goodreau SM, Cassels S, Kasprzyk D, Montano DE, Greek A, Morris M. Concurrent partnerships, acute infection and HIV epidemic dynamics among young adults in Zimbabwe. AIDS Behav. 2012;16(2):312–22.PubMedCentralPubMedCrossRefGoogle Scholar
  12. 12.
    Robinson K, Cohen T, Colijn C. The dynamics of sexual contact networks: effects on disease spread and control. Theor Popul Biol. 2012;81(2):89–96.PubMedCentralPubMedCrossRefGoogle Scholar
  13. 13.
    Hool A, Leventhal GE, Bonhoeffer S. Virus-induced target cell activation reconciles set-point viral load heritability and within-host evolution. Epidemics. 2013;5(4):174–80.PubMedCrossRefGoogle Scholar
  14. 14.
    Muller V, Fraser C, Herbeck JT. A strong case for viral genetic factors in HIV virulence. Viruses. 2011;3(3):204–16.PubMedCentralPubMedCrossRefGoogle Scholar
  15. 15.
    Murnane PM, Hughes JP, Celum C, Lingappa JR, Mugo N, Farquhar C, et al. Using plasma viral load to guide antiretroviral therapy initiation to prevent HIV-1 transmission. PLoS One. 2012;7(11):e51192.PubMedCentralPubMedCrossRefGoogle Scholar
  16. 16.
    Gouws E, Cuchi P, International Collaboration on Estimating HIV Incidence by Modes of Transmission. Focusing the HIV response through estimating the major modes of HIV transmission: a multi-country analysis. Sex Transm Infect. 2012;88 Suppl 2:i76–85.Google Scholar
  17. 17.
    Asher AK, Hahn JA, Couture MC, Maher K, Page K. People who inject drugs, HIV risk, and HIV testing uptake in sub-Saharan Africa. J Assoc Nurses AIDS Care. 2013;24(6):e35–44.PubMedCentralPubMedCrossRefGoogle Scholar
  18. 18.
    Pruss-Ustun A, Wolf J, Driscoll T, Degenhardt L, Neira M, Calleja JM. HIV due to female sex work: regional and global estimates. PLoS One. 2013;8(5):e63476.PubMedCentralPubMedCrossRefGoogle Scholar
  19. 19.
    Tanser F, de Oliveira T, Maheu-Giroux M, Barnighausen T. Concentrated HIV subepidemics in generalized epidemic settings. Curr Opin HIV AIDS. 2014;9(2):115–25.Google Scholar
  20. 20.
    Chersich MF, Luchters S, Ntaganira I, Gerbase A, Lo YR, Scorgie F, et al. Priority interventions to reduce HIV transmission in sex work settings in sub-Saharan Africa and delivery of these services. J Int AIDS Soc. 2013;16(1):17980.PubMedCentralPubMedCrossRefGoogle Scholar
  21. 21.
    Makofane K, Gueboguo C, Lyons D, Sandfort T. Men who have sex with men inadequately addressed in African AIDS National Strategic Plans. Glob Public Health. 2013;8(2):129–43.21.PubMedCentralPubMedCrossRefGoogle Scholar
  22. 22.
    Ngugi EN, Roth E, Mastin T, Nderitu MG, Yasmin S. Female sex workers in Africa: epidemiology overview, data gaps, ways forward. SAHARA J. 2012;9(3):148–53.PubMedCrossRefGoogle Scholar
  23. 23.
    Bicego GT, Nkambule R, Peterson I, Reed J, Donnell D, Ginindza H, et al. Recent patterns in population-based HIV prevalence in Swaziland. PLoS One. 2013;8(10):e77101.PubMedCentralPubMedCrossRefGoogle Scholar
  24. 24.
    van Loggerenberg F, Dieter AA, Sobieszczyk ME, Werner L, Grobler A, Mlisana K, et al. HIV prevention in high-risk women in South Africa: condom use and the need for change. PLoS One. 2012;7(2):e30669.PubMedCentralPubMedCrossRefGoogle Scholar
  25. 25.
    Conn C. Young African women must have empowering and receptive social environments for HIV prevention. AIDS Care. 2013;25(3):273–80.PubMedGoogle Scholar
  26. 26.
    Andersson N, Cockcroft A. Choice-disability and HIV infection: a cross sectional study of HIV status in Botswana, Namibia and Swaziland. AIDS Behav. 2012;16(1):189–98.PubMedCentralPubMedCrossRefGoogle Scholar
  27. 27.
    Yi TJ, Shannon B, Prodger J, McKinnon L, Kaul R. Genital immunology and HIV susceptibility in young women. Am J Reprod Immunol. 2013;69 Suppl 1:74–9.PubMedCrossRefGoogle Scholar
  28. 28.
    d’Albis H, Augeraud-Veron E, Djemai E, Ducrot A. The dispersion of age differences between partners and the asymptotic dynamics of the HIV epidemic. J Biol Dyn. 2012;6(2):695–717.PubMedCrossRefGoogle Scholar
  29. 29.
    Bershteyn A, Klein DJ, Eckhoff PA. Age-dependent partnering and the HIV transmission chain: a microsimulation analysis. J R Soc Interface. 2013;10(88):20130613.PubMedCentralPubMedCrossRefGoogle Scholar
  30. 30.
    Beauclair R, Kassanjee R, Temmerman M, Welte A, Delva W. Age-disparate relationships and implications for STI transmission among young adults in Cape Town, South Africa. Eur J Contracept Reprod Health Care. 2012;17(1):30–9.PubMedCrossRefGoogle Scholar
  31. 31.
    Zembe YZ, Townsend L, Thorson A, Ekstrom AM. “Money talks, bullshit walks” interrogating notions of consumption and survival sex among young women engaging in transactional sex in post-apartheid South Africa: a qualitative enquiry. Glob Health. 2013;9:28.CrossRefGoogle Scholar
  32. 32.
    Beauclair R, Delva W. Is younger really safer? A qualitative study of perceived risks and benefits of age-disparate relationships among women in Cape Town, South Africa. PLoS One 2013;8(11):e81748.Google Scholar
  33. 33.
    Cluver L, Boyes M, Orkin M, Pantelic M, Molwena T, Sherr L. Child-focused state cash transfers and adolescent risk of HIV infection in South Africa: a propensity-score-matched case–control study. Lancet Glob Health. 2013;1(6):e362–70.CrossRefGoogle Scholar
  34. 34.
    Baird SJ, Garfein RS, McIntosh CT, Ozler B. Effect of a cash transfer programme for schooling on prevalence of HIV and herpes simplex type 2 in Malawi: a cluster randomised trial. Lancet. 2012;379(9823):1320–9.PubMedCrossRefGoogle Scholar
  35. 35.••
    Abdool Karim Q, Kharsany ABM, Frohlich JA, Werner L, Mlotshwa M, Madlala BT, et al. HIV Incidence in Young Girls in KwaZulu-Natal, South Africa-Public Health Imperative for Their inclusion in HIV Biomedical Intervention Trials. AIDS Behav. 2012;16(7):1870–6. PMC3460144 This survey highlights the magnitude of the burden of HIV in adolescent girls.PubMedCrossRefGoogle Scholar
  36. 36.
    Kharsany AB, Mlotshwa M, Frohlich JA, Yende Zuma N, Samsunder N, Abdool Karim SS, et al. HIV prevalence among high school learners - opportunities for schools-based HIV testing programmes and sexual reproductive health services. BMC Public Health. 2012;12:231. PMC3359203.PubMedCentralPubMedCrossRefGoogle Scholar
  37. 37.
    April MD, Wood R, Berkowitz BK, Paltiel AD, Anglaret X, Losina E, et al. The Survival Benefits of Antiretroviral Therapy in South Africa. J Infect Dis. 2014;209(4):491–9.Google Scholar
  38. 38.
    Eaton JW, Johnson LF, Salomon JA, Barnighausen T, Bendavid E, Bershteyn A, et al. HIV treatment as prevention: systematic comparison of mathematical models of the potential impact of antiretroviral therapy on HIV incidence in South Africa. PLoS Med. 2012;9(7):e1001245.PubMedCentralPubMedCrossRefGoogle Scholar
  39. 39.
    Bor J, Herbst AJ, Newell ML, Barnighausen T. Increases in adult life expectancy in rural South Africa: valuing the scale-up of HIV treatment. Science. 2013;339(6122):961–5.PubMedCrossRefGoogle Scholar
  40. 40.•
    Tanser F, Barnighausen T, Grapsa E, Zaidi J, Newell ML. High coverage of ART associated with decline in risk of HIV acquisition in rural KwaZulu-Natal, South Africa. Science. 2013;339(6122):966–71. This study highlights the potential population-level impact of ART scale-up.PubMedCrossRefGoogle Scholar
  41. 41.
    Zaidi J, Grapsa E, Tanser F, Newell ML, Barnighausen T. Dramatic increase in HIV prevalence after scale-up of antiretroviral treatment. AIDS. 2013;27(14):2301–5.PubMedCrossRefGoogle Scholar
  42. 42.
    Johnson LF, Mossong J, Dorrington RE, Schomaker M, Hoffmann CJ, Keiser O, et al. Life expectancies of South African adults starting antiretroviral treatment: collaborative analysis of cohort studies. PLoS Med. 2013;10(4):e1001418.PubMedCentralPubMedCrossRefGoogle Scholar
  43. 43.•
    Walensky RP, Ross EL, Kumarasamy N, Wood R, Noubary F, Paltiel AD, et al. Cost-effectiveness of HIV treatment as prevention in serodiscordant couples. N Engl J Med. 2013;369(18):1715–25. This study highlights the economic arguments for immediate initiation of ART in HIV+ patients.PubMedCentralPubMedCrossRefGoogle Scholar
  44. 44.
    Hontelez JA, Lurie MN, Barnighausen T, Bakker R, Baltussen R, Tanser F, et al. Elimination of HIV in South Africa through expanded access to antiretroviral therapy: a model comparison study. PLoS Med. 2013;10(10):e1001534.PubMedCentralPubMedCrossRefGoogle Scholar
  45. 45.
    Barnighausen T, Bloom DE, Humair S. Economics of antiretroviral treatment vs. circumcision for HIV prevention. Proc Natl Acad Sci U S A. 2012;109(52):21271–6.PubMedCentralPubMedCrossRefGoogle Scholar
  46. 46.
    Granich R, Kahn JG, Bennett R, Holmes CB, Garg N, Serenata C, et al. Expanding ART for treatment and prevention of HIV in South Africa: estimated cost and cost-effectiveness 2011–2050. PLoS One. 2012;7(2):e30216.PubMedCentralPubMedCrossRefGoogle Scholar
  47. 47.
    Cohen MS, Smith MK, Muessig KE, Hallett TB, Powers KA, Kashuba AD. Antiretroviral treatment of HIV-1 prevents transmission of HIV-1: where do we go from here? Lancet. 2013;382(9903):1515–24.PubMedCrossRefGoogle Scholar
  48. 48.
    Delva W, Fleming Y, Chingandu L. When to start ART in Africa–primarily guided by RCTs or patient autonomy? J Int AIDS Soc. 2013;16:18756.PubMedCentralPubMedGoogle Scholar
  49. 49.
    Nosyk B, Audoin B, Beyrer C, Cahn P, Granich R, Havlir D, et al. Examining the evidence on the causal effect of HAART on transmission of HIV using the Bradford Hill criteria. AIDS. 2013;27(7):1159–65.PubMedCrossRefGoogle Scholar
  50. 50.
    Gabillard D, Lewden C, Ndoye I, Moh R, Segeral O, Tonwe-Gold B, et al. Mortality, AIDS-morbidity, and loss to follow-up by current CD4 cell count among HIV-1-infected adults receiving antiretroviral therapy in Africa and Asia: data from the ANRS 12222 collaboration. J Acquir Immune Defic Syndr. 2013;62(5):555–61.PubMedCentralPubMedCrossRefGoogle Scholar
  51. 51.
    Le T, Wright EJ, Smith DM, He W, Catano G, Okulicz JF, et al. Enhanced CD4+ T-cell recovery with earlier HIV-1 antiretroviral therapy. N Engl J Med. 2013;368(3):218–30.PubMedCentralPubMedCrossRefGoogle Scholar
  52. 52.
    Hirnschall G, Harries AD, Easterbrook PJ, Doherty MC, Ball A. The next generation of the World Health Organization’s global antiretroviral guidance. J Int AIDS Soc. 2013;16:18757.PubMedCentralPubMedCrossRefGoogle Scholar
  53. 53.
    Sibbald B. HIV prevention: new pilots for beleaguered Swaziland. Lancet. 2013;381(9861):103–4.PubMedCrossRefGoogle Scholar
  54. 54.
    Novitsky V, Wang R, Bussmann H, Lockman S, Baum M, Shapiro R, et al. HIV-1 subtype C-infected individuals maintaining high viral load as potential targets for the “test-and-treat” approach to reduce HIV transmission. PLoS One. 2010;5(4):e10148.PubMedCentralPubMedCrossRefGoogle Scholar
  55. 55.
    Hayes R, Ayles H, Beyers N, Sabapathy K, Floyd S, Shanaube K, et al. HPTN 071 (PopART) Study Team. HPTN 071 (PopART): Rationale and design of a cluster-randomised trial of the population impact of an HIV combination prevention intervention including universal testing and treatment - a study protocol for a cluster randomised trial. Trials. 2014;15(1):57.PubMedCentralPubMedCrossRefGoogle Scholar
  56. 56.
    Iwuji CC, Orne-Gliemann J, Tanser F, Boyer S, Lessells RJ, Lert F, et al. Evaluation of the impact of immediate versus WHO recommendations-guided antiretroviral therapy initiation on HIV incidence: the ANRS 12249 TasP (Treatment as Prevention) trial in Hlabisa sub-district, KwaZulu-Natal, South Africa: study protocol for a cluster randomised controlled trial. Trials 2013;14:230.Google Scholar
  57. 57.
    Chen Y. Treatment-related optimistic beliefs and risk of HIV transmission: a review of recent findings (2009–2012) in an era of treatment as prevention. Curr HIV/AIDS Rep. 2013;10(1):79–88.PubMedCentralPubMedCrossRefGoogle Scholar
  58. 58.
    McGrath N, Eaton JW, Barnighausen TW, Tanser F, Newell ML. Sexual behaviour in a rural high HIV prevalence South African community: time trends in the antiretroviral treatment era. AIDS. 2013;27(15):2461–70.PubMedCentralPubMedCrossRefGoogle Scholar
  59. 59.
    Stover J, Brown T, Marston M. Updates to the Spectrum/Estimation and Projection Package (EPP) model to estimate HIV trends for adults and children. Sex Transm Infect. 2012;88 Suppl 2:i11–6.PubMedCentralPubMedCrossRefGoogle Scholar
  60. 60.
    Halperin DT, Mugurungi O, Hallett TB, Muchini B, Campbell B, Magure T, et al. A surprising prevention success: why did the HIV epidemic decline in Zimbabwe? PLoS Med. 2011;8(2):e1000414.PubMedCentralPubMedCrossRefGoogle Scholar
  61. 61.
    Johnson LF, Hallett TB, Rehle TM, Dorrington RE. The effect of changes in condom usage and antiretroviral treatment coverage on human immunodeficiency virus incidence in South Africa: a model-based analysis. J R Soc Interface. 2012;9(72):1544–54.PubMedCentralPubMedCrossRefGoogle Scholar
  62. 62.
    Langhaug L, Buzdugan R, Copas A, Dirawo J, Benedict C, Mundida O, et al. Change over time (2007–2009) in HIV preventive behaviours, evidence from two serial population-based surveys in rural Zimbabwe. Trop Med Int Health. 2012;17(7):827–35.PubMedCrossRefGoogle Scholar
  63. 63.
    Shisana O, Rehle T, Simbayi L, Zuma K, Jooste S, Pillay-van-Wyk V, et al. South African national HIV prevalence, incidence, behaviour and communication survey 2008: A turning tide among teenagers? Cape Town: Human Sciences Research Council; 2009.Google Scholar
  64. 64.
    Cori A, Ayles H, Beyers N, Schaap A, Floyd S, Sabapathy K, et al. HPTN 071 (PopART) study team. HPTN 071 (PopART): A Cluster-Randomized Trial of the Population Impact of an HIV Combination Prevention Intervention Including Universal Testing and Treatment: Mathematical Model. PLoS One. 2014;9(1):e84511.PubMedCentralPubMedCrossRefGoogle Scholar
  65. 65.
    Abdool Karim Q, Abdool Karim SS, Frohlich JA, Baxter C, Mansoor L, et al. Effectiveness and safety of tenofovir gel, an antiretroviral microbicide, for the prevention of HIV infection in women. Science. 2010;329:1168–74.PubMedCentralPubMedCrossRefGoogle Scholar
  66. 66.
    Karim SS, Karim Q. Effectiveness and safety of vaginal microbicide 1 % tenofovir gel for prevention of HIV infection in women. Abstract TUSS0204 presented at the XVIII International AIDS Conference; July 18–23, 2010; Vienna, AustriaGoogle Scholar
  67. 67.
    Mossong J, Grapsa E, Tanser F, Barnighausen T, Newell ML. Modelling HIV incidence and survival from age-specific seroprevalence after antiretroviral treatment scale-up in rural South Africa. AIDS. 2013;27(15):2471–9.PubMedCentralPubMedCrossRefGoogle Scholar
  68. 68.
    Mahiane GS, Ouifki R, Brand H, Delva W, Welte A. A general HIV incidence inference scheme based on likelihood of individual level data and a population renewal equation. PLoS One. 2012;7(9):e44377.PubMedCentralPubMedCrossRefGoogle Scholar
  69. 69.•
    Kassanjee R, McWalter TA, Barnighausen T, Welte A. A new general biomarker-based incidence estimator. Epidemiology. 2012;23(5):721–8. Describes exciting new biomarker-based approach for evaluating HIV incidence which is needed to accurately monitor epidemiological trends of HIV.PubMedCentralPubMedCrossRefGoogle Scholar
  70. 70.
    Laeyendecker O, Kulich M, Donnell D, Komarek A, Omelka M, Mullis CE, et al. Development of methods for cross-sectional HIV incidence estimation in a large, community randomized trial. PLoS One. 2013;8(11):e78818.PubMedCentralPubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media New York 2014

Authors and Affiliations

  1. 1.The South African DST/NRF Centre of Excellence in Epidemiological Modelling and Analysis (SACEMA)University of StellenboschStellenboschSouth Africa
  2. 2.Center for StatisticsHasselt UniversityDiepenbeekBelgium
  3. 3.International Centre for Reproductive Health (ICRH)Ghent UniversityGhentBelgium
  4. 4.CAPRISA, Nelson R Mandela School of MedicineUniversity of KwaZulu-NatalCongellaSouth Africa

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