SAHCS 2021 Conference Summary

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In a letter to the Lancet in 2017, Brian Williams and Reuben Granich remark (correctly) that ending AIDS by 2030 does not mean 'the end of HIV'. 1 Without a cure and an effective vaccine, an ever-expanding population of those living with the virus will require antiretroviral treatment (ART) indefinitely. So far, the world has no cure nor effective vaccine against HIV. However, carrying out something more to dramatically reduce the impact of virus on Africa's current and future generations makes scientific and humanitarian sense. In October 2021, the Southern African HIV Clinicians Society (SAHCS) hosted its biannual 4-day conference in Johannesburg, South Africa (SA), with its opening plenary theme being 'Game-changers for Epidemic Control'.
In 2014, the Joint United Nations Programme on HIV/AIDS (UNAIDS) launched an initiative to reduce HIV infections by 2020. 2 Implementation of the 90-90-90% targets by 2020 began the following year. Unfortunately, few southern African countries met the 2020 deadline 3 (Figure 1 4 ); Botswana, 5 a small country with a large HIV burden, met this deadline. Nevertheless, it is on track to achieve the revised 2030 targets by 2025: 95% tested or diagnosed, 95% (of these) on ART and 95% (of these) virally suppressed. Can southern Africa end new HIV infections by 2030? Perhaps. However, it will require (1) a greater determination and commitment than previously observed, (2) an in-depth reappraisal of local targets, (3) settup of monitoring systems yearly or more frequently, (4) community mobilisation or input -to give momentum to the goal, and (5) a conscious effort to find the missing 'KEY GROUPS' that include: • the infected but untreated • the uninfected but at-risk • the treated but unsuppressed or lost to care.
Will the point-of-care tests and the new antiretrovirals -the integrase inhibitors, the long-acting injectables, the new drug classes and the two-drug regimens -detail discussed at the October 2021 conference -achieve the 95-95-95% targets? Not on their own. Are the important scientific advances also discussed at the conference likely to induce citizens to arrive, get tested, take treatment and stay in care? No. Something more is needed.
We have learned much from the coronavirus disease 2019 (COVID-19) pandemic. What works? Clearly reported and accessible science (targeting everyone), truthful and frequent communication in national media by credible scientific leaders, defining a role for everyone, and the engagement of political and community leaders to mobilise constituencies towards an AIDS-free future.
We have made mistakes. In aiming at the 2020 targets, children lagged behind, particularly the very young and adolescents, 6 and also young women. The seroprevalence range of antenatal HIV in Soweto, South Africa, is currently at 27% -30%. It has been at this level for the past two decades. 7 Similar levels are reported in other South African districts ( Figure 2). 8 Jeremy Nel (chief of Infectious Diseases at the Helen Joseph Hospital, the University of the Witwatersrand, Johannesburg) chaired proceedings. The opening plenaries began with the 'Game-Changers': the long-acting injectables (Sinead Delaney-Moretlwe), pre-exposure prophylaxis (PrEP) on demand for all (Linda-Gail Bekker), pharmacy-initiated antiretroviral treatment (PIMART) (Francois Venter) and U (undetectable) = U (untransmissible) (Mandisa Dukashe). Each presentation covered new territory or developments in care. Pharmacy-initiated antiretroviral treatment is a 'new' venture that asks our community pharmacists to get involved. A decade ago, nurses were trained to assist with HIV-patient care -the nurse-initiated management of antiretroviral treatment (NIMART). Without the support of these nurses, it would have been impossible to roll out care to the near six million South Africans currently on treatment. A shortfall of approximately two million remain infected but untreated. Pharmacy-initiated management of antiretroviral treatment is an international movement, where community pharmacists assist clients with HIV

SAHCS 2021 Conference Summary
Read online:   Tulio de Oliveira's description in 2017 of HIV transmission reported in the province of KwaZulu-Natal (KZN), SA, is a classic (Figure 3). 14 The authors describe a cycle of sexual networking and viral transmission between adjacent rural and urban districts and between men and women in KZN. Women are particularly vulnerable to acquiring infection. The region is easily accessed by road and not far from the province's commercial hub, eThekwini (Durban). Of the 8912 people enrolled in this study, 3969 (45%) tested HIVpositive. Some were already on treatment. However, a large number had detectable viral loads that permitted phylogenetic analysis and identification. In the under 25-year age group, the prevalence rates of HIV amongst the men and women were 7.6% (n = 1472), and 22.3% (n = 2224), respectively. The prevalence of HIV amongst those aged 25-40 years was high for both women (n = 2835, 59.8%) and men (n = 1548, 40.3%) but greater amongst women. The prevalence of HIV in women in both age groups outstripped that of men. At a time of sexual debut, girls or young women in this community had a three-fold greater risk of testing HIV positive than men of the same age. The researchers were able to fingerprint ('cluster genotype') viruses and follow their movement between groups. HIV transmission followed a path from the 25-40-year-old men to the younger, < 25 years women. Simultaneously, the virus spread horizontally between the men and women in the 25-40-year-old group. Women in the latter group also had a disproportionately higher level of infection. The story is not new: 15,16,17 The differential status of men and women in almost every society is perhaps the most pervasive and entrenched inequity. Indeed, the feminisation of the AIDS epidemic in southern Africa clearly indicates the lack of power of women to participate as equals in the social freedoms of men. 18 If the virus could speak and if we had ears to hear, it would repeat these words and ask why (our) society has performed so little to change this inequity? Antiretroviral treatment programmes across southern Africa have been very successful. Numerically and geographically, SA is the largest of these. AIDS-related deaths have fallen. However, new infections contribute to the high prevalence rate. In her two talks on PrEP, Linda-Gail Bekker (Cape Town, SA) observed that this form of protection is poorly marketed and inadequately utilised in SA. Young women of schoolgoing age and students need protection. Pharmacy-initiated antiretroviral treatment would be an ideal pathway to do this. There will not be an end of new infections without addressing the gender inequity of HIV.

South African antenatal survey in ciƟes and districts
The conference was held virtually and broadcasted live from Johannesburg. The first day included the familiar format of workshops -new guidelines and old themes -the resistance workshop, how to write a scientific paper, and sponsored sessions: HIV and viral hepatitis, 5-flucytosine, cryptococcal meningitis (the AMBITION Study), and long-acting antiretroviral therapy. There were many familiar names  amongst the speakers, and then the gender-affirming healthcare guidelines. I had read these some months earlier. 19 For some, the guideline may appear to be a novelty. However, they do need to be taken seriously: they represent a 'HEADS-UP' to us all. What did Africa learn from the Stonewall riots of the 1960s? Or the gay men's marches in Los Angeles and New York in the 1980s? Or the beautifully (and lovingly) crafted AIDS remembrance quilts for the thousands of young men who died from AIDS? It is time to allow individuality to blossom, to let people be who they are.
Ubuntu is a local term meaning we 'love one another'. The freedom of the LGBTQIA+ community was not gained without cost. The history of the epidemic in Africa is not only that of heterosexuals in need. But of gay and bisexual, of transgender men and women imprisoned in Uganda, murdered in SA, despised and denigrated by African politicians and Africa's religious leaders … Take a look at these guidelines. Our world is changing. Be part of the new world. Learn the vocabulary. Congratulations to the conference organisers for placing a sensitive yet timely subject before the delegates.