South Africa is recognized globally as the country with the largest number of people living with HIV, making it the epicenter of the worldwide epidemic. Despite a period of delayed response, the nation has established the most extensive Antiretroviral Therapy (ART) program in the world. The effort to control the epidemic involves balancing expanded treatment access with aggressively implementing new prevention strategies. This sustained commitment holds significant global implications for the future of HIV management.
Scale of the Epidemic
The South African HIV epidemic includes an estimated 8.0 million people living with HIV in 2024. This translates to an overall prevalence rate of approximately 12.7% across the total population. The adult population aged 15 to 49 years faces an even higher prevalence (16.7%), illustrating the concentration of the epidemic within reproductive and working age groups.
The epidemic features a pronounced gender disparity, particularly among young people. Women are disproportionately affected, accounting for approximately 5.2 million people living with HIV. In 2022, prevalence among females was 16.4% compared to 8.8% for males, and new infections remain concentrated in adolescent girls and young women. The burden is geographically uneven, with provinces like KwaZulu-Natal and Mpumalanga recording the highest prevalence rates, in contrast to the Western Cape, which reports the lowest.
Historical Context and Policy Evolution
The initial spread of HIV was compounded by political denialism that lasted from 1999 to 2008 under President Thabo Mbeki. During this time, the government questioned the scientific link between HIV and AIDS and delayed the rollout of life-saving antiretroviral drugs. This controversial stance resulted in the estimated preventable deaths of hundreds of thousands of citizens, hindering the national response.
The turning point was driven by civil society activism, notably the Treatment Action Campaign (TAC). The TAC successfully challenged the government in the Constitutional Court in 2002, forcing the state to provide the antiretroviral drug nevirapine to pregnant women to prevent mother-to-child transmission. This legal victory affirmed the constitutional right to health care and paved the way for a comprehensive national response. Following a change in political leadership, the government abandoned denialist policies, approving a national Antiretroviral Therapy (ART) rollout plan in 2003.
Current Treatment and Healthcare Infrastructure
South Africa’s current response is defined by its massive and decentralized Antiretroviral Therapy (ART) program, which provides treatment to over 6.2 million people. The country adopted the Universal Test and Treat (UTT) policy in September 2016, mandating ART initiation for all people living with HIV regardless of their CD4 count. This policy aims for rapid treatment initiation, with Same Day Initiation (SDI) being the preferred model in many clinics.
The delivery of this extensive program relies on the decentralization of care to Primary Health Care (PHC) clinics and differentiated service delivery models. These models include multi-month dispensing (MMD), where stable patients receive up to a six-month supply of medication at once, reducing the frequency of clinic visits. This strategy is supported by the Centralised Chronic Medicines Dispensing and Distribution (CCMDD) program, which streamlines medication collection logistics.
The concept of Undetectable = Untransmittable (U=U) is actively promoted through public information campaigns to reduce stigma and encourage adherence. Data indicates that 81.4% of people on ART have achieved viral suppression, meaning the virus is at a level too low to transmit sexually. However, the program’s scale places a considerable burden on the public health system, leading to challenges like increased workload for nurses and the need for constant efforts to retain patients in care.
Prevention Strategies and Behavioral Change
South Africa implements a combination prevention strategy aimed at stopping new infections. The Prevention of Mother-to-Child Transmission (PMTCT) program has reduced the mother-to-child transmission rate to 2.3% in 2024. This achievement is due to the high Antiretroviral Therapy coverage among pregnant women, with over 95% of HIV-positive expectant mothers initiating treatment.
Pre-Exposure Prophylaxis (PrEP) has been scaled up since 2016, targeting populations at high risk of infection. The country has seen over 1.2 million oral PrEP initiations between 2016 and 2023, focusing on adolescent girls, young women, and key populations like female sex workers. The nation is also preparing for the introduction of newer prevention technologies, such as the long-acting injectable cabotegravir (CAB-LA), to offer convenient alternatives to daily oral medication.
Voluntary Medical Male Circumcision (VMMC) is widely promoted as a structural intervention, shown in clinical trials to reduce the risk of female-to-male HIV transmission by approximately 60%. While the COVID-19 pandemic caused a temporary decline in VMMC procedures, the program continues to target young men. Modeling shows that circumcising men aged 15-34 offers the most cost-effective long-term impact on reducing national incidence. These prevention methods, alongside behavioral campaigns promoting condom use and awareness, form the defense in controlling the epidemic.