A Wednesday morning in April, a line of 0 people infected with HIV winds through the corridors of the first room waiting clinical Themba Lethu, a wing of the hospital Helen Joseph in Johannesburg, South Africa. In most places in the country, where clinics are overtaxed, it presages a wait of up to 10 hours. But here's something different happens. Staffers at computer screens quickly connect in people and ship them for sorting or, if they have tuberculosis, a special area away from others. Those who are not their (ARVs) for antiretroviral drugs to walk directly to pharmacists, recovering electronic medical record of each patient and use a robotic system to take medication tablets and fill orders. The average waiting time is 30 minutes to 2 hours for a visit to the doctor or nurse and 15 minutes to the pharmacy. An ATM prototype promises to continue the rate of visits by distributing directly ARV pills; one day, hopefully, similar pills machines in malls could make a few visits to the clinic useless.
"This is an awesomely efficient place," said Ian Sanne, head right to care, a nongovernmental organization that works this and several other clinics in collaboration with the Ministry of Health. In developed countries where patients complain about waiting much shorter, this bravado may seem absurd. But in South Africa, Themba Lethu Clinic is celebrated as an example of what can be done to take care of a large number of people infected HIV. This is both a compliment to the clinic and a hint of overwhelming challenge of HIV / AIDS in the country.
South Africa has promised to step up efforts to end its huge HIV / AIDS, the largest in the world. Come September, it will offer all ARVs infected person, which both ward off illness and make people less infectious. the immediate objective is to achieve what is known 0-0-0 as 2020: to have 0% of infected people know their status, 0% of known positives start ARVs, and 0% of this group lead the amount of virus in their bloodstream to undetectable levels. The theory is that the viral load drops, the transmission, too, leading the epidemic spiral downward. The 0-0-0 target is the cornerstone of a great campaign, articulated by the United Nations Programme on HIV / AIDS (UNAIDS) and widely adopted by world leaders to end the AIDS epidemic "as a threat to global public health" by 2030.
in a nation estimated at least 6.6 million people in 18 HIV-infected% of the world total-player to hit 0- 0-0 2020 seems too ambitious to many experts. and the obstacles faced by South Africa provide a reality check sobering to high laudable aspiration to end AIDS, a topic that promises to occupy a central place later this month in Durban at the biannual international AIDS Conference.
models and reality
a model predicts how the various response scenarios to HIV / AIDS would affect infection rates, or impact. As seen on the map, some regions have many more HIV than others.
HIV in South Africa and case investment tuberculosis SANAC and National health Department
South Africa has made huge gains against the HIV epidemic / AIDS. During his last hosted this international meeting in 00, then President Thabo Mbeki and his health minister have questioned whether HIV causes AIDS even, sparking widespread outrage. At the time, only the wealthiest South Africans had access to ARVs, which cost about $ 5,000 per person for an annual supply. But at the end of 2015, the price had dropped to $ 100, and 3.4 million HIV-positive South Africans were receiving ARV-more than in any other country in the world. South Africa, in fact, consumes the same amount of drugs vital importance that Asia and the Pacific, North America, and Western and Central Europe combined.
Consequently, life expectancy jumped 9 years between 05, when ART started to become widely available, and 2014. The country has developed innovative ways to deliver medications and assist people stay on them. And strong team of South African researchers on HIV / AIDS has made the country a hub of cutting-edge basic research and clinical trials. "Given our resources, we have done amazing things," says Glenda Gray, a researcher on HIV / AIDS who heads the Medical Research Council of South Africa in Cape Town
This family tree is derived from the genetic material of thousands HIV isolates South Africa and it shows how the virus has evolved over periods of 5 years. the darker blue dots represent sequences from 2010 to 2015 and the lightest points in 1989.
Andrew Rambaut, Univ. of Edinburgh, and Tulio de Oliveira, Africa Centre for population health
yet nearly half of the infected population today is still treated. Some have not suffered enough damage to the shelter of the virus to deserve ARVs in the current policy framework of the government. Many others infected do not know their status or never seek treatment, and others entering treatment have difficulty taking their daily pills for years. According to estimates, due to flaws in this "continuum of care", only one in four South African HIV has completely removed the virus. "We must ride two horses at the same time," says Fareed Abdullah, who heads the quasi-governmental South African Council National AIDS (SANAC) in Pretoria. "One is to improve our system so that more than 3 million on treatment are kept in the care and well managed, and we also extend to a group that is in large part asymptomatic and well."
Adding to those challenges is alarming HIV incidence-the percentage of the South African population becoming infected each year. the Government indicates that HIV incidence has fallen from a high of 1.67% among adults in 05 to 1.22% last year, but that still translates into 330,000 new infections per year. the rate is extremely high among women under 25, particularly in the most affected province, KwaZulu -Natal, where the incidence tops 6% in some communities.
Health Minister Aaron Motsoaledi, who acknowledges that aggressive HIV / AIDS country program had a late start because of Mbeki, is convinced that South Africa has the will and the money to knock 0-0-0. "Can we afford not to treat people?" Application Motsoaledi. "Certainly, we will pay much more socially, politically and economically if you can not." To this end, the government, which already spends $ 1.2 billion annually on HIV / AIDS and gets another $ 300 million in foreign currency support, is adding $ 65 million per year until 2019 .
As part of an exercise to determine what he could afford, the south African government put price tags on many interventions proven to work now.
[TBSouth Africa HIV and investment case, SANAC and National Health Department
But a new report concludes that to achieve the objective of UNAIDS will require an additional $ 8 billion over the next five years. "UNAIDS pushing very hard on our health ministry, which does not yet caughtshort and wants to make the case that we can achieve 0-0-0" said Linda-Gail Bekker, who co-directs the Desmond Tutu HIV Foundation (DTHF) in Cape Town and is one of the co-authors of the report. The cost of drugs is just part of the equation, she said. To achieve the goal will also require massive HIV testing and costly provision of ARVs to patients should be monitored and helped if they do not remove the virus. "I'm really, really worried about the resources it will take."
There are scientific questions, too. The assumption that to reach the goal 0-0-0 ending AIDS is based on mathematical models that take into account the "cover" ARV in combination with other proven prevention strategies such as male circumcision, condom promotion and behavior change efforts. the researchers note that in large epidemics such that in South Africa, which exceeded the population "concentrated" as men who have sex with men and sex workers, such strategies might prove less effective than expected, allowing HIV to continue disseminating high levels even after the country achieved 0-0-0.
Epidemiologist Salim Abdool Karim, director of the Centre for AIDS Programme of research in South Africa (CAPRISA) in Durban, points of recent data from Botswana who question the assumptions of the model. Botswana, which is relatively rich and has a small population of 2 million, has almost reached 0-0-0, as shown in a study published online March 23 in The Lancet. But the impact has barely moved, in part because the missing 10-10-10 continue to spread the virus. "For a country that is close to 0-0-0, the incidence is ridiculously high," Karim said. "It is outrageous." A report published by the Ministry of Sanac and other health issues of mathematical modeling 0-0-0. Although 0-0-0 led to sharp declines in new infections in 2030, this report suggests that the incidence in the population of South Africa's 53 million will not quite go below 0.1 % -the level as UNAIDS says it needs to reach to an epidemic in the end.
The bottom line is that it remains an open question whether the treatment 0-0-0 goal can really stop the spread of HIV in South Africa. Some of the biggest global controlled treatment trials as prevention (TasP) are underway in the country to try to answer.
South Africa now processes 3.4 million people with antiretroviral drugs, more than any other country in the world. James Oatway a staff member scans a bottle of pills he then puts the back of a pharmacy-dispensing unit a vending machine that maybe one day in the malls. James Oatway The robot, made by Germany Mach 4, helps the clinic occupied effectively serve 0 patients infected with HIV every day. James Oatway A robot takes antiretroviral drugs on the shelf to help the team pharmacy Rajan Gudala the Themba Lethu Clinic. James Oatway 
in a region known as the Mfekayi in rural KwaZulu-Natal, two dozens of people sat on the shaded porch of a cabin plywood waiting their turn to see a counselor. The cabin is Egedeni Clinic, and people are participants in a 28,000 person, multi-site clinical trial that will assess the precise relationship between increasing levels of HIV suppression in a community and the impact of declines. A Egedeni and 10 other clinics throughout the province, TasP study provides ARVs to all infected participants. 11 other clinical tASP offer instead of the treatment according to current recommendations of the government, which means that people start ARV only after their immune system show signs of damage.
One by one, participants bottles by hand ARVs they received a month earlier to counselors, who count the remaining pills. This ritual, which is a crude way to monitor compliance underlines an obvious limitation of the underlying strategy: Although ARVs make people less infectious, TasP based on human fickle relationship have with medication daily.
Managed by the African Centre for Population Health around Mtubatuba, TasP is the longest of the four similar trials in sub-Saharan Africa that examine the continuum of care and outcomes of real world 'universal treatment. "Preliminary analysis of the results tASP found that less than 40% of those who tested positive have sought care within 3 months, as recommended. This first step has always been a major obstacle on the road to 0- 0-0.
at the international AIDS Conference later this month, the researchers plan to reveal whether their intervention helped to reduce the impact. "this will be the first opportunity assess whether, in fact, the purpose of bio-logic is actually true in practice, "says Deenan Pillay, a clinical virologist who heads the Africa Centre. But Pillay said the study has already clarified that the end of AIDS is not simply a matter of "we will treat everyone and everything will be OK." In the final analysis, he said, the power depends as much TasP on human behavior as it is about biology.
Jacqualine Ncube, a restaurant worker of 19 years, first took an HIV test when she was in high school. at the time, Ncube spent many hours after school to hang out at DTHF youth Center, adjacent to the town of Masiphumelele fight outside Cape town. the youth Centre offers internet access of adolescents, holds football matches, boards of loans surfing, and provides care in a health clinic. children also earn "Tutus" good for vouchers or food for every-thing to help the community to take an HIV test. When Ncube obtained its first results, she was overwhelmed. "I really cried," she said. It was negative.
Ncube has tested negative several times, and in April 2015, she joined Pillsplus Youth Centre, a study of what is known as pre-exposure prophylaxis, or PrEP, in 150 adolescents. With PrEP, uninfected people take pills daily ARVs to prevent infection. Although PrEP is a proven strategy, South Africa recommends its use in sex workers, and Ncube is one of the first hetero-sexual adolescents worldwide on ARVs for prevention. She always uses condoms with her boyfriend, but said she wanted to try PrEP because "no 100% protection."
of DTHF Bekker, head Pillsplus to assess the acceptability of PrEP among adolescents, argues that PrEP must be provided to all people at high risk of infection. "When I sit in front of a 17-year-old young woman, I have nothing to offer," says Bekker.
Karim said CAPRISA PrEP among young women could be the key to break the back of the epidemic. About 30% of new infections in South Africa occur in young women between 15 and 24 years. the new infection rate among men in the same age is over four times lower. in some districts of KwaZulu-Natal, a woman has a chance of being infected by age 34. 60%
Gender and age
HIV infects more girls and young women and boys and men of the same age in South Africa. the gender difference narrows to 35 years, while the prevalence drops.
A. Cuadra / Science ; (Data Sources) map Prevalence: 2013 National Antenatal Sentinel HIV Prevalence Survey in South Africa / South African National HIV Prevalence, incidence and Behaviour Survey, 2012 Social Sciences and Humanities Research Council
Rachael Dellar et al., CAPRISA
to understand the viral spread scheme, and the African Centre CAPRISA mapped on the cycle of infection between men and women of different ages in KwaZulu-Natal . The study analyzed the genetic sequences of HIV isolated from 858 men and women, all aged between 16 and 35, who belonged to the same sexual networks. different isolates associated viral genetics and said those who were older, which allows researchers to deduce who infected whom. Teenage girls were infected by men who were on average 8 years older. After age 24, people in general were infected by partners of their age, with the transmission shift more often from women to men. "They try to find life partners at this age," says Karim. These older men are the same group who have sex with younger women. "We need to break the chain of men in their late 20 and teen girls, "he said.
PrEP can help TasP address gaps, said Karim. in the study infection cycle, men who infected young women had extremely high levels of HIV, indicating that they have recently acquired the virus and does not seem infected on standard antibody-based tests. "If your strategy is to test and treat people, you do not going to catch them, "says Karim. men are also less connected to the health care system and often migrate for work, he adds, making it more difficult to help those who know they are infected completely remove the virus. Giving young women PrEP prevents the male dilemma. "We just have to protect girls for 5 years in this period of critical risk until they find their partners," he said.
Karim said new biomedical interventions the horizon may strengthen prevention efforts. His group plans to report to the Durban meeting that identified a microbe related to unusual vaginal inflammation in women in KwaZulu-Natal. Treat it could potentially reduce their risk of HIV infection. injectable ARVs that last two months are also tested in South Africa and elsewhere, and those that could eliminate the challenge of taking pills, daily key problem for the treatment and PrEP. Next fall, South Africa plans to launch trial of effectiveness in the world with a stronger vaccine AIDS preventive medicine of all.
For now, 0-0-0 is the most powerful tool available in South Africa in its quest to end the epidemic, even if PrEP and other emerging strategies are needed ultimately. Abdullah SANAC has a pragmatic vision to meet the deadline of UNAIDS. "I think we should plan, because if we do not get it by 2020, we'll do it in 2022," he predicted. "What we're really after is lowering new infections to levels low, "and to get the largest number of people infected with HIV as possible on treatment and live a longer life. the virus itself Abdullah said," will be with us for the next 100 years. "
the Pulitzer Center on crisis reporting provided support for the reporting in this story.
for science the coverage on HIV / AIDS, visit our topic page.
in this week's podcast, Jon Cohen speaks with Julia Rosen about South Africa to end AIDS.
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