STELLENBOCH, SOUTH AFRICA — A new study by a graduate researcher from the Africa Centre for Inclusive Health Management at the Stellenbosch University, has found drivers behind HIV patients’ unending struggle with viral suppression in South Africa.
According to UNAIDS and the World Health Organization (WHO), South Africa has the highest HIV burden globally, with approximately 8.15 million people living with HIV in 2025 and an estimated 13.9% HIV prevalence in 2022.
Although progress has been made, the country is not yet on track to meet the 2025 global targets for reducing new infections, which stood at 1.3 million in 2024 worldwide.
It is against this background that the study has found out that in the bustling townships of Ekurhuleni District, Gauteng province, a silent crisis is unfolding.
Now a new study, by a Stellenbosch University masters student, Nosiphelo Ntshiqa, has raised urgent alarms about the hidden factors undermining anti-HIV efforts among adults on antiretroviral treatment in the province.
The study, accessed by Research Finds News, foregrounds factors such as social and relationship dynamics, poor education, sexual behavior, and reliance on traditional medicines.
“Despite South Africa’s world-leading rollout of antiretroviral therapy (ART), more than half of HIV-positive adults on treatment are failing to suppress the virus,” roared the study that was in presented in fulfilment of the requirements for the degree of Master of Philosophy (HIV/AIDS Management) in the Faculty of Economic and Management Science at Stellenbosch University, in February 2024. It was supervised by Dr. Munyaradzi Saruchera.
Why this study?
Information obtained by this website from hiv.gov, viral suppression, defined as the reduction of HIV in the blood to undetectable levels, is the cornerstone of HIV control. When patients consistently take ART as prescribed, their viral load drops below 200 copies per milliliter of blood. At this point, the virus becomes untransmutable, drastically reducing HIV-related illness and death.
And Ntshiqa observes in this study that although South Africa’s HIV program, launched in 2004, has been a global success story, and new infections between 2004 and 2012, fell from 2.8% to 1.5%, with millions gaining access to ART, gaps remain more than 15 years later.
“The 2020 District Health Barometer revealed Gauteng’s viral suppression rate stood at 88.8%, falling short of the UNAIDS 95% target,” Ntshiqa finds out. It is this gap that Ntshiqa set out to investigate.
The study was conducted between 25 August 2023 and 12 December 2023. The study team approached 424 adults who were accessing healthcare services in HIV wellness clinics at Ekurhuleni North Sub-district. This included 351 participants, of which 61.2% (215/351) being females and a median age of 40 years.
351 (82.8%) of the participants met the criteria to be included in the research study and accepted to take part and agreed to sign the informed consent, while 73 (17.2%) were screening failures. Of the 73 screening failures, 25 (34.2%) were on ART for less than 6 months, 20 (27.4%) were assessing ART in the facilities for less than 12 months, 16 (21.9%) were HIV negative, and 12 (16.4%) were on second line ART regimen.
The Alarming Findings
Using a cross-sectional research design, among 351 HIV-positive adults studied in Ekurhuleni North facilities, a staggering 57.8% had unsuppressed viral loads — meaning ART was failing to achieve its intended purpose.
“This means that more than half of the individuals on treatment are not achieving the desired level of viral suppression, which can lead to increased risk of HIV transmission, treatment resistance, and decreased quality of life,” Ntshiqa observes in the study.
The study strangely found that certain demographic and behavioral factors were associated with poor viral suppression as well. The first of these was marital status. The study found out that married individuals in the province but who were not cohabiting with their partners were four times likely to have unsuppressed viral loads compared to faithful ones.
“This finding suggests that long-distance relationships and infidelity were contributory factors to inconsistent adherence to ART and risky sexual behaviors,” Ntshiqa observed.
The second factor was the level of education among adults living with HIV in the province. The researcher found out that adults with lower levels of education, specifically those with primary education or no schooling at all, were more likely to experience poor viral suppression.
“This indicated that sufficient amount of education is very important in understanding HIV management and adherence to treatment,” the researcher says.
The researcher further observes that this particular is in line with the well-established theory which states that there is a link between health outcomes and educational status.
“This correlation suggests a direct relationship which means the lower educational attainment the lower the health outcome or vice versa,” argues Ntshiqa.
The third factor was sexual activity. The study reveals that sexual behavior plays a significant role in viral suppression. Individuals who had sex in the past 12 months were more likely to have poor viral suppression, suggesting that risky sexual behavior, such as inconsistent condom use and multiple sexual partnerships, were enhancing the problem.
“The association between sexual encounters in the past 12 months was suggestive of risky sexual behavioral practice such as inconsistent condom use and multiple sexual partnership,” the study pointed out,” observes the researcher.
He researcher adds that having different sexual partnerships and inconsistent use of condoms were cited as some of the predisposing factors for unsuppressed viral load, and thus increasing HIV transmission.
The fourth factor was found to be a bad history of ART Defaulting. The study discovered that the association between history of ART default and poor viral suppression, was real. For instance, individuals who had defaulted on their treatment were more likely to experience poor viral suppression, highlighting the need for interventions to improve treatment adherence.
The fifth driver that was identified is the use of traditional or over –the counter medicines.Participants who reported using medicines from traditional healers or over-the-counter sources were almost four times more likely to have unsuppressed viral loads, raising concerns over potential drug interactions and treatment discontinuation.
The researcher observed that although fewer studies have been conducted to explore the association between concomitant medicines, concerns have been raised that associated drug use may result in drug-to-drug interaction which may also result in reduced ART efficacy for some regimens.
Implications for Public Health
Ekurhuleni District, one of Gauteng Province’s key regions, has historically struggled to meet HIV treatment targets. While the national goal is to have 95% of HIV-positive individuals on ART achieve viral suppression by 2030, current performance indicates significant gaps. Nosiphelo Ntshiqa emphasized the importance of these findings for public health:
“Our study highlights that social and behavioral factors, such as relationship dynamics, educational attainment, and treatment adherence, are central to improving viral suppression. Addressing these aspects is essential to meet both provincial and national HIV/AIDS targets.”
This study integrates a multifaceted approach to HIV intervention, emphasizing enhanced adherence counseling tailored to cultural contexts, couple and family testing to mitigate risks in long-distance relationships, and educational campaigns designed for low-literacy populations to improve understanding of HIV management and the dangers of unregulated treatments. It also prioritizes community engagement by partnering with traditional healers and local leaders to dispel misconceptions about antiretroviral therapy (ART), while advocating for improved healthcare infrastructure to ensure consistent access and support for individuals at heightened risk of treatment default.
To enhance public awareness, researchers suggest leveraging digital platforms such as ResearchFinds News, which translates complex scientific findings into accessible content for non-specialist audiences, and Q & A News, an interactive forum where people can engage in discussions on HIV treatment and viral suppression.
A Step Toward Achieving Global Goals
South Africa, home to the world’s largest HIV epidemic, has committed to meeting the UNAIDS 95-95-95 targets, which aim for 95% of those infected to know their status, 95% of diagnosed individuals on ART, and 95% of those on treatment achieving viral suppression by 2030.
However, this study suggests that progress remains uneven across districts, with Ekurhuleni among the districts lagging behind. The new findings underscore the urgency of addressing the complex socio-behavioral challenges that hinder treatment success.
Moving Forward
The study’s authors stress that understanding and tackling these factors require multi-sectoral collaboration involving healthcare providers, community leaders, policymakers, and patients themselves. Implementing comprehensive, targeted interventions could significantly improve viral suppression rates, ultimately reducing HIV transmission and saving lives.
As South Africa strives toward ending the HIV/AIDS epidemic, the insights from this research provide a critical roadmap for refining strategies and ensuring no one is left behind in the fight against HIV.
About the Africa Centre for Inclusive Health Management
The Africa Centre for Inclusive Health Management is a pioneering institution committed to transforming health systems through education, research, and community engagement.
Originally founded to address the HIV/AIDS epidemic in South Africa, the Centre has evolved to tackle broader health challenges by integrating critical management theory and African knowledge systems.
It offers postgraduate programs that equip students with leadership and policy-making skills to promote equity, social justice, and inclusive innovation in health management. Through its interdisciplinary approach, the Centre fosters transformative change in complex health ecosystems across the continent.
EDITOR: For further information about the study please get in touch with the Africa Centre for Inclusive Health Management director on ms********@****ac.za. Additional MPhil research projects by the Africa Centre students are available on: https://share.google/El0Ct8G6mXlWCNrYZ
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