Major progress has been made in combating the epidemic of HIV in South Africa. Of the 7.7 million people living with HIV, 62%, that is about 4.77 million, were taking HIV treatment in 2018. There are some more HIV statistics for South Africa.1UNAIDS, 2019, https://www.unaids.org/en/regionscountries/countries/southafrica/ This is good progress considering that when AIDS denialism came to an end around 2007, ART was unobtainable for most HIV positive people. However there is still much more that needs to be done by both the government and civil society.
HIV in South Africa - The National Strategic Plan (NSP)
The desired government action, as well as that of many other organisations and individuals, is set out in the South African National Strategic Plan for HIV, TB and STIs for 2017 - 2022 (NSP).2Let Our Actions Count, 2017, SANAC, https://sanac.org.za/wp-content/uploads/2018/09/NSP_FullDocument_FINAL.pdf The main approach set out in the plan is that although comprehensive prevention and care will be provided countrywide, there should be intensified action on both HIV prevention and treatment in the 27 districts that account for 82% of all people living with HIV and for the majority of new infections. These districts are:
|Province||Provincial Prevalence %||High HIV Burden Districts|
|Gauteng||17.6||City of Johannesburg, Ekurhuleni, City of Tshwane, Sedibeng|
|KwaZulu-Natal||27.0||eThekwini, Umgungundlovu, Uthungulu, Zululand, Ugu, uThukela, Harry Gwala|
|Mpumalanga||22.8||Ehlanzeni, Nkangala, Gert Sibande|
|Eastern Cape||25.2||OR Tambo, Amathole, Alfred Nzo, Chris Hani, Buffalo City|
|Free State||25.5||Thabo Mofutsanyane, Lejweleputswa|
|North West||22.7||Bojanala, Ngaka Modiri Molema, Dr Kenneth Kaunda|
|Western Cape||12.6||City of Cape Town|
In each of the high burden districts the NSP says that efforts should be targeted towards the populations among whom the need is greatest. This will also be the populations where the impact of efforts will be most pronounced.
HIV in South Africa - who should be targeted and why?
Of the South Africans newly infected each week, approximately one third are adolescent girls/young women (AGYW) aged 15-24.3New modelling research shows partial progress in South Africa's response to HIV, 2019, https://www.unaids.org/en/keywords/south-africa Transmission among adolescent girls and young women is considered to be driving HIV across the country.
So every province, district and ward has been instructed to take steps to intensify efforts to reduce new HIV infections and increase service access for AGYW. This includes addressing the social factors that increase their vulnerability. Adolescent boys and young men should also be included in the intensified efforts.
Other key populations identified include sex workers, transgender people, men who have sex with men, people who use drugs and prison inmates.
There is also to be a focus on generally improving service quality and on reducing "lost to follow-up" among people who start treatment.
The public healthcare system
Some people consider that the policy for combating the HIV epidemic is sound. What is missing, and the largest gap is between policy and implementation. Effective implementation would require an overhaul of the public health infrastructure. There are significant health worker shortages and a rising non-communicable disease burden which are adding to the strain on already overstretched health facilities.4The World's Largest HIV Epidemic in Crisis: HIV in South Africa, 2019, CSIS, https://www.csis.org/analysis/worlds-largest-hiv-epidemic-crisis-hiv-south-africa
At the time the NSP was launched it was said that:
"the plan is silent on ongoing and widespread dysfunction in the public healthcare system"5Joseph Cotterill, South Africa reaches a make-or-break point over HIV, 2017, https://www.ft.com/content/c9019d82-566c-11e7-80b6-9bfa4c1f83d2
How is the combating of the HIV epidemic to be financed?
Another major issue is that of finance. The total cost of implementing government policy is estimated at R207 billion over the five years. The annual cost is likely to rise from R35.1 billion in 2017/18 to R45.7 billion as more people are enrolled on treatment. The costs will also rise as prevention efforts and responses to "social and structural drivers" are scaled up.
In 2017 South Africa's development partners contributed approximately 20% of the total funding available for the national response. But there was said to be uncertainty over future funding committments.6Let Our Actions Count, 2017, SANAC, https://sanac.org.za/wp-content/uploads/2018/09/NSP_FullDocument_FINAL.pdf
In 2019 it was announced that the U.S. President's Emergency Plan for AIDS Relief (PEPFAR) would be providing R10 billion funding towards increasing the number of people living with HIV on treatment and ensuring that patients remain on treatment.7South African Government Welcomes PEPFAR HIV Funding Commitment, 2019, https://za.usembassy.gov/government-welcomes-pepfar-hiv-funding-commitment/
Although very welcome additional commitments will be required from other donors and from the South African government as well.