HIV/AIDS in South Africa: Improved Prognosis

EDITOR’S NOTE: South Africa’s renewed commitment to fighting HIV/AIDS may have an impact on the entire region, suggests Peter Navario, a global health fellow at the Center for Foreign Relations. The Zuma administration should treat infected South Africans and lower the rate of new HIV cases, he argues. A few excerpts:

On February 11, South African President Jacob Zuma delivered his State of the Nation speech, twenty years to the day after Nelson Mandela’s release from Robben Island prison. Zuma recommitted his administration to building a better future for all South Africans and noted that improving the country’s health was fundamental to this effort. He announced a plan to expand access to HIV/AIDS prevention and treatment services, but failed to mention specific targets or commitments. This lack of specifics was reminiscent of the head-in-the-sand speeches delivered by the administration of his predecessor Thabo Mbeki. Despite recent progress in some facets of the national HIV program and successfully reversing the domestic course (and discourse) on HIV/AIDS since taking office, the administration needs to continue to lower the rate of new infections and find the human and financial resources to treat millions of infected South Africans.

Looking ahead

Still, the Zuma administration has exceeded most expectations regarding the management of HIV. On World AIDS Day, December 1, 2009, President Zuma stated his intention to get an HIV test and encouraged all South Africans to learn their HIV status. The new minister of health publicly acknowledged the failed policies of the past administration and has advanced new, evidence-based policies, which include starting treatment earlier for pregnant women, patients co-infected with TB, and infected children. The finance ministry has announced an increase in budget support for HIV/AIDS in 2010 to pay for the additional patients who will qualify for treatment under the new guidelines, although the amount of the increase has not yet been announced. The epidemic appears to have stabilized, as HIV prevalence has held steady for the past two years. But there are still major challenges to achieving universal access to proven HIV prevention and treatment interventions.

Future imperfect: Capacity and financing constraints

The domestic budget is only part of the overall HIV financing, however. Almost half of South Africa’s approximately $1 billion annual HIV budget comes from donors. The largest of these is PEPFAR, which provided more than $400 million this year. The global recession is squeezing donor budgets, and there has been talk (health-e) of PEPFAR reducing its investment in South Africa over the next five years, although this has been refuted by the U.S. Embassy in South Africa and the head of PEPFAR. In addition, the Global Fund for AIDS, TB, and Malaria, which also provides financing to South Africa, is facing a multi-billion dollar shortfall.

It would be a mistake for PEPFAR and other donors to divest from South Africa. While the South African government should be working toward self-sufficiency and reducing donor dependence, it is not realistic to expect this will happen in the next five years. Treating only those who are currently infected for ten years will cost in excess of $60 billion with drug prices at their current levels. The recent leadership shown by the government on HIV/AIDS should be rewarded with continued support, and any eventual drawdown of donor support should be carefully negotiated and planned over a period of years. While the recent donation by the United States of an additional $120 million to South Africa for the purchase of HIV treatment is commendable, at current prices this is enough to provide one year of HIV treatment for 200,000 patients or treat 20,000 patients for 10 years. This is sobering when one considers the 5.5 million infected South Africans who will eventually need treatment.

Better coordination between the national treatment program and donor partners would address service redundancies in some areas, and service gaps in others, as well as fragmentation of services, such as separate TB and HIV clinics. This would also result in significant savings and better service coverage. Finally, there may be some value in challenging conventional wisdom regarding HIV treatment guidelines. Recent research in Uganda showed that twice-yearly laboratory monitoring for patients recommended by the World Health Organization had no impact on patient outcomes. The National AIDS Council should assess whether laboratory monitoring should be reduced to once yearly for stable patients, as well as the possibility of moving to quarterly dosing.

Failure is not an option

All of this is taking place against a backdrop of AIDS fatigue in the global health community. But while HIV/AIDS may not be an exceptional health concern everywhere, it remains exceptional in South Africa and the region. South Africa’s HIV/AIDS epidemic is a matter of importance far beyond its borders. As PEFPAR’s biggest partner, South Africa’s success is to a large degree intertwined with PEPFAR’s legacy. As the country with the largest number of HIV-infected people in the world and the largest country in the most affected region, the global fight against HIV and AIDS cannot be won without a success in South Africa. And as the most populous country in southern Africa, South Africa’s ability to address its health challenges will have important consequences for the entire region. Many of the 3 million Zimbabwean refugees have been living in South Africa for several years now, and will eventually return home if stability there can be maintained. Much of the population of Botswana lives along the South African border, and the tiny kingdoms of Lesotho and Swaziland are so enmeshed with the South Africa populace and economy that the trajectory of their epidemics will depend as much on decisions made in Pretoria as in their own capitals.

The forthcoming budget announcement from the Ministry of Finance, including a planned increase in spending for HIV/AIDS, will begin to fill in some of the “how” that was missing from the State of the Nation speech, as well as indicate the degree to which this administration is serious about addressing the epidemic. Strategies and tactics for turning off the tap of new infections remain unclear, however, and many experts believe that none of the existing prevention tools will be broadly effective without fundamental societal behavior change. Solving the “how” of prevention will be the greatest challenge and potentially the most important legacy of this administration, and will determine how many South Africans are around to watch subsequent State of the Nation speeches.

Re-published with permission by the Council on Foreign Relations. Visit the original article.

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