South Africa and HIV/AIDS
August 3, 2011
A delegation from the Center for Strategic and International Studies (CSIS) Global Health Policy Center will be traveling to South Africa in August, 2011 to look at the major efforts underway to renew the United States’ bilateral relationship with South Africa, with a particular focus on creating sustainable partnerships in health and other areas of U.S. foreign assistance. South Africa is a leading strategic partner on development, health, and other critical issues. U.S. investments in South Africa are the single largest bilateral health account in the world. The CSIS staff will look specifcally at: The U.S.-South Africa Strategic Dialogue; South Africa's shift toward greater country ownership in the health sphere; and turning the tide on the HIV epidemic.
In the days to come, we will post blogs on the current HIV/AIDS, Tuberculosis, Maternal and Child Health, and Non-communicable diseases situations in the country. Please let us know if you questions on any of these topics that you would like our experts to answer.
Overview
South Africa has the highest number of people living with HIV/AIDS in the world at 5.7 million. 330,000 children under 14 years are infected and 1.9 million children have become orphans due to AIDS. With just 0.7% of the world’s population, its share of the global HIV epidemic is a staggering 17%.
South Africa’s first case of HIV was reported in 1982. What started out as a disease for high-risk groups like sex workers, migrant workers and men who have sex with men (MSM) quickly spread to the entire population. Presently, most people contract HIV during heterosexual intercourses and by vertical transmission from mother to child during pregnancy, labor or breastfeeding.
So devastating to the population, HIV caused demographic changes as well. In 2006, nearly 60% of deaths were of individuals under 50 years of age. Mortality peaked at 30-34 years of age in 2002 compared to 70 years in 1997.[1] This phenomenon is shifting the burden of childrearing to the grandparent generation and placing additional strains on youth.
Women are disproportionately affected by HIV. Health Minister Motsoaledi considers HIV “a disease brought on by males but suffered by females” referring to the culture of widespread gender inequity which often leaves women without the power to negotiate how and with whom they have sex. The common practice of intergenerational sex makes young women especially vulnerable to sexually transmitted diseases. Young women are just one of several vulnerable groups represented in South Africa’s seven most at-risk populations (see Table 1.1).
In 2010, President Zuma launched a massive public health campaign to promote HIV testing and to reduce the stigma and discrimination associated with HIV that impede access to HIV testing and treatment.. The President’s HIV Testing and Counseling campaign increased the annual testing rate from 2 million to 11.9 million with a goal of testing 15 million by 2011.
The government also launched an initiative to strengthen the Prevention of Mother-to-Child Transmission (PMTCT) programs that will be essential to further controlling the epidemic. Three key PMTCT policy changes are: 1. raising the CD4 count at which pregnant women and HIV-TB co-infected individuals are eligible for ARVs from 200 to 350; 2. starting PMTCT measures earlier in pregnancy at 14 weeks; 3. immediately initiating prophylactic ARVs for newborns regardless of their CD4 count. These changes have resulted in some quick successes. In 2009, over 83% of HIV-positive pregnant women received ARVs compared to 30% in 2005.[1] In 2011, nine years after the start of a national PMTCT program, the mother-to-child transmission rate fell to below 4%.
While South Africa has successfully reduced mother-to-child transmission of HIV, many children still acquire the virus during the first two years of life due to unsafe feeding practices.
Background
**This information was lifted from the CSIS Report, "Key Players in Global Health: How Brazil, Russia, India, China, and South Africa are Influencing the Game" and was written by CSIS' Jennifer G. Cooke**
The transition in South Africa from the administration of President Thabo Mbeki to that of Jacob Zuma, who took office in May 2009, has ushered in a period of relief and guarded optimism among those engaged in public health in South Africa. President Mbeki’s early denial of a link between HIV and AIDS and his initial refusal to authorize public provision of anti-retroviral medicines were a serious and damaging blow to South Africa, both in confronting the country’s most pressing domestic health challenge and in its global engagement on health. President Zuma’s first 18 months in office have signaled an unambiguous reversal of his predecessor’s reluctant engagement on AIDS. The government has set out an ambitious plan to restructure the health system, with a strong emphasis on expanding HIV and TB treatment and services. The president has acknowledged that South Africa is not winning the war against AIDS, and, beginning with a public HIV test on World AIDS Day 2009, has launched one of the largest national HIV testing campaigns in the world.
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With the departure of President Mbeki, there is now considerable hope that President Zuma and Minister Motsoaledi will devote the attention, leadership, and resources that the country’s health challenges warrant, although given current trend lines and the last decade’s lost opportunities, success is by no means assured. The public health system, which serves some 80 percent of the population, is underfunded and overstretched, and, despite South Africa’s strong economic growth rates in recent years, the resource gaps remain debilitating.
HIV is not South Africa’s only health threat, but the implications of the HIV burden will dominate the country’s health policy for decades to come and HIV and is seen by many as the priority platform through which other health challenges can be addressed. The virus continues to spread rapidly in South Africa. With 0.7 percent of the world's population, the country bears 17 percent of the global burden of HIV infection. Prevalence among 15-49 year olds is an estimated 18 percent. By the end of 2009, the public ARV program reported 919,923 people on treatment, with the private sector and nongovernmental organizations supporting treatment for an additional 51, 637. These treatment figures translate to 56 percent coverage for those in need (based on protocols to initiate treatment when a patient’s CD4 count falls below 200). The government’s stated goal is to reach 80 percent treatment coverage by the end of 2011. Incidence remains unacceptably high—with some 350,000 to 500,000 new infections each year, and if current rates persist, some estimates project that South Africa will need to treat upwards of 3 million people by 2020.[2] If new WHO protocols for treatment are widely adapted, such as raising recommended CD4 count for beginning ART from 200 to 350, the number of those in need will rise dramatically. Domestic pressures for a “test and treat” strategy may increase over time.
The gradual shift in demand from first- to second-line therapy will add another layer of cost. For the foreseeable future, demand for treatment will far outstrip current resources and capacity, and the government will be forced into difficult political and ethical questions on how to prioritize access to treatment and how to balance HIV requirements with other health and development concerns.
Prevention must be a central and persistent focus if South Africa is to make headway in closing the treatment gap and avoiding painful political and ethical trade-offs in resource allocation down the line. Expansion of PMTCT has been a significant success, with services almost universally available in primary health clinics. But sexual transmission has remained an intractable challenge. South Africa appears to be embracing the “Know Your Epidemic” strategy that calls for more tailored and targeted prevention interventions and that may move the country away from broad-based communications campaigns. Strong national leadership and vision will be need to maintain focus on prevention, since there is no strong domestic constituency for prevention, as there is for treatment.
So far the signs of leadership are good. Zuma and Motsoaledi have acknowledged the mistakes of the previous administration and have laid out an ambitious strategy to combat the country’s greatest health threat, HIV/AIDS. In April, President Zuma announced a massive HIV counseling and testing campaign, with an ambitious target of testing 15 million people by June 2011. The country’s new national strategic health plan calls for a decentralization or “down-scaling” of integrated, comprehensive health services, including nurse-initiated HIV treatment, from largely hospital-based services to some 4,000 primary health facilities, an undertaking that will require significant investments in health infrastructure, health professional capacities, and new forms of task-sharing among health personnel. The government has announced plans to train 6,000 nurses in ART initiation by the end of 2011; as of August 2010, 2,500 had been trained. At the president and health minister’s request, an additional $1 billion of the 2010 budget was allocated to HIV treatment, and the government is providing hundreds of pharmacies and retail chains with free HIV test kits.
South African public health experts have welcomed this new energy and enthusiasm, but some caution that managing expectations and accurately mapping out the cost and personnel implications of these ambitious plans will be critical, and some suggest that the government has rushed into a number of these commitments without adequate attention to the consequences. Already, remuneration for the current public health workforce is a source of political tension. Many health professionals joined in mass public sector strikes in August 2010, with the National Education, Health and Allied Workers' Union (NEHAWU) rejecting the government’s initial offer of a seven percent pay raise. Major hospitals shut down in five provinces, with strikers in some instances blocking access by those health professionals who sought to come to work. The August strikes are a stark illustration of South Africa’s dilemma in meeting the basic needs of public sector workers and the demands of politically powerful unions while at the same time attempting to train, retain, and employ a significantly expanded cadre of health professionals. Meanwhile, the government bureaucracy for health, many argue, is oversized, costly, and not always merit-based, although downsizing will be an extremely sensitive political challenge.
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