CSIS conducted research over 2019 and early 2020 into why the world’s largest HIV epidemic persists in South Africa. The remote and on-the-ground research sought to understand the reasons for continuing large numbers of new infections and what is being done to address them.
Even before the threat of COVID-19 to South Africans’ health and economic wellbeing, South Africa had an ongoing public health crisis. It has the largest HIV epidemic in the world, accounting for 19 percent of all people living with HIV (PLHIV) worldwide.
With more than 3 million PLHIV still in need of treatment and a high rate of new infections—close to a quarter of a million in 2018—primarily among adolescents and young adults, the HIV epidemic threatens the future social and economic stability of the country. It demands a more focused, financed, and high-level response from the government of South Africa and its partners, including the U.S. government.
- In South Africa, there are 7.7 million PLHIV.
- Women make up 63 percent of all adults living with HIV and 64 percent of new infections.1
- There are approximately 240,000 new infections annually—14 percent of all new infections worldwide.
- Adolescent girls and young women (15-24) constitute one-third of new infections.
- Nearly 4.8 million people were on anti-retroviral treatment (ART) in South Africa at the end of 2018, with approximately 680,000 newly initiated during that year.2
- An estimated 71,000 South Africans died of AIDS-related causes in 2018.
- Prevalence rates in South Africa:3
- 20 percent of overall population
- 58 percent of sex workers (SWs)
- 22 percent of people who inject drugs
- 18 percent of men who have sex with men (MSM)
- Progress toward the 90-90-90 goals (90% of all people living with HIV know their HIV status, 90% of all people with diagnosed HIV infection are on sustained treatment, and 90% of all people receiving treatment are virally suppressed) stood at 91-70-83 as of September 2019.
- Life expectancy has rebounded from 52.5 years in 2005 to nearly 63 years in 2018 as a result of a 70 percent and 59 percent decline in deaths among adult women and men, respectively, since 2005.
- Together, 27 districts in 8 provinces account for approximately 80 percent of PLHIV.4 KwaZulu-Natal and Gauteng Provinces, which house the municipalities of Durban, Pietermaritzburg, Pretoria, and Johannesburg, together account for approximately 50 percent of the HIV burden.
Approximately 20 percent of South Africa’s people are living with the virus, but that hides extremes in rates across the country, such as 60 percent of women in some communities of KwaZulu-Natal (KZN) province.5 Public health interventions have resulted in progress, but the sheer breadth of the HIV crisis in South Africa overwhelms the current response level. There are insufficient resources to cover the country and deliver important tools at the scale needed to contain the spread of HIV.
In addition, HIV is fueled by syndemics of health conditions—the simultaneous occurrence of epidemics of different health or social conditions in the same geographical area which enhances the transmission, frequency, and virulence of the epidemics—and of social conditions such as high levels of violence, especially against women. South Africa has one of the highest burdens of tuberculosis (TB) in the world, including of multi-drug resistant TB (MDR-TB), and faces increasing rates of non-communicable diseases (NCDs). Health workers are overburdened and under-resourced. South Africa’s public health system cannot handle the size of its HIV treatment program.
The immediate and long-term implications of COVID-19 for PLHIV and the overall public health system are likely to expose the fragility of the HIV response. PLHIV, especially those who are not virally suppressed, are already immunocompromised and at increased risk of TB and other infectious and opportunistic diseases. They are vulnerable to severe SARS-Cov-2 symptoms. Further, disrupted access to HIV prevention and treatment service and breaks in supply of critical HIV commodities may put people at risk for infection or treatment failure, make reaching national HIV treatment goals more challenging, and increase the risk of disease resurgence.
The country is off track to meet its own target of 6.1 million on HIV treatment by the end of 2020, which would help put it on the path to controlling its epidemic. Only 30 percent of all PLHIV in South Africa were virally suppressed in 2018. Viral suppression is critical to the welfare of PLHIV but also for prevention, as someone with an undetectable viral load cannot pass on the virus.
In addition, the country is off track to meet the 2020 Fast Track milestones set out by the United Nations Joint Programme on HIV/AIDS (UNAIDS) to end HIV as a public health threat by 2030. As of September 2019, South Africa’s progress toward the 90-90-90 goals stood at 91-70-83. South Africa’s success, or lack thereof, will factor greatly in whether this goal can be attained globally.6
Despite significant progress over the last decade, control of South Africa’s HIV epidemic is unlikely in the near future without more aggressive action to push through barriers to effective and impactful program implementation. Such barriers keep the country from achieving its targets by hindering the implementation of well-planned policies. Complacency has set in as the country has been challenged by political and economic crises, high rates of unemployment, and one of the highest rates of income inequality in the world.
What will it take to address the HIV emergency in South Africa and accelerate its path to controlling the epidemic? To meet its epidemic control goals, South Africa will need to address key barriers, including:
- Public health system capacity;
- Adequate funding;
- Coverage and scale of services across the country; and
- Implementation gaps and failures for HIV programs and supporting interventions.
The critical shortfall in reducing new infections and achieving epidemic control in South Africa is not between evidence and policy but between policy and implementation.
1. Policy, Governance, and Health System Capacity
The government of South Africa deserves tremendous credit for its leadership on HIV over the last decade. Today, the government funds more than 70 percent of the national response. South Africa has also been an early adopter of WHO guidelines. However, its federal system of government with decentralized power and responsibility for public sector implementation at the provincial levels has led to variation in the HIV response across the country.
The delivery of high-quality HIV prevention and treatment services is affected by limited funding to cover the entire country, roadblocks from local gatekeepers, and ongoing infrastructure and human resources crises within the public health system, which cares for approximately 80 percent of the population.
Continuing challenges have led the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR), the country’s leading partner, to threaten funding cuts. In response, the government launched Operation Phuthuma in 2019 to coordinate actions at facility, district, and province levels to improve quality.
2. Service Delivery
The gaps between policy and implementation are evident in the execution of HIV treatment and prevention programs more broadly but also in the way those programs address the needs of specific groups of people. These barriers drive inefficiency and ineffectiveness and inhibit South Africa’s ability to meet its epidemic control goals.
Implementation is required at scale, and gaps need to be closed. A July 2019 report from Global Advocacy for HIV Prevention highlights four common factors to reducing HIV incidence and mortality in six places worldwide: (1) campaigns to encourage HIV testing; (2) free and easy access to ART at the time of HIV diagnosis; (3) scale up of evidence-based HIV prevention, such as pre-exposure prophylaxis (PrEP); and (4) human rights-based services and social supports.7
3. Treatment Initiation and Retention
South Africa has done exceedingly well with its HIV testing program, with an estimated 90 percent of PLHIV knowing their status. However, it continues to be plagued by initiation and retention issues in its treatment program, which has resulted in low overall viral suppression rates.
Approximately 680,000 PLHIV were newly initiated on ART in 2018, but more people stopped treatment than started. As a result, nearly 300,000 people must start treatment per quarter in 2020 to meet the target 6.1 million on ART by the end of the year.8
4. Prevention Challenges with Youth
While South Africa is not experiencing the same sort of youth bulges as its neighbors, approximately 45 percent of the population is under the age of 25.9 An estimated 10.8 percent of adolescent girls and young women (AGYW) have HIV, with higher prevalence rates increases among women in older age bands.10
Aggressive action is needed to overcome stumbling blocks, especially among youth. Without a massive decline in the new HIV infection rate among those under 35 years old, the sheer numbers becoming infected will stay alarmingly high. If this is the case, providing decades-long treatment to ever-growing numbers of people will remain a financial burden for the government.
The country has struggled with its prevention programs, especially for youth. There have been barriers to provision of basic health education and service delivery in schools, and youth seeking prevention and treatment services often encounter stigma and discrimination at health facilities.11
5. Access to Oral PrEP
The introduction of an oral PrEP pill taken daily to reduce vulnerability to HIV infection by 99 percent offered hope of dramatically decreasing infections. However, South Africa’s oral PrEP implementation has been slow and inadequate since it was approved in national guidelines in 2016. There have been issues with messaging, health worker sensitization and training, and PrEP availability.
According to current WHO guidelines, all young women up to the age of 24 and young men up to 29 should be eligible for PrEP. Yet only an estimated 35,000 people were on PrEP as of October 2019.12 The national target is 18,000, but that equates to only 14.5 percent of the 240,000 presumed to be at risk based on the new infection rates in 2018.13
Wider spread use of PrEP could be especially beneficial for women, who face an epidemic of gender-based and interpersonal violence, including rape. Having a discreet, user-friendly tool could protect women from HIV infection even when they cannot control their own sexual activity.
6. Failure to Reach Men
Reaching men—who are less likely to access testing or treatment and achieve viral suppression—will be key as well. In 2018, 62 percent of women 15 years or older were on ART, compared to only 56 percent of men in the same age group.14
Data has shown that the time from infection to transmission is short for men, whereas it is long for women.15 Young men tend to have much higher comparative viral loads, which is likely driving women’s incidence, as more copies of the virus make it easier to transmit.
Getting men diagnosed and virally suppressed as quickly as possible is therefore critical, especially because of the HIV transmission patterns. A recent study found a significant increase in HIV prevalence in AGYW in age-disparate relationships with a partner more than five years older.16 This group also had higher rates of sexually transmitted infections (STIs), lower condom use, and more episodes of physical and intimate partner violence. The prevalence among women aged 20-24 is three times higher than in men in the same age range.
The answer to solving HIV in South Africa does not lie in targeting HIV alone. The spread of HIV is compounded by many factors, including:
- The legacy of 300 years of colonial and apartheid rule, which disenfranchised the majority of the population;
- Cultural and social norms such as patriarchal relationships;
- The prevalence of interpersonal violence and rape, which affects children and men but puts women and girls at especially higher risk of acquiring the virus.
The response must be more comprehensive, targeting quality of education, opportunities for economic skills and empowerment, community engagement, and violence prevention and access to justice.
Programs such as PEPFAR’s DREAMS (Determined, Resilient, Empowered, Aids-Free, Mentored, and Safe), the Global Fund’s HER Campaign, and South Africa’s She Conquers have attempted to address a broad range of social, economic, and health issues that increase HIV risk. While there is evidence that these programs are having an impact, there are insufficient funds to implement them at a national scale.
Further, simply distributing ART in a standalone HIV clinic is not enough to reach those in need of testing and treatment services. Integration of HIV with services for STIs and family planning/reproductive health would help maximize individual touchpoints with facility and community health providers, thus making it more efficient for the patient and the provider. In addition, greater use and nationwide deployment of mobile units and non-traditional ART dispensing methods, such as ATM machines, will be needed.
The situation in South Africa is precarious. Progress has been made against the world’s largest HIV epidemic, but the gains are fragile and there are many challenges that should be addressed notwithstanding the COVID-19 impact. HIV remains a crisis, and the potential for an HIV resurgence in South Africa is a threat to take seriously.
- Eliminate barriers to implementation.
- Enable full PrEP access.
- Sustain funding and expand private-sector partnerships.
- Assess the level of PEPFAR investment.
- Address societal and structural issues.
The South African national government, with strong coordination and buy-in from provincial and local governments, should remove implementation barriers to the provision of health education, prevention, and treatment services for adolescents and young adults. Non-stigmatizing health information, preventative tools, and treatment services should be made available at all education levels, including primary schools. South Africa also should correct any policies that hinder HIV response and opportunities to reach youth, including the screening protocols for STIs.
The government should make oral PrEP available at full scale across the country, with mass messaging campaigns and easy access at distribution points in communities away from health centers. Education campaigns are needed to overcome the stigma barriers, ensure health workers are trained and equipped to provide non-discriminatory care, and educate young adults on the benefits. Additional financial support for community health workers, mobile vans, and mechanisms can enable more efficient and community-based oral PrEP distribution.
The government should sustain and expand its financial investment as well as develop strong partnerships to help extend its reach to ensure these policies and programs can be implemented. Upcoming implementation of its long-awaited National Health Insurance may enable the government to expand the financing for HIV response. In the meantime, the government should encourage greater participation by businesses and the private sector in HIV response.
As South Africa’s largest HIV partner, PEPFAR should consider whether its level of investment is rightsized to its goals—not only in South Africa but globally—and appropriately matched to the scale and need in South Africa.
Overall, total funding for PEPFAR was $6.78 billion in fiscal year (FY) 2019, with a planned spend of $752 million in South Africa—just shy of 11 percent of annual appropriations.17 PEPFAR’s reduction to $523 million for FY 2020 would reduce South Africa down to less than 8 percent.
It will be important for the U.S. government to consider whether U.S. political and financial investment matches South Africa’s epidemic and the role it plays in driving the number of new infections globally (i.e., 19 percent of all global HIV cases and 14 percent of new infections).
The South African government, the U.S. government, and other partners should consider ways to scale up concurrent efforts to combat the social inequalities, toxic masculinity, unemployment, and chronic health system failures that help fuel the spread of HIV.
Incredible progress has been made against HIV over the last decade. South Africa has the capacity to achieve more, building off its incredible cadre of dedicated and experienced HIV leaders, scientists, and implementers. Using the tools at its disposal, aggressive action to push through access barriers to ensure PrEP, ART, and other services could help turn off the tap of approximately 685 new infections every day. These actions will be needed now more than ever as the country also seeks to contain the impact of COVID-19 and preserve the gains it's made against HIV.
Sara M. Allinder
Senior Associate, Global Health Policy Center
Sara M. Allinder is a senior associate with the CSIS Global Health Policy Center. She was executive director and senior fellow of the CSIS Global Health Policy Center from April 2016 to April 2020. She has extensive experience with the U.S. government in global health, foreign policy, international development, human rights, and program management. For 10 years, she worked on the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) in Washington and in Uganda. In four stints at the Office of the U.S. Global AIDS Coordinator (2003–2016), Allinder was a senior adviser on PEPFAR management and operations issues, including field-based staffing.
In February 2019, Ms. Allinder conducted research in South Africa with Janet Fleischman, a senior associate with the CSIS Global Health Policy Center. She thanks Janet and her colleagues Maggie McCarten-Gibbs and Madison Hayes for their research support.
She also thanks the many colleagues and young South Africans who gave their time and shared their expertise over the course of the project, especially those working tirelessly every day to fight the HIV epidemic in South Africa.
This report is made possible by generous support from the Bill & Melinda Gates Foundation.
A product of the Andreas C. Dracopoulos iDeas Lab, the in-house digital, multimedia, and design agency at the Center for Strategic and International Studies.