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.
A Decade of Ignominy
When Mandela left Robben Island twenty years ago, HIV prevalence in South Africa was just over 4 percent and life expectancy was sixty years. As president of South Africa, Mandela instituted progressive HIV policies, including a comprehensive "AIDS Plan," but a failure of leadership and lack of national and provincial capacity undermined efforts. By the late 1990s, progressive policy was replaced by nearly a decade of political missteps, controversies, misinformation, and hundreds of thousands of preventable deaths. These included a costly, flawed play--which never opened--intended to educate the public about HIV/AIDS, promotion by government officials of a toxic industrial solvent to treat HIV, and refusal to provide infected pregnant mothers with AZT and nevirapine (proven anti-HIV drugs) to prevent transmission of HIV to newborns. The era culminated with President Mbeki's public questioning of HIV/AIDS science; his health minister's promotion of garlic, beetroot, and lemons instead of anti-HIV drugs; and government refusal to provide HIV treatment to sick patients until 2004, when threatened by legal action from activists such as the Treatment Action Campaign.
South Africa is the front line in the global battle against HIV, the regional epicenter of tuberculosis, and the largest beneficiary of U.S. President's Emergency Plan for AIDS Relief (PEPFAR) funds--approximately $1.5 billion to date. And despite the fact that at its peak in 2001 more than 20 percent of South African adults were infected with HIV and life expectancy fell to forty-one years, the government for years obfuscated, obstructed, and dithered about the domestic HIV crisis. As a result, many died or were needlessly infected. Nonetheless, a turnaround has been slowly building since 2004, and in its first year the new administration has rolled out more progressive policies and aggressive programs.
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.
Many South Africans engaged in the fight against HIV and AIDS greeted Jacob Zuma's election in 2009 with skepticism, thanks to his position as deputy president under Mbeki, as well as his highly publicized relations with a much younger, HIV-infected woman who subsequently accused him of rape. (He was acquitted.) When questioned about precautions taken to prevent contracting HIV during the encounter, Zuma infamously responded that he had showered afterwards. In recent weeks, Zuma apologized (UPI) for fathering a child out of wedlock (his twentieth), following further controversy (health-e) about the president's personal conduct and its impact on HIV prevention efforts in an epidemic driven by intergenerational sex and concurrent multiple sexual partnerships.
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
HIV has not had the deleterious macroeconomic impact predicted by many economists earlier in this decade. But macroeconomic indicators mask the many HIV-associated deaths among the unemployed and informally employed, and the microeconomic impact on the most disadvantaged individuals, families, and communities. It is tougher to marshal resources for disadvantaged classes, and many argue that the government could afford to do more than it currently is. And the continuing large number of new infections, despite a stabilized rate, means ongoing demand for treatment and budget support for years.
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.
[A]s the most populous country in southern Africa, South Africa's ability to address its health challenges will have important consequences for the entire region.
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.
Outside of working to secure donor contributions and increasing its domestic investment, the South African leadership must identify efficiencies within the current system of care and treatment. South Africa pays approximately 20 percent more than the lowest available prices for HIV drugs, despite having the largest market for HIV treatment in the world. Drug prices are the largest contributor to HIV care and treatment costs, and this is a needless waste of precious funds. The current drug tender expires in May 2010 and must be renegotiated to procure drugs at the lowest available prices.
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.
Human resources are as critical as financing to meeting prevention and treatment targets by 2015. Not only have thousands of health professionals left to work in foreign countries, within South Africa there has been a sustained flight from the public sector into the private healthcare sector resulting in a massive resource imbalance: Two-thirds of health spending takes place in the private sector in South Africa, and fewer than half of the doctors and nurses are in the public sector, which serves 80 percent of the population. In addition to improving public sector working conditions and investing in better health system management, strategic partnerships with the private sector can help address the public sector human resource shortage. For example, pilot projects that outsource public sector HIV care and treatment to private sector providers have proven successful by leveraging excess private sector capacity.
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 African 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.