This post is by Center Director Christine Lubinski.
Dr. Catherine Sozi, the UNAIDS Country Director for South Africa, spoke to HIV advocates and PEPFAR implementers during a trip to Washington this week that included stops on Capitol Hill and at the Office of the Global AIDS Coordinator, where she conveyed a message about South Africa’s explosive HIV epidemic and the country’s significant resource challenges.
Sozi, a Ugandan family medicine physician who recently moved from her post as the UNAIDS point person in Zambia to South Africa, told a gathering of community advocates that she was somewhat surprised about misimpressions on Capitol Hill about the capacity of the South African government to finance HIV prevention, care and treatment services. Mired in a deep recession and playing catch up after years of government inaction on AIDS, South Africa is struggling to meet its own treatment targets, and even to accurately evaluate how many people are actually on ARV treatment.Country health officials know that roughly 800,000 people were initiated treatment at one point or another, but they know little about how many of those individuals have died or otherwise been lost to follow-up.
What data does exist is at the provincial level, and while they are working on a national database, it is not yet operational, nor is there a uniform set of data elements collected by programs. Because of this, there is little clarity on what government HIV funds are buying, even though 50-60 percent of the funding for the AIDS response comes from the South African government.
South Africa has recently changed its guidelines to recommend treatment initiation for individuals below 350 CD4 cells, but most individuals still present with an opportunistic infection, predominantly tuberculosis. Without significantly more resources, this change remains a paper directive.
Tuberculosis is a huge factor, with up to 1 percent of the South African population, some 500,000 people developing active TB disease each year. According to Sozi, there is little doubt that the treatment, as well as the prevention agenda, still urgently need outside support. There are widespread shortages of antiretroviral medications and many provinces including Kwa Zulu Natal, the most heavily affected area in the country, have stopped putting new patients on treatment. South Africa has requested emergency funding for medications from PEPFAR for 2010.
UNAIDS is working with the World Bank and the South African government to do an analysis of the epidemic at the provincial and district level so that resources are appropriately targeted to the epidemic in the particular region. Prevention services fare no better, with few programs scaled up to reach significant numbers of people. There is an urgent need to scale up a variety of programs. There are no programs, for example, targeting drug users in South Africa.
Programs to prevent vertical transmission have about 60 percent coverage, but 60,000 babies continue to be born with HIV infection each year. Reproductive health, including family planning and teen pregnancy prevention programs, remain modest efforts despite the fact that teen pregnancy is itself an epidemic and young women are at great risk for HIV infection.
Gender-based violence fuels the epidemic, with one of four South African men admitting that they raped a woman in the last 12 months. According to Sozi, it is not uncommon for women to use a female condom when they leave their homes, in case they are raped during the day. And basic knowledge among the country’s youth about how HIV infection is transmitted has declined in recent years with only 27 percent of youth having accurate information and knowledge.
In short, this young and fragile democracy will continue to need resources and support from the United States and other donor countries for many years to come.