South Africa must give itself a shake.
It has the largest antiretroviral (ARV) treatment programme in the world, comprehensive medical prevention programmes and a plan on how to combine these measures cost effectively. But 340 000 new HIV infections in 2014, as reported by UNAids, is simply too high.
Is there something missing?
The most pressing challenges in the fight against the pandemic worldwide will be debated at this week’s 21st International Aids Conference in Durban. Despite major successes, the United Nations’ Sustainable Development Goals acknowledge that ending the Aids epidemic by 2030 has to remain high on the international agenda.
South Africa spells out its strategy to prevent and treat HIV infection in the National Strategic Plan 2012-2016. Successes include reduced early mother-to-child transmission rates from 20.9% in 2004 to about 1.5% in 2015, according to data from the National Health Laboratory Services.
Prevention efforts lag behind
Despite the achievements, the country will have to provide ARV treatment to 4.9-million South Africans in the period 2018-2019 at a projected cost of R16-billion, according to the health department’s South African HIV and TB Investment Case. This number will continue to increase and, in September, the country will start to provide ARVs to everyone who tests HIV positive, regardless of the strength of their immune systems. UNAids estimates there are 6.8-million people with HIV in the country.
The South African National Aids Council acknowledged in its 2014 policy paper that “much more needs to be done to improve prevention efforts”. This is sensible, especially in light of an ever-growing funding gap and with large funders such as United States President’s Emergency Plan for Aids Relief and the Global Fund to Fight AIDS, Tuberculosis and Malaria gradually pulling out.
Although the country is investing in medical prevention such as the programme of pre-exposure prophylaxis (PrEP), which is a combination antiretroviral pill taken daily to reduce someone’s risk of contracting HIV, nonmedical HIV prevention at the social level does not get the attention it deserves. This includes comprehensive and interdisciplinary life skills education in schools.
Change will be slow to come
The spread of HIV is a social issue, and individuals and communities respond to it on that level. Social cohesion, which is essential to prevention, is a less attractive financing target. It is complex to implement, its effect takes longer to manifest and it is more difficult to measure. Change will only come about if we accept that. Change relies on the initiative and co-operation of the people, on open communication and room for entrenched perceptions and habits to shift.
A focus on the social and political dimension of preventing HIV may well be a game-changer in the long run.
Of the government’s R17.5-billion budget dedicated to HIV in 2016-2017, the lion’s share of more than R16-billion will be allocated to the department of health. The allocations for tackling HIV in the hands of the departments of education and of social development are comparatively small. But these departments oversee social tasks that are essential for achieving the social change required to curb the pandemic.
Governments and donors need to invest in nonmedical HIV prevention research. This will lay the foundation to bridge the gap between the prominence and effect of medical and nonmedical interventions.
Given South Africa’s multicultural society and high levels of inequality, creating the social environment required to slow the spread of HIV will be a complex and long-term undertaking. It calls for open and transparent communication both among the population itself and in the government and its organs. This should be underpinned by social capital, shared values and a culture of trust and respect.
Strong leadership is needed to achieve this change.
Nina Baltes and Michael Thiede work for the German management and policy consulting firm, Scenarium. Baltes is a research and evaluation associate, Thiede is the director. Scenarium specialises in the areas of health financing, health economics and social protection.