From the Front Lines of the Global AIDS Fight. 7/10

Worrisome lack of progress in preventing new adult infections.

Global Health Magazine

The picture of the current state of AIDS in South Africa is ambivalent. There are some notable successes in preventing mother-to-child transmission and access to antiretroviral treatment (ART), but a worrisome lack of progress in preventing new adult infections. Prospects for resourcing and financing over the next five years are equivocal at best.

Earlier this year a group of South Africa's leading HIV experts, the authors among them, gathered to reflect on progress, identify challenges, and recommend strategies and tactics for surmounting obstacles in the fight against HIV and AIDS. The Special Report on the State of HIV/AIDS in South Africa summarizes the analysis and recommendations that emerged from that meeting.

One theme was transcendent - winning the AIDS fight requires a paradigm shift on the part of all South Africans. Two strategic objectives were mooted again and again as essential to galvanize this shift: 1) The South African department of health must change the way it does business; and 2) Reversing the trend of new infections requires a mass social movement. At a glance, these objectives appear as inchoate as they do intractable, though they reflect several fundamental truths about the current state of AIDS. With five infections for every two people started on ART, HIV incidence remains too high. Extant public sector health staff, including doctors, pharmacists and laboratory technicians, cannot cope with the 3 million plus people needing ART by 2015. Finally, there is not enough money in the AIDS budget to treat everyone needing ART.

The success of prevention and treatment programs in South Africa hinges on leadership from the department of health at national and provincial levels. Management capacity within the health sector merits a great deal more attention than it currently receives. Far too few people in leadership and management positions have any management training; the drug stock outs in Free State Province and high rates of ART patients, who are lost to follow-up, are just two indicators of the current state of health system management. Fiscal management is also a major concern. The independent Budget and Expenditure Monitoring Forum reports that provincial health departments routinely incur large amounts of unplanned expenditures, fail to budget based on estimated service needs, and suffer widespread corruption.

Doctors, nurses and other key leadership staff should be incentivized to receive management training. Better management should lead to more efficient use of resources, improved supply chain efficiency and reliability, greater levels of accountability, improved working conditions, and ultimately, better patient care at lower cost. For example, given the talk of clinic overcrowding and health worker burden, it is curious that clinics across the country are empty every day by three o'clock and closed after one o'clock on Fridays and on weekends. Moreover, the public health system does a notoriously poor job of holding non-performing and/or negligent health professionals accountable, jeopardizing patient health and program efficacy.

The health department's policy options to cut costs and reduce workload and patient burden include better use of community health workers; modification of the current treatment guidelines to permit quarterly dosing for patients who are adherent and stable on treatment; and less intensive laboratory monitoring - recent research from Uganda and Zimbabwe found twice-yearly laboratory monitoring to be cost-ineffective.

Finally, data management is a shambles. Public sector data are poor quality and not used to inform program management or even future budgets, which are just carried over from year to year with small annual increases. Worse still, some provincial health departments have undermined facility-based efforts to implement their own data management systems, citing fragmentation and quality concerns. The time has come to either expedite the database selection process or publish data standards and guidelines and let the facilities select the database that best suits their needs.

Changing the course of the South African epidemic cannot be the sole responsibility of government, and a commensurate effort by individuals and communities across the country is essential. All South Africans should know their HIV status. The new testing campaign announced by President Zuma is a start, but HIV testing must become habitual for all sexually active adults and adolescents. The Botswana model of opt-out testing, where doctors and nurses automatically suggest an HIV test during consultations - and the patient may elect to decline - resulted in the highest treatment coverage in Africa.

In the absence of a "game-changing" bio-medical intervention (e.g. vaccine), it is up to all South Africans to cut the infection rate. Even under the rosiest of scenarios, 5 million are expected to contract HIV over the next 10 years. But this need not be a fait accompli. New research estimates that incidence among young women aged 15 to 24 dropped by 60 percent between 2005 and 2008, driven in part by higher rates of condom use. Significant reductions in new infections are possible through behavior change. A national social movement for behavior change, rooted in a national dialogue led by national and local leaders, churches, traditional healers, chiefs, private sector companies and others should focus on prevention in the context of epidemic drivers: intergenerational sex, multiple concurrent sex partnerships, and discordant couples. Indigenous leadership and organic, context-specific prevention initiatives are crucial: all prevention is local.

Government has two options to address the HIV program financing gap: increase investment and reduce costs. In reality, it needs to do both. The new budget allocations from the Treasury show a clear commitment to grow domestic investment in HIV. However, with the U.S. President's Plan for AIDS Relief (PEFPAR) - South Africa's biggest AIDS donor - budget essentially frozen, and the Global Fund for AIDS, TB and Malaria facing its own multi-billion dollar budget gap, the prospects for additional donor money are bleak. Cost cutting and improved efficiency is imperative, starting with HIV drugs, which typically comprise more than 50 percent of total treatment costs. Incomprehensibly, South Africa pays more for drugs than its neighbors despite having the largest ART drug market in the world. The next biggest cost driver is staff - training lower level staff to perform more of the routine aspects of HIV care should yield savings without compromising quality.

The current PEPFAR law expires at the end of 2013. Increased domestic spending shows the U.S. Congress that South Africa is serious about addressing AIDS, and should put it in a favorable position as it requests an extension of PEPFAR funds through 2015 (at which point the number of patients starting treatment should level off). The government would do well to organize an "all donors" financing meeting to secure longer-term commitments, coordinate funding streams and harmonize domestic and donor-funded programs.

The demand for HIV services in South Africa is beginning to exhaust the financial and human capacity to provide them. Tough choices need to be made to close the demand-resource gap, but it's not clear just how willing leaders and citizens alike are to engage in HIV/AIDS realpolitik. What is the government willing to pay for HIV and AIDS care? What is required of communities and individuals? The role of the private sector? And civil society?

At the January meeting in Cape Town, there was consensus that South Africa is exceptional, not just for the scale of its epidemic, but also for its ability to lead the region and the world in responding to the global AIDS crisis. Its ability to succeed requires bold leadership and an engaged populace: the paradigm shift begins now. The success of the World Cup shows this is indeed possible.