The Politics and Epidemiology of Transition: PEPFAR and AIDS in South Africa

Matthew M. Kavanagh, MEd


J Acquir Immune Defic Syndr. 2014;65(3):247-250. 

In This Article

PEPFAR and the Changing SA AIDS Response

When PEPFAR arrived in SA in 2004, rollout of antiretroviral (ARVs) relied on a sustained effort from civil society led by the Treatment Action Campaign, NGOs, and provincial officials. The Mbeki government's denialist response to AIDS had cost more than 3.8 million lost "person-years" by one estimate.[3] PEPFAR invested more than $3.2 billion in the country to fund parastatals, NGOs, unions, private doctors, and universities to tackle the AIDS crisis.[4] By the end of 2010, the program reported "directly" supporting a million people on ARVs.[5] PEPFAR also helped to build much of the AIDS workforce, including thousands of doctors, nurses, adherence counselors, and data capturers.

In recent years, the Presidency and Department of Health have reset SA AIDS policy, speeding ART rollout begun under activist pressure, increasing domestic funding, and building a new science-based National Strategic Plan to reshape the role of the SA public health sector on HIV.[6] SA's HIV treatment program is now the largest in the world. Household surveys confirm that more than 2 million people received ARVs in 2012.[7,8] However, to reach the goal of universal access under the new World Health Organization guidelines,[9] the country needs to double the number of people who have access to treatment for HIV, as Figure 1 shows.

Figure 1.

Source: Treatment scale up, incidence, and mortality, 1990–2016. Graph is based on achieving 80% of the total 5.3 million people in need as per US Agency for International Development (USAID) 2013.10 New World Health Organization guidelines recommend treatment initiation at any CD4 cell count for children under 5, pregnant women, patients coinfected with tuberculosis (TB) or hepatitis, or seropositive persons in a serodiscordant relationship; all other patients testing positive should initiate treatment at CD4 counts <500.

The good news is that the AIDS response is already decreasing mortality and incidence, increasing life expectancy,[11] and driving down child mortality.[12] If scale-up continues, modeling suggests for every 1% increase in ART coverage in highly affected areas, and risk of acquiring HIV declines by 1.4%.[13] A model of combination prevention, especially with attention to key populations, could end SA's AIDS crisis, but it requires unprecedented scale.

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