In his first official visit to South Africa as Executive Director of The Global Fund to Fight AIDS, Tuberculosis and Malaria, Mark Dybul met with President Jacob Zuma to discuss advancing the fight against these infectious diseases in the country. South Africa has made significant gains in the fight against HIV and AIDS and the Global Fund has been a major partner in the country's efforts. Recently, South Africa's government has stepped up domestic financing of HIV programmes to cover approximately 82 per cent of the country's total HIV and AIDS expenditure. It has been supplemented by further support from international funding mechanisms such as the Global Fund and the President's Emergency Plan for AIDS Relief (PEPFAR). These investments have resulted in important health gains for the country.
With 1.9 million people on treatment as of June 2012, South Africa has the largest antiretroviral therapy (ART) programme in the world. By local standards, ART is relatively expensive and many have questioned whether scaling up such treatments could be justified. However, co-ordinated action by South Africa and external supporters has helped to increase life expectancy from 54 years in 2005 to 60 years in 2011. In fact, in a recent study published in Science (2013;339:961-965), researchers analysed the effectiveness of a US$10.8 million campaign in KwaZulu-Natal province in South Africa and found that as well as considerably increasing life expectancy, treatment scale-up was also in fact very cost-effective. The investment of US$1,593 for ART in this community saved one life year. For investments in health interventions to be considered cost effective, the spending must be less than the annual per capita gross national income to save one life year; South Africa's per capita gross national income in 2011 was US$6,960.
However, with hundreds of thousands of additional South Africans now entering ART programmes, as well as the cost of HIV prevention and care of orphans, the financial challenge is mounting into a major risk for South Africa, particularly at time when the country is suffering due to the global economic recession and is struggling to maintain its government budget for varying needs, beyond HIV and AIDS. This is why the ongoing commitment by global partners is crucial. While the exact amount is not known, the South African Treasury estimates that total external funding for HIV/AIDS amounts to R5 to 6 billion per year, with The Global Fund and PREPFAR having been major contributors in recent years. The Global Fund Board recently approved an additional R216 million for HIV programmes in South Africa. An estimated additional R1.95 billion is available to South Africa for programmes to be implemented between 2013 and 2016. Further funding amounting to R296 million for HIV will be available through the new funding model that the Global Fund recently launched. South Africa is also helped considerably by PEPFAR. In 2010, a Partnership Framework between the US and South Africa was signed, providing a five-year joint strategic plan to fight HIV/AIDS. By the end of this period, the collaboration is expected to result in greater prevention efforts and expanded services for HIV, as well as a strengthened national health system.
However, the drug scale up is useless if patients fail to adhere to their therapy. There are many reasons for non-adherence, these include religious obstacles, stigma, ART-associated costs, transport problems, lack of support and side effects. Despite the effect that the lack of ART adherence can have on an individual's health, it also creates the risk of developing drug resistance. If this happens, many patients would need to be switched to second-line treatments, which are much more costly than first-line drugs, putting further burden on the government. Although not an ART, the recent failure of a large trial (VOICE) of three different HIV pre-exposure prophylaxis (PrEP) methods in African women demonstrates the challenges posed by adherence in South Africa; the lack of adherence was blamed for the failure of the study. However, according to a study published in PLoS ONE in 2010 (10.1371/journal.pone.0013646), PrEP is only cost effective when ART coverage is lower, and with this new drive by the South African government, it seems doubtful that PrEP will be an avenue that it will want to venture down any time soon. Early ART treatment however can be cost-effective. At AIDS 2012, data from the HIV Prevention Trials Network (HPTN) 052 showed that early ART treatment was very cost effective. The cost-effectiveness analysis was modelled on South Africa and India. In fact, it was HPTN 52's results that were used to revise World Health Organization treatment guidelines, which now recommend the earlier initiation of ART.
Although moving in the right direction, South Africa still needs to ensure that its ART expansion is carefully managed. Education is a key factor if the country is to shake off the hangover of Mbeki-advocated AIDS denialism and increase adherence to ART. The country must also clearly reduce the average cost of treating HIV/AIDS patients, for example via the procurement of cheaper generic combinations. The financial demands on South Africa over the next few years are huge and with the country's growth sluggish and below African average since 2008, the government may be forced to rely more heavily on external support to bridge the gap in funding. This scenario is mirrored in many of Africa's poorer nations, as Bernard Schwartlander of UNAIDS phrased it: "The lives of more than 80 per cent of the people who receive AIDS treatment in Africa depend every morning on whether or not a donor writes another cheque". With the renewed funding commitment by The Global Fund and Ambassador Eric Goosby, current US Global AIDS Co-ordinator, saying that the plan is for the US to continue to play a transformative in the global response to HIV, the commitment to funding seems to be in place. The onus is now on African governments to ensure that it is utilised appropriately, something that may in the short-term yield less dramatic results than those seen in the past.