A complex hand-off: Preparing South Africa to take over its AIDS response

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South Africa has one of the worst AIDS epidemics – home to the highest number of people living with HIV in the world.  With a population of about 49 million, approximately 5.6 million people were living with HIV there in 2009, and 310,000 people died of AIDS that same year. Facing an uphill battle, the country has made extraordinary progress in combatting the disease.

Seven years ago the country was in dire need of the financial and programmatic donations from the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) program, but over the past three years South Africa has assumed increasing ownership of its HIV/AIDS response. A new report by the Center for Strategic & International Studies’ Global Health Policy Center, entitled “Terra Nova: How to achieve a successful PEPFAR transition in South Africa,” discusses what lies ahead for these two countries in a … “complex, multiyear handoff that will shift financial and managerial responsibilities for HIV/AIDS to the South African government and move the United States away from direct service delivery and into technical assistance.”

The U.S. has invested $3.1 billion in South Africa’s health since 2004 – including $560 million contributed to South African global health programs in fiscal year 2011 – a number which will be scaled down greatly in the coming years, according to the report. Vital health service interruptions, criticism of the U.S., and dissolution of U.S.-South African relations are risks that must be avoided in the transitional period. 

CSIS organized a delegation and sent them to South Africa to investigate the topic. Their report highlights interviews the delegation conducted and their findings, and outlines five “key” steps the U.S. and South Africa need to take in order to ensure a smooth transition of full ownership to the South African government.

  1. Get the facts out by addressing the South African government’s desire for more transparency in the PEPFAR investment in South Africa and how that money is spent.
  2. Strengthen the U.S.–South Africa negotiating teams to enhance the quality and reliability of negotiations
  3. Outline a five-year framework to create concrete budgetary and policy milestones – to include how to establish a “hybrid” service delivery model during the transition period – to help manage the expectations of the outcome of this process.
  4. Have an effective communications strategy throughout the process to keep both governments on the same page.
  5. Make even clearer that prevention is a strategic long-term priority in the U.S. health approach, key in South Africa where many areas still face dire HIV and TB emergencies and prevention continues to lag. Work to create linkages with family planning, reproductive health and maternal child health services while providing combination behavioral change interventions as well as biomedical interventions like treatment as prevention.

The report also describes the history of the U.S.-South Africa relationship, with a special section devoted to how it was intensified by the HIV/AIDS epidemic, and the complexities surrounding the transitional period into which they are entering.

CSIS published a companion report in October that looks into how PEPFAR can better link reproductive health and family planning services to improve women’s health and save lives. CSIS also plans to release another publication looking at South Africa as an emerging economy with growing influence in the global health and development arenas, and how the United States plays in.

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