HIV and AIDS in South Africa

KEY POINTS

South Africa has the biggest HIV epidemic in the world, with 7.7 million people living with HIV.

HIV prevalence among the general population is high at 20.4%. Prevalence is even higher among men who have sex with men, transgender women, sex workers and people who inject drugs.

South Africa has made huge improvements in getting people to test for HIV in recent years. It has now met the first of the 90-90-90 targets, with 90% of people living with HIV aware of their status in 2018.

The country has the world’s largest ART programme, which has undergone further expansion with the implementation of ‘test and treat’ guidelines.

South Africa was the first country in sub-Saharan Africa to fully approve PrEP, which is now being made available to people at high risk of infection.

Explore this page to find out more about groups most affected by HIV in South Africa, HIV testing and counselling programmes, HIV prevention programmes, antiretroviral treatment availability, civil society’s role, HIV and TB in South Africa, funding for HIV and the way forward for South Africa.

South Africa has the biggest and most high-profile HIV epidemic in the world, with an estimated 7.7 million people living with HIV in 2018.1

South Africa accounts for a third of all new HIV infections in southern Africa.2 In 2018, there were 240,000 new HIV infections and 71,000 South Africans died from AIDS-related illnesses.3

South Africa has the world’s largest antiretroviral treatment (ART) programme. This has been largely financed from its own domestic resources: in 2017, the country was investing more than $1.54 billion annually to run its HIV programmes.4 The success of South Africa’s ART programme is evident in the increase in national life expectancy from 56 years in 2010 to 63 years in 2018.5

South Africa is making good progress towards the UNAIDS 90-90-90 targets, particularly in regards to testing and viral suppression. In 2018, 90% of people living with HIV were aware of their status, of which 68% were on treatment. Of those diagnosed and on treatment, 87% were virally suppressed. This equates to 62% of all people living with HIV in South Africa on treatment and 54% virally suppressed.6

HIV prevalence remains high, with 20.4% of people (one in five) living with HIV.7 However prevalence varies markedly between regions, ranging from 12.6% in Western Cape to 27% in KwaZulu-Natal.8

Groups most affected by HIV in South Africa

Women

Women are disproportionately affected by HIV in South Africa. In 2017, 26% of women were estimated to be living with HIV, compared to around 15% of men.9

In 2018, 140,000 women and 86,000 men became HIV positive.10 In the same year, 4.7 million women were living with HIV compared to 2.8 million men.11

Poverty, the low status of women and gender-based violence have all been cited as reasons for this disparity in HIV prevalence.12 In 2017, it was estimated that around a third of women will have experienced intimate partner violence in the past 12 months, a level that is similar across all age groups.13

Young women and adolescent girls

HIV prevalence among young women is nearly four times greater than that of young men.14 In 2018, 540,000 young women were living with HIV, compared to 180,000 young men.15

In the same year, 69,000 young women became HIV-positive, compared to 28,000 young men, meaning they are over three times more likely to acquire HIV than their male counterparts. The difference is particularly acute among 10 to 19-year-olds, with 33,000 adolescent girls becoming HIV-positive in 2018, compared to 4,200 adolescent boys.16

Intergenerational relationships between older men, a group with high HIV prevalence, and young women are understood to be driving a cycle of infections. The National Strategic HIV Plan has centred its approach to HIV prevention around interrupting this cycle.1718

CASE STUDY: Sugar daddies

Lebogang Motsumi was 27 when she acquired HIV from a 'sugar daddy' – a significantly older man who showered her with gifts, which she believed she needed to fit in with her friends and feel more accepting of herself. She was reluctant to use a condom in case she was perceived as promiscuous by men and felt she was “not in control” of the situation when she was with her sexual partners.

Now a mother, Motsumi says she wishes she had received more information at home and at school about risky sexual behaviour, and is using her experience to advocate non-judgemental, face-to-face conversations with young people about relationships with older men.19

In addition, social attitudes towards young people’s sexuality means they are less likely to access HIV prevention services and testing than older age groups. This is hampered further by the need for under 14-year-olds to obtain parental or guardian consent in order to test for HIV.20

In 2016, the government launched a national campaign to try to improve health outcomes for young women. The ‘She Conquers’ campaign focused on decreasing teenage pregnancies, preventing gender-based violence, keeping girls in school, and increasing economic opportunities for young women. Young women and adolescent girls who are considered at high risk of HIV infection are also now eligible for pre-exposure prophylaxis (PrEP).21

Sex workers

Nationally, HIV prevalence among sex workers is estimated at 57.7%. However this varies between areas, with prevalence estimated at 71.8% in Johannesburg, 53.5% in Durban and 39.7% in Cape Town.22 23

Certain factors increase HIV risk for South African sex workers, most notably exposure to high levels of violence and poverty and low educational levels.24 A study in Soweto found that 50% of female sex workers had experienced some form of physical assault in the past 12 months; of these 55% had been raped or sexually assaulted.25

The criminalisation of sex workers compounds the issue of violence as it discourages sex workers from reporting rape and assault. It also perpetuates discrimination and abuse in all forms, including violence.26

Injecting drug use, substance abuse and binge drinking alcohol is also common among sex workers and this, coupled with having multiple sexual partners (both clients and intimate partners), exacerbates their vulnerability to HIV infection.27

Studies have also found that understanding of HIV risk is often low among female sex workers. In Durban it was reported that only 4.6% of female sex workers could correctly identify HIV transmission risks and reject myths. In 2015, it was found that only 19% of female sex workers living with HIV in Johannesburg were accessing treatment, rising to 25.6% in Durban and 27.7% in Cape Town.28 These rates are well below the national average.

In 2016, 86% of female sex workers reported using a condom with their last partner.29 However, the Soweto study mentioned above found that, although a similar proportion of female sex workers reported condom use at last sex (85%), only 22% reported consistently using condoms when they had sex.30

In 2016, the South African government launched a progressive new National Sex Worker HIV Plan, outlining a peer-led approach to providing HIV services that had been tailored to meet the specific needs of sex workers.31

However, educational organisations have reported difficulties in delivering HIV prevention services to sex workers due to ongoing police harassment. A study conducted by Human Rights Watch in four South African provinces in 2018 found 75% of sex workers had been arrested multiple times, some as often as two or three times per month. Many reported having to pay bribes to be freed and some reported being raped or sexually assaulted by police during these encounters.32

There is no violence from the police, but they just force me to have sex with them or else they say I will arrest you... six or seven times this has happened.

– Esther Makaza, a Zimbabwean sex worker living in South Africa.33

Men who have sex with men (MSM)

It is estimated that 18.1% of men who have sex with men (sometimes referred to as MSM) in South Africa are living with HIV.34This varies considerably between urban and rural areas and according to socio-economic status. The Human Sciences Research Council’s Marang Men’s Study found HIV prevalence among men who have sex with men of 22.3% in Cape Town, 48.2% in Durban and 26.8% in Johannesburg.35

Despite a constitution that protects the rights of lesbian, gay, bisexual, transgender and intersex (LGBTI) communities, many men who have sex with men face high levels of social stigma and homophobic violence as a result of traditional and conservative attitudes. One study found that 24.5%

of men who have sex with men in Cape Town reported experiencing at least one human rights violation in their lifetime.36

There is also a lack of knowledge around the issues faced by men who have sex with men. This makes it difficult for these men to disclose their sexuality to healthcare workers and get the healthcare they need.37

There’s also discrimination whereby you find these old kinds of nurses who don’t have this knowledge about gays and lesbians … when you go to clinics and then maybe let’s say you have an STI or something. They then start calling you names, and saying, 'Guys don’t sleep with guys, why do you do that?… Boys don’t sleep together'.

– Gay man living in Free State, South Africa.38

In 2017, the South African government released a national LGBT HIV strategy for the first time, recognising that these groups have specific needs that have been overlooked in the past.39 Among the recommendations made in this strategy are increasing the availability of lubricants for men who have sex with men and providing them with (PrEP) to protect them from infection.40

Transgender women

Transgender women in Sub-Saharan Africa are twice as likely to have HIV as men who have sex with men.41 However, trans women are often neglected by both policy and research in South Africa. It is common for trans women to either be excluded from participating in studies or to be categorised as men who have sex with men.

In January 2018, the first study to investigate HIV prevalence in transgender women in South Africa was launched. With this study will come an insight into the drivers of HIV amongst transgender women, and so the means for better targeted interventions in this community.42 As of February 2020 the results of this study were yet to be released.

The South African National AIDS Council’s LGBTI HIV Framework recognises transgender women as a key affected population. It aims to address this through peer-led interventions, in which members of the transgender community will identify other at-risk individuals and help to provide them with psycho-social support as well as better targeted information and services.43

Stigma is another major barrier to transgender individuals receiving care. A report by GenderDynamix, a South African NGO that promotes transgender rights, shows the role healthcare provider stigma can play in putting trans women off accessing HIV prevention services.44

Yes. I tested for HIV and was not of the best as the person who pricked me urged me to change my life - as I being like I am is immoral, she said.

- Anonymous45

People who inject drugs (PWID)

Injecting drug use has increased in South Africa over the last two decades. It is estimated that around 75,000 people in the country inject drugs.46

Data on HIV prevalence among people who inject drugs (sometimes referred to as PWID) has been scarce but is improving. In 2018, results of a population-level survey suggest 21.8% of people who inject drugs are living with HIV.47

A 2016 study of people who inject drugs in five South African cities found 32% of men and 26% of women regularly shared syringes and other injecting equipment and nearly half reused needles.48

People who inject drugs are also associated with other high-risk behaviours such as sex work and unsafe sexual practices. For example, the same study reported fewer than half of those surveyed used a condom during their last sexual encounter.49

Children and orphans

In 2018, an estimated 260,000 children (aged 0 to 14) were living with HIV in South Africa, 63% of whom were on treatment.50

New infections have declined among South African children, from 28,000 in 2010 to 14,000 in 2018.51This is mainly due to the success of prevention of mother-to-child transmission (PMTCT) programmes.52

As it stands, for every child initiated on to treatment, 1.4 are newly infected with HIV.53.

Children are also affected by HIV through the loss of family members. In South Africa more than 1.2 million children and adolescents (ages 0-17) have been orphaned by HIV and AIDS.54Orphans are particularly vulnerable to HIV because of economic and social insecurities; they are often at risk of being forced into sex, have sex in exchange for support, and typically become sexually active earlier than other children.55

South Africa’s National Strategic Plan (NSP) 2017-2022 aims to renew the focus on children, putting emphasis on eliminating new infections and building resilience in families.56

HIV testing and counselling (HTC) in South Africa

South Africa has made impressive progress in recent years in getting more people to test for HIV. In 2017, South Africa reached the first of the 90-90-90 targets, with 90% of people living with HIV aware

of their status, up from 85% in 2015.57

This progress follows the launch of two nationwide testing initiatives: the national HIV testing and counselling (HTC) campaign in 2010 and the HTC revitalisation strategy in 2013, which focused on getting people from the private sector, farms and higher education to test.58 Thanks to campaigns such as these, more than 10 million people in South Africa test for HIV every year.59

Yet the progress made in getting people to test has been uneven. In South Africa women are much more likely to test than men. This is partly because PMTCT programmes enable women to access HIV testing services during routine antenatal appointments.60

In addition, recent research has shown that men often see health facilities as being ‘women’s places’ and so feel that testing for HIV is non-masculine. Men also report worrying that queuing outside a testing facility will be taken as evidence that they are living with HIV, and talk of avoiding testing because they are ‘terrified’ of a positive result.61 As a result of the testing discrepancy between sexes, 93% of women living with HIV in 2018 were aware of their status compared to 88% of HIV-positive men.62

In South Africa links have also been made between an individual’s socio-economic background and the likelihood they will test for HIV. Those who have taken an HIV test and know their status are more likely to have a higher level of education, be employed, have accurate HIV knowledge and a higher perception of risk.63

Although rates of HIV testing are similar across provinces – ranging from 82% in Gauteng to 88.3% in KwaZulu-Natal – those living in rural areas are as much as two times less likely to have tested for HIV than those in urban areas.6465 The new NSP has identified closing these gaps as a key priority and plans on decentralising testing, so that more workplaces and community settings are able to provide HIV tests.66

South Africa is also rolling out self-testing on a wider scale.67 Initial trials have shown that 88% of those who refuse traditional testing accept the offer of HIV self-testing.68 A number of studies have found self-testing to be a preferable testing option among young people and people from key affected population groups, such as men who have sex with men.69 70

There are many people who want to test and who do not want to interface with the healthcare system. We believe the more people testing, the better. Let's get as many people to test as possible.71

CASE STUDY: The impact of HIV testing within churches

An HIV testing campaign conducted within South African churches successfully recruited 43% of the congregation for HIV testing on campaign days and was most successful at reaching men, particularly men who had never tested before.

Compared to women, an analysis of the intervention found HIV testing rates were significantly higher among men, with 52% of men getting tested compared to 40% of women. In addition, a higher proportion of men (35%) than women (18%) were also first-time testers.

This suggests religious leaders and churches in South Africa may be able to play an important role in increasing HIV diagnoses among those who normally avoid testing.72

HIV prevention programmes in South Africa

South Africa aims to reduce the annual number of new infections to under 100,000 by 2022.73

The government plans to achieve this by intensifying prevention efforts in the 27 districts that account for 82% of all people living with HIV and for the majority of new infections. It has also committed to achieving zero new infections due to mother-to-child transmission by 2022.74

In addition, the 2017-2022 South African National LGBTI HIV Plan commits to reaching 95% of people from the LGBTI community with HIV prevention and ensuring 90% of LGBTI people living with HIV know their status.75

A number of South Africa’s HIV prevention strategies being implemented to reach these targets are outlined below.

Prevention of mother-to-child transmission (PMTCT)

Over the past decade, South Africa has made great progress in reducing mother-to-child transmission of HIV, largely due to improvements in the choice of antiretroviral medicines and the widespread accessibility of its prevention of mother-to-child transmission (PMTCT) programme.76 The rate of mother-to-child transmission stood at 1.3% in 2017, down from 3.6% in 2011.77

In 2018, 88% of pregnant women were tested for HIV and 87% of those living with HIV received antiretroviral medicine to reduce the risk of MTCT. In the same year, 89% of infants exposed to HIV were tested within six weeks of birth.78 However, the number of children born with HIV is still relatively high at 14,000 in 2018.79

To achieve South Africa’s goal of zero transmissions from mother-to-child transmission by 2022, the country must focus on enabling mothers to adhere to treatment throughout breastfeeding as well as during pregnancy and birth.80

Maternal mortality is also declining but at a much slower rate. The previous national HIV strategy aimed to reduce maternal mortality by three quarters between 1990 and 2015, from 150 deaths per 100,000 live births to 38 per 100,000. However these targets weren’t met; the maternal mortality rate was reported at 119 per 100,000 in 2015 and 116.9 in 2017.8182

Condom use and distribution

In the most recent NSP, the South African National AIDs Council aimed to increase the number of male condoms distributed annually to 850 million by 2018.83 However, between 2016/17 and 2017/18 the number of male condoms distributed by the government decreased by more than 220 million.84

South Africa’s female condom programme is also one of the biggest and most established in the world, with over 26 million female condoms (also known as internal condoms) distributed in 2016.85 By 2022, the South African National AIDS Council hopes to increase this to 40 million.86

In regards to condom use, South Africa’s 2017 national HIV impact survey found around 56% of adults (ages 15-64) with two or more sexual partners in the last year reported using a condom the last time they had sex. Men and women aged between 25 and 49 had similar levels of condom use, at around 53%. Among young people (ages 15-24), 68% of young men with multiple partners reported using a condom the last time they had sex, compared to 47% of young women. In contrast, only 33% of older adults (ages 50-64) with multiple partners used condoms at last sex.87

Challenges remain in ensuring that condom programmes are able to serve all groups, particularly those with higher HIV risk. The new strategy will expand condom distribution, making them available at non-traditional outlets such as hair salons, petrol stations, shops, hotels, truck stops and brothels as well as secondary schools and non-traditional community settings.88

Voluntary medical male circumcision (VMMC)

In 2010, research emerged from sub-Saharan Africa suggesting that voluntary medical male circumcision (VMMC) can reduce the risk of female-to-male HIV transmission by up to 60%.89 This led the South African government to rapidly roll out a national VMMC programme, which aimed to reach 80% of HIV-negative men (4.3 million) by 2016.

However, this target has been missed. In 2017 around 32% of adult men (ages 15-64) were estimated to have been medically circumcised. The highest proportion of circumcisions have been carried out on young men (ages 15-24), with 43% undergoing VMMC.90

Despite being off-target, South Africa is continuing to increase the number of circumcisions. In 2018 more than 572,000 circumcisions were performed, compared to 485,500 in 2015.91 Across the country the VMMC programme has mostly been well received with 78% of women preferring their partner to be circumcised, according to the 2011 youth sex survey.92

Pre-exposure Prophylaxis (PrEP)

In December 2015 South Africa became the first country in sub-Saharan Africa to fully approve PrEP.

In 2019, it was estimated that between 23,000 and 24,000 people were using PrEP in ongoing and planned projects across South Africa.93 The 2017-2022 National Strategic Plan aims to expand this to begin 85,858 people from groups most affected by HIV on PrEP by 2022.94

In 2015, an initial trial of PrEP was conducted amongst South African women. Results showed an adherence rate of 76% among the trial population, demonstrating that women in South Africa were both able and willing to use PrEP.95 These results pave the way for the wider implementation of PrEP.

People ask me, 'How can you afford to implement new interventions?' and I always reply, 'How can we afford not to?' Once

you answer this question, you will find the way to work it out.

- Aaron Motsoaledi, South Africa’s Minister of Health96

A series of in-depth interviews with female sex workers in South Africa found many did not believe PrEP would be effective in preventing HIV. This attitude meant many sex workers did not come to a clinic to access PrEP despite being eligible, or were poor at adhering to PrEP once starting it. This study, one of the first to report real-world experiences of PrEP use among female sex workers outside a clinical setting, found that those who stopped taking PrEP had a low perception of their HIV risk, suggesting more education is needed about the benefits of PrEP.97

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HIV education

Despite their elevated risk of infection, many young people do not have comprehensive knowledge of how to prevent HIV. A study published in 2019, based on data from South Africa’s 2012 National HIV, Behaviour and Health Survey, found just 11% of young people questioned displayed 100% accurate knowledge of HIV, while 25% had 75% knowledge accuracy. Young people who were unemployed or living in rural locations were least likely to be knowledgeable about HIV, while those who were sexually active had better HIV knowledge than those who were not.98

Only 5% of schools were providing comprehensive sexuality education in South Africa in 2016, but over the next five years the government has committed to increasing this to 50% in high burden areas.99

Barriers to providing comprehensive sex education in schools include high drop-out rates, a shortage of teacher training, and resistance in schools because of the perceived sensitive nature of the subject matter.100

We need to be able to assist our learners to prevent and report incidents of violence and I think this more in-depth training will help. These topics are so important to the emotional, social and moral development of learners who need to feel equipped to make the right decisions in their lives.

- Sexuality teacher, Life Orientation Programme, South Africa

HIV awareness

A number of HIV awareness campaigns run in South Africa. These include:

loveLife

Founded in 1999, loveLife is best known for its 'ABC' billboard campaign, which promoted ‘abstinence, be faithful and condomise’ in the early years of the epidemic. However, the organisation has since turned its attention to breaking down the social and structural drivers of HIV among young people, including poverty and lack of opportunities. loveLife promotes the economic empowerment of young people, using a range of different communication techniques, including TV and Radio. loveLife’s radio programmes reached over 1 million young people in 2017. In addition, loveLife has worked in more than 2,700 schools, directly reaching more than 320,000 young people.101

Soul City Institute

The Soul City Institute is another NGO that focuses on health promotion in South Africa, most notably through TV and radio edutainment programmes. Soul City, the Institute’s flagship television show and one of South Africa’s most watched programmes, mirrors the social, health and development challenges faced by poor communities. The fourth series dealt with the issue of gender based violence, with an accompanying information booklet created in partnership with the National Network on Violence Against Women (NNVAW). Building on the popularity and emotions generated by the storyline, NNVAW coordinated an extensive social mobilisation campaign, which helped pressurise the government to introduce new legislation on domestic violence.102

Also popular is the Soul Buddyz series, a multimedia vehicle across television, radio and print for children aged between 8 and 12, designed to promote their health and wellbeing.103

MTV Shuga

MTV Shuga is a mass-media behaviour-change campaign that aims to improve the sexual and reproductive health of young people. It began in 2009 and centres around an awarding-winning TV series, supported by radio, digital, social media and mobile elements. Previous series have been set in Kenya and Nigeria.

The most recent series of MTV Shuga, which aired in 2019, was set in South Africa.104 A previous series, also set in the country, aired in 2016 and featured the show’s first gay character. 105

Evaluations of previous series have found that viewers of MTV Shuga were more likely to get tested for HIV and the airing of the show was associated with reduced chlamydia infections in young women.106

Antiretroviral treatment (ART) availability in South Africa

South Africa has the largest ART programme in the world. In 2018, UNAIDS reported that 4.8 million people were receiving treatment in South Africa. This equates to 62% of people living with HIV in the country.107

South Africa’s ART services have undergone dramatic expansion in recent years, in keeping with the World Health Organization’s (WHO) changing guidelines. In 2016, South Africa implemented the ‘test and treat’ strategy, making everyone with a positive diagnosis eligible for treatment regardless of how advanced HIV is in their body. This has seen the number of people eligible for treatment more than double in recent years: from 3.39 million in 2015 to 7.7 million people in 2018.108

Initially many were concerned that the dramatic scale-up of ART would overstretch clinics and services and reduce the quality of care. However, evidence suggests the increase in ART provision has had no significant effect on patient outcomes, either in terms of either AIDS-related deaths or illnesses.109

Studies have, however, highlighted other issues around treatment provision. They found that men were more likely to start ART at an older age and later stage of infection and had almost double the mortality rate than that of women. In 2018, 65% of women living with HIV were accessing treatment, compared to 56% of HIV positive men.110 This again highlights the need to engage men in testing services and ensure that they are linked to treatment.111

There is less of a discrepancy between men and women in regards to viral suppression. In 2018, 87% of people living with HIV who were on treatment were virally suppressed (89% of HIV positive women, compared to 85% of HIV positive men on treatment). However, due to the lack of men testing for HIV, this equates to just 47% of men and 58% of women living with HIV overall being virally suppressed.112

There is also an issue with retaining people on HIV treatment. In 2018, official data suggested just 57% of people were still in HIV care after 12 months. However, a study released in the same year suggests migration and people moving to other clinics might mean the attrition rate has been overestimated.113

Retention in care for children living with HIV is of particular concern. Despite PMTCT coverage and early infant diagnosis being relatively good, many children diagnosed with HIV are late into care and there are poor viral suppression rates.114

Linked to the issue of adherence is the rising prevalence of drug resistant HIV. An analysis of HIV drug resistance in people who had not been on treatment before found prevalence was below 5% until 2009 but then began increasing, peaking at 11.9% in 2015. These findings support the South African government’s decision in 2017 to modify the standard first-line ART regimen it offers to a Dolutegravir-containing fixed dose combination, which has been found to have fewer side effects. However, it also highlights the need for broader action to prevent the further emergence and transmission of drug-resistant HIV.115

Now we have moved to 'test and treat', the disparity of health between rich and poor is smaller. Although there is still a lot of stigma, the normalisation of treatment is helping people talk differently about HIV. The main challenge around treatment is stopping people from defaulting, either because pastors and churches suggest that they are not needed or because people cannot cope with poor side effects including depressive symptoms.

– Sibongile Tshabalala, Chairperson of the Treatment Action Campaign, commenting on the current

challenges around treatment in an interview with Avert.

Civil society's role in South Africa

In March 2015 an estimated 136,453 civil society organisations were working in the South African HIV response. In 2017 a new civil society forum was created to provide a platform for civil society and government to work together in the HIV response. 116

One of the most visible civil societies is the Treatment Action Campaign (TAC), formed in 1998. TAC has been a driving force in the South African response, promoting access to HIV treatment and care for all South Africans. TAC’s first major success came in 2002, with the Constitutional Court ruling that the South African government must provide ARVs to prevent mother-to child-transmission.117 The organisation is currently campaigning to improve and strengthen the healthcare system.118

Funding is a major issue facing many civil society organisations. Drops in external funding are making civil society organisations more dependent on financing from the government. While domestic funding is a more sustainable model, the shift has increased competition amongst organisations, and is seen by some as undermining their ability to challenge government policy in their work.119

HIV and tuberculosis (TB) in South Africa

South Africa has the world's sixth largest tuberculosis (TB) epidemic, and the disease is the leading cause of death in the country.120 South Africa’s HIV epidemic fuels the TB epidemic because people living with HIV are at a far higher risk of developing TB due to weakened immune systems. It is estimated that 60% of people living with HIV in South Africa are also co-infected with TB. In 2017 there were 193,000 new cases of TB among people living with HIV and 56,000 people living with HIV died due to a TB-related illness.121

In light of this, the South African National AIDS council combined the HIV and STI strategy with the national TB strategy to improve the integration of these two services. One of the aims of this strategy is to get more people living with HIV on isoniazid preventative therapy (IPT), a preventative medicine for TB.122 But as of 2017, only around half of people living with HIV in the country (52.9%) had access to IPT.123

The TB treatment success rate has improved in recent years, and stood at 83% in 2016.124

We cannot fight AIDS unless we do much more to fight TB.

- Nelson Mandela125

Funding for HIV in South Africa

South Africa largely funds its HIV programmes domestically, only receiving 12% of its HIV funding from external sources in 2018.126

South Africa’s National Strategic HIV, STI and TB Plan 2017-2022 is predicted to cost 207 billion rand in total. In light of this, in 2017 the South African government increased its budget allocation for HIV and AIDS, despite general budget reductions across the health sector.127

Still the South African National AIDS Council has predicted there will be some funding gaps. However, it is unclear how severe these will be, especially since there is a level of uncertainty around the availability of international funding for HIV and AIDS in the coming years.128

An encouraging sign came with the announcement from the US President’s Emergency for AIDS Relief (PEPFAR) that it will be providing 10 billion rand in funding (US$732 million) for 2019/2020, an increase from 2018 and 2017 funding levels.129

Treatment and care make up the biggest proportion of the costs, outlined in the NSP. In recent years South Africa has been working hard to negotiate better prices for ARVs, having previously been paying more than most other low- and middle-income countries despite having the world’s largest procurement programme.130 In September 2017 UNAIDS announced a breakthrough pricing agreement, which will allow the single pill regime of Dolutegravir to be sold at around $75 per person per year in south Africa and 90 other low- and middle-income countries.131

The future of HIV in South Africa

South Africa has made great strides in tackling its HIV epidemic in recent years and now has the biggest HIV treatment programme in the world. Moreover, these efforts are now largely funded from South Africa's own resources.

HIV prevention initiatives are having a particularly significant impact on mother-to-child transmission rates, which are falling dramatically. New HIV infections overall have fallen by half in the last decade, however there are still too many. For certain population groups, such as transgender women, a lack of data is hampering HIV prevention efforts. In addition, the criminalisation of at-risk groups such as sex workers, and widespread gender inequity – particularly gender-based violence – continues to fuel transmission.

While the short term financing of South Africa's HIV epidemic is secure, in the longer term, the government needs to explore other strategies in order to sustain and expand its progress.

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25. Ibid.

26. Ibid.

27. Ibid.

28. South African National AIDS Council (SANAC) (2017) ‘Let our Actions Count: National Strategic Plan 2017-2022’ [pdf]
29. UNAIDS (2017) 'Ending AIDS: Progress towards 90-90-90 targets' [pdf]

30. Coetzee J, Jewkes R, Gray GE (2017) ‘Cross-sectional study of female sex workers in Soweto, South Africa: Factors associated with HIV infection’, PLoS ONE, Volume 12, Issue 10, e0184775.

31. South African National AIDS Council (SANAC) (2017) ‘The South African National Sex Worker HIV Plan 2016-2019’ [pdf]
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33. Ibid.

34. UNAIDS 'AIDSinfo' (accessed September 2019)

35. South Africa National AIDS Council (2017) ‘The South African National LGBTI HIV Plan,

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36. South Africa National AIDS Council (2017) ‘The South African National LGBTI HIV Plan, 2017-2022’, p.15. [pdf]
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39. South Africa National AIDS Council (2017) ‘The South African National LGBTI HIV Plan,

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40. Ibid.

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45. Ibid.

46. Scheibe A et al. (2019) ‘Still left behind: Using programmatic data to assess harm reduction service coverage and HIV treatment cascades for people who inject drugs in five South African cities’, 10th International AIDS Society Conference on HIV Science (IAS 2019), Mexico City, session, MOAC0103, 2019.
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49. Ibid.

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