On this World Aids Day, South Africa still has the world’s largest HIV burden, with 7.7 million people currently living with the virus amid a shrinking HIV budget.
Following this year’s medium term budget policy statement (MTBPS), civil society organisations have raised concerns that diminished funding to provinces, both through the equitable share and through conditional grants, may result in crucial HIV/Aids targets being missed.
National Treasury has also failed to provide clear information or concrete plans to assist provinces to meet their HIV programme targets amid these budget constraints. The February national budget tabled by former minister of finance Tito Mboweni saw the baseline of the conditional grant for HIV reduced by a total of R5.8 billion over the next three years. No additional funding was allocated in the MTBPS for next year.
Concerns over the decline in HIV financing and the effect on the health department’s ability to deliver services effectively can be traced back to 2017, when the UNAids special advisor for resources tracking and finances, Jose-Antonio Izazola Licea, warned that “with donor support plateauing and expected to decline, the success of South Africa’s HIV programme will rest on its ability to mobilise and manage a sustainable flow of domestic resources.”
The impact of the HIV conditional grant
Over the past decade, South Africa has made progress in tackling the HIV epidemic, channelling critical investments through the HIV conditional grant. In collaboration with developmental partners and agencies including the Global Fund to Fight Aids, Tuberculosis and Malaria and the US President’s Emergency Plan for Aids Relief (Pepfar), great strides have been made with the UNAID’s 90-90-90 treatment targets.
South Africa adopted these targets in its National Strategic Plan for HIV, TB and STIs 2017-2022. According to the latest outputs from the Thembisa model, a mathematical model of South Africa’s HIV epidemic, this year, 92.4% of people living with HIV knew their status; 71.9% of those diagnosed were on HIV treatment, and 91.2% of those on treatment were virally suppressed.
Further, connected to the progress of the country’s antiretroviral therapy programme and HIV prevention tactics, life expectancy for people living with HIV has improved from a life expectancy at birth of 53.5 years in 2004 to 66.6 years in 2020.
To deal with the underlying causes of HIV incidence we need to consider how best to overcome gaps and push progress, including through funding allocations.
Addressing only the symptom, or the cause?
Health activists have called for closer interrogation of the effectiveness of the HIV conditional grant.
Even before the Covid-19 disruptions to the HIV programme, South Africa faced social, economic, gender and health-based challenges including high rates of teenage pregnancy, gender-based violence, high rates of sex work, lack of quality education, widespread poverty, inequality and unemployment.
These challenges are underpinned and exacerbated by poor policy choices and negligible resource allocation to the social and structural determinants of health that give rise to new infections, low treatment uptake, and low adherence rates among key population groups.
Programmes for target populations must be supported
The Thembisa model shows that the highest incidence rates are among female sex workers and men who have sex with men (MSM). Despite efforts to provide condoms and pre-exposure prophylaxis (Prep) to female sex workers and some MSM, there is still low uptake and retention rates of these preventative interventions. The Thembisa model (version 4.3) estimated a Prep coverage rate of only 3% and 1% in female sex workers and MSM, respectively.
“These groups require special attention with respect to prevention and significantly increased access to treatment”, said former deputy director-general in the national department of health, Yogan Pillay.
Although in 2019, President Cyril Ramaphosa launched an HIV programme for sex workers and declared that “sex work is work”, female sex workers remain vulnerable to police harassment and stigma.
The relationship between sex work and HIV rates is an issue that a number of reports have drawn attention to. Sex work is a profession that is disproportionately practised by women who are driven by food insecurity and insecure living conditions. These women also face a higher risk of contraception-free sex and gender-based violence, so the need for the decriminalisation of sex work remains a pressing issue.
Roping in the basic education sector – the HIV/Aids life skills conditional grant
Tackling the effects of HIV is not something that the health sector can do alone. While the health sector has made great strides in testing and treatment of HIV, more needs to be done to prevent new infections, encourage adherence to treatment, educate communities, and counter stigma and discrimination.
Government has flagged the basic education sector as a crucial role-player in these HIV prevention efforts. The HIV/Aids life skills conditional grant funds educational initiatives within schools related to HIV. Some of the strategic goals of the conditional grant include “addressing social and structural drivers of HIV” and to “contribute to preventing new HIV, STIs, and TB infections”. But what is concerning is how the HIV/Aids life skills conditional grant was slashed by R60 million in the June 2020 supplementary budget.
The grant was cut further when R40 million of it was reprioritised for Covid-19 information at schools, which meant less money for training teachers to deliver comprehensive sexuality education (CSE). Accounting for this reduction, the supplementary budget review explained that “all planned training sessions for over 20 000 educators [were] cancelled” last year.
Research from around the world, including South Africa, has found that effective CSE programmes delivered by well-trained teachers result in improved knowledge about HIV and pregnancy prevention; decreased sexual risk-taking; the prevention of learners having multiple concurrent sexual partners; improved attitudes towards sexual refusal and condom use and delayed sexual debut.
Despite the clear need to strengthen South Africa’s CSE programme as part of efforts to reduce new HIV infections and address the attitudes and behaviours that lead to gender-based-violence, this does not seem to be a funding priority for government.
The R100 million lost to the HIV/Aids life skills conditional grant was not recovered in the February 2021 budget, and the new Finance Minister Enoch Godongwana’s MTBPS reduced the conditional grant by R860 000 in nominal terms in the 2022/2023 financial year.
Providing CSE in schools and training teachers to deliver this curriculum will be vital if South Africa wants to strengthen the prevention arm of its HIV programme. It is important that the HIV/Aids life skills grant, as one of the key pieces of a broader HIV prevention strategy, be supported and strengthened.
The HIV conditional grant also remains a vital funding stream for the prevention and treatment of HIV, but its ability to meet the various challenges faced in our HIV response is under threat. Cuts to the grant and a lack of investment in comprehensive sexuality education and in specialised services for key populations undermine the possibility of “an end to Aids” – and to a future where no one is left behind.
Mbali Baduza is legal researcher in the health rights programme at Section27 and Julia Chaskalson is a research and advocacy officer at Section27.
This article was produced by Spotlight – health journalism in the public interest.