The HIV/AIDS epidemic is severely hampering South Africa’s ability to achieve several Millennium Development Goals (MDGs).
Nearly 800 South Africans died every day from AIDS-related illnesses in 2009 and more than 1,110 became newly infected daily, according to the South African Health Review (SAHR) 2010, which reveals the immense challenges in achieving the eight goals set by the UN in 2000.
The country has not achieved the goal of universal access to ARV treatment for all those who need it by 2010, despite having by far the largest antiretroviral (ARV) treatment programme in the world, and will struggle to achieve the MDG of halting and reversing the spread of HIV and tuberculosis (TB) by 2015.
An annual publication compiled by Health Systems Trust, an NGO focused on health systems research, the 2010 edition of the SAHR notes that far from achieving a 75 percent reduction in maternal mortality, the number of deaths resulting from pregnancy or childbirth has actually doubled in the past 20 years. Deaths of children under five have also been rising steadily, reaching a peak of 62 per 1,000 in 2007 and then levelling off, but not declining.
HIV is the major cause of the upward trajectory in maternal and child deaths in South Africa. Non-pregnancy related infections, most of them due to AIDS, accounted for nearly 44 percent of maternal mortality between 2005 and 2007, with HIV-positive women nearly 10 times more likely to die during pregnancy or childbirth than HIV-negative women.
South Africa recently changed its treatment guidelines to prioritize ARV treatment for HIV-positive pregnant women, a move that is expected to bring down maternal mortality if fully implemented.
The SAHR notes, however, that “guidelines do not, by themselves, produce access to essential quality care. Significant weaknesses in already overstretched ARV services should urgently be addressed in order to ensure that the increased number of eligible pregnant women actually access treatment.”
The authors add that, even without HIV, South Africa would probably not be on track to meet MDG5 because of the “unacceptably high” rate of deaths due to preventable obstetric causes.
Estimates of child mortality in South Africa are based on incomplete and often conflicting data, but it is clear that the HIV/AIDS epidemic reversed gains made before 1990. Looking at data from 2007, the most recent year with reliable figures, the SAHR notes that although the major causes of childhood deaths were neonatal problems, intestinal infections, acute respiratory infections and TB, in many cases the underlying causes of death were HIV, malnutrition and the loss of a mother. The data also revealed marked discrepancies between provinces, with the Western Cape recording 39 under-five deaths per 1,000 and the Free State 110 per 1,000.
Gap between policies and outcomes
Besides the MDGs, South Africa’s National Strategic Plan includes targets to halve new HIV infections and achieve 80 percent treatment coverage by 2011. Progress on these and the MDGs is difficult to monitor, however, because of the very limited availability of routine surveillance data.
“This disconnect between policies, implementation and evaluation is a critical shortcoming in the planning process and a major obstacle in achieving goals,” write the authors.
South Africa's TB epidemic, the fifth most severe in the world, has further set back efforts to achieve the MDGs. The TB disease burden almost doubled between 2001 and 2006 with an estimated 55 percent of patients co-infected with HIV. In the face of poor cure rates in some provinces, increased levels of multi-drug resistant TB and an over-burdened health system, the TB caseload continues to increase.
Since 2009, President Jacob Zuma has announced a number of policies and initiatives aimed at strengthening the government’s HIV/AIDS response, including a national HIV counselling and testing campaign and the decentralization of ARV treatment from doctors prescribing at hospitals to nurses providing the drugs at primary healthcare facilities. The amount of the national health budget allocated to HIV and AIDS has also increased from R4.3 billion (US$627 million) in 2008 to an estimated R5.3 billion ($774 million).
HIV incidence rates have dropped slightly but remain high, especially among young women. In rural KwaZulu-Natal, the province with the highest HIV burden, nearly 8 percent of women aged 15 to 49 years become infected per year between 2003 and 2005. Nationally, the HIV incidence rate was estimated at 1.3 percent in 2008.
Struggling to keep up
Given the rate of new infections it is not surprising that ARV treatment provision is struggling to keep up. More than one million people have been initiated on ARVs but this still only represents about 60 percent of adults and 38 percent of children who are eligible for the drugs, according to national treatment guidelines. Those guidelines do not reflect the latest recommendations by the World Health Organization (WHO) to initiate all patients at a higher CD4 count of 350 or less.
Writing in a local newspaper on 7 December, Rachel Cohen, head of mission in South Africa and Lesotho for international medical NGO, Médecins Sans Frontières (MSF), urged the government to implement the new WHO guidelines and translate the policy of allowing nurses to initiate ARVs into practice. Cohen said South Africa also needed a tender system to enable it to negotiate better prices for ARVs.
As well as better monitoring of HIV programmes, the SAHR authors call for each of South Africa's nine provinces to customize their HIV response and for HIV and TB services to be urgently integrated.
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