Special Report on the State of HIV/AIDS in South Africa - Lessons for Kenya

South Africa’s (SA) leading experts analyze the current status of HIV/AIDS and make bold recommendations for the future if SA is to reach its 2015 targets . The short, well written paper reviews current practice in prevention and treatment.  The paper stresses the need for a “focus on fundamentals and leadership in order to change the trajectory of the epidemic”.

The picture the report paints is blunt but appears realistic:

Despite this recent spate of encouraging news, the South African epidemic remains as daunting as ever. Prevention interventions have failed to gain traction with between 350,000 and 500,000 new infections still occurring annually. Even under the most optimistic of projections, about 5 million more South Africans will become HIV infected over the next two decades – roughly the number infected today. Even with the anticipated domestic spending increases, just 2.1 million of the more than 3 million eligible patients will have access to treatment by 2013.

The authors leave no doubt, that the current HIV/AIDS strategies need to be profoundly reviewed:

“The current curative, facility-based, hospital- and staff-intensive model of health care will never be able to address the needs and burden associated with HIV. There are too few doctors, nurses and other essential assets, and the system does not effectively reach rural populations. Simple mathematics reveals that management of more than 5 million people on a chronic basis dependent on fixed facilities and highly specialized staff is logistically untenable and would likely cannibalize the entire health budget.”

The report is also reviewing issues related to cost and financing and sustainability.

“There have been a number of attempts to project resource needs, most notably for the recent aids2031 project. This project modeled three possible scenarios, all of which showed costs rising rapidly growing from ZAR10-15 billion (US$ 1.3-2.0 billion) during 2007-2009 to ZAR30-37 billion (US$ 4.0-4.9 billion) by 2015-16. The majority of costs (60-70 percent) are for treatment – but these estimates could be reduced through more efficient government procurement practices, and by lower unit costs of labor and other inputs if South Africa adopts more community-based models for delivering ART. This anticipated two- to three-fold increase in program costs as numbers on treatment increase from 1 million to 3 million, will put considerable pressure on the government and the South African economy if it is to come from domestic resources.”

While SA’s prevalence (20%)  is almost three times  that of Kenya, the report contains a number of issues that appear relevant for the design of HIV/AIDS response in Kenya. Of particular relevance  for the work of GTZ and our partners are the findings and recommendations on Prevention of Mother- Child Transmission (PMTCT). PMTCT is SA’s area  of success:

Prevention of mother-to-child transmission (PMTCT) is one of the few bright spots in an otherwise bleak prevention landscape. Recent estimates indicate that nearly two-thirds of women in need of PMTCT services in South Africa received them in 2008, up sharply over previous years.

However, important challenges remain and they sound quite familiar when comparing with Kenya:

Perhaps the biggest challenge in PMTCT is what experts call the “PMTCT cascade,” referring to patient attrition at each step along the service continuum. …  Reasons for the cascade include human resource and infrastructural inadequacies (i.e. laboratory access), disaggregated services resulting in multiple clinic trips for patients and high out-of-pocket costs, poor health information, and a lack of community-based support services.

The authors conclude:

In order to sustain the current (PMTCT) momentum, issues of access, patient retention, and capacity must be addressed. First, all facilities that manage pregnant women must offer HAART. …

Other priorities include treatment throughout the course of breastfeeding, either as extended daily nevirapine for babies or HAART for mothers, in order to prevent post-natal transmission. And finally, interventions to drive demand for antenatal services – social marketing and education campaigns – are needed to bring in more women during their first trimester for timely testing and treatment initiation.

German Development Cooperation through GTZ has for years been supporting PMTCT in various districts of Kenya. GTZ also supports the strengthening of leadership, management and quality of care in selected health facilities with a particular focus on Sexual and Reproductive Health and Gender - Based Violence.