The Politics and Epidemiology of Transition: PEPFAR and AIDS in South Africa

Abstract

As South Africa (SA) and the US craft a new political relationship on AIDS, the stakes of success have never been higher. SA remains the country with the largest HIV epidemic in the world; yet, new science shows that an aggressive response could enable an epidemiologic transition, cutting HIV incidence and substantially improving overall population mortality. One of the most effective foreign aid efforts in history, the US President’s Emergency Plan for AIDS Relief (PEPFAR) SA, now is managing the largest “transition” of a global health program — withdrawing direct staff and funding for the treatment of hundreds of thousands of HIV-positive patients as the SA public sector takes over.

Recent commentary has painted an optimistic picture of the transition and “country ownership” in SA. In important ways, however, the politics are outpacing effective health policy and the accelerated process is undermining the prospects for “getting to zero.” Thousands of patients and the health system have experienced significant disruption. PEPFAR should take urgent steps to ensure that the transition does not undermine hard-fought gains in SA. More broadly, the SA experience has important lessons for the future of aid to fight global HIV.

Keywords: AIDS, Politics, South Africa