US Reverses Course on PEPFAR Cuts In South Africa as Demanded by Activists

The U.S. government has formally announced it is abandoning its previous policy of "transitioning" out of funding for South Africa's HIV treatment program--pledging $410 million next year to support the SA AIDS response.  This reflects a reversal of the Partnership Framework policy that activists in South Africa and the U.S. have sharply criticized--highlighted in the Health GAP report "The Politics of Transition" and analysis by TAC/MSF/Section 27.

Many will remember that the early years of the Obama administration proved a tumultuous time for global AIDS programs. Funding did not match the expansion promised by candidate Obama and some of the President's advisors openly questioned whether expanding HIV treatment was “cost effective.” This time also coincided with the economic rise of the BRICS--leading some within the administration's foreign policy arms to question continued funding to middle-income South Africa. This analysis was always deeply flawed--which activists have pointed out from the start.

The decision was therefore made to "transition" PEPFAR out of supporting South Africa's HIV treatment program. The PEPFAR Partnership Framework with South Africa announced this plan to cut funding to half of what it was when Obama took office by next year and to move out of supporting HIV treatment programs. 

A chorus of activists pushed back against this--both because of the poor planning and implementation of "transition" and for the completely unrealistic expectations that South Africa, with the largest burden of HIV on the planet, would have sufficient resources to fully fund the pace of treatment scale up needed to gain epidemiological control. The South African government, after an extended campaign by the Treatment Action Campaign and others, has announced an aggressive roll out of HIV treatment and dramatic rise in domestic AIDS funding. Yet reaching 6 million people living with HIV while transforming the post-apartheid health system, challenged by far more than just HIV, is a herculean task.

As researchers and activists many of us have argued that the U.S. was confusing the necessary move toward respecting South African ownership and authority over the AIDS response alongside the important move from parallel systems into a public-sector-led response with the idea that it was an appropriate time for a rapid exit of donor funding.
In recent years it has become clear to the administration that it could not both promise to support an "AIDS free generation" and pull out of support for the largest epidemic--and funding has not been cut as planned.  We're very glad, therefore, to see this officially stated as policy going forward. 
Now that this decision has been made, PEPFAR needs to take a hard look at what it is funding in South Africa and how that fits with the realities of the epidemic and the needs of communities in 2016: 
  • how is PEFPAR funding directly supporting the South African public sector, which is crumbling in many of the highest HIV-prevalence provinces?
  • what portion funding is actually reaching front-line services?
  • how can PEPFAR better support the programs needed to make maximal use of treatment for all--including major investments currently missing in treatment literacy and adherence support?
  • how can PEPFAR directly support rapid community health workforce expansion in collaboration with the Ministry of Health's plans?

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