Reflections on the U.S.-South African HIV/AIDS Relationship

J. Stephen Morrison
Senior Vice President, CSIS & Director, Global Health Policy Center at CSIS

The story of US engagement in South Africa to battle HIV/AIDS over the past decade is one of strategic choice, sustained commitment, and significant human impact, matched by recent strong action by the South African government to assert its leadership in reversing the course of its AIDS epidemic.  There are persistent problems, most significantly the limited progress in preventing new HIV infections and the enduring challenges of overcoming South Africa’s skills and management deficits. But there is much for which Americans and South Africans should be very proud.

The story unfolding today is of a delicate, complex transition in lead responsibilities – from the United States to South Africa -- that is highly fraught with risks.

I and several colleagues visited South Africa in August to examine this change in Pretoria, Johannesburg and KwaZulu Natal, the latter province the epicenter of the global HIV and TB epidemics. Our core conclusion: special care and determined U.S. and South African commitment are essential to ensure a workable transition and avoid a costly mess.   If the United States stays the course, preserves momentum and manages in a disciplined way the multiple tough pressures that are emerging, it can build a model of foreign assistance success. The stakes are considerable, both for U.S. foreign policy and U.S. global health engagement. South Africa matters significantly to U.S. national interests, and the U.S. health investment in South Africa is the centerpiece of the US bilateral relationship and is the single largest U.S. commitment of its kind anywhere in the world. The outcomes in South Africa in the coming few years will matter to U.S. health engagement across many other key partner countries.

In 2003, when President Bush launched the historic five-year $15 billion President's Emergency Plan for AIDS Relief (PEPFAR), his administration made the strategic decision to invest on a massive scale in South Africa, despite the errant policies and active hostility of then President Thabo Mbeki.  The logic was simple and compelling: South Africa was the epicenter of the global epidemic, and on moral, public health and stability grounds South Africa had to be a priority. Over the next six years, the U.S. investment exceeded $2.7 billion, underwrote treatment for a million persons living with HIV/AIDS, saved and enhanced countless lives, and preserved hope. There was little choice but to erect treatment, care and prevention programs through stealth, largely outside South African government channels, delivered overwhelmingly through non-governmental (NGO) entities. The U.S. investment earned popular good will and gratitude, even in the face of enduring suspicion and anti-Americanism within South Africa’s political class. Through this vast, sustained U.S. commitment at this critical phase in South Africa’s burgeoning epidemic, a full-blown catastrophe was averted.   

Since coming to power in late 2008, the Zuma government has embraced robust, sound HIV/AIDS policies. It has sharply increased the government’s budgetary commitments, to the point where the U.S. share (over $500 million in this current year) has dropped from 60-65% of total commitments to 30-35%. 1.7 million persons are today on treatment, and that number is projected to rise to 3 million by 2014. Perhaps most dramatic, the South African government has made very clear that it is capable and committed to carry the lion’s share of present and future costs. It has also acknowledged that its health infrastructure faces serious morale, capacity and performance problems that have to be addressed if South Africa is to assume greater direct HIV/AIDS service delivery responsibilities at the local level.

This is an emerging story of a successful handoff. There is consensus that the Obama administration is transitioning from emergency mode to a long-term sustainable approach, and will shift funding away from NGO-delivered services and give priority to directly strengthening the South African government’s human and management capacity. Over the next several years the United States can and should scale down its financial commitments as South Africa increases its own domestic contributions.

But this delicate complex transition carries considerable risks: of a disruption of vital health services; of loud and potentially damaging criticism that the United States is ‘abandoning’ South Africans, fueled perhaps by NGOs on the losing end of these changes; and of a breakdown of essential trust and cooperation between U.S. and South African authorities. It is a transition that will be exceedingly complex: over the next several years, we are likely to see new hybrid institutions that blend NGO and the health ministry into new service arrangements. Negotiating to that point will be very difficult.

There are five key steps that the United States can take, in close partnership with South Africa, to reduce these risks and raise the prospects of success.

Get the facts out.  There is considerable frustration within the South African government over the lack of transparency by the United States in accounting for its total PEPFAR investment and how the money is currently spent. Clearly mapping U.S. flows, and sharing data, are essential next steps.

Strengthen the US-South African negotiating teams.  The United States has not had a coherent, senior-level team at the table. A similar criticism can be leveled at the South African government. A high-level, structured planning and negotiation process should be accelerated at both the capital and provincial levels. Very careful sustained action at the provincial levels and below is needed to tailor plans to the variable demands across different local areas.

Outline a five year plan. The sooner the United States explicitly spells out the concrete budgetary targets for an orderly five year transition and phase-down, the easier it will be to begin implementation planning in earnest. That should include a clear upfront statement that the end goal is not a termination of U.S. support. Rather, the United States should signal its intention to remain committed beyond 2016, in the range of $100-200m per annum, to support prevention efforts and critical technical and training needs. In the midst of the current U.S. budget environment, it will be critical also to cultivate bipartisan support within the U.S. Congress.

Have an effective communications strategy. Both the United States and South Africa have to communicate better to key audiences in both countries why and how this transition is to unfold. In the absence of an effective communications strategy, the field will almost certainly be dominated by tension and noise.

Elevate prevention as a strategic priority. Despite promising movement on male medical circumcision and prevention of mother- to- child transmission of HIV, prevention efforts are lagging far behind in South Africa. The U.S. needs to step up its prevention efforts, recognizing that many areas of South Africa are still facing a dire emergency with rates of new HIV infections outpacing patients placed on treatment. The United States should consciously and systematically build prevention into the 5-year transition strategy, and commit itself to breaking the arc of new infections.

The U.S. historic engagement in South Africa to combat HIV/AIDS has become the central dimension of the U.S.-South Africa bilateral relationship. It has been ongoing for almost a decade, generated significant results, and should be a source of considerable pride among Americans and South Africans. Under the Zuma and Obama administration, the relationship is undergoing promising, fundamental changes that require a new, updated vision that can carry forward progress in smart, predictable ways over the next five years and beyond.

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