On 5 April 2016, GFO reported that $630 million in funding was approved by the Board in March. Below, we provide details on the award to South Africa. (See separate GFO article on details of the awards to several other countries.)
South Africa was awarded $314.5 million in TB/HIV grants to be implemented by eight principal recipients. The Board approved this amount based on the recommendation of its Grant Approvals Committee (GAC). Of the total amount approved, $49.8 million was an incentive funding award.
The goals of the program, as reflected in the current National Strategic Plan, are:
- to reduce new HIV infections by at least 50% using combination prevention approaches;
- to initiate at least 80% of eligible patients on ART, with 70% alive and on treatment five years after initiation;
- to reduce the number of new TB infections and deaths from TB by 50%;
- to ensure an enabling and accessible legal framework that protects and promotes human rights in order to support implementation of the national strategic plan; and
- to reduce self-reported stigma related to HIV and TB by at least 50%.
South Africa is home to the largest and fastest growing HIV epidemic in the world. There are an estimated 6.8 million people living with HIV and approximately 400,000 new infections occurring each year, according to the Human Sciences Research Council household survey. South Africa also has the fourth largest TB burden (after India, China, and Indonesia) and the highest number of people co-infected with TB and HIV of any country in the world.
Global Fund investment makes up a small proportion of total TB and HIV spending in South Africa – approximately 5%. The majority of the national response is funded by the government.
The activities under South Africa’s new Global Fund grants will focus on key populations and high-impact interventions, including a comprehensive package of integrated services to young women and girls, sex workers, men who have sex with men, transgender people, people who inject drugs, inmates, and people who live in informal settlements and peri-mining communities. In addition, activities will be implemented to address structural and environmental vulnerabilities and barriers to access, including gender-based violence and stigma. Finally, the program will focus on strengthening community and health systems to build capacity among civil society, promote treatment adherence and integrate data management and information systems.
As part of the grant, South Africa will be piloting some new and innovative approaches. Two PRs will be engaging a total of 30,000 young women aged 19-24 in a cash transfers program called “cash plus care.” The cash transfers will be conditional rewards-based incentives that serve to stimulate health-seeking behavior and behavior change to minimize the risk of HIV infection. The “care” element includes linking eligible young women to the appropriate health services as well as linking the young women and their families to social protection such as government welfare grants, as appropriate. Combining cash transfers with additional care components has been shown to be even more effective at reducing HIV incidence than programs which offer cash alone.
The funding approved for South Africa also includes programs based on innovative finance mechanisms. With catalytic investment from the Global Fund grant, a social impact bond will be introduced for prevention of HIV among sex workers. These bonds are contractual agreements whereby results-based donors only pay for delivery of agreed outcomes. This model provides upfront working capital to service providers while promoting accountability.
The aim of the social impact bonds is to leverage additional contributions from domestic and other sources to complement the government’s existing investment in HIV treatment and prevention programs for sex workers and their clients. In March 2016, South Africa launched a groundbreaking new National Sex Worker HIV Plan for 2016–2019. The Plan includes providing immediate antiretroviral treatment to all sex workers with HIV, regardless of CD4 count (sometimes called “test and treat”). In addition, at least 3,000 HIV-negative sex workers will be eligible to begin taking the combination antiretroviral pill Truvada as pre-exposure prophylaxis.
The cash transfer and social impact bond pilots are part of South Africa’s incentive funding award. Further scale-up of these activities is contingent upon adequate operations research to establish effectiveness, document lessons learned and evaluate impact of the proposed innovations.
The GAC also welcomed South Africa’s plans to expand the multi-drug-resistant tuberculosis (MDR-TB) program through a decentralized model. The grant will support the work of linkage officers who operate at the community level to improve TB surveillance and link MDR-TB patients to care. South Africa will also continue to roll out trainings on nurse-initiated treatment for MDR-TB and ensure that these nurses are supported to be able to provide these services.
According to Dr. Nevilene Slingers, Executive Manager of Donor Co-ordination at the South African National AIDS Council, “the Global Fund grant will continue to serve as a catalyst for the national TB program by supporting the funding for identified priorities as well as assisting with the costing and future planning of TB services based on the lessons learnt.”
The eight PRs who will implement the grants are: the National Department of Health; Right to Care; the Networking HIV/AIDS Community of South Africa; the Soul City Institute for Health and Development Communication; the Western Cape Department of Health; the KwaZulu-Natal Treasury; Kheth'Impilo; and the AIDS Foundation South Africa.
The last three of these PRs are new. The Global Fund country team for South Africa will closely monitor them to ensure that minimum requirements are met before the grant is signed, and that systems are functioning at a satisfactory level before the first disbursement is made. During the first six months of implementation, efforts will be made by all partners – the Global Fund country team, the local fund agent and the CCM secretariat – to ensure that these new PRs are supported to implement as quickly and effectively as possible.
Information for this article comes from the March 2016 report of the Secretariat’s Grant Approvals Committee to the Board (GF-B34-ER12-EDP16-17). This document is not available on the Fund’s website.