South Africa on 15 July submitted a joint HIV/TB concept note for some $380.5 million in funding, more than half of which is to support prevention interventions specifically targeting key populations including young women and girls, men who have sex with men and people living in disease hot spots. Of this, $142.2 million constitutes an above-allocation request.
The proposed slate of interventions would position the Global Fund as the single biggest investor in key populations programming in the country, complementing the government’s annual budget for its High Transmission Areas program ($9.3 million/year), and the PEPFAR/USAID budget for DREAMS, inmates and other key populations ($51.5 million/year).
The remainder of the funding would support improvements in quality of care through high-impact interventions that focus on gender-based violence, stigma, treatment adherence and strengthening health and community systems, supporting multi-sectoral work by the government of South Africa.
South Africa embraced good practice for an inclusive country dialogue. Health Minister Aaron Motsoaledi joined a prioritization discussion at the CCM in March, and consultations included a wide range of constituencies. A series of smaller technical consultations was led by South African National AIDS Council (SANAC): a coordination and oversight body that deliberately does not take funding from the Global Fund. The CCM also published a Civil Society Priorities Charter, as well as a Key Populations Supplement: important guiding documents for the prioritized interventions in the concept note.
Brian Kanyemba, a civil society representative for the LGBTI communities in the country coordinating mechanism (CCM), drove the development of the Key Populations Supplement.
“Key populations are too often ignored and stigmatized, or patronized in trials and studies, rather than being truly engaged in solutions to the epidemic,” said Kanyemba.
While the final concept note was indubitably strengthened by the extensive consultations, it bore a high cost: three times higher than development of proposals under the rounds-based system.
The decision to focus on key populations and specific geographic hot spots was informed by emerging evidence supporting a more targeted approach to HIV and TB resource distribution in South Africa. Preliminary results from a first geospatial mapping show that there are clear hot spots and cold spots within provinces, and that a district-based approach that strategically saturates hyper-endemic hot spots (which could be as focused as 16km2 sub-districts) is a more efficient method.
Preliminary results from South Africa’s recent Key Populations Size Estimate further highlight geographic areas with higher numbers of certain vulnerable people. This is the first survey estimating the distribution of transmen as well as transwomen in South Africa, providing important data on where efforts should be focused to reach these groups.
Other recent evidence from South Africa’s People Living with HIV Stigma Index, launched at the South African AIDS Conference in Durban in June 2015, provided strong rationale for the inclusion of this critical enabler in the concept note. The results from the survey in 18 districts show that 43% of the more than 10,000 respondents reported having feelings of internalized stigma, and 31% blamed themselves for their HIV status. Feelings of being unclean or dirty in relationship to a TB diagnosis were reported by 27% of survey respondents.
The country’s recent Investment Case also revealed which activities were the most cost-effective. Adherence clubs emerged as one of the only money-saving interventions, with the potential to reduce HIV treatment spending by 13%. Further, the Investment Case highlighted the need for South Africa to dramatically increase funding for antiretroviral therapy (ART). Government is bearing an increasing proportion of the cost for ART, with Global Fund support filling the gap. Supporting the request for ART are also requests for strategic investments in health systems strengthening, including procurement and supply chain management, and monitoring and evaluation. There is also the intention to introduce a unique patient identifier system, to improve treatment monitoring.
In addition to offering a comprehensive package of services to key populations in targeted districts, South Africa has also presented innovative activities for consideration for incentive funding, including mobile smartphone applications and sustainable finance mechanisms.
The broad slate of innovative and highly targeted interventions are not without potential hurdles. There are eight principal recipients (PRs) proposed in the concept note, which poses a significant coordination challenge. To mitigate this, there has been concerted effort in the early stages of planning to clearly articulate PR responsibilities by geographic location and by expertise. The country submitted prioritization maps as an attachment to the concept note, which delineate PR accountability for each program element in each priority district, by implementing partner.
There are also challenges associated with the sheer size of the HIV and TB epidemics in South Africa, which add an element of risk to the success of most interventions. South Africa is home to the greatest number of people living with HIV globally (at 6.4 million people), and has the third largest TB burden (next to India and China). The country has set ambitious targets, aiming to screen nearly 7 million people for TB in the next year and have 7.5 million people on ART by 2019.
“The resulting concept note is a well-balanced proposal that supports the very ambitious treatment program that has made South Africa a world leader in the AIDS response,” said Dr. Fareed Abdullah, CEO of SANAC. “The program also scales up interventions for previously neglected key populations such as sex workers, men who have sex with men, transgender women and men, people who inject drugs and prison inmates, to levels that will have a national impact."