South Africa, home to the largest national HIV epidemic globally, is getting ready to begin implementation of a new Global Fund grant for the period 1 April 2019 to 31 March 2022 in the amount of $353.3 million. The funding request was submitted during Window 6 (on 6 August 2018) and was reviewed by the Technical Review Panel (TRP) in September 2018.

The TRP recommended South Africa’s funding request.

(Editor’s note: In this article, we report on the contents of the funding request, which at the time of publication was in the final stages of grant-making.)

The grant focuses on adolescent girls and young women (AGYW) as a top priority, with $84.6 million (23% of total allocation) requested for a combination prevention program targeting adolescents and youth aged 15 to 24 years, in and out of school. This is significant as it is the country with by far the largest Global Fund investment in adolescents and young people. “As South Africa is a country with the highest HIV burden among young girls and women, and also the biggest male-female disparity, for the Global Fund it is a critical country for addressing HIV among this population,” said Heather Doyle, Senior Coordinator, Gender, at the Global Fund.

The remainder of the allocation was requested for comprehensive prevention programs for sex workers and their clients, men who have sex with men, transgender people, and people who inject drugs and their partners ($105.7 million); tuberculosis ($60.0 million); TB/HIV ($4.6 million); and cross-cutting activities to strengthen resilient and sustainable systems for health ($97.3 million).

The adolescent girls and young women (AGYW) program will be implemented by three principle recipients: AIDS Foundation South Africa, NACOSA and Beyond Zero.  The grant aims to reach 166,000 girls and young women with a comprehensive package by year three of grant implementation.

In South Africa, girls and young women continue to face a disproportionate HIV burden throughout their life cycle. An alarming third of all new HIV infections in the country occur in AGYW aged 15 to 24 years – a staggering 1,674 cases each week. The Thembisa model – a mathematical model developed to describe different aspects of the South African HIV epidemic – suggests that HIV incidence peaks for 19-year-old girls at 2.74%. However, the age and gender disparity in new infections is greatest among 17-year-olds, the age at which girls are 8.7 times more likely to acquire HIV than their male peers (Figure 1).

Figure 1. HIV Incidence Among Adolescents and Young People in South Africa (2016)

A recent national survey found that social and structural factors exacerbate adolescent girls’ and young women’s vulnerability to HIV. In 2017, 35.8% of adolescent girls aged 15 to 19 had a male sexual partner who was 5 or more years older, and 37% of young women (aged 20 to 24) reported receiving money or gifts at last sex.

This intensified program will be delivered through five targeted service-delivery models:

1. High schools targeting girls and boys aged 15 to 19 years;
2. Tertiary institutions, universities and Technical Vocational Education and Training colleges targeting youth aged 20 to 24;
3. Safe spaces targeting adolescents and youth aged 15 to 24 years, out of school;
4. Communities, targeting norm change among men, boys, parents and caregivers;
5. Public-private mix (PPM) approach, targeting male sexual partners of girls and young women.

As a first, the program will be implemented in 360 of South Africa’s poorest high schools in eight of the country’s nine provinces – these are schools that are 100% dependent on government funding to operate and do not charge school fees to learners.

For sustainability, investments will be used to build the capacity of school leadership structures to support the implementation of the Department of Basic Education’s National Policy on HIV, STIs and TB – which allows condoms and other sexual and reproductive health (SRH) services to be available to learners at school. Furthermore, in support of the Department of Basic Education’s peer education program, tailored messages on HIV and SRH will be delivered through the popular television program, MTV Shuga.

In addition, twelve roving mobile clinical teams will provide selected HIV/TB/SRH services and make linkages to nearby school sites. The program will also offer homework support and dignity packs to encourage girls to stay in school. This is linked to overwhelming evidence that shows the likelihood of girls struggling to perform academically and dropping out of school is exacerbated by lack of access to menstrual products.

In universities and Technical Vocational Education and Training Colleges, funding has been requested to supplement HIV/TB/SRH services targeted at young women (aged 20 to 24) through existing university campus clinics, and the placement of 36 commodity vending machines. Each machine will be stocked with HIV self-screening kits, pregnancy tests, condoms, lubricants and menstrual health products to increase access to vital commodities. Early results from an ongoing Global Fund evaluation have flagged that lack of access to commodities, especially condoms, is a major barrier to HIV prevention among young women in this age group.

Targeted at out-of-school (including after school) girls and young women from 15 to 24, the grant will pilot the use of safe spaces as a new approach to delivering certain elements of the package. The safe-space model is geared to be a ‘one-stop-shop’ to deliver the full combination HIV-prevention package to girls and young women who may be in or out of school. This will build on emerging evidence and lessons from the USAID and PEPFAR funded DREAMS program.

At community level, the focus will be on embedding behavioral and structural interventions, particularly around gender-based violence prevention and gender-norm change. Legal literacy programs are expected to raise awareness and educate communities about laws regarding the age of consent to access SRH services and engage in sexual relations – a barrier identified in South Africa’s human rights baseline assessment.

A public-private mix approach is expected to reduce gender-related barriers to care and improve enrollment of working men into HIV services. Workplace programs aimed at taxi drivers and factory workers will offer convenient services, linking men to further care through capitation-based agreements (a healthcare plan which pays the healthcare provider a fixed amount of money for each patient it covers and manages appropriately) with specialized men’s health-service providers.

Pre-Exposure Prophylaxis roll-out for AGYW

Following the introduction in South Africa of Pre-Exposure Prophylaxis (PrEP) for sex workers in June 2016, then for men who have sex with men in April 2017, South Africa began PrEP rollout to adolescent girls and young women in March 2018. This was based on international guidelines to offer PrEP to all AGYW at risk of HIV infection. (WHO published new modules on PrEP, expanding them from MSM to other at-risk populations, including adolescents and youth, in July 2018.)

Offering PrEP to girls and young women is a new addition to the Global Fund program in South Africa and is informed by South Africa’s HIV/TB investment case – an ongoing analysis conducted by HE2RO – which has assessed (among other things) the impact and cost-effectiveness of PrEP implementation. It found the greatest impact of the introduction of oral PrEP on new HIV infections averted was among female adolescents aged 15 to 19. It concluded that investments in PrEP for this group can lead to cost efficiencies and eventual cost savings down the line. Funding has been requested to support the establishment of government PrEP sites and demand creation for the uptake of PrEP among girls and young women.

Matching Funds

South Africa was eligible to receive Global Fund matching funds for programs targeting AGYW for the amount of $5.0 million. The catalytic funding will be used to deliver economic empowerment interventions for young women and girls; development of a comprehensive, electronic referrals directory for AGYW; piloting HIV self-screening among male sexual partners of AGYW; and providing tailored psychosocial adherence support programs for adolescents living with HIV.

The scale of the Global Fund’s investment for AGYW to South Africa is in line with one of its key strategies, which is to support countries to use their own goal-setting methodologies in order to determine better HIV incidence projections for distinct age groups, particularly 15 to 24 years. In South Africa, this model is the She Conquers Campaign, an organizing framework to ensure alignment of all activities targeting girls and young women across sectors. Global Fund gender coordinator Doyle added that “it is critical for countries to have their own targets, effective strategies and financing plans towards long-term goals to reduce HIV incidence amongst girls and young women”.

Country Dialogue and Community Engagement  

The prioritization of girls and young women in South Africa’s funding request was the result of successful community engagement during country dialogue. With support from the Global Fund Community, Rights and Gender technical assistance program, the Civil Society Women’s Sector conducted a situational analysis of the needs of girls and young women and drafted a plan on how to engage girls and young women throughout the grant life-cycle.

“Without this support we would not have been able to have two extensive consultations with girls and young women in the Eastern Cape and Kwazulu-Natal provinces” said Khanyisa Dunjwe, Civil Society Leader of the Women’s Sector. She added that “we were able to really bring the voice of the girls and young women that these programs are meant to serve to be reflected in the funding request, including the need for practical skills development and building the leadership capacity of young women to be able to participate in Global Fund governance and oversight structures in the country”.

Final grant negotiations are nearly completed, with the new grant set to be submitted to the Grant Approvals Committee and Global Fund Board for approval before its scheduled start date of 1 April 2019.