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2008 PEPFAR Country Profile Update: South Africa

 

Administered by the Office of the Global AIDS Coordinator, the President’s Emergency Plan for AIDS Relief (PEPFAR) provides $15 billion dollars over 5 years for AIDS, Malaria and Tuberculosis programs globally. A majority of funds are allocated to the 15 focus countries of Botswana, Cote d’Ivoire, Ethiopia, Guyana, Haiti, Kenya, Mozambique, Namibia, Nigeria, Rwanda, South Africa, Tanzania, Uganda, Vietnam and Zambia.

 
(The following document is a 2008 update to the status of PEPFAR funding and related issues in South Africa.  Click Here to South Africa's 2005 Original Country Profile)
 
 
Introduction
 
In 2005, SIECUS published PEPFAR Country Profiles: Focusing on Prevention and Youth, an in-depth look at the then-new funding stream opened up through the President’s Emergency Plan for AIDS Relief (PEPFAR).  
 
PEPFAR directed $15 billion over five years, primarily to 15 focus countries and to a lesser extent to over one hundred other countries.  PEPFAR gave voice to the concern of the people of the United States to care for those around the world affected by HIV /AIDS and demonstrated the political will to put that concern into action.  At the outset, advocates were hopeful that this generous funding stream would offer a meaningful contribution to the fight against HIV/AIDS at a time when millions were dying.  Still, much of the language in the legislation gave advocates cause for concern, and it was unclear how the implementation of this program would play out.  
 
Advocates were particularly concerned with some of PEPFAR’s policies regarding prevention. First, a maximum of 20 percent of the funds could be spent on prevention efforts.  Moreover, 33 percent of those funds that were spent on prevention were earmarked for abstinence-until-marriage programs.  Together these made a glaring statement about the program’s priorities. PEPFAR also made funds available to faith-based organizations (FBOs), taking advantage of the vast social service networks already in place in many countries around the world. While these organizations often displayed expertise in areas such as care for orphans and hospice for the dying, they were, and still are, entitled to exclude information, particularly as relates to programs for the prevention of sexual transmission of HIV, that they believed to be inconsistent with their religious teachings. 
 
In the early years of PEPFAR very little was known about how these provisions, among others, impacted the efforts of national and international organizations. To fill this gap in information, SIECUS did what we have done in the United States for many years; we followed the money. For the original Country Profiles, we drew together information to create a more cohesive picture of the nature of each epidemic in the 15 focus countries and how PEPFAR responded to those epidemics, with a particular eye to the prevention and youth components. Specifically, we tracked prevention funds: how much money was distributed, who it went to, and how it was used. These were all elusive pieces of information at the time. 
 
Unfortunately, this type of information remains elusive. SIECUS conducted follow up research in 2008 to provide an update to those original Country Profiles. Each update features recent demographic data pertinent to the epidemic in that country, a breakdown of funding allocations for prevention, care, and treatment, and a list of those PEPFAR grantees that are implementing prevention programs. Wherever possible we also include additional information on grantees and the type of programs they are running with PEPFAR funds. 
 
In addition to this data, each update also offers further analysis on particular items of note in the country.  And, we follow this analysis with our recommendations for moving forward with PEPFAR to ensure truly comprehensive prevention strategies in the focus countries.  While these updates can be read independently of the original profiles, reading them together, affords an even richer perspective. 
 
 
Overview
South Africa remains one of the countries most affected by HIV/AIDS in the world. The first case of HIV was identified in the early 1980s. Since then the prevalence of HIV has increased, and today about 18.1 percent of the population or almost 1 in 5 adults is living with HIV. South Africa has the highest estimated number of people living with HIV (5.7 million) in the world and has the second highest HIV prevalence (Botswana’s prevalence rate is 23.9 percent) of all the PEPFAR focus countries. Some provinces are more affected than others with estimates of HIV prevalence ranging from as high as 39.1 percent in the KwaZulu-Natal province to as low as 15.1 percent in the Western Cape Province.[1] Unfortunately, there is no indication that the overall prevalence in South Africa has changed since 2000.[2] Over 2.5 million people have died of AIDS-related illnesses since the epidemic began and roughly 350,000 adults and children died from AIDS in 2007 alone; an average of over 950 deaths per day.[3] In addition, it is estimated that 1.4 million children ages 0–17 have been orphaned due to AIDS.[4]
 
The chart below offers a snapshot of some of the key facts and figures which highlight the particular landscape of the epidemic in South Africa. The stories behind these statistics are fleshed out in greater detail following the chart.
 
 
A PORTRAIT OF SOUTH AFRICA IN NUMBERS
Total population (2005)[5]
47,432,000
Percentage of the population under the age of 24
N/A
Gross national income in purchasing power parity (GNI PPP) per person (Int’l$, 2005)[6]
$10,960
Per capita total expenditure on health (Int’l$, 2005)[7]
$258
Secondary school enrollment rate (1999–2007)[8]
97% Females
90% Males
Estimated number of people ages 15 and over living with HIV (2007)[9]
5,400,000
HIV prevalence in people ages 15–49 (2007)[10]
18.1%
HIV prevalence in people ages 15–24 (2007)[11]
17.0% Female upper estimate
6.0% Male upper estimate
 
9.1% Female lower estimate
1.7% Male lower estimate
Median age of first intercourse
N/A
Median age of first marriage
N/A
Young people ages 15–24 who have had sex before age 15 (2005)[12]
12% Females
5% Males
Percentage of women and men ages 15–49 who have had sexual intercourse with more than one partner in the last 12 months (2005)[13]
18% Females
3% Males
Percentage of women and men ages 15–49 who had more than one sexual partner in the past 12 months reporting the use of a condom during their last sexual intercourse (2005)[14]
47% Females
67% Males
Contraceptive prevalence rate (2007)[15]
Any method: 56%
Modern: 55%
Percentage of couples using condoms for family planning (2005)[16]
1.7%
Number of births per 1,000 women ages 15–19 (2005–2010)[17]
61
Percentage of females (20–24) who have given birth by age 18 (2005)[18]
20%
Young people ages 15–24 who both correctly identify ways of preventing the sexual transmission of HIV and who reject major misconceptions about HIV transmission (2005)[19]
N/A
Percentage of schools that provided life-skills-based HIV/AIDS education in the last academic year (2007)[20]
96%
 
Though the first HIV/AIDS cases were reported in the 1980s, the government did not fully respond to the epidemic until over a decade later. In 1985, due to riots against Apartheid policies, a five-year State of Emergency was declared. During this time there was little emphasis on HIV/AIDS. In fact, the South African government took its first step in addressing the crisis in 1992 with the creation of the National AIDS Coordinating Committee of South Africa (NACOSA). NACOSA was responsible for creating a mandate to develop a national strategy on HIV/AIDS, which was subsequently adopted in 1994. Five years later, an HIV/AIDS & STI Strategic Plan for South Africa (NSP) was created for 2000–2005. This plan was updated in 2007, and is currently in effect until 2011.
 
An assessment of the NSP 20002005 concluded that stigma against people living with HIV/AIDS (PLWHA) remains very high. This was echoed by a recent survey conducted among PLWHA in Cape Town which found that acquisition of HIV is still widely perceived as an “outcome of sexual excess and low moral character.”[21] Although awareness of the larger societal dynamics of HIV/AIDS has increased, this phenomenon remains relatively unchanged. The NSP 20072011 recognizes the failures of past efforts and is moving forward to remedy them.
 
The NSP 20072011 also acknowledges that the key drivers of the epidemic are poverty, unemployment, gender-based violence and inequality, stigma and discrimination, and mobility.[22] Women are especially vulnerable to HIV due to rampant sexual violence and gender-based inequality. South Africa has the world’s highest rate of violence against women, with over 53,000 rapes reported to the police in 2000. One in three men believe that women are raped because of things they say or do, and half of men think women are raped because they send “sexual signals.”[23] Not surprisingly, women bear the brunt of the epidemic, accounting for 55 percent of people living with HIV in South Africa.[24] The NSP 20072011 states that the relationship between culture and HIV, specifically the impact that gender inequalities and sex-related cultural beliefs have on the epidemic, is under-researched.[25] However the NSP does not mention how it will seek to change this.  
 

Key Priorities of the National Strategic Plan 2007–2011
1.      Reduce the rate of new HIV infections by 50% by 2011
2.      Reduce the impact of HIV and AIDS on individuals, families, communities and society by expanding access to appropriate treatment, care and support to 80% of all HIV positive people and their families by 2011


South Africa also targets youth, specifically those ages 1524, in an effort to reduce HIV prevalence by 20 percent by 2015.[26] The NSP 20072011 plans to implement programs which promote health-seeking behavior, encourage adoption of safe-sex practices, improve access to male and female condoms, and increase access to youth-friendly reproductive health services. So far, it seems as if South Africa’s efforts to promote education are paying off. For example, 96 percent of schools are providing an HIV/AIDS curriculum, though it is not yet known whether this has translated to increased knowledge about HIV in young people.[27] Data on sexual behavior, however, is encouraging. Almost half of females and 67 percent of males ages 15–49 report using condoms with a non-regular sexual partner. And, the highest condom use is among younger individuals; young people ages 15–19 reported using condoms with non-regular partners 80 percent of the time and those ages 20–24 reported using condoms 72 percent of the time.[28] In addition, there were 376 million male condoms distributed in 2007, up from 256 million in 2006. In both 2006 and 2007, 3.6 million female condoms were distributed.[29] 
 
Despite this progress, many issues remain in addressing HIV/AIDS in South Africa. 
The United Nations General Assembly Special Session on HIV and AIDS 2008 (UNGASS) reports that in addition to the overarching issue of poverty, South Africa also faces a lack of coordinated programs which often results in minimum impact and confusion.[30] Many, including the United Nations Special Envoy for HIV/AIDS in Africa and the co-discoverer of HIV, Robert Gallo, argue that the South African government has been imprudent with its response and that it has, in fact, promulgated misinformation about HIV/AIDS treatment throughout the country.[31] For example, current president Thabo Mbeki has persistently refused to acknowledge the causal connection between HIV and AIDS.[32] He has also repeatedly sought counsel from “AIDS dissidents.” Health minister Manto Tshabalala-Msimang has attracted similar criticism, as she has promoted nutritional remedies such as garlic and beetroot as an effective treatment for individuals living with HIV.[33]The consequences of these actions have been seen, in part, in the slow pace at which antiretroviral therapy (ART) has become available in South Africa.  
 
Though the NSP 2007–2011 has a goal of providing care and treatment for 80 percent of all people in need, there are 35,000 people currently on waiting lists for ART. It is estimated that one million people are already in need of ART in South Africa but less than 30 percent are actually receiving it.[34] South Africa’s Department of Health developed the Human Resources for Health Plan separately from the NSP 2007–2011 without taking into account the impact that the decreased healthcare workforce would have on the ability to carry out the anticipated plans. This plan is merely one example of how a lack of coordination by government entities can have consequences on the success of HIV/AIDS services.
 
South Africa is considered a middle-income country, but Apartheid has left a vast disparity in wealth and access to health care. The current NSP seeks to overcome the shortcomings found in the NSP 2000–2005 and has devoted R3.4 billion ($480 million) in 2007. South Africa finances over 74 percent of its own HIV/AIDS expenses.[35] Additional funding comes from many international sources including the Global Fund ($80 million in 2007), the UK Department for International Development (DfID) ($18 million in 2007), and the President’s Emergency Plan for AIDS Relief (PEPFAR) ($399 million in 2007.) Despite the strong commitment to fighting the HIV/AIDS epidemic as demonstrated through the substantial financial contribution that the government is making, it is clear that a lack of coordination and misinformation are curtailing these efforts. 
 

Key Terms to Understanding PEPFAR Prevention Programs and Funds
 
ABC: ABC stands for “Abstain, Be-Faithful, and Correct and Consistent Condom Use.” ABC is PEPFAR’s guiding principal for HIV-prevention programs. PEPFAR requires that a minimum of one-third of all prevention funds be spent on abstinence programs and it limits the promotion and marketing of condoms to specific groups outlined in PEPFAR’s ABC guidance. No discussion or promotion of condoms is permitted with youth under the age of 14 using PEPFAR funds.
 
Country Operation Plan (COP): A yearly program and budget plan developed for each PEPFAR focus country. The COP is developed by U.S. staff in conjunction with country governments. It divides programs into three main categories of prevention, care, and treatment: Abstinence-Be-Faithful (AB), Other Prevention (OP), and Prevention of Mother-to-Child Transmission (PMTCT). A country’s COP is not the same as its National Strategic Plan/Framework (NSP/F). Unlike a NSP/F, a COP is specific to PEPFAR programs and funds, and is developed annually. In comparison, the NSP/F is a multi-year, country-wide strategy on HIV/AIDS that is developed by each country’s government. Although the NSP/F may make reference to PEPFAR and other international donors, it is not limited to a description of activities funded by international donors, and an NSP/F may or may not be developed with input from the United States or other donors. 
 
Abstinence-Be-Faithful (AB): One category of prevention programs and funding under PEPFAR. Grantees that provide AB programs focus on education and promotion of abstinence-until-marriage and be-faithful messages. Grantees that receive OP funds, such as those to promote condom use, are listed in both sections of the COP.
 
Other Prevention (OP): One category of prevention programs and funding under PEPFAR. The OP category includes any prevention program that is not an AB program or a PMTCT program. This category includes surveillance programs, programs aimed at reducing stigma and discrimination, training for healthcare workers, and the promotion and marketing of correct and consistent condom use. Grantees that receive funds for OP programs in addition to AB funds are listed in both sections of the COP.
 
Prevention of Mother-to-Child Transmission (PMTCT): One category of prevention programs and funding under PEPFAR. The PMTCT category includes routine rapid HIV-testing in antenatal and maternity settings, counseling and support for infant feeding, and linking to care, treatment, and support services.
 

President’s Emergency Plan for AIDS Relief (PEPFAR)

 
South Africa receives the most financial support of any of the PEPFAR focus countries at over half a billion dollars in funding.[36] In 2004, the country received an initial grant of $89,390,423, and that amount has increased dramatically over the past four years. In fact, its 2008 funding is more than six times the original grant. 
 
The following chart details the allocated funds from PEPFAR to the different areas of funding. Within the prevention framework, PEPFAR promotes an ABC message, which signifies: Abstinence-only, Be faithful, and Correct and Consistent Condom Use. Abstinence-only/Be-faithful (AB) programming utilizes an AB-only message, while Other Prevention (OP) includes AB programming as well as messages that address correct and consistent condom use (ABC).
 
Allocated PEPFAR Funds 2004–2008*
 
2004[37]
2005[38]
2006[39]
2007[40]
2008[41]
Total Funds Allocated**
$89,390,423
$129,575,807
$195,463,482
$363,792,948
$532,277,347
Total Prevention Funds Allocated
N/A
$30,952,602
$36,342,280
$54,480,011
$98,250,585
Total AB Funds Allocated
N/A
$10,002,326
$15,695,840
$19,729,011
$37,463,363
Total Other Prevention Funds Allocated (includes condom funding)
N/A
$7,609,177
$8,750,000
$12,124,000
$22,723,720
Total Treatment Funds Allocated
N/A
$61,325,762
$94,855,097
$184,739,831
$265,211,303
Total Care Funds Allocated
N/A
$37,297,443
$64,266,105
$124,573,106
$168,815,459
* The Office of the U.S. Global AIDS Coordinator (OGAC) only releases data on the funds that are allocated to each country. No data is available on the PEPFAR funds that are disbursed per country.  
** Total funding allocated to Field Programs only, excludes Agency costs.
 
As the table above indicates, treatment remains the most funded area, and in 2008 was allocated roughly half of the total budget. This area alone has received an increase of almost a $100 million each year since 2006. Care is the second most funded area; it was allocated over $168 million in 2008, making up 31.7 percent of the total budget. Prevention funding is the least funded area with under $100 million in 2008, making up less than 20 percent of the total budget. AB funds made up 7 percent of the total budget and roughly 38 percent of the prevention budget while OP funds made up 4.3 percent of the total budget and roughly 23 percent of the prevention budget. 
 
Prevention Programming
Prevention programming under PEPFAR utilizes an “Abstain, Be faithful, and when appropriate use Condoms” (ABC) approach. However, programs which promote abstinence and fidelity are the predominant intervention used with the general population. Programs addressing correct and consistent condom use are most often used with specific target populations that the PEPFAR guidance identifies as being most at-risk. Programs that support a comprehensive ABC approach are calculated into “Other Prevention” (OP) funding. 
 
The most comprehensive data available on PEPFAR funding for each focus country is in the 2007 Country Operational Plan (COP).  The COP delineates the total amount, according to program area, that each grantee or organization is given for that fiscal year. While general program descriptions are listed with the information about funding allocations, details on the specific activities that each grantee carried out and how these activities were executed are rarely included in the COP. This lack of detail on program content makes it difficult to conduct a thorough analysis of each program or of PEPFAR’s overall impact on prevention programming in the country. 
 
The following is a list provided of PEPFAR grantees receiving prevention funding as reported by the Office of Global AIDS Coordinator in the 2007 Country Operational Plan for South Africa. This list indicates whether grantees received only Abstinence-only/Be faithful (AB) funding, only Other Prevention (OP) funding or both. While there is a summary of funding projections available through 2008, the breakdown of funding according to recipient and amount granted in the full Country Operational Plan is only available for 2007.[42]
 
Organizations that received AB funding only:

  • CARE International
  • Children’s AIDS Fund
  • CompreCare
  • Family Health International
  • Humana People to People in South Africa
  • Living Hope
  • National Department of Education
  • National Department of Health, South Africa
  • Pact, Inc.
  • Salesian Mission
  • Salvation Army
  • Scripture Union
  • South Africa National Blood Service
  • Training Institute for Primary Health Care
  • U.S. Peace Corps

 
Organizations that received AB and OP funding:

  • Africare
  • Association of Schools of Public Health
  • Aurum Health Research
  • Education Labour Relations Council
  • EngenderHealth
  • GOLD Peer Education Development Agency
  • Hope Worldwide South Africa
  • Humana People to People in South Africa
  • Johns Hopkins University Center for Communication Programs
  • LifeLine North West - Rustenburg Centre
  • Mpilonhle
  • Population Council
  • Soul City
  • South African Business Coalition on HIV and AIDS
  • South African Democratic Teachers Union
  • South African Military Health Service
  • The Futures Group International
  • Ubuntu Education Fund
  • University of KwaZulu-Natal, Nelson Mandela School of Medicine
  • Youth for Christ South Africa

 
Organizations that received OP funding only:

  • Human Science Research Council of South Africa
  • Jhpiego
  • Medical Research Council of South Africa
  • National Department of Correctional Services, South Africa
  • Partnership for Supply Chain Management
  • Perinatal HIV Research Unit, South Africa
  • Reproductive Health Research Unit, South Africa
  • Research Triangle Institute
  • South African Clothing & Textile Workers’ Union
  • Tsephang Trust
  • U.S. Centers for Disease Control and Prevention (CDC)

 
 
Within prevention activities, there were 15 organizations that carried out AB programs, 20 organizations that carried out both AB and OP programs, and 11 organizations that carried out OP programs. Roughly $20 million was allocated to AB programs and it was estimated that 7,487,917 individuals were reached through community outreach. Roughly $12 million was allocated to OP programs which reached about half as many individuals through community outreach as AB programs did.[43] 
 
The organization that was granted the most AB-only funds was the National Department of Education (DOE), receiving $1,050,000 in 2007.[44] The DOE is responsible for mitigating the impact of HIV and AIDS within the education sector. However, the actual implementation of programs in schools has been carried out largely by locally based peer-education programs that lack central DOE oversight. The DOE’s AB program was established in 2006 and is currently administered in over 200 primary and secondary schools, targeting over 12,000 students, ages14–19. Students are taught that abstinence is the “best and only way to protect themselves from exposure to HIV” and are reportedly referred to other outside groups for information on and distribution of condoms.[45]
 
Some AB grantees continue to use on ideologically based programs. For example, the program Sakhulutsha is carried out by the faith-based NGO Scripture Union which received $950,000 in AB funds to reach over 25,000 youth. It delivers abstinence and be faithful messages to in and out-of-school youth. The program describes its vision as “to introduce young people to Jesus” and ensure a “commitment to Jesus and also to abstinence, whichever comes first.”[46] In order to carry out this mission, Scripture Union holds school programs, breakaway workshops, and youth development programs. As part of the breakaway workshops, Scripture Union holds single sex “gender camps” that allow staff to focus on gender-specific issues particularly relating to girls including “abstinence skills and the power to say no.”[47] The subtitle of its June 2008 newsletter about the camp is “Supporting the Church in introducing young South Africans to Jesus, the Bible and the Church.” In the newsletter, Scripture Union’s general director states his mission is to “see young people’s lives transformed by Christ.”[48] Scripture Union blesses its staff workers before going out to schools to run programs like Sakhulutsha: “Pray that as she goes to the schools, she will let the light of Jesus shine through her so that many will come to know Him.”[49] The current AB framework in PEPFAR continues to allow organizations like Scripture Union to carry out limited and ideological activities rather than focus on comprehensive evidence-based HIV prevention activity. 
 
The organization that received the most combined AB and OP funds was Johns Hopkins University’s Center for Communication Programs at $6,975,000 in 2007.[50] Johns Hopkins used both its AB and OP funds to start two television shows designed to bolster prevention messaging. Trailblazers (or Masupatsela), a community health show, aired 13 episodes highlighting “individuals that provide models of positive behaviors for others to emulate.” The project has recently begun a twenty-six episode drama that deals with “contextual issues relating to social and cultural norms that inhibit and/or support positive male norms and behaviors, including positive examples that counter violence and coercion.”[51] Johns Hopkins dedicated its OP funds to promoting the correct and consistent use of condoms and educating young women, including female sex workers, about sexual health and condom negotiation skills. In addition, Johns Hopkins used its AB funds to deliver AB messages in workplaces and schools. Dance4Life, also carried out though Johns Hopkins, is a creative arts program in secondary schools designed to support young people in postponing sexual debut and avoiding sexual violence and coercion. It utilizes a “proven methodology of drumming, dancing and drama as an entree to young people” to discuss sexual behavior.[52] In addition to PEPFAR funds, Dance4Life is supported by Coca Cola and various European NGOs.
 
Youth for Christ, another organization that carries out both AB and OP programs received $500,000 in AB funds and $250,000 in OP funds. The organization targets young people ages 10–18, promoting abstinence and be faithful activities in its AB activity, and the use of condoms in its OP activity.[53] Youth for Christ presents “AIDS productions” designed by creative educational youth teams that promote AB lifestyles to “high schools, youth centers, churches, and prisons.”[54] In addition to life skills camps based on the Rutanang curriculum, a peer education plan published by the South African Department of Health for use in schools, Youth for Christ also holds peer education programs that discuss a “host of issues relating to HIV and AIDS, peer pressure, self-esteem, and goal setting.”[55] Youth for Christ also reports that it distributed 15,000 male and 5,000 female condoms in 2007 as part of an awareness campaign under its OP activity.[56] Peer educators encouraged discussion around condoms and HIV and AIDS in order to “alleviate stigma and discrimination in the communities in which YFC [Youth for Christ] is working.”[57] 
 
The organization granted the most OP-only funds was the Human Science Research Council of South Africa which received $500,000 in 2007.[58] This OP program adapts the U.S. Centers for Disease Control and Prevention’s (CDC) Healthy Relationships program in various regions in South Africa. Healthy Relationships is an evidence-based behavioral intervention that focuses on reducing HIV transmission among individuals already infected with HIV.[59] In the United States, the program has had significant success in reducing unprotected sex, increasing refusal to engage in unprotected sex, increasing condom use, and reducing the number of sexual partners among HIV-positive individuals. Human Science Research Council’s program also teaches individuals how to safely and effectively disclose HIV status to family members, friends, employers, coworkers, and sex partners. In addition, participants are taught to advocate for increased HIV testing.  
 
Eleven OP programs included information on correct and consistent condom use. For example, The CDC developed a condom-skills building video for young, sexually active individuals with the objective of “reducing acquisition and transmission of HIV through consistent and correct condom use.”[60] It is not known how effective the brief, animated video is in conveying the full ABC message; the CDC also states that, “additional information such as the roles of abstinence, mutually monogamous partnerships, and knowledge of HIV serostatus in preventing HIV acquisition will also be discussed in the video.”[61]
 
Items of Note: Gender-Based Violence and AIDS
Underlying many of the issues in South Africa is the disparate impact that the HIV/AIDS epidemic has had on women. In sub-Saharan Africa, women ages 15–24 account for nearly 75 percent of HIV infections and are approximately three times more likely to be infected than their male counterparts.[62] The violence experienced by women in South Africa is particular concerning. Current police reports indicate that in 2007 there were at least 22,887 cases of rape in South Africa.  This figure is substantially lower than the 53,000 cases of rape reported in 2000, however, the actual figure is undoubtedly higher than considering that many incidents of rape go unreported.[63] 
 
Women in South Africa are often said to face a triple oppression: discrimination based on race, class, and gender.  Gender-based violence impacts women’s lives in a myriad of ways and has many direct connections to the HIV/AIDS epidemic. Forced or coerced sexual acts increases the risk of HIV transmission, and violence or the threat of violence may limit a woman’s ability to adopt safer sex practices.[64] is also evidence that women’s experience with violence may lead to increased risk-taking behavior later in life, such as engaging in transactional sex or having multiple partners. Moreover, early sexual assault is associated with early sexual debut, anal sex, sex with unfamiliar partners, and low rates of condom use.[65] Women living with HIV have more lifetime experience of violence and South African women with violent or domineering male partners are 50 percent more likely to contract HIV.[66] Fear of violence or stigma can also prevent a woman from seeking treatment or finding out their HIV status.     
 
South Africa has enacted a number of laws which seek to decrease violence against women and children. However, many of these have been poorly implement and some impose measures that may inhibit a woman from receiving access to treatment and care she may need. For example, South Africa created the Thuthuzela Care Centers (TCC) in 2002. These centers are a “one-stop shop” for women and children who have experienced sexual violence.[67] TCC offers counseling, a medical examination and post-exposure prophylaxis (PEP). This prompt medical attention can reduce the likelihood of HIV transmission.
 
The implementation of this program at the local level has faced numerous difficulties. A study conducted by Human Rights Watch in 2004 found that there has been failure in providing adequate information or training about PEP to police, health professionals, and counselors working with rape survivors.[68] The public in general was also largely unaware of these centers. 
 
There are other obstacles facing women who want to use a TCC. First, women must file criminal charges in order to access to these services. In addition, women are required to take an HIV test before PEP can be administered because it cannot help women who are already HIV positive. Unfortunately, because of the stigma still associated with a positive diagnosis, some women refuse the treatment altogether. 
 
The intersection between violence against women and HIV/AIDS is often largely ignored or at best marginalized by multi- and bi- lateral agencies.  In addition to legal reforms, social and economic reforms must be made as well. In a country like South Africa, which has such a small funding emphasis on prevention to begin with, an extension to address violence against women and children is even less likely to occur. Moreover, PEPFAR programs do not adequately address the issues inherent in sexual violence. No matter how persuasive PEPFAR’s ABC approach may be, or how strongly it is adhered to, women and children who do not choose where or when to engage in sexual activity can do little with a message that urges them to abstain, be faithful and use condoms.  PEPFAR and other international funders must help the government of South Africa address the social factors which enable gender-based violence and therefore impede HIV-prevention efforts.  
 
Recommendations
 
In 2005, when SIECUS released the original PEPFAR Country Profiles publication, we made six recommendations: immediate actions necessary to remedy the problems in the PEPFAR legislation and its implementation. Sadly, although not surprisingly, three years and $19 billion in U.S. taxpayer funding later, little has been done. Lawmakers missed the opportunity to remedy the shortcomings of the original law in the reauthorization of PEPFAR in July 2008, despite ample evidence provided by researchers and advocates to guide them to create more sounds policy. Today, we reiterate each of these six recommendations as well as adding an additional one, and contribute evolving insight relevant to the current context:
 
1.  Abandon the Ideological Emphasis on Abstinence-Until-Marriage Programming
 
The newly reauthorized law brought about a technical change in the shape of the abstinence-until-marriage funding restrictions, although the impact is equally stifling. A hard earmark in the original legislation requiring that 1/3 of all prevention funding be spent on abstinence-until-marriage programming has been supplanted by an onerous reporting requirement. Despite the overwhelming evidence that abstinence-until-marriage programs are ineffective at preventing the transmission of HIV, they remain the cornerstone of the prevention policy. The new requirement states that if funding in this area falls below 50 percent of the total allocation for prevention of sexual transmission of HIV in any country, the Office of the Global AIDS Coordinator (OGAC) must issue a report to congress to explain the failure to prioritize abstinence and marriage promotion.  As long as there is a clear bias towards abstinence-until-marriage promotion programming in the law, countries will disproportionately seek to please the U.S. government and will funnel more monies into this failed approach. This wastes enormous resources on the ground and has created a situation that, if left unchecked much longer, will wholly destroy a comprehensive approach to HIV-prevention in many of the focus countries. Every attempt must be made to promote evidence-based strategies in prevention programming, not the ideological and hypermoralistic framework that characterizes the promotion of abstinence-until-marriage.
 
 
2. Increase Transparency of PEPFAR Prevention Funds
           
Since 2005, some progress has been made on the part of OGAC to provide more disaggregated prevention funding data in the 15 PEPFAR focus countries providing a somewhat clearer understanding of who is receiving the funds and what sort of programs are being carried out. For example, there is a greater delineation between prevention providers solely engaged in AB programming and those doing more comprehensive interventions. However, the substance of the actual initiatives being carried out remains elusive, particularly when it comes to entities receiving pass-through sub-grants from a primary agency. While there has been some improvement, OGAC must provide a fuller documentation of the content and delivery of prevention initiatives. This recommendation should not prove unduly onerous to OGAC given the extensive grantmaking and reporting requirements imposed on implementers that have generated a wealth of information already in OGAC’s possession. 
 
3. Enact Appropriate Oversight Mechanisms of PEPFAR Prevention Grantees
 
In 2005, this recommendation cited two key concerns. First, we cited a lack of oversight regarding the use of funds by faith-based organizations to ensure they are not proselytizing in their work funded by PEPFAR. Given the escalation in PEPFAR funding and the increasing proportion of funding going to religious organizations, we reiterate that OGAC must provide for a systematic review of the prevention programs by these groups both including closely looking at the materials programs are using and on-the-ground monitoring of program delivery.
 
Second, we recommended then and reiterate now that OGAC collect data and report on the organizations taking advantage of a clause in the law that allows them to opt out of any condom/contraception education under the claim that to do so would be a violation of their religious beliefs. This information seems even more critical as abstinence and partner reduction programs have eclipsed those that include condom and contraceptive instruction. Tracking this information more closely would allow better analysis about the extent to which the clause is invoked and the extent to which condom related services are not being provided.
 
We also now add a third concern in this area and call on Congress to conduct a systematic review of the process by which countries are involved in the development of their annual Country Operational Plans. A great deal of evidence has emerged from individual countries that suggests that the Country Operational Plans are written by OGAC and U.S. personnel in the USAID missions of the countries to meet ideological mandates. As a result, Country Operational Plans too often fail to conform to the actual needs of the countries to combat their epidemics.  
 
4.  Rescind the Anti-Prostitution Pledge
 
As the United States Congress began debate in 2008 on the reauthorization of PEPFAR, one message was sent loud and clear from social conservatives and the Bush White House: the anti-prostitution pledge was non-negotiable.  The anti-prostitution pledge requires all recipients of PEPFAR funds to denounce commercial sex work in order to receive U.S. government funding. SIECUS’ own research in Zambia has documented that the anti-prostitution pledge is more than just a piece of paper. It has manifested itself as the strongest of ideological weapons to shut down any outreach to women engaged in sex work, leaving them at an even greater risk for infection. The lack of political courage in Congress has meant the continuation of this dangerous policy as the reauthorization passed in July 2008 made no efforts to reverse this requirement. Congress must request an inquiry by the General Accounting Office (GAO) to undertake a survey in each of the 15 focus countries to determine the impact of the anti-prostitution pledge on HIV-prevention program delivery to women engaged in sex work. Further, a new administration in 2009 should provide leadership in directing OGAC to work with focus country governments to scale-up HIV-prevention programming to this population and actively engage in mobilizing non-U.S. government resources to fill this vital need. And of course, when the opportunity presents itself in the next reauthorization, this provision must be removed from the law itself.
 
5. Work with the International Community to Implement Programming and Policy that Connects HIV/AIDS to other Issues of Sexual and Reproductive Health
 
The current trend of separating public-health foreign aid into disease-specific silos, such as HIV/AIDS, malaria, and tuberculosis, purports to create a strong enough resource flow to significantly reduce the manifestations of each disease.  However, such segmentation has also led to too narrow a framework/conceptualization.  Sexual transmission is the most widespread driver of the epidemic globally, and women, particularly women in committed relationships, often including marriage, and the children they bear are increasingly becoming infected with HIV. Curbing the epidemic requires greater integration of sexual and reproductive health services to provide the education and commodities needed to prevent the spread of HIV, whether through sexual transmission between partners, or mother to child transmission. Sexual and reproductive health service delivery sites are often the only interface a woman has with healthcare, offering of the opportunity to engage with and gain access to someone who may not seek out information and services elsewhere. For reasons of stigma and discrimination, a woman may not be able to seek out services at healthcare delivery sites specifically oriented towards HIV/AIDS.
 
While OGAC has promoted “wraparound” with reproductive health services funded through funding streams outside of that authorized by PEPFAR, this has not proved sufficiently adequate. Such a narrow focus on HIV/AIDS specific health services has actually meant less money, not just a comparatively lower amount to the PEPFAR funding, on the ground for general sexual and reproductive health services. Due to this reality, the “wraparound,” while it may seem sound in theory, is not, in fact, a solution on the ground. 
 
From a public health perspective, integration of sexual and reproductive health with HIV/AIDS is simply good medicine, but on the policy end, the individual ideologies of policymakers have interfered with the creation of strong policy to support this end. OGAC needs to work with the international community to implement programming and policy that connects HIV/AIDS to other issues of sexual and reproductive health.
 
6.  On-the-Ground Monitoring of Funded Activities
 
Over the past four years of PEFAR funding, it has become disturbingly clear that PEPFAR has transformed the landscape of HIV-prevention programming in each of the 15 focus countries in worrisome ways.  Not the least of these is that the vast majority of PEFAR funding is going to international or U.S.-based NGOs and, in the process, indigenous NGOs in the focus countries are failing to benefit from this record investment. A quick look at the list of grantees in each country testifies to a lack of investment in building up the capacity for prevention programming among local NGOs, and distributing funds so that they may also carry out HIV-prevention programming.  PEPFAR’s largesse will not continue in perpetuity and therefore, investments in local capacity in this area seem among the wisest of investments in a long-term strategy to assist these countries. OGAC should be directed to begin an immediate scaling up of investment in indigenous prevention program providers and to set escalating targets over the next five years that will ensure than at least 50 percent of prevention program funding goes directly to indigenous NGOs.  We have a responsibility to these countries and to U.S. taxpayers to invest in system change in these countries, and that begins with building and investing in NGOs on the ground.
 
7. Eliminate the Clause Which Opens the Door for Implementers to Discriminate Against Certain Populations
 
 
The original law included a provision permitting implementers of prevention and treatment programs to opt out of delivery of services that they deemed to go against their religious beliefs. This provision offered a loophole which benefited the implementer more than those in need of prevention and treatment services, deferring to moral frameworks of the implementers instead of championing the evidence-based strategies. It granted the authority to the implementer to pick and choose which elements of a comprehensive approach to utilize, even when doing so undermines the integrity and effectiveness of the overall program. This troublesome provision raised the concerns of advocates early on whether ideology would trump evidence. In the time that has unfolded since the initial roll-out of PEPFAR programs, this provision has shown to be particularly problematic regarding the implementation of HIV-prevention interventions addressing sexual transmission. Many faith-based organizations have experienced a “moral panic” over the delivery of comprehensive prevention services, fearing a contradiction with the moral frameworks on sexuality derived from their faith traditions. The new law expanded this provision to apply to care services in addition to prevention and treatment services. This move is clearly a step in the wrong direction and must be remedied by fully repealing this clause in the next authorization of this law.
 
 
 
 


[1] UNGASS 2008 United Nations General Assembly Special Session on HIV and AIDS Country report – South Africa
Reporting period: January 2006 – December 2007,(Department of Health, 2008), accessed 23 July 2008, http://data.unaids.org
[2] 2007 AIDS epidemic update—regional summary: Sub-Saharan Africa, UNAIDS, (New York, NY), accessed 18 August 2008,http://data.unaids.org; 2008 Report on the Status of the global HIV epidemic, UNAIDS, (New York, NY), accessed 12 August 2008, http://data.unaids.org 34
[3] Epidemiological Country Profile on HIV and AIDS, UNAIDS, (New York, NY), accessed 12 August 2008, http://www.who.int; 2008 Report on the Global AIDS Epidemic Annex 1: HIV and AIDS estimates and data, 2007 and 2001, UNAIDS, (New York, NY), accessed 12 August 2008, http://data.unaids.org 217
[4] Ibid., 218
[5] 2006 UNAIDS Report: Country profiles annex 1, UNAIDS, (New York, NY), accessed 2 June 2008,
[6] Ibid., 22
According to the World Bank, “GNI PPP is measured in current international dollars which, in principal, have the same purchasing power as a dollar spent on GNI in the US economy.”
[7] Ibid., 22
[8] Monitoring ICPD Goals – Selected Indicators, UNFPA, (New York, NY), accessed 5 August 2008, http://www.unfpa.org/swp/2007/english/notes/indicators/e_indicator1.pdf 86
[9] 2008 Report on the Global AIDS Epidemic Annex 1, 214
[10] Ibid., 215
[11] Ibid., 217
[12] 2008 Report on the Global AIDS Epidemic Annex 2: Country Progress Indicators, UNAIDS, (New York, NY), accessed 5 August 2008,http://data.unaids.org 302
[13] Ibid., 309
[14] Ibid., 313
[15] Monitoring ICPD Goals – Selected Indicators, 86
According to UNFPA, “Modern or clinic and supply ­methods include male and female sterilization, IUD, the pill, injectables, hormonal implants, condoms and female barrier methods.” 
[16] 2006 Update Condoms Count 6: Meeting the Need in the Era of HIV/AIDS, Population Action International, (New York, NY), accessed 5 August 2008,
[17]  Monitoring ICPD Goals – Selected Indicators
[18] The World’s Youth 2006 Data Sheet, Population Reference Bureau, (Washington, DC), accessed 5 August 2008, http://www.prb.org/pdf06/WorldsYouth2006DataSheet.pdf 13
[19] 2008 Report on the Global AIDS Epidemic Annex 2, 297
[20] Ibid., 292
[21] HIV/AIDS & STI Strategic Plan for South Africa, 2007-2011, Department of Health, March 14 2007, (South Africa), accessed 15 September 2008, http://www.doh.gov.za/docs/misc/stratplan/2007-2011/part1.pdf 35; Simbayi, L.C, et al. (In press) Internalized AIDS Stigma, AIDS Discrimination, and Depression among Men and Women Living with HIV/AIDS, Cape Town, South Africa. Social Science & Medicine
[22] HIV/AIDS & STI Strategic Plan for South Africa, 32-34
[23] Ibid., 32
[24] Ibid., 9
[25] Ibid., 33
[26] Ibid., 35
[27] UNGASS 2008 United Nations General Assembly Special Session on HIV and AIDS Country report – South Africa, 22
[28] 2008 Report on the Global AIDS Epidemic Annex 2, 313
[29] UNGASS 2008 United Nations General Assembly Special Session on HIV and AIDS Country report – South Africa, 27
[30] Ibid., 50, 55
[31] AIDS in South Africa: Treatment, Transmission and the Government, AVERT (27 July 2008), accessed 18 August 2008, http://www.avert.org/aids-south-africa.htm
[32] Ibid
[33] Ibid
[34] Epidemiological Country Profile on HIV and AIDS, UNAIDS
[35] UNGASS 2008 United Nations General Assembly Special Session on HIV and AIDS Country report – South Africa, 24-25
[36] 2008 Report on the Global AIDS Epidemic Annex 2, 260
[37] South Africa FY 2004 Country Operational Plan (COP), Office of U.S. Global AIDS Coordinator and the Bureau of Public Affairs, U.S. State Department, (Washington, DC), accessed 8 August 2008,
[38] Total Dollars Planned for FY 2005 by Program Area, U.S. State Department, (Washington, DC), accessed 8 August 2008, http://www.state.gov/s/gac/progress/other/data/program/59802.htm
[39] Approved Funding by Program Area: South Africa: FY 2006, PEPFAR, Office of U.S. Global AIDS Coordinator and the Bureau of Public Affairs, U.S. State Department, (Washington, DC), accessed 8 August 2008, http://www.pepfar.gov/about/77687.htm
[40] Approved Funding by Program Area: South Africa: FY 2007, PEPFAR, Office of U.S. Global AIDS Coordinator and the Bureau of Public Affairs, U.S. State Department, (Washington, DC), accessed 8 August 2008, http://www.pepfar.gov/about/82458.htm 
[41] Approved Funding by Program Area: South Africa: FY 2008, PEPFAR, Office of U.S. Global AIDS Coordinator and the Bureau of Public Affairs, U.S. State Department, (Washington, DC), accessed 14 August 2008, http://www.pepfar.gov/about/opplan08/102026.htm
[42] South African FY 2007 Country Operational Plan, Office of U.S. Global AIDS Coordinator and the Bureau of Public Affairs, U.S. State Department, (Washington, DC), accessed 18 August 2008, http://www.pepfar.gov/documents/organization/103940.pdf
[43] Ibid., 200, 392
[44] Ibid., 275
[45] Ibid., 277
[46] Scripture Union South Africa: Vision, accessed 29 August 2008, http://www.su.org.za/vision.htm; http://www.su.org.za/reach.htm
[47] South African FY 2007 Country Operational Plan, 308-309
[48] National Newsletter, June 2008, Scripture Union South Africa, accessed 29 August 2008, http://www.su.org.za
[49] Prayer Diary, August 2008, Scripture Union South Africa, accessed 29 August 2008, http://www.su.org.za
[50] South African FY 2007 Country Operational Plan., 243, 425
[51] Ibid., 426
[52] Ibid., 244
[53] Ibid., 311-312, 468-469
[54] Ibid., 313
[55] Ibid., 312
[56] Ibid., 469
[57] Ibid., 469
[58] Ibid., 402
[59] Healthy Relationships (December 28, 2006), Divisions of HIV/AIDS Prevention
National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, (Atlanta, GA), accessed 18 August 2008, http://www.cdc.gov
[60] Ibid., 479
[61] Ibid., 479
[62] Violence Against Women and HIV/AIDS: Critical Intersections – Intimate Partner Violence and HIV/AIDS, (World Health Organization, 2004), accessed 4 June 2008, http://data.unaids.org 1
[63] Rape in the RSA for the period April to September 2001 to 2007, South African Police Service (SAPS), accessed 4 June 2008, http://www.saps.gov.za
[64] Ibid., 32
[65] Violence Against Women and HIV/AIDS, 2
[66] Zero Tolerance: Stop the Violence Against Women and Children, Stop HIV/AIDS (Washington, DC: Global AIDS Alliance, August 2006), accessed 18 August 2008, http://aidsalliance.3cdn.net 6
[67] Ibid., 25
[68] Deadly Delay: South Africa's Efforts to Prevent HIV in Survivors of Sexual Violence, Human Rights Watch, March 2004, Vol. 16, No. 3 (A), (New York, NY), accessed 18 August 2008, http://hrw.org/reports
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