Combating the Human Immunodeficiency Virus in South Africa Although Swaziland has the highest incidence rate for the human immunodeficiency virus (HIV) at 27.7%, South Africa suffers from the largest number of people living with HIV in the world (6.8 million) (The global HIV / AIDS epidemic, 2016) out of a total population of around 53.5 million (South Africa population, 2016). In fact, during the time required to read this introduction, someone died of HIV in South Africa. Unfortunately, South Africa is certainly not unique in experiencing these high rates of infection and many sub-Saharan African nations are likewise seriously affected by the disease (The global HIV/AID epidemic, 2016). South Africa, though, is also suffering from a number of social problems that have exacerbated the HIV epidemic. In response to these alarming trends, the international community, including the United States, has allocated an enormous amount of resources to help stop the spread of HIV in affected countries including South Africa. This paper reviews the relevant literature to identify salient social factors that have impacted the spread of HIV in South Africa and the economic costs that are associated with treating the disease. A discussion concerning U.S. global health policies and initiatives for fighting the HIV epidemic is followed by an analysis of the resources that are being allocated for this purpose. In addition, a discussion concerning the progress that has been made to date in addressing this public health issue in South Africa is followed by an assessment of the additional human and financial resources that are needed to combat this problem today. Finally, a summary of the research and important findings about HIV in South Africa are presented in the conclusion.

Social factors

Following the first multi-racial elections in 1994, South Africa has experienced a number of social problems and challenges, including most especially dramatic increases in drug abuse (e.g., cocaine, hashish and heroin), the country is currently the world's largest market for illicit methaqualone (South Africa transnational issues, 2016) and an ongoing HIV epidemic (Birnbaum & Murray, 2011). Indeed, South Africa accounts for fully 17% of the global burden of HIV (Birnbaum & Murray, 2011). The current high prevalence rates for sub-Saharan African countries, including South Africa, can be readily discerned from Figure 1 below.

Figure 1. Adult HIV global prevalence rates

Source: https://kaiserfamilyfoundation.files.wordpress.com/2015/07/3030-19-figure-1.png

Several social factors are believed to account for these inordinately high HIV prevalence rates, at least in part, including the country's male homosexual population that accounts for about 10% of the total population as well as nearly 10% of all new HIV infections; these prevalence rates, though, vary widely by geographic region of the country, including the highest rates of 43.6% in Johannesburg and Durban (du Toit & Burger, 2010). Moreover, social stigmatization associated with HIV discourages many members of this population from seeking professional healthcare services (du Toit & Burger, 2010). Despite these trends, South Africa is the only sub-Saharan African country where gay rights have been codified in the law and national policies encourage social justice and equity for all citizens and prohibits discrimination on the basis of sexual orientation (du Toit & Burger, 2010). Consequently, international HIV activists point to South Africa as a potential role model for the provision of effective interventions in the future (du Toit & Burger, 2010).

Notwithstanding this future potential, however, there are still several other social factors that are going to make the process more challenging, including most especially the large numbers of sex workers employed in South Africa (du Toit & Burger, 2010). Indeed, sex workers account for nearly 20% of all new HIV cases in the country today, about twice as many as for homosexual men (du Toit & Burger, 2010). Although precise numbers are not available, some estimates place the prevalence of HIV among female sex workers as high as 88%, with sex workers under the age of 25 years being especially affected by the disease (du Toit & Burger, 2010). In addition, du Toit and Burger add that, "Sex workers in South Africa face high levels of stigma and discrimination and are restricted by the laws under which they have to work. Moreover, many sex workers also inject drugs, exacerbating their vulnerability to HIV infection" (p. 72). Further, widespread harassment and abuse of sex workers by law enforcement authorities has made the provision of educational services to this population exceedingly difficult (du Toit & Burger, 2010).

Beyond the high rates of HIV among male homosexuals and sex workers, researchers also believe that the HIV prevalence among people who inject drugs (PWID) in South Africa is about 16.2%, but these individuals only account for about 1.3% of new HIV cases each year (du Toit & Burger, 2010)....

Finally, South African women suffer from an HIV prevalence rate almost twice as high as their male counterparts in the same age groups and women account for 25% of all new HIV cases each year (du Toit & Burger, 2010). According to du Toit and Burger, "Poverty, the low status of women and gender-based violence have also been cited as reasons for the disparity in HIV prevalence between men and women in South Africa" (2010, p. 72). Nevertheless, these high rates are believed to have declined somewhat over the past decade or so (du Toit & Burger, 2010).
A breakdown of HIV prevalence in South Africa and gender and age is provided in Figure 2 below.

Figure 2. HIV prevalence in South Africa by gender and age

Source: https://www.avert.org/sites/default/files/South-Africa-bar-chart.png

Economic factors

While it has around 10% of the global population, Sub-Saharan Africa has just 1% of the money and more than 70% of the global population that is currently infected with HIV / AIDS. At present, HIV kills approximately 600 South Africans every day, and this human toll does not take into account the staggering economic impact the disease exacts (du Toit & Burger, 2010). Today, South Africa spends more than $1 billion annually to operate its HIV and AIDS programs (HIV and AIDS in South Africa, 2016). Despite having abundant natural resources and a modern economic infrastructure, a number of constraints remain firmly in place that have adversely affected the ability of the South African population to participate fully in any economic growth. For example, U.S. analysts emphasize that, "Unemployment, poverty, and inequality - among the highest in the world - remain a challenge. Official unemployment is roughly 25% of the work force, and runs significantly higher among black youth" (South African economy, 2016, para. 3).

U.S. global health policies and initiatives

The United States federal government is the world's largest funder and implementer of global health initiatives (The U.S. government and global health, 2016). These initiatives include bilateral partnerships between two countries such as the United States and South Africa as well as multilateral partnerships that are intended to address healthcare issues, including HIV treatment and prevention, at the global level (The U.S. government and global health, 2016). This support is provided by a number of different agencies and organizations, including:

The U.S. Department of State's Office of the Global AIDS Coordinator (OGAC),

The U.S. Agency for International Development (USAID),

Department of Health and Human Services (HHS) operating divisions (e.g., the Centers for Disease Control and Prevention), (CDC),

The Health and Human Services Office of Global Affairs, and The U.S. Department of State's Global Health Diplomacy (GHD) office (The U.S. government and global health, 2016).

Resource allocation

One of the most active international organizations committed to fighting the HIV epidemic is the Global Fund. This organization was established in 2002 as a collaborative public-private partnership that invests almost $4 billion annually to provide HIV-related interventions and programs that are operated by local clinicians and experts (Global Fund, 2016). As shown in Figure 3 below, funding for the Global Fund has steadily increased over the past decade (levels for 2015-2017 are projections).

Figure 3. Funding for the Global Fund, FY 2006-FY 2017

https://kaiserfamilyfoundation.files.wordpress.com/2014/06/global-funding_2017.png

Besides the Global Fund, the Kaiser Family Foundation is also a major provider of funding for HIV research, treatment and prevention. As shown in Figure 4 below, this funding has experieced a minor decline in FY 2013, but has since already regained its former levels.

Figure 4. Kaiser Family Foundation funding for HIV

https://kaiserfamilyfoundation.files.wordpress.com/2014/06/hiv-funding_2017.png

Progress

Despite the grim picture painted above, there are some signs of progress in South Africa's battle against its HIV epidemic. For example, unlike most other African countries, South Africa tracks HIV cases through a national registration system using reviews of death certificates and the quality of the data collection has steadily improved since the program was implemented in 1996; however, the coverage of the program remains limited and the quality of the death certificate review process is questionable (Birmbaum & Murray, 2011). Moreover, fear of being stigmatized as a result of being diagnosed with HIV or of being denied health care insurance benefits may also discourage many HIV sufferers from being counted in the totals. Likewise, community leaders in rural regions of South Africa frequently omit this information when they complete death…