GAM REPORT 2020 | 1 - South African National AIDS Council
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GAM REPORT 2020 | 1
Acknowledgements
REPORT PREPARATION TEAM
Braimoh Bello
Pedzisai Ndagurwa
Seyi Omogiate
Layout design: Joshua Ekeh
2020 GLOBAL AIDS SANAC TEAM
MONITORING REPORT Billia Luwaca
Lifutso Motsieloa
Zwebuka Khumalo
Anthony Odama
SUGGESTED CITATION
Bello B, Ndagurwa P, Omogiate S, Luwaca B, Motsieloa L. Republic
of South Africa: 2020 Global AIDS Monitoring Report (2021).
Johannesburg: CESAR; 2021.
REPUBLIC OF SOUTH AFRICA
Harrow Court 2, Isle of Houghton Office Park,
36 Boundary Rd, Houghton Estate, Johannesburg, 2198
www.cesar-africa.com
2 | Acknowledgements
Table of List of
Contents Tables
Acknowledgements ���������������������������������������������������������������������������������������������������������������������������������� 2 Table 1: Prevention of mother-to-child transmission performance indicators
in South Africa, 2017–2019�����������������������������������������������������������������������������������������������������������������������17
Table of Contents �������������������������������������������������������������������������������������������������������������������������������������� 3
List of Tables ����������������������������������������������������������������������������������������������������������������������������������������������� 3 Table 2: Mother-to-child transmission rates of HIV in South Africa, 2018–2020�����������������������17
List of Figures ��������������������������������������������������������������������������������������������������������������������������������������������� 4 Table 3: Number of new HIV infections in South Africa by sex and age, 2016–2020���������������21
Abbreviations ��������������������������������������������������������������������������������������������������������������������������������������������� 5 Table 4: Number of new HIV infections in South Africa by sex and age, 2016–2020���������������22
Introduction ������������������������������������������������������������������������������������������������������������������������������������������������ 6 Table 5: Number of male and female condoms distributed in South Africa, 2018–2020��������24
Summary of Progress Towards Commitments ���������������������������������������������������������������������������������� 8
Table 6: South Africa Family Planning 2020 core indicators performance, 2018–2020�����������29
Overview of the Epidemic HIV/AIDS Epidemic in 2020 ����������������������������������������������������������������� 10
Table 7: Number of South Africans social grants by grant type 2018/19 and 2019/2020������32
Commitment 1 ���������������������������������������������������������������������������������������������������������������������������������������� 13
Table 8: Functionality of community engagement through provincial and district
Commitment 2 ���������������������������������������������������������������������������������������������������������������������������������������� 16 AIDS councils in South Africa, 2021��������������������������������������������������������������������������������������������������������35
Commitment 3 ���������������������������������������������������������������������������������������������������������������������������������������� 20 Table 9: South Africa Government expenditure (amount and percentage)
on HIV/AIDS by program����������������������������������������������������������������������������������������������������������������������������38
Commitment 4 ���������������������������������������������������������������������������������������������������������������������������������������� 25
Commitment 5 ���������������������������������������������������������������������������������������������������������������������������������������� 28 Table 10: HIV Funding by entities for three fiscal year periods������������������������������������������������������39
Commitment 6 ���������������������������������������������������������������������������������������������������������������������������������������� 31 Table 11: South Africa’s total expenditure (amount and percentage)
on HIV/AIDS by program����������������������������������������������������������������������������������������������������������������������������40
Commitment 7 ���������������������������������������������������������������������������������������������������������������������������������������� 34
Commitment 8 ���������������������������������������������������������������������������������������������������������������������������������������� 37
Commitment 9 ���������������������������������������������������������������������������������������������������������������������������������������� 41
Commitment 10 �������������������������������������������������������������������������������������������������������������������������������������� 43
Discussion and Recommendations ��������������������������������������������������������������������������������������������������� 46
Conclusion ����������������������������������������������������������������������������������������������������������������������������������������������� 50
References ����������������������������������������������������������������������������������������������������������������������������������������������� 51
GAM REPORT 2020 | 3
List of Figures Figure 1: Trends in HIV prevalence in South Africa, 2016–2020���������������������������������������������������������������������������10 Figure 19: Trends in the numbers of gender-based offences reported to SAPS, 2016/17 to 2020/21����� 26 Figure 2: Prevalence of HIV in males and females in South Africa, disaggregated by age, 2020����������������� 10 Figure 20: South Africa’s legal and policy environment for Commitment 5������������������������������������������������������28 Figure 3: Trends in HIV prevalence among AGYW and ABYM, 2016–2020��������������������������������������������������������10 Figure 21: Knowledge about HIV prevention among young people aged 15–24 years���������������������������������� 29 Figure 4: Prevalence of HIV in South Africa by district, 2020���������������������������������������������������������������������������������11 Figure 22: South Africa’s legal and policy environment for Commitment 6������������������������������������������������������31 Figure 5: Prevalence of HIV in South Africa by province, 2016 and 2020����������������������������������������������������������11 Figure 23: Social Protection in South Africa���������������������������������������������������������������������������������������������������������������32 Figure 6: South Africa’s legal and policy environment for Commitment 1���������������������������������������������������������13 Figure 24: South Africa’s legal and policy environment for Commitment 7������������������������������������������������������34 Figure 7: Trends in number of PLHIV in South Africa, 2016–2020�����������������������������������������������������������������������14 Figure 25: NACOSA primary focus areas in the HIV/AIDS and TB response effort������������������������������������������ 35 Figure 8: South Africa’s achievement of the UNAIDS 90-90-90 targets by 2020���������������������������������������������� 14 Figure 26: South Africa’s legal and policy environment for Commitment 8������������������������������������������������������37 Figure 9: Trends in AIDS-related deaths in South Africa, 2016–2019�����������������������������������������������������������������14 Figure 27: Total expenditure on HIV and TB in South Africa, 2017/18 – 2019/20������������������������������������������� 37 Figure 10: HIV testing volumes and positivity rate among adults in South Africa, 2016–2020��������������������� 15 Figure 28: Breakdown of ART cost by item, 2019/20�����������������������������������������������������������������������������������������������38 Figure 11: HIV testing volumes and positivity rate among children in South Africa, 2016–2020����������������� 15 Figure 29: Percentage distribution of funder’s contributions to HIV intervention categories, 2019/20���� 39 Figure 12: South Africa’s legal and policy environment for Commitment 2������������������������������������������������������16 Figure 31: Regional ART unit cost comparison����������������������������������������������������������������������������������������������������������40 Figure 13: Number of HIV PCR tests conducted at birth (less than 7 days) in South Africa, 2016–2020��� 16 Figure 30: Financial gap in HIV funding in South Africa (2017–2020)������������������������������������������������������������������40 Figure 14: Quarterly number of congenital syphilis cases in South Africa, 2018–2020��������������������������������� 18 Figure 32: South Africa’s legal and policy environment for Commitment 9������������������������������������������������������41 Figure 15: Number of infections transmitted from mother to child at birth and after birth, 2016–2020� 19 Figure 33: South Africa’s legal and policy environment for Commitment 10����������������������������������������������������43 Figure 16: South Africa’s legal and policy environment for Commitment 3������������������������������������������������������20 Figure 34: Co-management of TB and HIV, 2016–2020�����������������������������������������������������������������������������������������43 Figure 17: South Africa’s legal and policy environment for Commitment 4������������������������������������������������������25 Figure 35: TB/HIV co-infected client on ART rate, 2015–2018������������������������������������������������������������������������������44 Figure 18: External and internalized stigma among PLHIV, 2020/2021�������������������������������������������������������������26 4 | List of
Abbreviations NASA
NACOSA
National AIDS Spending Assessment
Networking HIV & AIDS Community of Southern Africa
and Acronyms
NDMP National Drug Master Plan
NDoH National Department of Health
NDP National Development Plan
NGO Non-Governmental Organization
AGYW Adolescent Girls and Young Women
NHI National Health Insurance
AIDS Acquired Immunodeficiency Syndrome
NICD National Institute of Communicable Diseases
ANC Antenatal Care
NHLS National Health Laboratory Service
ART Antiretroviral Therapy
NSP National Strategic Plan for HIV, TB and STIs
ARV Antiretroviral
OST Opioid Substitution Therapy
AYP Adolescents and Young People
OVC Orphans and Vulnerable Children
CBO Community-Based Organization
PCR Polymerase Chain Reaction
CCMDD Centralized Chronic Medicines Dispensing and Distribution
PEPFAR United States President’s Emergency Plan for AIDS Relief
CESAR Centre for Statistical Analysis and Research
PHC Primary healthcare
CHC Community Health Center
PLHIV People living with HIV
CHW Community Healthcare Worker
PMTCT Prevention of Mother-to-Child Transmission
COP Country Operational Plan
PrEP Pre-Exposure Prophylaxis
COVID-19 Coronavirus Disease 2019
PSE Population size estimate
CSO Civil Society Organizations
PWID People Who Inject Drugs
DBE Department of Basic Education
PWUD People Who Use Drugs
DHET Department of Higher Education and Training
SABSSM South African National HIV Prevalence Incidence, Behaviour and Communication Survey
DHIS District Health Information System
SAG South African Government
DOJ&CD Department of Justice and Constitutional Development
SAHRC South African Human Rights Commission
DSD Department of Social Development
SANAC South African National AIDS Council
EID Early Infant Diagnosis
SAPS South African Police Service
eMTCT Elimination of Mother-to-Child Transmission
SASSA South African Social Security Agency
FSW Female Sex Workers
SDG Sustainable Development Goal
GAM Global AIDS Monitoring
SRH Sexual and Reproductive Health
GBV Gender-Based Violence
SMART Specific, measurable, achievable, realistic and time-bound
GDP Gross Domestic Product
SRD Social Relief of Distress
Global Fund Global Fund to Fight AIDS, Tuberculosis and Malaria
Stats SA Statistics South Africa
GPS Governance, Public Safety and Justice survey
STI Sexually Transmitted Infections
HIV Human Immunodeficiency Virus
SWEAT Sex Worker Education and Advocacy Task Force
HTC HIV Testing and Counselling
TB Tuberculosis
IPV Intimate Partner Violence
Thembisa Thembisa Model Version 4.4
LGBTI People with Disabilities, Other Lesbian, Gay, Bisexual,
Model
Transgender and Intersex
TPT Tuberculosis preventive therapy
MDR-TB Multi-drug-resistant TB
UN United Nations
M&E Monitoring and evaluation
UNAIDS Joint United Nations Programme on HIV/AIDS
MMC Medical Male Circumcision
UTT Universal Test and Treat
MSM Men who have sex with men
WHO World Health Organization
MTCT Mother-to-Child Transmission
MTEF Medium Term Expenditure Framework
GAM REPORT 2020 | 5
Introduction PROGRESS TOWARDS THE 2020 FAST-TRACK The 2020 GAM report is important for several reasons. First,
COMMITMENTS AND EXPANDED TARGETS TO END it is the year by which countries should have achieved the
AIDS 90-90-90 targets. Second, it serves as the baseline for the
2016 UNITED NATIONS POLITICAL DECLARATION The 2020 Fast-Track commitments and expanded targets to
revised Global AIDS Strategy 2021–2030, and for moving
ON ENDING AIDS end AIDS resulted from the UNAIDS’ acknowledgement that
towards the global AIDS targets set for 2025 and 2030.
The 2016 Political Declaration on Ending AIDS: On the Fast- Third, it was a peculiar year for HIV services due to the
without a rapid scale-up of HIV services, the epidemic will
Track to Accelerate the Fight against HIV and to End the AIDS Coronavirus Disease 2019 (COVID-19) pandemic. In January
continue to outstrip the response. The Fast-Track approach
Epidemic by 2030 was adopted at the United Nations (UN) 2020, the World Health Organization (WHO) declared the
means working towards the 10 commitments and reaching
General Assembly High-Level Meeting on AIDS in June novel coronavirus an international public health emergency
the following key milestones by 2020.
2016. The Declaration, built on three previous five-yearly and, on 11 March 2020, it declared it a pandemic.1 An
1. Reduce the number of people newly infected with HIV important part of the 2020 GAM report is the impact of
declarations (2001, 2006 and 2011), sets the world on the
to fewer than 500 000 globally by 2020 the COVID-19 pandemic and the associated lockdown
Fast-Track strategy to end the HIV/AIDS epidemic by 2030.
Through the Declaration, all signatory countries, including 2. Reduce the number of people dying from AIDS-related regulations on the HIV response in the country
South Africa, agreed to a laudable agenda to accelerate causes to fewer than 500 000 globally by 2020
efforts towards ending the AIDS epidemic by 2030. 3. Eliminate HIV-related stigma and discrimination by DATA SOURCES AND INCLUSIVENESS OF THE
2020 REPORT
The 2016 Political Declaration on Ending AIDS focuses on
The cornerstone strategy for reaching these milestones is
the five-year period ending 2021. In 2016, the international The South African National AIDS Council (SANAC), which
the 90-90-90 targets, which requires countries to ensure
community reviewed progress towards reaching the 2020 manages the country’s multi-sectoral response to the
that by the end of 2020, 90% of people living with HIV know
Fast-Track commitments and expanded targets to end HIV epidemic, coordinated the 2020 GAM report, as
their HIV status; 90% of people who know their HIV status
AIDS, highlighting that a successful AIDS response should with previous GAM reports. Technical experts from the
are receiving antiretroviral treatment; and 90% of people on
be measured by the achievement of concrete, time-bound Centre for Statistical Analysis and Research (CESAR)
treatment have a suppressed viral load.
targets. The 2016 Declaration calls for careful monitoring synthesized and triangulated diverse data for evidence
of progress in implementing commitments and requires The annual Global AIDS Monitoring (GAM) report is of progress towards the Fast-Track commitments and
countries to issue annual progress reports. the monitoring and evaluation (M&E) document that led the report writing. While short term trends for key
provides evidence of country progress towards the Fast- indicators focused on the last three years (2018 to 2020),
Track commitments and expanded targets. The report interesting comparative analyses between 2016 and 2020
describes the epidemic and status of the national response, were also conducted. Various existing source documents
identifies challenges and constraints, and makes bold were accessed and critically appraised. These included
recommendations to accelerate the achievement of targets. government departments’ annual reports; relevant national
The 2020 GAM report contains South Africa’s monitoring policies, strategies and guidelines; data from national
data and narrative for the year ending December 2020. surveys and bio-behavioral surveys; data from projection
The report is important to the country and its local and models (Thembisa and Naomi models); the country’s
international partners in that it documents the country’s national health management information system; program
progress, so far, towards signed commitments. It is also data; and scientific publications.
important to the country for advocacy and resource
mobilization from local and international partners.
6 | Introduction
STATUS AT A GLANCE POLICY AND PROGRAMMATIC RESPONSE The NSP 2017–2022 involved multi-sectoral partnerships
and embraced innovative interventions with community-
South Africa’s National Strategic Plan for HIV, STIs and
centered delivery in a supportive legal and policy
TB (2017–2022), also written as “NSP 2017–2022”, is the
ON THE FAST-TRACK, NSP 2017–2022 environment. The NSP 2017–2022 identifies the
fulcrum of the country’s response to the HIV/AIDS and TB
To significantly reduce new HIV infections heterogeneity of the epidemic and sets plans to intensify
epidemics. The NSP 2017–2022 is largely aligned to the
To increase the number of people on ART efforts in geographical areas and sub-populations
To decrease HIV-related deaths in the country UNAIDS 2016 Political Declaration, aiming to significantly
disproportionately affected by the epidemic. Also reflected
reduce new HIV infections, increase the number of people
in the NSP 2017–2022 is the 2016 Political Declaration call
on antiretroviral therapy (ART), and decrease HIV-related
for a successful AIDS response to be measured by specific,
deaths in the country, among other targets. Furthermore,
measurable, achievable, realistic and time-bound (SMART)
the NSP 2017–2022 contains the strategic framework for
indicators.
achieving targets set in the period under review.
1 2 3 4 5 6 7 8 9 10
COMMITMENTS
Ensure that 30 Eliminate new Ensure access to Eliminate gender Ensure that 90% Ensure that 75% Ensure that at Ensure that HIV Empower Commit to
million people HIV infections combination prevention inequalities and of young people of people living least 30% of all investments people living taking AIDS
living with HIV among children options, including pre- end all forms have the skills, with, at risk of service delivery increase to US$ with, at risk of out of isolation
have access by 2020 while exposure prophylaxis, of violence and knowledge and and affected by is community- 26 billion by and affected through people-
to treatment ensuring that voluntary medical male discrimination capacity to protect HIV benefit from led by 2020 2020, including by HIV to know centred systems
through 1.6 million circumcision, harm against women themselves from HIV-sensitive a quarter for HIV their rights to improve
meeting the children have reduction and condoms, and girls, people HIV and have social protection prevention and and to access universal health
90–90–90 access to HIV to at least 90% of people living with access to sexual by 2020 6% for social justice and coverage,
targets by 2020 treatment by by 2020, especially HIV and key and reproductive enablers legal services including
2018 young women and populations by health services to prevent treatment for
adolescent girls in high- 2020 by 2020, in order and challenge tuberculosis,
prevalence countries to reduce the violations of cervical cancer
and key populations— number of new HIV human rights and hepatitis B
gay men and other men infections among and C
who have sex with men, adolescent girls
transgender people, sex and young women
workers and their clients, to below 100 000
people who inject drugs per year
and prisoners
Achieved by
end 2020?
If not,
likely to be
achieved by
end 2025?
Yes No
GAM REPORT 2020 | 7
Summary of Progress Commitment 3: Ensure access to combination PLHIV still exist. The overall levels of internalized and external
prevention options, including pre-exposure stigma in 2020 were 23.4% and 15.4%, respectively. Members of
key populations commonly experience stigmatization and poor
prophylaxis, voluntary medical male circumcision,
Towards Commitments harm reduction and condoms, to at least 90%
of people by 2020, especially young women and
treatment when accessing public healthcare.
South Africa has one of the highest intimate partner violence (IPV)
adolescent girls in high-prevalence countries rates in the world, with 29% of ever-married or partnered women
Commitment 1: Ensure that 30 million people
and key populations — gay men and other men aged 15-49 years reporting physical or sexual violence from a
living with HIV have access to treatment through
who have sex with men, transgender people, sex male intimate partner in the past 12 months. South African Police
meeting the 90–90–90 targets by 2020 Service (SAPS) data suggest that IPV increased during the COVID-19
workers and their clients, people who inject drugs
In 2020, there were 7.9 million people living with HIV (PLHIV) in pandemic (2020). However, these reported increases may not be
and prisoners
South Africa. Of those, 92% knew their HIV status. Of those who fully reflected in the national crime statistics for the 2020/21 period
knew their status, 72% were on ART, and of those on ART, 91% Due to the country’s HIV response efforts, HIV incidence in South
because of increased under-reporting by victims. Despite this grim
were virologically suppressed. Thus, by 2020, South Africa had Africa has been on the decline since 2016. In 2016, the total
picture, there have been developments in a positive direction, such
achieved only the first of the three targets since the achievement of number of new HIV infections in the country was 285,000. This
as the introduction of five policy documents in 2019 and 2020; an
the third target is conditional on achieving the second target. declined by 24% to 216,000 in 2020. It is also good news that the
increased number of convictions for sexual offences in 2019 and
declining HIV incidence is observable in both genders and all age
2020; and the 2020 commitment by the media to fight Gender-
The country has continued to revise the policy environment for HIV groups, with the fastest decline during this period seen among
Based Violence (GBV).
treatment in the bid to achieve these targets, with the most recent adolescent boys and young men (ABYM).
policy revisions released in 2019. The 2019 guidelines introduced
an ART formulation that will reduce viral resistance and side effects However, it should be stated that the decline is not rapid enough Commitment 5: Ensure that 90% of young people
and increase viral load suppression. Also, to offset the negative to achieve the NSP target of less than 100,000 new infections by have the skills, knowledge and capacity to protect
impact of the COVID-19 pandemic on this commitment, the country 2021/22. This is because the country’s prevention program has themselves from HIV and have access to sexual
embarked on initiatives to increase the number of PLHIV who not been optimum. Pre-exposure prophylaxis (PrEP) uptake is and reproductive health services by 2020, in
initiate treatment. While the 90-90-90 targets were not achieved by low. Condom use is abysmally low, notably among adolescents order to reduce the number of new HIV infections
and young people (AYP). Key population programs have primarily
2020, the country should work hard to achieve them by 2022, while among adolescent girls and young women to
pursuing the updated UN 95-95-95 targets set for 2025. been left in the hands of civil society and ABYM are often left out
below 100,000 per year
of community prevention programs. And then, in 2020, there was
the negative impact of the COVID-19 pandemic. For example, Although HIV incidence has been declining among young people in
Commitment 2: Eliminate new HIV infections there was a drastic reduction in the number of voluntary medical South Africa, the incidence rate remains high. In 2020, adolescent
among children by 2020 while ensuring that 1.6 male circumcisions (MMCs) from 600,000 in 2019/20 to 130,000 in girls and young women (AGYW), i.e., 15–24-year-old females, had
million children have access to HIV treatment by 2020/21. the highest HIV incidence rate by age group in South Africa (1.35%),
2018 contributing 56,974 to the total 216,008 new infections in the
It is unlikely that the country can achieve the current NSP target country in 2020. This means that there were more than 1,000 new
South Africa did extremely well to drastically reduce new HIV
for HIV incidence by 2021/22. However, if the government can HIV infections among AGYW, weekly, in 2020. Among adolescent
infections among children by 2020. The aforementioned 2019
prioritize increasing comprehensive HIV knowledge among AYP boys and young ABYM, i.e.,15–24-year-old males, there were 16,453
revisions to the HIV treatment guidelines also aimed to reduce
and increasing PrEP and MMC uptake in the general population, new infections in 2020.
unintended pregnancies and arrest the currently high rate of
the target may be achieved by 2025. The role of high ART coverage
postpartum mother-to-child transmission (MTCT) of HIV. Despite
in reducing HIV incidence in the general population should also be Despite these high rates of HIV incidence among AYP, the country
the COVID-19 pandemic, the number of children tested at birth and
highlighted. still lags significantly in ensuring that 90% of young people have
the early infant diagnosis (EID) rate increased annually from 2016
the skills, knowledge and capacity to protect themselves from HIV
to 2020. Furthermore, the percentage of HIV-positive pregnant
infection. The most recent data (2017 and 2019) showed that less
women who received antiretroviral (ARV) medicines to prevent Commitment 4: Eliminate gender inequalities
than 50% of AYP have the necessary skills, knowledge and capacity
MTCT of HIV increased from 2018 to 2020. These efforts resulted and end all forms of violence and discrimination to protect themselves from HIV. Thus, Commitment 5 was not
in the continuous decline of the MTCT rate of HIV at birth, at 12 against women and girls, people living with HIV achieved by 2020.
months, and at 18 months: 0.8%, 1% and 3.5%, respectively, in and key populations by 2020
2020. However, the high rate of postpartum MTCT of HIV needs to However, South Africa continues to look for ways to achieve
Despite being armed with a cocktail of human rights legislation and
be addressed to complete the admirable success the country has this commitment in a bid to realize the vision of the National
policy documents to build a progressive society; the country is far
achieved towards this commitment. Development Plan (NDP) of an HIV-free generation of under-20s
from achieving this commitment. Discriminatory attitudes towards
8 | Summary of Progress Towards Commitmentsby 2030. In pursuance of this, the country introduced the National community-led monitoring of HIV and TB services reflects the the country is yet to fully empower its people to know their rights
Adolescent and Sexual Reproductive Health and Rights Strategy widening involvement of civil society in the national response. The and to access justice and legal services to prevent and challenge
(2019–2030) in 2019 and the National Youth Policy 2020–2030 Networking HIV & AIDS Community of Southern Africa (NACOSA) violations of those rights. The most recent South Africa index
in 2020. By implementing these policies and intentionally taking comprises more than 2,500 civil society organizations (CSOs) Survey (2020/2021), which tracks stigma and discrimination among
educational programs to in-school and out-of-school young people, working in 21 primary focus areas in the HIV/AIDS response. PLHIV, showed that only 54.1% of PLHIV had knowledge of the laws
the country can hope to achieve this target by 2025. that protect people living with HIV from discrimination, and only
Commitment 8: Ensure that HIV investments 56% were aware of organizations that can protect the rights of
Commitment 6: Ensure that 75% of people living people affected by HIV.
increase to US$ 26 billion by 2020, including a
with, at risk of and affected by HIV benefit from quarter for HIV prevention and 6% for Social Nonetheless, the country appears to be doubling its efforts towards
HIV-sensitive social protection by 2020 Enablers achieving this goal. Human rights awareness programs are being
South Africa has a responsive and HIV-sensitive social protection The most recent National AIDS Spending Assessment (NASA) implemented by the government and civil society. There are
system, which ensures care and assistance for poor and vulnerable showed that R37.5 billion was expended on HIV programs programs that provide rights- and ethics-related training to law
populations, as ingrained in the Constitution. About a third of the in 2019/20, which is a R7 billion increase from the 2017/18 enforcement officers, members of the judiciary and healthcare
population benefits from the county’s social safety net. By the end expenditure. This increase in HIV expenditure was due to the workers. Also, the South Africa Human Rights Commission (SAHRC),
of the financial year 2019/20, there were 18.3 million South Africans increased funding commitment from the South African Government an organ of government, monitors human rights violations.
benefiting from one or other forms of social grant. This was (SAG) and its development partners, notably the United States However, some of these programs were interrupted by the
500,000 more than the number of beneficiaries a year earlier. President’s Emergency Plan for AIDS Relief (PEPFAR) and the Global COVID-19 pandemic in 2020.
Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund). About
South Africa’s social protection system is beyond social grants, as
three quarters (71%) of the total HIV expenditure in 2019/20 went Commitment 10: Commit to taking AIDS out of
there are multiple social assistance programs implemented across
into the antiretroviral treatment program. As a result, the fraction of isolation through people-centered systems to
different government agencies. UNAIDS defines HIV-sensitive social
the HIV expenditure spent on prevention was less than the target improve universal health coverage, including
protection as being inclusive of people who are either at risk of HIV
of 25%. Also, less than 6% was spent on social enablers. However,
infection or susceptible to the consequences of HIV. Although the treatment for tuberculosis, cervical cancer and
if the expenditure on the country’s social protection is considered,
South Africa social grants program does not specifically define an hepatitis B and C
the amount spent on social enablers will exceed 6%. The critical
HIV category, it is HIV-sensitive in many ways. This comprehensive This commitment focuses on the linkage of HIV with TB and sexually
issue under this commitment is the widening financial gap in HIV
and expanding social protection system means that the country transmitted infections (STIs). The co-management of TB and HIV
spending in the country. The total HIV expenditure of R37.5 billion
achieved this commitment by 2020. has recently declined. UNAIDS data showed that the proportion of
in 2019/20 was R6 billion less than the amount needed. In 2017/18,
the gap was R2 billion. HIV-positive incident TB cases that were on ART and TB treatment
Commitment 7: Ensure that at least 30% of all declined during the review period. Furthermore, the proportion of
service delivery is community-led by 2020 Although South Africa has done well in mobilizing resources for its the population co-infected with TB/HIV and on ART decreased from
HIV and TB response programs, attainment of this commitment 91% in 2015 to 87% in 2018.
The NSP 2017–2022 paved the way for achieving this indicator by
cannot be confirmed due to the widening gap between needed and
recognizing the need to strengthen community-based responses However, the proportion of PLHIV who started tuberculosis
available resources, the less than 25% spent on HIV prevention
to HIV. SANAC’s role in the HIV response, through its sub-national preventive treatment (TPT) appears to have increased significantly.
programs and the less than 6% spent on social enablers.
structures, and the coordination of civil society multi-sectoral In 2019, the country’s achievement for this indicator was 69%, but
players in the response, has been central to this commitment. the National Department of Health (NDoH) 2020 data showed that
Although there are no clear indicators for measuring the Commitment 9: Empower people living with, at
it was 93% in 2020. It is noteworthy that reporting on all indicators
achievement of this commitment, a conscientious scoping of the risk of, and affected by HIV to know their rights under Commitment 10 was hampered by the unavailability of data.
HIV response landscape showed that South Africa achieved it by and to access justice and legal services to prevent
2020. and challenge violations of human rights
South Africa’s Constitution, considered by many to be the most
Diverse types of non-governmental organizations (NGOs) and
progressive in the world, includes laws that endorse human rights,
smaller community-based organizations (CBOs) play significant
access to justice, gender equality, and non-discrimination of any
roles in the HIV response. These roles include HIV testing and
kind. In addition to the Constitution, other policies and guidelines
counselling (HTC), treatment and care, and advocacy, among
exist to protect human rights and challenge their violations.
others. The formation of the Ritshidze Project in 2019 for
Despite this supportive legal environment for Commitment 9,
GAM REPORT 2020 | 9Overview of the Figure 1: Trends in HIV prevalence in South Africa,
2016–2020
Figure 3: Trends in HIV prevalence among AGYW and
ABYM, 2016–2020
HIV/AIDS Epidemic 13.1% 13.2% 13.3% 13.4% 13.4% AGYW
in 2020 (15 - 24)
OVERALL HIV PREVALENCE AND TRENDS
South Africa’s HIV prevalence, which rose rapidly from lower
than 1% 30 years ago, has plateaued at about 13% in the
last five years, evident by the overlapping 95% confidence
intervals1 in Figure 1. In 2020, the HIV prevalence was 2020
Source: Thembisa Model, V4.42
13.4%, translating to 7.9 million PLHIV in the country. 2 10.4%
2019
Although the HIV prevalence has plateaued, the number
10.8%
of PLHIV continues to increase annually as the country’s Figure 2: Prevalence of HIV in females and males in 2018
population size increases. In 2016, there were 7.3 million South Africa, disaggregated by age, 2020 11.1%
people living with HIV. 2017
2016 11.3%
HIV PREVALENCE BY AGE AND SEX 11.5%
HIV prevalence generally increases with age, reflecting
changes in risk behavior and accumulated risk of infection.
ABYM
The known pattern of HIV prevalence by sex in the country
(15 - 24)
subsists, with women more disproportionately affected than
men. A hurdle that the country continues to face is the fact
that this disproportionality by sex is more pronounced in the
younger age groups, with AGYW from 15 and 24 years old
being three times more likely to be HIV infected than their
male counterparts (Figure 2). 2020
4.0%
It should be noted that, despite the high disproportionality
Source: Thembisa Model, V4.42 2019
in HIV prevalence between AGYW and ABYM, recent trends 4.0%
2018
show a decreasing prevalence in the former group, while
4.0%
3
the prevalence is increasing in the latter (Figure 3).
2017
The ratio of HIV prevalence
3.9%
A 95% confidence interval is a range of values around an estimate where we can be AGYW:ABYM 2016
3.8%
95% certain the true (population) value we have estimated lies. For example, a study
can estimate the HIV prevalence in a population to be 13% and provide the 95%
confidence interval to be 11 to 15%. This means that although the study estimated
the HIV prevalence to be 13%, the researchers are 95% certain that the actual HIV
prevalence in the population lies between 11 and 15%. Source: Thembisa Model, V4.42
10 | Overview of theHIV PREVALENCE BY RACE Figure 4: Prevalence of HIV in South Africa by district, 2020
Race is an important determinant of HIV infection in South
Africa as it is also a determinant of education, income
and health access. The most recent general population
survey (the 2017 South African National HIV, Prevalence,
Incidence, Behaviour and Communication Survey (SABSSM
V)) showed that the burden of the epidemic in South Africa
is overwhelmingly borne by Black Africans (17%), while only
1% of White and Asian South Africans are living with the
virus.
HIV PREVALENCE IN ANTENATAL CARE (ANC)
ATTENDEES
The Thembisa Model Version 4.4 (or Thembisa Model for
short) shows that the HIV prevalence among pregnant
women in the country decreased only slightly from 27.2% in
2016 to 25.7% in 2020. The most recent national antenatal
care (ANC) survey, conducted in 2017 among pregnant
women using public facilities, showed the prevalence to Source: Thembisa Model, V4.42
be slightly higher at 30.7%. The Thembisa Model included
pregnant women accessing private and public healthcare
Figure 5: Prevalence of HIV in South Africa by province, By district
facilities. 2016 and 2020
The Naomi Model allows for the generation of subnational
estimates of HIV prevalence in the country.3 This helps to
HIV PREVALENCE BY GEOGRAPHICAL AREAS
further understand the heterogenicity of the HIV epidemic
By province across geographical subgroups. Sorting the 52 health
The relative distribution of HIV by province in 2020 was districts in South Africa by HIV prevalence shows a pattern
the same as that in 2016. In 2020, the HIV prevalence was that is congruent with HIV prevalence by province. The
highest in KwaZulu-Natal and Mpumalanga provinces and top eight districts (with the highest HIV prevalence) were
lowest in the Western Cape and Northern Cape provinces, in KwaZulu-Natal and Mpumalanga provinces, while the
as it was in 2016 (Figure 5). While the HIV prevalence bottom eight districts (with the lowest prevalence) were in
plateaued in most provinces between these comparative the Western Cape and Northern Cape provinces (data not
years, an approximate 10% increase was seen in the Cape shown).
provinces: 10% increase in the Western Cape and 7%
increase in the Eastern and Northern Cape.
Source: Thembisa Model, V4.42
GAM REPORT 2020 | 11The Naomi Model showed that as of September 2020, the burden of HIV (number of PLHIV) was highest in Johannesburg in Gauteng Province (686,600) and eThekwini in KwaZulu-Natal province (666,000) and lowest in Namakwa in the Northern Cape province (4200) and Central Karoo in the Western Cape province (2900), as shown in Figure 4.3 By urban-rural locality The Naomi and Thembisa models do not provide HIV estimates by urban-rural breakdown. The most recent national estimates of HIV across this dichotomy showed that the HIV prevalence was lower in urban areas (13.2%) than in rural areas (15.2% in tribal rural areas and 17.5% in formal rural areas). HIV PREVALENCE IN KEY POPULATIONS The two largest key populations in South Africa are men who have sex with men (MSM) and sex workers. Their respective population size estimates, as of 2020 were 309,686 and 146,048.4 The Thembisa Model estimated the HIV prevalence in MSM in 2020 as 30.3%, which is a decline from 32.3% in 2016. The prevalence for female sex workers (FSW) in 2020 was 63.8%, down from 67.6% in 2016.1 HIV INCIDENCE In 2016, there were 285,258 new HIV infections in South Africa.2 By 2020, the total number of new infections was 216,008, a 24% decline in four years. This overall decline is examined by age and sex in Chapter 3 of this report. 12 | Overview of the
Commitment 1 CURRENT STATUS AND RECENT TRENDS
viral load suppression. In March 2020, the 2019 guidelines
were updated to include:
5
Number of people living with HIV
Ensure that 30 million people 1. The CD4 count threshold for TB Preventive Treatment In 2020, there were 7.9 million PLHIV in South Africa (Figure
living with HIV have access to (TPT) eligibility in pregnancy was amended from 100 7).2 This is 622,140 more PLHIV than in 2016, when this
treatment through meeting the cells/μL to 350 cells/μL. Declaration was signed. It is notable, however, that the HIV
90–90–90 targets by 2020 2. All clients with a positive CrAg test should be referred prevalence — the percentage of the population infected —
for a lumbar puncture. has plateaued at around 13%. The significant upward trend
3. Removal of resistance testing for adults and in the number of PLHIV (annual increase 155,000, pFigure 7: Trends in number of PLHIV in South Africa, Antiretroviral medicine stock-outs Late HIV diagnosis
2016–2020
The NDoH National Surveillance Center measures the Late HIV diagnosis, the percentage of PLHIV with CD4 count
percentage availability of medicines as they appear less than a particular threshold at the time of diagnosis,
on facility formularies at health establishments.7 The monitors how early PLHIV are diagnosed. Data from the
percentage is calculated as a fraction of the total number of District Health Information System (DHIS) show that late HIV
medicine lines on the formulary at all fixed primary health diagnosis was 30.5% in 2020 when using the threshold of
care (PHC) and community health centers/community dayFigure 10: HIV testing volumes and positivity rate and planning of resources. Data on the positivity rate among and 73% of PLHIV should be virally suppressed. However,
among adults in South Africa, 2016–2020 those tested is important for determining the number of ART coverage remains low. In 2020, the ART coverage was
PLHIV diagnosed, and the effectiveness of testing modalities, a mere 66% — much lower than the target of 81%. The
T E S T V O LU ME POSITIVITY RA T E
in addition to other parameters. Figures 10 and 11 show coverage is lower in men (62%) than in women (72%).
11 2020 6.3% data on both indicators, first for adults 15 years and older;
and for children aged 19 months to 14 years. The number Gaps in policies
of tests conducted among adults increased from 14 to 18 There are gaps in the adoption and implementation of
18 2019 6.7% million from 2018 to 2019 before falling sharply to 11 million policies that affect this commitment. One example is the
in 2020. The positivity rate among those tested continued area of multi-month ART dispensing. South Africa has not
to decrease annually, to 6.3% in 2020. The test volume and yet expanded ART refills for HIV medicines to four to six
14 2018 7.4% positivity rate trends are similarly decreasing in children, but months as the WHO recommends.9
they are lower, as expected.
Children did not exceed 75% for all three
13 2017 8.3% ACHIEVEMENTS treatment fast track targets
The first 90% target achieved in men and women While the first and third 90% targets were achieved in
across all districts adults, children younger than 15 years did not exceed 75%
14 2016 9.2% for these targets.
The Naomi Model allows us to assess the UNAIDS 90-90-
90 targets across all 52 health districts. The data showed
Antiretroviral medicines stockout not negligible
Source: Thembisa Model, V 4.42 that, by 2020, the percentage of PLHIV diagnosed was at
Although the 93% average antiretroviral medicine availability
least 90% in all districts, except in Mangaung Metropolitan
Figure 11: HIV testing volumes and positivity exceeded the 90% current target set by the NDoH, the
Municipality, where it was 89%.
rate among children in South Africa, 2016–2020 shortfall of 7% is not negligible. The percentage translates
T E S T V O LU ME POSITIVITY RA T E Declining AIDS-related mortality into many PLHIV who could potentially default on their
medication and/or be lost to care due to stockouts.
AIDS-related mortality declined by 16% between 2016 and
8 2020 2.1%
2020, when using data from the Thembisa Model; 19%
Negative impact of COVID-19 pandemic
when using data from Statistics South Africa. Data from the
The COVID-19 pandemic and its associated lockdown
13 2019 2.2% Thembisa Model showed that the observed decline in AIDS-
regulations had a substantive impact on the country’s
related mortality in the last five years is sharper from 2018
performance regarding Commitment 1. For example,
to 2020 than from 2016 to 2018. This steeper decreasing
the number of HIV tests conducted in 2020 decreased
trend is unlikely to be related to the COVID-19 pandemic as
11 2018 2.5% dramatically from 2019, and the number of PLHIV starting
the number of deaths in 2020 were similar to that reported
ART declined in 2020 compared to 2019. This is within
in 2019.
the context of the renewed commitment by the NDoH in
10 2017 2.9% 2019 to rapidly initiate more clients. An interrupted time-
KEY ISSUES
series analysis of data from 65 clinics in rural South Africa
Second and third 90% targets not achieved by found a 47.6% decrease in HIV testing after lockdown
10 2016 3.2% 2020 implementation.10 Within the first week of lockdown
If all three Fast-Track targets are achieved, 90% of PLHIV implementation in 2020, ART initiation decreased by
Source: Thembisa Model, V 4.42 46.2%.10
should know their status, 81% of PLHIV should be on ART,
GAM REPORT 2020 | 15Commitment 2
of MTCT of HIV and related infections, including syphilis These revisions, which have been adopted in public and
and TB, a revision to the policy environment regarding this private healthcare settings, are expected to help the
Eliminate new HIV infections commitment became imminent. The most recent revision country surmount the current challenge of the increasing
among children by 2020 while — the National Guideline for the Prevention of Mother to number of babies who acquire HIV infection during the
Child Transmission of Communicable Infections (2019)11 — postnatal period.
ensuring that 1.6 million children provided guidance for:
have access to HIV treatment by CURRENT STATUS AND RECENT TRENDS
1. “Strengthening antenatal and postnatal care for both
2018 HIV negative and positive mothers. Early infant diagnosis
2. The introduction of a dolutegravir-based ART regimen Current testing guidelines recommend that HIV-exposed
SCORECARD which is more efficacious in reducing the risks of infants should have a routine HIV Polymerase Chain
transmission of HIV. Reaction (PCR) test at birth, at 10-weeks for those who
Is this a priority commitment for the country? Yes 3. Promoting integrated management of the mother- tested negative at birth, and at six months for those who
baby pair by aligning prevention of mother-to-child tested negative at 10 weeks, unless indicated by HIV-related
Does the National Strategic Plan address this symptoms. In South Africa, HIV-PCR tests conducted at
Yes transmission (PMTCT) interventions with BANC [basic
commitment?
antenatal care] visits during antenatal period and birth (within seven days after birth) are used for monitoring
Has the country reached the target and Expanded Programme on Immunization visits during this indicator. Figure 13 shows that the number of birth
Yes
commitment? HIV-PCR tests conducted increased from 230,000 in 2016
postnatal period.”
to 286,000 in 2020. The figure also shows the testing
coverage using total births to HIV-positive mothers from
LEGAL AND POLICY ENVIRONMENT Figure 12: South Africa’s legal and policy environment the Thembisa Model Version 4.4 as the denominator. In
for Commitment 2
The commitment to eliminate new HIV infections among 2020, the coverage was 95%. These achievements, although
children by 2020 is one that has been demonstrated by 2019 excellent, may be slightly underestimated, as National
Prevention of Health Laboratory Service (NHLS) testing numbers are for
the development of relevant policies and guidelines that unintended
create the environment for doing so (Figure 12). These preganncies, public health facilities while the Thembisa Model estimates
monitoring of maternal are for the entire country.
policies — heralded in 2013 by the introduction of fixed-
viral load, ensuring
dose combination ARV for all HIV positive pregnant women viral suppression, 2015
post-partum Infant Introduction of birth Figure 13: Number of HIV PCR tests conducted at birth
and mothers and consolidated in 2015 — seek to improve PCR testing to HIV (less than 7 days) in South Africa, 2016–2020
prophylaxis
the quality of treatment and care pregnant women receive exposed babies
No. of PCR
before, during and after delivery. Although South Africa tests at birth EID coverge
2015
230
has achieved great feats in reducing the rate of MTCT of
Immediate
HIV in the country, it has not yet met the WHO’s criteria lifelong ART for 2016
for validating countries that have eliminated MTCT of HIV all HIV positive 74%
pregnant women Millions
infection. The high antenatal HIV prevalence means that and mothers 2013
286
vertical transmission of HIV still exceeds the WHO threshold FDC ART for all HIV
positive pregnant
for eliminating MTCT. 2020
women and mothers 95%
(PMTCT), no need for Millions
As the country continue to strive towards the elimination CD4 results
Source: Corporate Data Warehouse, NHLS12
16 | Commitment 2HIV testing among pregnant women Preventing mother-to-child transmission of HIV
The percentage of pregnant women with known HIV status This indicator measures the number of pregnant women living with HIV who delivered during the past 12 months and
was 90% in 2019 - a decline from 94.8% in 2018.17 The received antiretroviral medicines to reduce the risk of mother-to-child transmission of HIV. The UNAIDS reports that in 2020,
2017 ANC survey reported the HIV testing rate among of the 310,000 women needing ARVs for PMTCT, 299,033 received them (Table 2). This translated to 97% of pregnant HIV-
pregnant women to be 99%.15 In 2020, DHIS data showed positive women who received ARVs for PMTCT in 2020, up from 95% in 2018. The number of new HIV infections averted due
that 1,133,478 women attended an antenatal clinic or gave to the PMTCT program is estimated to be around 52,000 to 55,000 annually from 2018 to 2020.
birth at a facility in the preceding12 months. Out of these,
1,095,716 were tested for HIV or already knew their positive Table 1: Prevention of mother-to-child transmission
status, translating to 97%, which is the same percentage performance indicators in South Africa, 2017–2019
reported in 2018 and 2019.13
Indicator (and data source) 2018 2019 2020
Mother-to-child transmission of HIV
The MTCT rate has continued to drop (Table 1). Data from
Pregnant women who needed
ARV for PMTCT (n)
320,000 320,000 310,000
300,000
the NHLS showed that, in 2020, of the 286,460 babies born Pregnant women who received
ARV for PMTCT (n)
304,933 302,936 299,033 HIV-positive women
to HIV-exposed mothers tested at birth, 2,150 were HIV- reached with PMTCT in 2020
Coverage of pregnant who
positive — a positivity rate of 0.75%. In 2018, the positivity 95% 96% 97%
received ARV for PMTCT (%)
rate was 0.9%.12 The Thembisa Model shows a similar
New HIV infections averted due
estimate of the MTCT rate at birth, viz. 0.8% in 2020.2 54,000 55,000 52,000
to PMTCT (n)
The MTCT rates around two months, at 12 months, and Source: UNAIDS14
later than 12 months, which capture early, mid and later
postpartum transmissions respectively, also continued to Table 2: Mother-to-child transmission rates of HIV in South Africa, 2018–2020
decline, although the numbers and rates were, as expected,
higher than the MTCT rates at birth, which reflects Indicator (and data source) 2018 2019 2020
antepartum and intrapartum transmission of HIV (Table 1). MTCT rate at birth
HIV-diagnosed mothers (NHLS Data) 0.90% 0.79% 0.75%
MTCT rate at birth, 0.75% in 2020 HIV-diagnosed mothers (Thembisa Model) 0.83% 0.80% 0.77%
MTCT rate after birth
HIV-diagnosed mothers at 2 months (NHLS Data) 1.14% 0.92% 0.87%
All HIV-positive women at 12 months (DHIS) 1.75% 1.65% 0.96%
All HIV-positive women at 18 months (Thembisa Model) 3.82% 3.65% 3.48%
Source: NHLS12, Thembisa Model, V4.42 and DHIS13
GAM REPORT 2020 | 17ACHIEVEMENTS
Syphilis among pregnant women Early Infant Diagnosis increased despite the
Congenital syphilis rate COVID-19 pandemic
South Africa’s guidelines for PMTCT includes those for Data from the Congenital syphilis (CS) surveillance
The COVID-19 pandemic appeared to have had little or
screening and treating maternal syphilis, in line with team at the National Institute for Communicable
no impact on the country’s performance for this indicator,
WHO’s call for dual elimination of HIV and syphilis. Diseases (NICD) showed upwards trends in notified
as the number of birth PCR tests conducted by the NHLS
However, because syphilis testing and positivity rate in cases in the last three years, at the rate of seven
increased by about 12,000, from 274,813 in 2019 to
pregnant women are not part of the National Indicators additional cases per quarter (pHence, this 2020 GAM report, as with previous editions The NSP target for congenital syphilis may not be
of the report, presents birth testing data (testing done achieved
within the first seven days of birth), which has a negligible The NSP 2017–2022 aims to “virtually eliminate congenital
likelihood of duplications. The NDoH should work to syphilis by reducing incidence to 50 or fewer cases per
introduce a unique identifier at birth that can be linked to 100,000 live births” by 2022. For this to occur, the incidence
the SA ID number, as the latter is not available at birth. of congenital syphilis in the country should be less than
600 cases annually. However, the incidence data showed
High uninetended pregnancies an upward trend for the last three years and the current
One of the four pillars of PMTCT for HIV in the country is the annual incidence is likely higher than 600, considering that
prevention of unintended pregnancies among women living 373 cases were notified in 2020 from only 23 facilities in 17
with HIV. However, the numbers of unintended pregnancies districts.
remain high in the country, including among teenagers and
women living with HIV. Figure 15: Number of infections transmitted from
mother to child at birth and after birth, 2016–2020
Is PMTCT going down?
Although the coverage of HIV-positive pregnant women who
received ARVs for PMTCT increased from 95% to 97%, from
2018 to 2020, there was a decrease in the absolute number
of women served. It is not known if this decrease was due
to lower projections and target setting at the NDoH, budget
constraints, or the impact of the COVID-19 pandemic. It is,
however, noteworthy that, with decreasing HIV incidence in
pregnant women, if the target for absolute numbers served
is maintained or increased slightly, PMTCT coverage can be
bumped to 100% in the next two to three years.
High post-partum MTCT rate
Although MTCT rate at birth was lower than 1% in 2020, by
18 months, the overall rate was 3.5%, reflecting a high post-
partum transmission of HIV infection from mother to child Source: Thembisa Model, V4.42
(Figure 15). Although the number of post-partum infections
decreased by 25% from 2016 to 2020 (P=0.001), the actual
number remained high.
GAM REPORT 2020 | 19Commitment 3 LEGAL AND POLICY ENVIRONMENT regarding this commitment. The NSP 2017–202218, the
Commitment 3 is another area in which the country has guiding document for the country’s coordinated HIV/AIDS
Ensure access to combination seen rapid and progressive developments in legal and response, is the pivot policy document for this commitment.
policy environment. The laws of the land, and healthcare It sets clear goals and measurable targets to reduce new
prevention options, including pre-
policies and guidelines, do not discriminate against HIV infections among AGYW and key populations. The
exposure prophylaxis, voluntary individuals regarding employment, movement, sexuality, period for the current South African National Sex Worker
medical male circumcision, harm marriage, healthcare or other rights of gay men, sex HIV Plan (2016–2019)19 has ended, and discussions with
reduction and condoms, to at least workers and members of other key populations. SANAC officials have revealed progress in the development
of the next version of the plan, although delayed by the
90% of people by 2020, especially Having dedicated policy documents to reduce new HIV
COVID-19 pandemic. However, at the end of 2020, sex work
young women and adolescent girls infections in the general and key populations is the
remained decriminalized in South Africa.
country’s way of putting its money where its mouth is
in high-prevalence countries and One of the latest additions to the country’s policy framework
key populations—gay men and Figure 16: South Africa’s legal and policy environment for this commitment in the period under review was the
other men who have sex with men, for Commitment 3 South African Guidelines for the Provision of Pre-exposure
Prophylaxis (PrEP) to Persons at Substantial Risk of HIV
transgender people, sex workers and 2020 Infection.20 These guidelines, which were based on research
their clients, people who inject drugs South African Guidelines
evidence and WHO recommendations, were developed by
for the Provision of Pre-
and prisoners exposure Prophylaxis (PrEP)
2020
the NDoH to boost comprehensive combination prevention
to Persons at Substantial Risk
National Drug Master among South Africans. On 26 June 2020, the Minister of
of HIV Infection
Plan 2019–2024 Social Development, Ms Lindiwe Zulu, officially launched
SCORECARD 2018 the fourth edition of the National Drug Master Plan (NDMP)
Health Sector Drug 2019–2024, which reflects the country’s responses to the
Is this a priority commitment for the country? Yes Master Plan
substance abuse problem as set out by the United Nations
2018 Conventions and other international bodies.21 This edition
Does the National Strategic Plan address this Roll-out of PrEP for
Yes of the NDMP acknowledges the ineffectiveness of punitive
commitment? adolescent girls and
young women was approaches to drug control, placing emphasis on rights-
Has the country reached the target and 2017 started at selected
No public clinics
based, evidence-based and multisectoral principles for
National Strategic
commitment? Plan for HIV, TB and social protection and health.
STIs (2017–2022)
How likely is the country to reach the target 2016
Not likely Important legal and policy instruments in South Africa
by 2025? South African
National Guidelines that ensure that AGYW and members of key populations
for Medical Male have access to HIV combination prevention options are
2016 Circumcision
National launch of summarized in Figure 16.
oral PrEP for sex
workers
2016
South African
National Sex
Worker HIV Plan
20 | Commitment 3You can also read
