South Africa's relative development plays a major role in the economic success and political stability of the region. South Africa's relative wealth means that, unlike most other sub-Saharan nations, the government is able to provide over 90% of all funds for its health sector, rather than relying on bilateral aid and NGOs. In absolute terms there is considerable donor support for research in South Africa, as the country combines high incidence rates of communicable diseases with a highly developed infrastucture conducive to research.

South Africa is one of the nations worst hit by the HIV/AIDS epidemic and also has one of the highest rates of tuberculosis in the world. By the end of 2003, it was estimated that 5.3 million South Africans were infected with HIV. The national HIV infection rate among pregnant women attending antenatal services in 2003 was 27.9%, with variation among the country's nine provinces. Undoubtedly, the HIV/AIDS epidemic presents short-term and long-term threats to the development of South Africa.

The degree of commitment to address the HIV/AIDS epidemic in South Africa is comparatively high. Currently, South Africa has a national multisectoral strategic plan for 2003-2005 to fight the HIV/AIDS epidemic, and the government has made some progress in efforts such as providing anti-retroviral therapy to pregnant mothers. This plan, approved in 2003 is titled a Comprehensive National Plan on HIV and AIDS Care, Management and Treatment. One goal of this plan is to provide access to antiretroviral treatment to more than 1.4 million South Africans by 2008.

Malaria is not as serious a health concern for South Africa as is HIV/AIDS. The high-risk areas for malaria are South Africa's northeastern provinces of Northern Province, Mpumalanga and Kwa-Zulu Natal, but most of South Africa lies outside of the malarial zone. The number of reported malaria cases in those provinces grew from about 10,000 in 1989 to well over 40,000 in 1999; in 2003 it was announced that an anti-malarial campaign had succeeded in reducing malaria in Kwa-Zulu Natal by about 90 percent.

Sources: UNAIDS, Government of South Africa (AIDS Plan 2000), Synergy Project, Malaria Research Programme of the MRC

The South African government allocates 15.4 percent of government expenditures to the health sector; this slightly exceeds the proportion pledged in 2001 at the Abuja conference. Government expenditures account for 45 percent of all health sector spending, and health sector spending accounts for 7.5 percent of South Africa's GDP.

In its Health Sector Strategic Framework for 1999-2004 the Department of Health is shifting the focus from ensuring equitable access to health services, to "accelerating quality health service delivery". The ten components of South Africa's Strategic Framework are (as listed in South African Health Review 2000):

1. Decreasing morbidity and mortality rates through strategic interventions
2. Revitalisation of public hospital services
3. Accelerating delivery of an essential package of Primary Health Care services through the Department of Health Services
4. Improving resource mobilisation and management and equity in allocation
5. Improving human resource development and management
6. Improving quality of care
7. Enhancing communication and consultation in the health system and with communities
8. Legislative reform
9. Re-organisation of certain support services
10. Strengthening co-operation with international partners

The Strategic Framework includes timelines and measurable objectives by which to judge the success of implementation.

Despite measurable progress in achieving the goals laid out in the Strategic Framework, and the implementation of DOTS coverage for TB, and a comprehensive National HIV/AIDS Plan, South Africa has not had clear and consistent political leadership in advancing a coherent national health policy. For example, President Thabo Mbeki, has questioned the existence of a link between HIV and AIDS, and the government had opposed the provision of anti-retroviral therapy drugs to pregnant women. However, in December, 2001 the Pretoria High Court ruled that the national government must treat pregnant women with AIDS and their newborn babies with nevirapine.

More positive have been the TB/HIV Pilot Projects the South African Department of Health instituted for April 1999-December 2002 in four districts. To prevent TB the government provides HIV-positive clients in the districts with isoniazid or cotrimoxazole prophylaxis. The Medical Research Council of Canada and staff of the London School of Hygiene and Tropical Medicine (LSHTM) have worked with this project. The WHO reports that 60 percent of adult TB cases are also HIV+ and the expansion of joint HIV/TB activities has been made a priority.

South Africa has adopted the DOTS anti-TB program, and reported a DOTS detection rate of 86 percent for the 2002 cohort, and a treatment success rate of 65 percent in the 2001 cohort. The policy of the government of South Africa is to provide TB diagnosis and treatment as a free service. NGOs are actively involved in South Africa's TB programs. The government of South Africa has provided most of the resources for the anti-TB campaign, but has received some technical assistance from KNCV and CDC, and some financial assistance from USAID, DFID and Belgium. The WHO has estimated South Africa's TB expenditures at around $300 million annually.

In 2003, The South African government approved a long-awaited treatment plan for HIV and AIDS. The program will eventually distribute free AIDS medicine to anyone in South Africa who needs it. Click here to see an article describing the program and the challenges facing its implementation.VOA news

Sources: AllAfrica.com, Business Day (Johannesburg), November 12, 2003; South African Health Reviews; Online NewsHour; LSHTM; United Nations Statistics Division; WHO Report 2004: Global Tuberculosis Control; South Africa Department of Health homepage

Demographic data contained in this section was obtained from the following sources: The Population Reference Bureau’s 2009 World Population Data Sheet was used for total population, life expectancy at birth, infant mortality, fertility, birth rate, death rate, % of married women 15-49 using modern methods of contraception, % of population 15-49 with HIV/AIDS in 2007/2008, and the GNI PPP per capita (2008). Literacy rates were found in the Population Reference Bureau’s publication 2005 Women of Our World. HIV prevalence data for 2001 and 2003 was obtained from the UNAIDS Barcelona 2002 report; HIV prevalence and orphan data for 2005 was obtained from the UNAIDS Report on the Global AIDS Epidemic 2006. Data on the % women who have discussed AIDS prevention with their husband or partner can be found in ORC Macro and USAID’s Women’s Lives and Experiences: Changes in the Past Ten Years (Research Findings from the Demographic and Health Surveys). Childhood malaria mortality data was accessed in 2003 from the United Nations Statistics Divisions’ Millennium Indicators. Tuberculosis data was obtained from the United Nations Statistics Division’s Millennium Indicators: MDGInfo 2006. In some cases information was unavailable.

South Africa's Department of Health (DoH) is responsible for the overall management of the national health infrastructure. The HIV/AIDS and Sexually Transmitted Disease (STD) Directorate is the key national body within the Department of Health which deals with AIDS. Most provincial governments also have separate HIV/AIDS Directorates, or have integrated the HIV/AIDS function within a broader directorate. Besides the provision of key services such as clinics, hospitals, AIDS training, information and counseling centers, the directorate also annually produces a database of AIDS organizations in the country.

The DoH produces a monthly HIV/AIDS and TB newsletter that highlights important issues and developments in South Africa.

Aurum Research Unit, Aurum Health Research

• Alison Grant and other staff of the London School of Hygiene and Tropical Medicine (LSHTM)
• Dick Chaisson of Johns Hopkins University
• Kevin de Cock of the CDC
• Lynn Morris and Clive Gray of the National Institute for Virology, Johannesburg, SA

Tuberculosis studies conducted by this group include:

• A cohort study to investigate the effect of tuberculosis on the progression of HIV disease in South African mineworkers. The study began in 1999 and analysis of HIV viral load in TB/HIV dual-infected miners is in progress in 2002.
• A cohort study to investigate the effect of a special clinical service on a population of HIV-infected mineworkers. This study investigates TB preventive therapies using isoniazid and/or cotrimoxazole in an HIV-positive population.
• Recurrent tuberculosis: relapse or reinfection?
• Phenotypic and functional analysis of CD8+ T cells in patients with tuberculosis and/or HIV infection. This study investigates the hypothesis that TB impairs human immune response to HIV.
• Randomised controlled trial to determine the effectiveness of annual vs. 6-monthly screening with mass miniature radiography (MMR) for the active case-finding of tuberculosis. This study is funded by SIMRAC, South Africa.
• Provisional assessment of the impact of adding sputum screening to existing active case findings methods in a gold mining workforce. This study is also funded by SIMRAC.

Source: LSHTM

Global Alliance for TB Drug Development, South Africa c/o Medical Research Council ( website )

The primary objective of the GATB is to work with the international pharmaceutical industry to develop new TB drugs.

Medical Research Council, South Africa (MRC) ( website )

Its Cape Town office is one of three governing sites for the Global Alliance for TB Drug Development (GATB), and its staff works to ensure that high-burden countries in Africa, Asia, and Latin America participate in the research.

The MRC has a five-year cooperative agreement to research the challenges of multi drug-resistant tuberculosis and HIV in South Africa, including the use of modern technology to promote rapid data collection and transfer and to improve the capacity to address MDR-TB in rural areas.

The MRC serves as the base for the South African AIDS Vaccine Initiative, involving the collaboration of hundreds of international scientists engaged in the search for an effective and safe HIV vaccine.

Epidemiological projects track emerging trends in the spread of diseases, including HIV/AIDS, tuberculosis, and malaria.

The MRC has collaborated with the Buffalo City Municipality to develop a strategy for response to HIV/AIDS, including an HIV prevalence study, to conduct a Knowledge, Attitudes and Practice study, and to combine the research with a voluntary counseling and testing program. With the expertise of economists, the city was provided information on the cost implications of HIV to the municipality in its role as a major employer.

MRC maintains the African Trials Register (http://www.mrc.ac.za/ATR/), a database for all health trials conducted in Africa and published in any journal.

The MRC continues to investigate applications of new technologies, including Telemedicine, telecommunications, and the Internet to strengthen the provision of primary health care services.

The MRC’s Unit for Clinical and Biomedical Tuberculosis Research Unit conducts clinical research in TB and HIV, including examining TB and HIV interaction.

The MRC’s HIV Prevention Research Unit is conducting research on microbicides and other barrier methods. The unit works closely with the International Partnerships on Microbicides, the International Working Groups on Microbicides, and the Global Campaign on Microbicides.

Its Malaria Research Lead Program conducts research comparing the efficacy of insecticide treated bed nets and residual house spraying. It also researches insecticide resistance and is engaged in a project examining malaria within refugee camps.

These are just examples of MRC’s work: please see the Key Funders section below for more in depth descriptions of research performed by several of the MRC’s research divisions.

Source: http://www.mrc.ac.za/

Medical University of Southern Africa (MEDUNSA) ( website )

Santa Cape Town

• Educating the community.
• Instituting DOTS coverage.
• Establishing care groups for people with TB.

South African HIV Vaccine Action Campaign (SA HIVAC)

The South African National Institute for Virology (NIV) ( website )

• WHO Collaborating Center for Haemorrhagic Fevers and Arboviral Diseases.
• WHO Poliovirus Regional Reference Laboratory.
• National Laboratory for Influenza.

University of Cape Town, Faculty of Medicine

Another drug development study affiliated with the University of Cape Town is investigating the anti-mycobacterial properties of red algaes for efficacy against MDR-TB. Dr. Denise Saravanakumar is the PI for this study. Source: WHO MDR-TB Research Database

University of Natal, Faculty of Medicine ( website )

The Health Economics and HIV/AIDS Research Division at the University of Natal is an important center of research into the economic impact of the epidemic, and the costs of responding to it.

The University of Natal is affiliated with the Africa Center for Population Studies and Reproductive Health, located at King Edward VIII Hospital, the teaching hospital for the university. The Africa Center is funded by the Wellcome Trust; its core research team has years of experience studying perinatal HIV transmission (including participating in the PETRA study). The Africa Center is coordinating HIVNET trials in Hlabisa.

Professor Noddy Jinabhai of the University of Natal is leading a study of MDR-TB in HIV positive and negative patients. Source: WHO MDR-TB Research Database

University of Pretoria, Centre for the Study of AIDS ( website )

Established in 1999, the Centre for the Study of AIDS at the University of Pretoria has the goal of "mainstreaming" the response to HIV/AIDS at the University. The Centre is involved in:

• Developing home based care kits for the treatment of AIDS, TB, cancer and other deadly diseases.
• Conducting community outreach.
• Collaborating with the South African AIDS Vaccine Initiative.

University of Stellenbosch, Faculty of Health Sciences - School of Medicine ( website )

University of the Free State, Faculty of Health Sciences ( website )

Professor P.N. Badenhorst is the research chairperson for the Faculty of Health Sciences.

University of Transkei (UNITRA), Faculty of Medicine and Health Sciences ( website )

University of Witwatersrand ( website )

Wits is affiliated with the Perinatal HIV Research Unit (PHIVRU) at Chris Hani Baragwanath Hospital in Soweto. The Reproductive Health Research Unit (RHRU) at Wits, directed by Dr. James McIntyre and Dr. Helen Rees, is involved in HIV/AIDS research, training (including distance education programs), and policy and advocacy. PHIVRU and RHRU are participants in both the UNAIDS PETRA study and the HIVNET of NIAID.

1. Future plans for developing the health sector in South Africa are contained within the Health Sector Strategic Framework for 1999-2004 (see the National Health Policy section above). To fulfill this plan, government expenditures to fight AIDS are rising quickly. South Africa's HIV/AIDS budget for 2001-02 was R342 million, and the government is projecting a budget of R3.6 billion for 2005-06.

2. The GFATM has approved two grants to fight HIV/AIDS in South Africa. The grants are for $15.5 million and $8.4 million, respectively. Grant agreements have not yet been signed.

   Source: GFATM