Fifty-three thousand — yes, 53,000! That’s the number of people estimated to have died of Aids-related complications in South Africa in 2024. While Aids is no longer prominent in the public eye, it continues to impact our society, our health services and our economy.
This is despite the impressive progress that’s been made in the last two decades, especially in the rollout of treatment to about 6.2-million people in South Africa. While treatment availability has directly slashed Aids-related deaths, our country still has much to do to reduce Aids deaths closer to zero.
A look at how the numbers have changed in the last 20 years tells a story of the bumpy transition from despair to hope to disappointment. In 2004, the year that South Africa initiated its Aids treatment programme in the midst of Aids-denial despair, there were 280,000 Aids-related deaths, as estimated by the Joint United Nations Program on HIV/Aids.
Fast forward to 2014 and this number dropped three-fold to about 81,000 deaths, principally due to treatment access and rollout. In the last 10 years, Aids-related deaths continued to decline, but at a much slower rate. This success story of an 80% reduction in deaths in the last 20 years — never to be taken for granted — created much hope, built on a celebration of partnerships between government, industry, civil society and non-governmental organisations.
The global reductions in foreign assistance, led by abrupt US funding cuts, have placed an even greater stress on Aids control programmes — to get more done with less. While the concept itself is not bad, its brusqueness was harsh, giving little opportunity for transition planning. Several US-funded projects ground to a halt. US-funded HIV-related health services were forced to close.
But this progress has now slowed, disappointingly. As with almost all on-the-ground programmes, initial enthusiasm and commitment drive uptick at the start, but there will be those that are hard to reach and those who refuse to take Aids treatment. Programme planners often describe this as a “last-mile” phenomenon — that it takes a disproportionately large effort to get to the last 20%. At the rate at which our country’s progress has slowed, the goal of ending Aids as a public health threat by 2030 is now in jeopardy.
The global reductions in foreign assistance, led by abrupt US funding cuts, have placed an even greater stress on Aids control programmes — to get more done with less. While the concept itself is not bad, its brusqueness was harsh, giving little opportunity for transition planning. Several US-funded projects ground to a halt. US-funded HIV-related health services were forced to close.
The brutal stop work orders forced thousands of health-care workers into the unemployment line. Several Aids research projects were halted immediately. In the face of this challenge, South Africa found itself more fortunate than other African countries, with our HIV treatment programme remaining largely intact as our government had been paying for more than 80% of the programme costs, including all antiretroviral medication. Many of our neighbouring countries, which relied much more heavily on US funding, principally through Pepfar, were not as fortunate. Even reinstatement of some Pepfar funds months later cannot undo the damage and disruption of their abrupt cuts.
Since the initial US funding cuts, foreign assistance has also been cut by the UK and several other European and Scandinavian countries, driven by US demands that Nato members increase their military spending. The multitude of funding cuts comes at a time when even greater resources are needed to successfully navigate the last mile on the way to the 2030 ending Aids goal.
This is not the time for tears of disappointment. This is a time for us to return to the drawing board as we embark on this really difficult “last mile”
But this is not the time for tears of disappointment. This is a time for us to return to the drawing board as we embark on this really difficult “last mile”. As we focus on protecting and bolstering the core elements of treatment and prevention in our country’s Aids control programme, we must reduce wastage, cut back on low impact components and exploit opportunities for improved efficiency — for strong and effective leadership to forge a path forward and to achieve more with less.
South Africa is well placed to overcome disruption and transform its Aids response. It is blessed with long-established community partnerships. It is a country that overcame Aids denialism to become exemplary in its Aids response. South Africa has a deep, unshakeable commitment to fighting this scourge. It has followed the science and it has science on its side.
New, long-acting prevention technologies like Lenacapavir are now available. New approaches using digital technology are available to support treatment adherence. We have the capacity, technology and skills to reduce Aids deaths even more and to substantially reduce new infections. In the face of funding cuts, we are not a nation of defeatists; we are a nation ready to find new ways to defeat the threat of Aids and to rise up to meet the daunting challenges of the “last mile”.
• Karim is director of the Centre for the Aids Programme of Research in South Africa (Caprisa)
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