National Health Insurance
The Impact of HIV on a Future NHI

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South Africa has the largest number of people living with HIV/AIDS in the world, estimated to be some 5.7 million people by 2009, or 11.7% of the total population. This policy brief deals with predicting the course of the epidemic, costings of treatment that have been performed and the success of HIV disease management programmes. The intention is to gather the best available material for use when costing the impact of HIV and related diseases on a future NHI system.

The early history of the HIV/AIDS epidemic in Africa is summarised by UNAIDS and the World Health Organisation (WHO) as follows: “In 1981, a new syndrome, the acquired immune deficiency syndrome (AIDS), was first recognized among homosexual men in the United States. By 1983, the etiological agent, the human immunodeficiency virus (HIV), had been identified. By the mid-1980s, it became clear that the virus had spread, largely unnoticed, throughout most of the world.”

“Most of the available epidemiological data indicate that the extensive spread of HIV started in sub-Saharan Africa in the late 1970s. By the early 1980s, HIV was found in a geographic band stretching from West Africa across to the Indian Ocean, [while] the countries north of the Sahara and those in the southern cone of the continent remained apparently untouched.” But the epidemic began to move south.

Prof Rob Dorrington of the University of Cape Town (UCT) records that the “first two AIDS cases in South Africa were diagnosed in 1982 with the first recorded death occurring in 1985 (although there were undoubtedly others before this that went unnoticed).  By the end of 1990 Pattern II (heterosexual) had overtaken Pattern I (homosexual/bisexual) as the dominant form of transmission of the reported cases.  Pattern I transmission appears to have peaked around 1990. By February 1993 all but two of the 46 cases diagnosed as AIDS from 1982 to 1986 had died.”

Dorrington warned in 1999 that “South Africa has all the ingredients to ensure that the HIV/AIDS epidemic in this country will be the most explosive and extensive of any country in the world:

• the most developed infrastructure (roads, railways, airports, urban conglomerations) of any country in Africa;
• an entrenched system of migrant labour;
• the return of an estimated 40 000 MK guerrillas (from Zambia, Uganda, Angola and Tanzania, countries with a high prevalence of HIV) and their distribution to military bases throughout the country [see Shell for more detail on these issues];
• a changing of priorities and the influx of refugees due to a long war for southern African independence; and the worst drought this century (1992-93) coupled with economic structural adjustment programmes in most countries not 'at war'; ...
• the early stages of the epidemic were mismanaged by an illegitimate government who only as late as 1992 permitted the advertising of condoms on TV (and then only late at night). 
• Followed by the first democratically elected government whose primary concern, perhaps understandably, was to ensure transformation.”

Yet the “blue-print” for South Africa’s health system after the transition to democracy, the ANC Health Plan of 1994, recognised that “HIV/AIDS is emerging as a major public health problem”. Forecasts to the year 2005 were given, including the expected numbers with HIV, expected deaths and expected number of orphans. “In view of the devastating implications of the HIV/AIDS epidemic for South Africa, it is mandatory to define prevention and control interventions plus comprehensive care for those already infected, within the context of the Bill of Rights”.

The ANC policy on HIV/AIDS5 said: “HIV/AIDS must not be addressed as a single issue or by a vertical programme. A multi-sectoral approach is a pre-requisite for the containment of the spread of the infection. HIV/AIDS must therefore be taken into account in all policy areas.” Specific measures included:

• Development of an education programme for school children, adolescents and teachers, around health promotion, including sexuality and safer sexual practises. ... All schools to be running comprehensive education programmes on a regular basis by January 1996.
• Develop and implement an effective HIV/AIDS strategy by end 1995.
• Develop STD/HIV counselling and support services at all Community Health Centres (CHCs) by end 1999.”

Yet very little of this plan was implemented and AIDS-denialism took hold. Dorrington quotes a letter by Donald McNeil to the Mail and Guardian in 1999: “Many South Africans still don't believe in AIDS because they haven't seen enough bodies yet.  But they will.  It's going to change this country in ways no one is able to predict.”

The graph below shows that cumulative AIDS deaths are estimated to have exceeded 1 million by 2004 and are expected to exceed the total number of people living with HIV by 2017, some 6 million people. The crucial years for the expansion of the epidemic were from the early 1990s when attention of the governments of the day was on political issues rather than healthcare. The period 1994 to 2003 saw an increase in total HIV infections from an estimated 533,000 to 4,742,000 people.

Figure1 : Waves of the HIV/AIDS Epidemic in South Africa using the ASSA2003 Model

Combination therapy drug treatment for HIV becoming available from 1996 onwards but was initially unaffordable in Africa. The Treatment Action Campaign (TAC) was launched on 10 December 1998, Human Rights Day, “by a small group of political activists”.  Using a combination of “negotiation, litigation, and mobilization”, TAC was instrumental in getting substantial reductions in the drug prices for ARVs and pathology costs needed for on-going patient testing. TAC then turned its attention to the delivery of public sector health in South Africa. Heywood quotes Prof Leslie London: “The TAC, … has shifted the debate firmly to one of fundamental human rights and utilized the human rights machinery established by the same government to force its hand on the ARV issue.”

It was only in 2003 that the South African Government approved a plan to provide ARVs in the public health system and these began to be rolled out from 2004. South Africa is now judged to have the largest antiretroviral treatment programme in the world. In 2007 the South African Cabinet endorsed the HIV & AIDS and STI National Strategic Plan for South Africa, for the period 2007-2011. This was hailed for the broad consensus finally reached between Government and civil society on a comprehensive approach to HIV/AIDS. The document reflects the sentiments originally expressed in the ANC Health Plan of 1994 of the need for a multi-sectoral approach.

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