The following is a letter by the Treatment Action Campaign and AIDS and Rights Alliance for Southern Africa to U.S. Secretary of State Hillary Clinton about recent policy changes in the direction of PEPFAR and other assistance dealing with HIV and AIDS.

Dear Honourable United States Secretary of State Hillary Clinton,

We, the leaders of the Treatment Action Campaign and the AIDS and Rights Alliance for Southern Africa, greatly appreciate the assistance the United States has provided to tackle HIV/AIDS. We recognize the support of President Obama's administration for an evidence-based approach to the epidemic. However, we are concerned about the future of HIV/AIDS prevention and treatment programmes in Southern Africa. As you are aware, 5.5 million people are living with HIV in South Africa. While Western countries are experiencing AIDS fatigue and reluctance to sustain their financial support for HIV/AIDS prevention and treatment programmes, the reality in South Africa is that more than 1,000 people are newly infected with HIV each day [1]. Over half of the HIV-positive people in need of immediate access to life-saving antiretroviral treatment (ART) are currently unable to access the treatment [2].
Recent research has shown that ART is not only effective in treating HIV, but also in preventing HIV transmission [3]. An important epidemiological model published in the Lancet in December 2008 argued that universal, voluntary HIV testing with immediate initiation onto ART of all HIV-positive people could theoretically eliminate the epidemic by 2050 [4].

In controlling the HIV epidemic, the prevention-of-mother-to-child-transmission (PMTCT) of HIV is essential. In South Africa, the rate of childhood AIDS mortality is four times higher than adult mortality. PMTCT is a vital health service because of the dire consequences which result when it is not available to HIV-positive mothers. It is more cost-effective to treat HIV/AIDS at its earliest stages or to prevent transmission in the first place than to delay access to treatment, which later necessitates expensive clinical care as people living with HIV suffer from opportunistic infections due to their compromised immunity. The ART roll-out has been proven to reduce infant mortality, raise life expectancy and reduce HIV incidence [5]. To scale back or 'flatline' HIV/AIDS funding in South Africa therefore lacks both fiscal and moral insight. Results from the South African Children with HIV Early Antiretroviral Therapy (CHER) trial showed that starting ART before 12 weeks of age significantly reduced early mortality by 76% and HIV progression by 75%. These results show that treating HIV-positive infants is highly beneficial and cost-effective.

While PMTCT can prevent mothers from transmitting HIV to their infants, it does not address the underlying circumstance of the mothers' infection. The national HIV infection rate among young, South African women between ages 25-29 is very high at approximately 33%. The gender inequality that exists within South Africa is not coincidental with the high rates of rape and HIV-infection [6].  In a study aimed at understanding the intersections between rape and HIV in South Africa, it was found that men who had been physically violent were more likely to be HIV-positive, and more likely to engage in risky sexual behavior. It is vital that rape survivors have access to post-exposure prophylaxis (PEP) to prevent HIV infection and PMTCT services if necessary [7].
The release of the HSRC (Human Sciences Research Council) Third National Study of South African HIV Prevalence, Incidence, Behavior and Communication, presented encouraging data about the efficacy of South Africa's HIV prevention and treatment programmes. Among the successes reported were a reduction in HIV prevalence in the teenage population and a significant increase in reported knowledge of HIV status among the 15-49 age group [8]. However, the HSRC study presented evidence that there are still many goals that must be met, including reducing the 33% HIV prevalence rate among females in the 25-29 age group.

During the United States election campaign, President Obama promised to increase PEPFAR funding over the next few years in line with the growing demand for TB/HIV treatments as African patients continue to seek out the best biomedical remedies for these co-epidemics [9]. This promise has been diluted, as the President's latest proposal offers a significantly reduced increase of $100 million to the PEPFAR budget. This increase is far below what is needed, and will result in opportunities lost to strengthen African health, including through more effective HIV prevention. Moreover, President Obama's administration proposed no increase in US government funds to the Global Fund to Fight AIDS, Tuberculosis and Malaria – which is now facing a deficit of up to $6 billion.

We would also like to echo the concern of numerous partner organisations working on health in the developing world regarding the Concept Paper on Foreign Aid Reform which is currently passing through the House Committee. We are anxious that the authorization levels contained in the Lantos Hyde legislation would be effectively repealed should the changes outlined in the Concept Paper be implemented. This will have a negative impact on the predictability of funding, and therefore the sustainability of essential health interventions in the developing world. It would also compromise the momentum toward meeting international commitments on AIDS, TB and malaria.

Multi-year commitments are essential for effective health aid and the US should be strengthening its multi-year commitments. This will ensure the greater predictability of aid, which is a key donor commitment of the Paris Declaration (reinforced by the Accra Agenda for Action). Multi-year commitments would also enable civil society organisations as well as governments to strengthen structures of transparency and accountability to funders.

On 19 July 2009, TAC and our partners launched the Resources for Health Campaign in response to the dire need for sustained and increased funding for HIV/AIDS prevention and treatment methods in South Africa. Protests against long ART waiting lists and stock-outs of essential drugs, condoms and formula milk took place across the country. Funding constraints are already forcing health clinics to stop enrolling new patients onto ART. After urging patients to get tested and seek treatment, clinics have to turn people away who need treatment immediately to survive. It is possible that, when faced with the lack of ART, patients could start to share their drugs or decrease their doses, leading to drug-resistant strains of HIV [10].

In late 2008, the Free State province of South Africa instituted a moratorium on providing ART to new patients due to funding constraints. The moratorium has since ended, but about 30 additional people died each day that it was in place. Reports indicate that, even now, the effects of the moratorium continue to be felt. Across South Africa there are long waiting lists for ART, and frequent shortages of essential medical supplies. An important study conducted in the Free State showed that 87% of people who died while enrolled in the public ART program in the province were not accessing ART [11]. Furthermore the South African Department of Health is currently R1 billion short of the amount needed to meet the National Strategic Plan's targeted number of people on ART for 2009 [12].

While there have been many successes in treating and preventing HIV/AIDS in South Africa, serious challenges remain. Increased funding for treatment and prevention programmes is essential if these challenges are to be addressed. Failing to continue to support the roll-out of ART for prevention and treatment of HIV/AIDS translates into the direct loss of human lives. We hope that you will do everything within your power to protect the lives of women and children in South Africa at risk of being infected with HIV/AIDS, and of not being granted access to life-saving ART, by sustaining the assistance of the United States government.

We would greatly appreciate the nearest opportunity to discuss these issues further with you.

Yours sincerely,

Vuyiseka Dubula
General Secretary of the Treatment Action Campaign

Nonkosi Khumalo
Chairperson of the Treatment Action Campaign

Paula Akugizibwe
AIDS and Rights Alliance for Southern Africa

Footnotes

1. Dubula, V. South African politics post election, what do they mean for women and access to quality health? Treatment Action Campaign Women's Leadership Training Briefing, Johannesburg, 2009.
2. Thom, A. Africa: Conference ends in optimism. Health-e Cape Town; All-Africa, 2009, retrieved 29/7/09 from http://allafrica.com/stories/200907250002.html.
3. Natrass, N. and Gonsalves, G. Economics and the Backlash against AIDS-specific Funding, paper presented at the WHO/World Bank/UNAIDS Economics Reference Group, 2009.
4. Granich, R; Dye, C; De Cock, K; Williams, B. Universal voluntary HIV testing with immediate antiretroviral therapy as a strategy for elimination of HIV transmission: a mathematical model, Lancet 373:48-57. 
5. Natrass, N. and Gonsalves, G. Economics and the Backlash against AIDS-specific Funding, paper for the WHO/World Bank/UNAIDS Economics Reference Group, 2009.
6. The Global Coalition on Women and AIDS. Violence Against Women, 2009, retreived 30/7/09 from http://womenandaids.unaids.org/issues_violence.html.
7. Jewkes, R. Sikweyiya, Y. Morrell, R. Dunkle, K. Interface of Rape and HIV in South Africa, MRC Policy Brief, June 1-2, 2009. 
8. Human Sciences Research Council, South African National HIV Prevalence, Incidence, Behavior, and Communication Survey 2008, June 2009.
9. Mugyenyi, P. Flatline funding for PEPFAR: a recipe for chaos, Lancet, June 25-Jul 31, 2009.
10. Ibid.
11. Thom, A. Africa: Conference ends in optimism, Health-e Cape Town, All-Africa, 2009. Retrieved 29/7/09 from http://allafrica.com/stories/200907250002.html.
12. Ibid.