The statistics laid out by the Honorable Dr. Aaron Motsoaledi, South African Minister of Health, during the Dean’s Distinguished Lecture at Harvard School of Public Health on March 30, 2011, were stark: South Africa has less than 1 percent of the world’s population but 17 percent of the global HIV-positive population. Nearly one in three women in the country is infected with HIV, with rates highest among girls and women of childbearing age. More than half of the deaths of young children are caused by HIV/AIDS. Babies who are HIV-positive are dying at a rate 15 times higher than uninfected babies.
“It is an epidemic that has grown so strong that it has changed mortality as we understand it,” Motsoaledi said. “When did this state of affairs occur? Does it take a lifetime for an epidemic to change a country? The answer is no.” In 1997, the highest number of deaths occurred among South Africans ages 75-79, he said. But in 1998, “HIV started biting and changing everything as we know it.” By 2005, South Africans in their mid-30s were dying in far greater numbers than the elderly.
Since his appointment in 2009, Motsoaledi has worked to reverse the tide. He developed a 10-point plan — which includes implementing a national health insurance plan, revitalizing the health care system’s physical infrastructure and accelerating efforts to tackle HIV/AIDS and tuberculosis — and had government ministers sign a compact holding them responsible for health outcomes.
In 2010, the government launched a massive HIV/AIDS counseling and treatment campaign with the goal of testing 15 million people by June 2011. In an attempt to overcome the stigma that prevents many South Africans — especially men — from getting tested, the campaign began by testing the president and other members of the government, prominent members of civil society, and Motsoaledi himself.
Those who test positive are provided with information and access to interventions to enable them to manage their health and to prevent HIV transmission to others. The program has so far tested 7 million people, counseled 9 million, and identified 1.4 million HIV positive people. Individuals in the program also receive testing for other conditions, including tuberculosis and diabetes.
Motsoaledi also faces the daunting challenge of changing human behavior. In South Africa, he said, “HIV is a disease suffered by women but caused by men.” He blamed intergenerational sex for the similarities between infection rates among teenage girls and older men. “Most of the young girls who are HIV-positive are actually orphans,” said Motsoaledi. “It becomes a vicious cycle. You’ve got women dying and leaving their children alone. They become vulnerable to older men who’ve got money because they cannot survive. We’ve got lots of orphans who are developing HIV because they had sex at an early age with a married man. That’s a problem we are struggling with.”
South Africa also carries a heavy tuberculosis burden—the highest rate of infection per 100,000 people in the world. Seventy-three percent of HIV-positive South Africans also suffer from tuberculosis. Motsoaledi is working to integrate HIV- and TB- treatment sites to better serve the co-infected, and implementing new testing methods that can rapidly tell whether a patient is infected with a drug-resistant strain.
In the long-term, Motsoaledi hopes to transform the South African health care system from centering on hospitals to making better use of primary care.
HSPH Dean Julio Frenk praised Motsoaledi for his leadership. “We look forward to bringing you back to the School many times, and observing and supporting your efforts,” Frenk said. “What happens in South Africa affects and inspires the world.”