But the prospect of the South African government being able to meet its target of treating 80 percent of those who need it by 2011 is being threatened by a lack of funds.

A number of organisations and prominent AIDS officials condemned the ‘€œflat-lining’€ of donor funds at the recent international AIDS conference in Vienna.

Last year, donors contributed $7.6-billion to the international fight against HIV/AIDS, slightly down from $7.7-billion the year before, according to the Kaiser Family Foundation.

Yet in order for more people to be put on life-saving medication, more money needs to be spent. South Africa alone needs an extra R2-billion a year to reach all those who need antiretroviral treatment.

Scenario planning by the SA Treasury indicates that the demand for treatment and care will peak in 2021, when the country would need close to R30-billion.

‘€œWe are facing a double whammy of having to rapidly scale-up spending on HIV/AIDS at the same time that we have to replace donor funds,’€ said Dr Keith Cloete of the Western Cape Treasury.

‘€œFor the next five to 10 years, we need additional funds. This is not the time to pull out funds as programmes are going to collapse,’€ said Cloete, addressing a meeting of South African projects funded by the US President’€™s Emergency Plan for AIDS Relief (Pepfar) earlier in the year.

In the current budget year, Pepfar contributed R4,3-billion to the country’€™s ARV treatment programme ‘€“ almost matching the government’€™s total contribution of R5-billion, according Treasury.

Last December, the US government announced that it would be giving South Africa an extra $120 million (approximately R900 million) ‘€œin direct response to a request from President Jacob Zuma’€ to ‘€œprocure ARVs will help ensure that there are adequate stocks on hand to meet the growing demand for ARVs in South Africa’€.

This followed ARV shortages most notably the Free State, which suspended its HIV treatment programme as it had overspent it budget.

However, the extra Pepfar contribution is regarded as being exceptional and not likely to be repeated, according to Dr Roxana Rogers, USAID South Africa Health Team leader.

While Pepfar officials speak of making a transition from an ‘€œemergency plan’€ to a ‘€œsustainable programme’€, the prospect of additional US funding for the ARV treatment programme is remote.

Instead, donors and government alike are trying to find ways to cut costs. The first is the actual cost of ARVs, with South Africa paying around 20 percent more for ARVs than the cheapest drugs on the market. This is partly due to costs charged by Aspen, the generic pharmaceutical company that won the tender to supply ARVs to government.

The tender ran out in May and a new one has not yet been issued, but Health Minister Aaron Motsoaledi has made it clear that government is looking for the cheapest options.

Another problem, according to US health analyst and author Laurie Garrett, is the shortage of ‘€œgood news’€ about progress sub-Saharan African countries are making to prevent new HIV infections.

HIV prevention has been painfully slow, yet as health economist Professor Alan Whiteside says: ‘€œHIV treatment without prevention is like mopping the floor while the tap is running.’€

In South Africa the antenatal HIV infection rate (measuring HIV among pregnant women) has declined slightly over the past four years ‘€“ but is nowhere near the scale that is needed to turn the tide against HIV.

Bill Gates, the world’€™s biggest single donor to HIV/AIDS, told the Vienna AIDS conference last month: ‘€œWe have to be honest with ourselves: We don’t have the money to treat our way out of this epidemic. Even as we continue to advocate for more funding, we need to make sure we’re getting the most benefit from each dollar of funding and every ounce of effort.’€

Gates advocates ‘€œa new focus on efficiency, especially in prevention’€ that focuses on:

• Scaling up existing prevention tools such as male circumcision and preventing mother-to-child transmission.
• Focusing prevention efforts on high risk communities such as men who have sex with men, injecting drug users and sex workers.
• Innovations in basic science, including vaccines, new diagnostics and antiretroviral-based prevention (pills, injections and gels).

However, until these efforts start to make a significant impact, money to treat all those who need ARVs is going to be in short supply and rationing is likely to occur in which the poor, rural and most marginalised groups will once again suffer the most.