HIV epidemic control in South Africa: An analysis of shifting responsibilities between 2011 and 2019

This paper examines how shifting global health agendas focused on controlling the global HIV epidemic shape responsibilities among health system actors within a national HIV response. Focusing on South Africa-the country with the largest number of people living with HIV in the world-I examine two moments where such responsibilities were negotiated. First, the shift from a largely donor-funded programme to one of full government ownership, highlighting the tensions between donor and government implementers in this moment of change. Second, the shift in HIV treatment guidelines from eligibility based on disease progression to a 'treat all' approach in which all people living with HIV are immediately eligible for treatment. Drawing on ethnographic research conducted within South African HIV implementing organisations between 2011 and 2019, I explore how diverse health systems actors responded to evolving treatment landscapes and broader HIV agendas. I explain their actions, often out of sync with global HIV agendas, not as resistance, but as logical responses to constrained realities in context. The analysis demonstrates that as responsibility continues to shift amid declining external funding, prioritising embedded, context-specific knowledge will be essential for enabling pragmatic, locally tailored programme transitions and sustaining epidemic control.