Who is responsible for achieving HIV epidemic control? Responses to the HIV ‘treat all’ guideline recommendation among health systems actors in South Africa

In this thesis I explore how the global HIV pandemic, and the networks and constellations of stakeholders and agendas that have emerged from its response, have catalysed novel responsibilities for health systems actors in an HIV response in South Africa. I focus on a historical moment in the HIV response: the shift from antiretroviral treatment (ART) initiation based on disease progression and illness, towards a universal ‘treat all’ approach in which all people living with HIV are immediately eligible for treatment. South Africa, which contributes more than 20% of the global HIV burden and 15% of new infections, adopted this approach in 2016 to alter its epidemic trajectory toward control. However, successful implementation required expanding the ART programme from 5.6 million to 8.45 million people. At the policy’s adoption, the Health Minister called for an ‘all of government and all of society response,’ emphasising individual and collective responsibility for HIV testing and treatment. Drawing on my embedded experience within South Africa’s HIV research and service delivery programmes, I explain how responsibilities to ‘treat all’ people living with HIV were diffused, distributed, and shared (consciously or unconsciously) across multiple levels of the health system—including programme managers, frontline workers, community members, and people living with HIV. Through the imposition of policies and practices, the analysis highlights how the global HIV agenda produces relationships, obligations, and moral frameworks that did not exist before, and significantly impacts and shapes responsibilities of individuals towards themselves, towards others, and towards global and local public health imaginaries.