Emergence of universal antiretroviral therapy coverage in South Africa: applying the advocacy coalition framework to refine the narratives and inform current policy making processes

South Africa possesses the largest anti-retroviral therapy (ART) program in the world but the path to this record was dramatic. There is scarce literature employing a comprehensive framework to explain this ART policy change and inform current policy making processes. This paper applies the Advocacy Coalition Framework (ACF) to analyse the interactions among diverse actors, institutions and networks that were associated with the ART policy change in South Africa. Post-apartheid, HIV/AIDS and AIDS-related mortality were serious public health problems. At the time, the discernible coalitions in the AIDS policy subsystem were the prescience coalition and AIDS dissidents. In view of the availability of compelling scientific evidence on the pathogenesis of HIV/AIDS, the clinical usefulness of ART, the availability of funding for national ART roll-out, strong global advocacy to reduce the cost of ART, all of these in an era when access to adequate HIV care was increasingly considered a human right, the environment to establish an appropriate ART policy for the country was conducive. However, AIDS dissidents dominated the policy agenda via their control over key institutions, the use of various dimensions of power, biasing evidence to inform policy, and promoting the activities of strong interest groups that were not in support of ART. National ART roll-out ultimately emerged as a political priority as a result of external shocks (on the ART policy subsystem) which disfavoured the dominant coalition. Failure to supplement this application of the ACF with key pubic policy concepts such as power dimensions, evidence use in policy, governance and emergence of global health networks would have led to suboptimal appraisal of the ART policy change and misinformation of current policy making processes.


Introduction
The advent of antiretroviral therapy (ART) has greatly revolutionized HIV care and over the years, tremendous efforts to expand ART coverage have been observed in resource-limited settings [1]. In sub-Saharan Africa where over two-thirds of persons infected with HIV live, up to 12 million people were reported to be on treatment by 2016 [2]. This corresponded to an estimated double fold increase in ART coverage over the preceding five years [2]. With regards to South Africa, the country with the largest national ART program in the world [3][4][5], the path to national ART roll-out was extremely dramatic and even linked with the death of hundreds of thousands of persons living with HIV/AIDS [6]. Even though the country's pursuit of national ART roll-out post-apartheid has been extensively described using diverse approaches [7,8,17,[9][10][11][12][13][14][15][16], there is scarce literature applying a comprehensive framework to analyse the roles of state and non-state actors who were involved in the process of AIDS policy change. In view of this important gap in the literature and the intense ideological conflicts which characterized the quest for national ART roll-out in South Africa, this paper employs the Advocacy Coalition Framework (ACF) of Sabatier and Jenkins-Smith [18,19] to analyse and summarize interactions among diverse actors, institutions and networks that were associated with AIDS policy change in South Africa. A Medline search was done using the terms 'HIV' OR 'AIDS' OR 'anti?retroviral', AND 'polic*' AND 'South Africa' and their variations, with search periods from 1981 to 2019 to gather relevant published data on and evidence of the entire ART policy change process in South Africa. The authors also draw from other essential public policy concepts to further clarify the policy analysis.

Applying the Advocacy Coalition Framework (ACF) to South Africa's struggle for national antiretroviral therapy (ART) roll-out
Essential points about the ACF [18,19] The ACF proposes that a policy agenda or policy change is the result of competition among coalitions that exist within policy subsystems. A coalition comprises actors, institutions, networks or interest groups that share common fundamental belief systems regarding issues within a subsystem. Belief systems range from the way issues are perceived or framed (deep core beliefs) to solutions (policies) that should be formulated to address the issue (policy core beliefs). According to the ACF, belief systems are scarcely backed by personal interests but the exact motives for supporting specific coalitions are varied. In the long run, core beliefs tend to remain stable, but changes in secondary aspects of belief systems may occur even in the short run. Nonetheless, a shock from within (internal shock) or out of (external shock) a policy subsystem could potentially lead to adjustments in belief systems or major policy changes in favour of specific coalitions. Based on the ACF, some actors do not belong to any coalition but contribute to the policy-making process by promoting opportunities for coalitions to negotiate and come to compromises. These actors are referred to as policy brokers. Policy-oriented learning, a means by which coalitions improve their understanding of variables which are consistent with their policy cores, continuously occurs within and across coalitions.

Coalitions in South Africa's AIDS policy subsystem post-apartheid
There were two discernible coalitions in the country's AIDS policy subsystem post-apartheid.
AIDS dissidents comprised the minority (yet dominant) coalition. Their deep core beliefs were that HIV is harmless and does not lead to AIDS. They also believed symptoms of AIDS were consequent to poor nutrition, poverty and ART. They strongly discouraged ART by focusing on its toxic effects. Their policy core beliefs were that improvements in nutrition with food such as garlic, lemon juice, and beetroots could serve as treatment for HIV/AIDS. at the 16 th international AIDS conference had views that matched with this coalition [21].

The rise of AIDS dissidents
The first AIDS-related deaths occurred in 1981 and 1982, but little attention was accorded to the epidemic over the following decade [22]. In 1992, civil society advocated for the creation of the National AIDS Convention which produced a national AIDS plan. Two years later, the plan was adopted by Nelson Mandela's government [8]and two members of the team that drafted the plan (Dlamini-Zuma and Tshabalala-Msimang) were appointed first postapartheid health ministers. This bottom-up approach favoured by Mr Mandela's regime to tackle HIV/AIDS appeared to be effective as more cases were detected, and the prevalence of HIV rose from 0.8% in 1990 to 4.3% in 1994 [22]. Again, such an approach in a unitary state possibly indicated the pro-democracy stance of the then regime. distributing untested products in the country [23]. After the court ruled in favour of the TAC and SAMA, Tshabalala-Msimang made public declarations suggesting that ART were toxic, adding that she was being forced to give 'poison to her people', nutrition was more beneficial, and patients had the right to choose their treatment strategies. These assertions led to confusion among persons living with HIV/AIDS and there was widespread drop of ART for scientifically indefensible remedies. As was previously illustrated, such use of power as thought-control mechanism seemed to be an important strategy used by dissidents to sustain their policy core beliefs.

AIDS dissidents succumb
The

Discussion and Conclusion
Knowledge of the actors, context and processes involved in the AIDS policy making is key to understanding the direction of change of the policy as is the case with other policy changes.
Nonetheless, historical analyses highlighting the variety of instruments that could be employed by the actors is also fundamental to elucidate the drivers of major policy changes nowadays. The ACF is generally applied to domestic contexts as its initial construct was designed to understand how different actors worked together through the policy process to implement change in the United States environmental policy [26]. In this paper, we expand the application of the framework to the transnational level by capturing various actors, networks and institutions at the international scene that actively fostered core beliefs of coalitions. It is worth mentioning, in passing, that Sabatier et al had long encouraged the application of the framework on a wider scope [19] even though this is still lacking in current proposition of rolling-out ART as the products of conspiracies spear-headed by Western societies and he therefore countered every effort to roll-out ART in his high authority as president [31]. In line with the ACF, this may have been the origin of his core belief as an AIDS dissident and slowed down national ART roll-out. On the other hand, albeit the second part of the Sarafina play received several criticisms, it can be argued that the production of such a play illustrates that its initiators had framed HIV/AIDS in South Africa as an issue requiring the use of complex biosocial interventions and not just ART for the effective control of the pandemic.
Even though the ACF is one of the most comprehensive frameworks for explaining policy change, failure to borrow from other public policy concepts such as governance and policy implementation, dimensions of power, framing of global health issues, evidence use in policy and emergence of global health networks to supplement the ACF would lead to suboptimal appraisal of the AIDS policy change and misinformation of similar policy making processes.
Such complex system systems thinking approach should not only serve to better understand policy making processes but should also provide insights into the potential downstream effects of adopted policies and strategies to appropriately fine-tune them for population health gains.
The main limitation of this paper is that the historical analysis was not supplemented with evidence from key informant interviews and other qualitative data collection methods. This could have provided more perspectives on the policy change process and how the AIDS policy change was embraced by key stakeholders.