HIV/AIDS in South Sudan past, present, and future: a model of resilience in a challenging context

The Republic of South Sudan (RSS) is the newest state in the world which earned its independence on the 9th July 2011, following a peaceful secession from Sudan through a referendum in January 2011. In barely about 2.5 years after independence, the country ran into civil crisis starting on 15th December 2013, and refreshed in July 2016. The situation caused massive displacement and health systems disruption. The aim is to reflect on the HIV response in South Sudan despite the challenges of continued conflicts, displacement, and system disruption. Published data, as well as unpublished data available at the HIV Directorate in the Ministry of Health have been reviewed, including the HIV National Strategic plans, ANC sentinel Surveillance data, surveys and special studies, annual Health Management Information System cumulative reports from routine programmatic data (HTS, PMTCT, ART, TB/HIV, retention on care) and the UNAIDS spectrum data. The HIV epidemic in South Sudan is categorized as low and generalized (2.7%), with pockets of HIV concentration among key and vulnerable populations; who have a prevalence of 5% or more. The epidemic is thought to be widely variable across the country and geographically concentrated in the southern states of the greater Equatorial region formerly known as Western Equatoria with HIV prevalence of 6.8%, Central Equatoria 3.1%, and Eastern Equatoria 4.0%. The primary mode of infection is heterosexual exposure followed by mother-to-child transmission during pregnancy, at birth, and through breastfeeding. About 42% of the new HIV infections occurred mainly in clients of sex workers, while men and women involved in casual sexual relationships accounted for 14.5% of new infections. Female sex workers (FSWs) themselves only contributed to 11.2% of new HIV infections. Children born by HIV infected mothers accounted for 15.7%. In post conflict era in South Sudan, there is an urgent need for global initiative to conduct epidemiological studies about HIV. This will not only help peoples of South Sudan but will also increase our knowledge about how conflict and war can contribute in the spread of infectious diseases. Importantly, there are valuable lessons to learn from the South Sudan experience in terms of persistence and resilience during war and peace as HIV interventions continued to be implemented in a challenging context. Unless a strong health system is developed and sustained, building a sustainable HIV response will continue to be a challenge, and a lot more will be required.