Through our analysis of routinely collected PEPFAR monitoring data we found that in order to support the provision of antiretroviral treatment to a increasing number of people in need in South Africa, new governmental and nongovernmental facilities were rapidly capacitated to provide treatment. Despite health system constraints and the SAG's initial reluctance to show full support for a national ART program, [7
] the proportion of government facilities supported increased dramatically, as did the number of persons treated at governmental facilities.
The flexibility of PEPFAR to partner with both the private and public sector allowed for an initial engagement with the private sector, as it was equipped to assist in a quick roll-out of access to ART, followed by a transition to supporting a larger proportion of governmental facilities. Because governmental sites reach more individuals and are supported by the South African government scale-up of ART, supporting governmental sites may have a larger impact and be more sustainable. Flexibility in the scale-up of supported facilities allowed for this shift in the proportion of PEPFAR-supported sites with recorded management type from 32% public in 2005 to 44% public in 2009. While there were over 700 non-governmental facilities supported, about 65% were general practitioner sites with fewer than 10 patients. Additionally, the increase in number of persons treated at governmental sites indicates not only a PEPFAR ART scale-up, but also reflects the SAG's expanded commitment to universal access to treatment. The reduction in the median number of patients per facility in private facilities may indicate that as services become available in public facilities, people are less reliant on private facilities for treatment. Our findings are consistent with previous estimations of the number of persons on treatment by facility type, which showed that beginning in 2005 more people were on treatment through public sector sites than NGO or private and also that the increase in persons on treatment was more rapid in the public sector than non-governmental or private [9
From 2005 to 2009 the geographic distribution of facilities continued to be focused in areas with high numbers of persons living with HIV, but also shifted to increase coverage across all provinces, suggesting a move toward deliberate scale up [2
]. KwaZulu-Natal is the province with the largest number of persons living with HIV (approximately 1,489,972 persons in 2009), followed by Gauteng and Eastern Cape (approximately 1,132,901 and 674,420 persons respectively in 2009) [10
The number of facilities may have been underestimated, as some implementing organizations did not report the number of facilities. However, most of these reports were hospitals, not clusters of facilities, indicating that they were indeed only one facility. Because almost one third of patients on treatment were reported from partners with aggregated facilities, the median size of the facilities may be skewed. In addition, the reduction over time in the number of facilities reporting that they provide treatment services, but not reporting persons currently on treatment, suggests an improvement in the quality of reporting.
The rapid scale-up of access to ART was a "game changer" in the fight against HIV & AIDS [12
]. Treatment coverage has greatly increased, and was estimated to be about 85% in 2010 [1
]. To continue providing assistance toward increasing coverage and maintaining treatment for many years to come, next steps will involve making the transition from an emergency oriented program to one that is focused on sustainability, on achieving cost efficiencies, and on full alignment with the SAG priorities and systems [13
]. This will include transitioning from international to local implementing partners and increasing support for the SAG. PEPFAR technical assistance will increasingly emphasize health system strengthening, capacity development, quality of care, as well as innovative strategies such as nurse initiated and managed ART to provide sustainable, long-term access to care.