The new NSP contains a vast number of broad and specific targets. It would be impossible to discuss all of them here. Instead, we have selected for discussion some of the most interesting targets set by the new NSP. These targets are grouped and contextualised within the wider strategic objectives of the new NSP in order to demonstrate how specific targets are informed by the broad objectives and vision of the NSP.

Each strategic objective set by the NSP has a number of sub-objectives which provide more detail on how we can focus attention on the identified areas of concern. In future issues we will examine many of these targets and strategies more closely.

Strategic Objective 1:

Focus on Social and Structural Approaches to HIV and TB Prevention, Care and Impact

This objective emphasises the social, economic, political, cultural and environmental factors that lead to increased vulnerability to HIV, STIs and TB. These factors include unemployment, insufficient social services, income inequality, poor infrastructure, inefficient legal services and questions of gender justice. The strategic objective to focus on structural and social approaches to HIV and TB has eight sub-objectives.

Amongst others, Sub-Objective 1 states: “The poor living conditions in informal settlements provide fertile ground for HIV, STI and TB transmission, as well as the spread of many other communicable diseases, especially amongst children – mainly as a result of the lack of proper building materials, and the lack of access to basic services like sewerage, electricity and running water as well as lack of food security.”

In addition to identifying the conditions which increase vulnerability to HIV, TB and STIs, the NSP also stipulates that the state should identify and address “structural barriers to accessing HIV, STI and TB services to residents in informal settlements”.

Furthermore, the NSP requires that a national plan be developed to achieve this goal and identifies specific government departments that are responsible for making this happen.

Strategic Objective 2:

Prevention of HIV and TB Infections

The new NSP places great emphasis on combination prevention. This means that a combination of different interventions is required to slow the rate of new infections. These interventions can be structural (like increasing access to nutrition and transport), medical (including voluntary medical male circumcision), social (such as changing social norms that discriminate against homosexuals), or behavioural (like promoting correct and consistent condom use and reducing multiple and concurrent partnerships). The strategic objective to prevent HIV and TB infections has eight sub-objectives.

Amongst others, Sub-Objective 2 aims to: “prevent vertical transmission of HIV to reduce mother-to-child transmission to, at least, less than 2% at six weeks and less than 5% at 18 months by 2016.”

This will require the proper integration of prevention of mother-to-child-transmission services into primary health care and effective post-natal follow-up, including strengthening infant feeding practices.

Other interesting targets which flow from the ‘prevention objective’ include:

• 10 million people to be both tested for HIV and screened for TB in 2012. This target rises to 30 million for 2016.It is only through knowing one’s status that appropriate interventions and services can be accessed. Furthermore, evidence that early treatment initiation can decrease the risk of transmitting HIV and keep people with HIV healthy, should encourage early testing and screening in order to initiate treatment as soon as possible.
• 500 million male condoms and 9 million female condoms to be distributed in 2012. These targets rise to 1 billion and 20 million respectively by 2016. The low targets for female condoms are disconcerting given that new and better female condoms are due to be approved by the World Health Organization (WHO) in the coming months. Female condoms are one of the few female-initiated prevention interventions available to us and efforts for increased roll-out should be strongly supported.
• 500,000 males to undergo voluntary medical male circumcision in 2012. This target rises to 800,000 by 2016.New evidence showing that the risk of HIV transmission amongst circumcised men is reduced by up to 60% resulted in the roll-out of a national medical male circumcision programme in 2010. The new NSP aims to scale-up these efforts to reach 80% of men between 15-49 years of age by 2016.
• Reduce new TB infections by 50% against 2010 levels by 2016. This will require prompt diagnosis, improved infection control and a seamless link between screening, diagnosis and treatment.
• Provide antiretroviral treatment to 58% of those in need by 2012. This target rises to 85% by 2016. At the end of 2009, an estimated 37% of people with HIV were receiving treatment for HIV, according to the latest WHO guidelines (2010). Antiretroviral programmes must increase in size, accessibility and efficiency in order to provide these life-saving medicines to all who need them. In the wake of growing evidence that ARV treatment dramatically reduces onward transmission of HIV and decreases the risk of opportunistic infections which cause a spike in viral load, the scale-up of antiretroviral treatment is key to prevention efforts.

Strategic Objective 3:

Sustain Health and Wellness

The focus of this objective is to achieve a “significant reduction in deaths and disability as a result of HIV and TB infection through universal access to accessible, affordable and good quality diagnosis, treatment and care.”

The Department of Health’s plan to ‘re-engineer primary health care’ will see a radical expansion of primary health care services with an emphasis on community-based care services. Community-based services, are crucial to expanding the quality and reach of health and wellness services, which will help to improve diagnosis, follow-up, adherence and retention in care.

In addition to bolstering primary health care services, this objective places great emphasis on early treatment, in line with mounting evidence that earlier treatment is both beneficial for patients and reduces onward transmission.

The following key steps are identified in order to ensure earlier treatment:

• All ART must be started within 2 weeks of staging and adherence eligibility being confirmed;
• All ART must be started within 8 weeks of starting TB treatment;
• All TB treatment must be started less than 2 days after confirmation of TB at screening site (<5 days for MDR-TB);
• All primary care, antenatal, TB and mobile outreach health facilities must become fully functional nurse-initiated ART and MDR-TB initiation sites for adults, children and pregnant women;
• Unless clinically indicated otherwise, all patients started on ART and MDR-TB treatment should be managed at the primary health care level;
• Ensure 90% treatment success rate for drug susceptible TB (60% for MDR-TB).

Other interesting targets include:

• 70% of all TB patients and pregnant women must be initiated on lifelong antiretroviral treatment by 2012. This target rises to 100% by 2016.
• 20% of clinics must provide services on weekends and after hours by 2012. This target rises to 90% by 2016.
• Refugees, legal foreigners and undocumented migrants must have equitable access to TB screening, HIV testing and appropriate treatment in line with Department of Health policies and guidelines.

Strategic Objective 4:

Protection of Human Rights and Promotion of Access to Justice

The law has played a key role in ensuring access to treatment in South Africa. However, many legal challenges remain. The NSP takes as a starting point the constitutional recognition that access to health care and other social services – which includes reproductive health care – is itself a fundamental right. In fact, it could be argued that the state has a constitutional obligation to implement many of the legal reforms suggested under this objective of the NSP. This objective has four sub-objectives.

Amongst others, this section calls for reform of South Africa’s Patents Act 57 of 1978, which may unconstitutionally limit access to medicines by providing patent protection in excess of what is required under international trade law, thereby preventing the market entry of generic competition necessary to bring medicine prices down and ensure sustainability of supply. TAC has recently launched a campaign calling for such patent reform.

The NSP also requires a process that must result in the tabling of a bill to decriminalise adult sex work by no later than 30 June 2013.

Unlike the previous NSP, the new NSP identifies responsible government departments for many of the proposed legal reforms and sets concrete deadlines for specific steps to be taken. It is essential that we hold government departments accountable in this regard over the coming years.