The National Strategic Plan is a dynamic document that needs to be adapted through regular reviews of the evolving HIV epidemic, emergence of new knowledge on factors contributing to the epidemic or HIV prevention and treatment and impact of programmes being implemented.   Monitoring of activities that are outlined in the NSP is as important as evaluating the impact of these activities on the goals of reducing transmission of HIV, morbidity and mortality rates and reducing stigma and discrimination.

The South African National AIDS Council (SANAC) remains a key structure to play this role. The rapidity with which the new secretariat is able to be fully functional and operational will determine how effective it can be in fulfilling this role as a country co-ordinating mechanism and maximising cooperation between all sectors within and outside government.

On the global science front, we have seen how biomedical advances on vertical transmission and treatment have substantially reduced HIV infection in infants and transformed AIDS from an inevitably fatal condition to one that is a chronic, manageable one. Scientific advances, centrally around the use of ARVs to reduce vertical transmission, treat infants and adults and prevent HIV infection has injected new hope that the epidemic can be controlled reflected in optimistic talk of an AIDS-free generation, and the 3 zeroes (0 new infections, 0 deaths and zero stigma and discrimination.

An urgent and important task is to determine the role of PrEP (pre-exposure prophalaxis) and TasP (treatment as prevention) for South Africa and map out what the critical next steps are for programming.  Are there niche populations for TasP eg sex workers, truck drivers and migrant workers and for PrEP and who are they?   In the meantime research efforts to find an effective  microbicide, vaccine and cure continue.

As a country how are we doing implementing what we know works?  The most robust data we have come from the Department of Health. Data from the rural district of Hlabisa, one of three highest burden HIV districts in the country demonstrate that a modest 30-40% coverage of HIV infected individuals being initiated on ARV treatment based on DOH treatment guidelines of CD4 counts <200  has resulted in an 11 year  increase in life expectancy in this community. Overall, while good progress is being made on reducing vertical transmission and treatment access; preventing HIV infection remains a major challenge.  In terms of vertical transmission infant drug formulations and reducing HIV transmission through breastfeeding remain a challenge.

So why are we not seeing the kind of impact on the HIV epidemic that we would like to see?  There are at least four factors contributing to this:

• age-sex difference in HIV infection with young women a key driver of the epidemic and lack of availability of women initiated prevention technologies; weak health care delivery systems unable to achieve coverage rates of needed interventions or introduce new interventions;
• stigma and discrimination; and gender-power dynamics that underlie the vulnerability of those who bear the brunt of the burden of HIV.

A key and unique feature of the HIV epidemic in South Africa is the age-sex difference in HIV acquisition patterns.  Young women acquire HIV infection about 5-7 years earlier than men.  Young women in the 15-19 year age group have about 4-6 fold higher rates of HIV infection than their male peers.  Inter-generational sexual coupling patterns with young women aged 15-19 years with males in their mid-twenties and older is a key driver of the epidemic and our failure to prevent HIV infection in young women equals our failure to control the epidemic.  Preventing HIV infection in young women under 20 years is key to altering our current epidemic trajectories.

There is some evidence showing that women who complete 12 years of schooling have a seven-fold reduced risk of HIV acquisition compared to those who abandon their schooling earlier.  Gender based violence is also associated with higher HIV acquisition rates. High teenage pregnancy and rates of other sexually transmitted infections highlight that HIV prevention efforts in young women have to meet their sexual and reproductive health needs.

A key obstacle to prevention and care efforts remain stigma and discrimination.  AIDS related stigma and discrimination compounded with other forms of stigma and discrimination such as those based on sexual orientation, moral and judgmental attitudes with respect to age of sex debut, gender and recreational drug use.  It creates a vicious cycle of silence, ignorance, fear, and denial or personalisation of HIV risk.  It is a key reason why we continue to see people dying of AIDS, up to 500 000 in 2011 alone.

Window of opportunity

Our understanding of the HIV/AIDS epidemic, the collective body of knowledge on prevention and treatment and political and budgetary commitment provides a unique window of opportunity to South Africa to alter current epidemic trajectories for local and global benefit.  This confluence of factors enables us to effect a paradigm shift in our response.  Within this context, what are some of the key considerations for smarter and more effective implementation:

• Prioritise high HIV burden districts and key populations.  Although South Africa has a generalized epidemic there is a diversity of dynamic epidemics within and between provinces.  We need to shift from doing a little for everyone to focusing on geographical hotspots (districts in the country bearing a disproportionately high burden of HIV infection) or key populations driving the epidemic
• Intensify a customised comprehensive effort in these hotspot communities and populations  based on a nuanced understanding of key factors contributing to the epidemic in that community. Move away from a cookie cutter or magic bullet approach to a more customized set of evidence based activities responsive to the local epidemic
• Strengthening of health care delivery systems.  Sufficient and adequate infrastructure and resources and structural improvements are urgently needed to create a seamless integrated facilities.  Of particular important is ensuring good infection control to minimise health care facilities becoming a source of infection especially TB.  Ongoing training and support of health care workers to rapidly incorporate the policy changes that are required to make an impact on health outcomes and ensure a growing cadre of well-trained health workers who the ability to be trained to rapidly implement systems and procedures to undertake what needs to be done.  Strengthening of supply chain systems to minimise treatment interruptions and ensure comprehensive service delivery.  Health information systems that enable and inform decision making at the coalface.
• A more concerted and focused effort to reduce HIV infection in young women.  For young men and women adolescent friendly SRH services and treatment services that can be accessed at health care facilities and in school.  Knowledge is a pre-requisite and the existing life orientation school based programmes should be expanded to integrate SRH Information into into HIV prevention efforts.  At a school and community level a norms that eliminate inter-generational sex, reduce alcohol and substance abuse, eliminate  gender based violence, teenage pregnancies and foster high school completion rates can make a difference as we await biomedical advances.  At an individual level interventions that support internalisation of HIV risk, how to overcome peer pressure and create confidence in the future could complement the community efforts. Simple interventions in schools to separate out adult from child learners, reduce overcrowding in classrooms, support school completion rates for female learners, social services to learners from vulnerable/child-headed households are immediate things that can be done.