SANAC releases first NSP report

SANAC releases first NSP report
‘...although the THEMBISA model indicates declines for all age groups and both sexes, the HSRC estimates that incidence has increased among females aged 15-49 and 15-24.”
‘…although the THEMBISA model indicates declines for all age groups and both sexes, the HSRC estimates that incidence has increased among females aged 15-49 and 15-24.”

In 2011, the SANAC Plenary, chaired by the then Deputy President of South Africa, Kgalema Motlanthe, adopted the National Strategic Plan 2012-2016 (NSP). The responsibility to monitor the implementation of the NSP lies with the SANAC Secretariat. For the first time in more than a decade the Secretariat now has a Monitoring and Evaluation (M&E) Unit and has produced its first report of progress against the goals, objectives and targets set in the NSP. The report is late and covers the first year of the NSP. A second report will be published soon covering Year Two of the NSP. This will be rapidly followed by a mid-term review that covers the first two and a half years of the NSP. In this article we provide the reader only with the highlights of the report as described in the five main goals of the NSP.

Goal 1 Reducing new HIV infections by at least 50 percent, using combination prevention approaches

• There are now 6.4-million South Africans living with HIV.
• HIV incidence (percentage) in the 15-49 year age group has decreased from 1.79 in 2008 to 1.47 in 2012.
• HIV incidence is highest among young women aged 15 to 24, at 2.83 percent.
• A recent survey estimates that one quarter of all new HIV infections is in young women between the ages 15 to 24 pointing to major epidemic drivers underlying this phenomenon.

The NSP 2012-2016 utilises the 2008 HSRC survey finding of HIV prevalence of 8.7 percent among 15-24 year old youth as a baseline for a targeted 50 percent HIV prevalence decline of 4.35 percent in 2016. Using 2012 data as a baseline, the 50 percent HIV prevalence decline target for 2016 is 3.55 percent. A prevalence of 7.1 percent was measured in 2012, indicating a decline of 18 percent since 2008.

According to all three approaches to estimating HIV incidence in South Africa, there has been a decline in HIV incidence from 2008 to 2012 among the population aged 15- 49. However, although the THEMBISA model indicates declines for all age groups and both sexes, the HSRC estimates that incidence has increased among females aged 15-49 and 15-24. Spectrum estimates show a 19 percent decline in incidence for males and females aged 15-49, from 1.9 percent in 2008 to 1.54 percent in 2012. The HSRC household estimates that there were 469 000 new infections in 2012.

All estimation methods suggest a dramatic decline in perinatal transmission in recent years, with declines of 23  percent to 36 percent over the period from 2010 to 2011. Furthermore, the THEMBISA model estimates a decline of 76 percent from 2005 to 2012.

The overall picture is that there have been declines in adult HIV incidence but these declines to not meet the 50 percent decline required by the National Strategic Plan. Much more needs to be done to improve prevention efforts in South Africa, especially for young women.

Goal 2 Initiating at least 80 percent of eligible patients on antiretroviral treatment (ART), with 70 percent alive and on treatment five years after initiation There are 2.5-million South Africans (as at March 2013) on antiretroviral treatment making it the largest programme in the world.

• An estimated 2.3-million are on treatment in the public sector.
• More than 200 000 patients are on treatment in the private sector through medical schemes.
• Retention in care in the public sector is 75 percent after one year on treatment.
• 75 percent of patients in the public sector are virally suppressed.
• Life expectancy has increased from 53 years in 2006 to 61 years in 2012.

South Africa has the largest ART programme in the world, with more than 2.3-million people in the public sector on ART in 2013. Using current eligibility criteria, the coverage estimate of patients in need of ART using the old coverage definition was estimated by the THEMBISA model in 2011/12 to be 57 percent, compared to 36 percent of all HIV-infected patients being on ART using the new definition. This latter estimate is slightly higher than that found in the 2012 HSRC survey, which recorded an ART coverage of 31 percent of all HIV positive samples. Coverage in excess of 50 percent using the new definition has also been recorded at provincial level in some provinces based on routine data.

To maintain an ART enrolment ratio above 1.3, South Africa will need to continuously enrol in excess of 500 000 new patients onto ART per year. The growing number of patients previously initiated on ART will need to be retained in care. Greater attention needs to be paid to improving viral load monitoring and retaining patients in care.

Goal 3 Reducing the number of new TB infections and deaths from TB by 50 percent

• According to the WHO, TB incidence in South Africa continues to rise, with 530 000 new cases estimated for 2012. This is an incidence of 1 003 per 100 000 population.
• According to the TB register there were 323 644 cases of TB (new and relapses) in the same year.
• There were 88 000 deaths due to TB in PLHIV, and 31 000 deaths from TB in HIV-uninfected patients in 2012.
• Stats SA estimates that TB is the leading natural cause of deaths in South Africa.
• The TB register estimates that the case fatality rate is 8.4 percent.

Of 22 highest-burden countries in the world, South Africa has the third highest absolute TB burden after India and China and, with an estimated 530 000 new cases in 2012 or 1 003 per 100 000 population. This has increased from 490 000 new cases in 2009.

Using the WHO estimates, very little progress has been made in achieving both the NSP TB incidence and mortality targets of reduction by 50 percent. Using the TB register estimates, there has been a significant decline in both TB incidence and mortality. This is in keeping with the increased number of patients on antiretroviral treatment. The Department of Health is in discussions with the WHO to develop a common understanding of these very widely varying statistics for the same disease.

Goal 4 Ensuring an enabling and accessible legal framework that protects and promotes human rights in order to support implementation of the NSP

• There has been a growth in programmes for key populations, including sex workers, MSM and prisoners.
• Targets and indicators need to be set to track this goal as well as the objectives in Strategic Objective 4 as they do not exist in the current NSP.

South Africa’s response to HIV, STIs and TB acknowledges the importance of constitutional values and human rights. Unfair discrimination on the basis of HIV or TB status is illegal in South Africa. The legal framework for respecting, protecting, promoting and fulfilling rights in the context of HIV and TB is largely in place. Special attention is given to groups that are at higher risk of HIV and TB to ensure that wherever service provision occurs, it is provided in a manner that upholds the dignity of PLHIV and people living with TB.

The NSP recognises that ongoing campaigns to educate citizens on human rights and discrimination are needed. Various initiatives address rights in South Africa, although improved monitoring and tracking is necessary to determine progress.

Goal 5 Reducing self-reported stigma related to HIV and TB by at least 50 percent

• A national stigma index survey is currently underway looking at various aspects of stigma. This will include interviews administered to as many as 10 000 PLHIV throughout the country.
• A pilot stigma reduction programme is being planned for two districts in the Eastern Cape with a view to national rollout in areas of high stigma.
• Indicators and targets for this goal and related objectives needs to be revised. None are clearly stated in the current NSP.

The NSP calls for implementation of a Stigma Mitigation Framework and SANAC is leading a national stigma index survey that will cover 18 districts, and is mobilising resources for the implementation of a national stigma mitigation programme. Nationally, CSOs and government departments continue to deliver stigma and discrimination reduction programmes in line with the NSP goals and objectives.

National surveys indicate low levels of stigma and discrimination at population level, and the current Stigma Index Survey will further inform understanding.

Conclusions and recommendations
The main conclusions to be reported at the end of the first year of the NSP are as follows:
• Considerable progress has been made in reducing HIV transmission during pregnancy and child birth, and perinatal transmission is estimated to be 2.7 percent. The country is on track to reach the NSP target of less than 2 percent perinatal transmission by 2016.
• In 2013, ART reached 2.5-million South Africans including more than 200 000 patients being treated in the private sector. The provincial health departments will, however, need to enroll approximately 500 000 people onto treatment over the next four years to reach the NSP targets for ART coverage.
• It is likely that there is a decline in TB incidence and mortality due to the scale up of antiretroviral treatment though the WHO reports an increase incidence and high mortality for TB. The country is not on track to achieve the ambitious targets of reducing both incidence and mortality by 50 percent.
• In relation to rights, those of some vulnerable key populations, such as sex workers, MSM and prison inmates, are being addressed. Work is also underway to create access to legal services for persons discriminated against because of their HIV status, while there is also unfolding work towards addressing gender-based violence (GBV).
• While surveys show low levels of stigmatising attitudes, the extent of stigma and discrimination from the point of view of PLHIV is yet to be determined. The implementation of the SANAC-commissioned national Stigma Index Survey, will provide necessary insight and also contribute to the development of appropriate indicators to track progress.

It should be highlighted that this first Progress Report on the NSP does not adequately capture all the available data. This is especially the case in respect of government departments such as DBE, DHET, DSD and DCS. Neither does it capture data from NGOs, provinces or the private sector. It is SANAC’s intention to address this over each subsequent year. In many cases, the systems are not in place to capture these data or the NSP does not, in its current form, require this information to be captured. While there has been sound progress in relation to monitoring and surveillance, it remains an issue that measuring, monitoring and tracking the progress of the NSP is not fully addressed through present systems. It is necessary to identify available indicators that can serve as the basis for understanding progress over the 2012-2016 period, while also establishing appropriate approaches to address gaps for assessing progress in future. This includes a process of engagement between SANAC and various research bodies, as well as expanding the role of research, monitoring and evaluation within the multisectoral response as a whole.

This report has revealed weaknesses in programme implementation as well as weaknesses in the monitoring system. The programme weaknesses must be presented to government through the structures of SANAC so that they can be addressed. The report has also highlighted weaknesses in the M&E System in respect of the main indicators selected for monitoring, as well as indicator definitions, targets set and baselines selected in the NSP. These must be addressed as part of the mid-term review.

The NSP Review congratulates the South African National AIDS Council for producing its first report on progress against the goals, objectives and targets set in the NSP. This is a major step, as SANAC has not produced a comprehensive report in the more than 10 years of its existence.

In the last issue of the NSP Review we published a table to indicators we endeavor to track. This SANAC report has been a significant development in efforts to track our response to the epidemic against a set of indicators. We encourage all stakeholders and organisations to study the report in detail – engage with it and make sure feedback reaches the council.
In this issue we publish an article co-authored by SANAC CEO Dr Fareed Abdullah and the head of the Monitoring and Evaluation Unit Matseliso Pule. We will be publishing further responses to this report in due course and invite readers to submit opinion pieces which will be published on our website at