NSP REVIEW COMMENT

The South African National AIDS Council is critical to our AIDS response. It is a structure, which allows various sectors to shape the response and ensure that their constituencies are influenced and mobilised. However, as NSP Review we have to note that some of the sectors contacted for this story were either not aware of SANAC’s latest report – their first review of the implementation of the 2012-2016 National Strategic Plan –  or had not engaged with it in a meaningful manner. The fact that some of the sectors claim that they were not aware of the report shows that there has been a breakdown in communication, and it needs to be repaired. Sectors need to ensure they are up to date and producing evidence, which informs strategy going forward. We also find that some of the responses by some of the sectors to the report are superficial and do not show true engagement with the critical issues. This is unacceptable for people who have accepted the great responsibility of membership of SANAC. – NSP Review Editor

In November last year, the South African National AIDS Council (SANAC) released their first review of the implementation of the 2012-2016 National Strategic Plan on HIV, STIs and TB (NSP) in a Progress Report1 of 2012, the first year of implementation of this NSP.

The responsibility to monitor the implementation of the NSP lies with the SANAC Secretariat. The Secretariat now has a Monitoring and Evaluation (M&E) Unit, and this first report weighs up the progress that has been made against the goals, objectives and targets set in the NSP. The report is late – and a second report will be published soon, covering Year Two (2013) 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 (www.nspreview.org/2014/11/10/sanac-releases-first-nsp-report/).

The main conclusions 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 childbirth, and perinatal transmission is estimated to be 2.7%. The country is on track to reach the NSP target of less than 2 percent perinatal transmission by 2016.
• In 2013, antiretroviral treatment (ART) reached 2.5 million South Africans, including more than 200 000 patients being treated in the private sector. The provincial health departments, however, will need to enroll about 500 000 people for treatment over the next four years to reach the NSP targets for ART coverage.
• It is likely that there will be a decline in TB incidence and mortality due to the scale-up of antiretroviral treatment, though the World Health Organisation (WHO) reports increased 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, men who have sex with men (MSM), and prison inmates – are being addressed. Work is also under way to create access to legal services for persons discriminated against because of their HIV status, and to address gender-based violence (GBV).

While surveys show low levels of stigmatising attitudes, the extent of stigma and discrimination experienced by people living with HIV/AIDS (PWA) is yet to be determined. The implementation of the SANAC-commissioned national Stigma Index Survey will provide the necessary insight and also contribute to the development of appropriate indicators to track progress.
The NSP Review asked five of the key SANAC civil society sectors to share their responses to the findings of the report.

 

Women’s Sector

Interview with Mashudu Mfomande, Chairperson, SANAC Women’s Sector
Women (young black women in particular) continue to bear the brunt of HIV: more young women than men are infected with the virus. Women of all ages are usually the caretakers of those who are ill, and those orphaned due to AIDS-related deaths.

The NSP is unequivocal about the limitations of the response to HIV (and other STIs) and TB infections unless key structural and social drivers are addressed. As outlined in the report, an analytical review of the NSP 2012–2016 response to women’s sexual and reproductive rights conducted by the AIDS Legal Network in 2012 concluded that interventions and programmes are unlikely to successfully address women’s risks to HIV exposure and transmission, and to related rights abuses, stigma, discrimination and violence, unless the concerns with regard to the response to women and HIV, including the conceptualisation of women’s realities, risks and needs, are addressed.

“The NSP promises us to reach what is known as the ‘Three Zeros’: zero new infections, zero AIDS-related deaths, and zero discrimination. From the Women’s Sector perspective, we are asking: where is the ‘zero’ relating specifically to women, who we know are the group most affected by HIV and AIDS?” asks Mfomande.

The goal of the NSP is to reduce new infections by at least 50%, using combination prevention approaches. However, new HIV infections are increasing for women, especially young women between the ages of 15 and 24, where the HIV incidence was at 2.83% for 2012.

A recent survey estimates that one quarter of all new HIV infections is in young women aged 15 to 24, pointing to major epidemic drivers underlying this phenomenon.

“One of the major challenges we face in responding to HIV for women is that no biomedical prevention method (such as microbicide gels) has been proven to work for women. There is huge investment in male condoms in South Africa and many resources are spent on distributing them. Government also recently distributed flavoured condoms. Who is being prevented from becoming infected here? It is usually the men, because women do not have the power to negotiate the use of condoms,” continues Mfomande. “Female condoms are nowhere to be found. We are told they are too expensive. Who is deciding this? We need proper investment and support to prevent HIV in women, as we are the most affected group.”
The links between HIV and gender-based violence (GBV) are well established. GBV affects a much higher proportion of girls and young women, leading to lifelong negative impacts. Intimate partner violence (IPV) in South Africa includes severe assault and violence, and it has been found that the rate of intimate partner homicide among women in 2009 was 5.6 per 100 000. More than one in 20 women experienced partner violence, and this figure is higher for younger women – 7.7% for women aged 15 to 19 and 7.3% for women aged 20 to 24. Women were also found to have been physically assaulted by household visitors and strangers.
“It is SANAC’s role to advise and monitor government’s response to HIV and TB. This is supposed to be a multi-sectoral approach and SANAC must bring together leadership within the South African Police Service (SAPS) and the departments of Justice and Health to address GBV in South Africa,” recommends Mfomande. “A policeman must understand that when he arrests a GBV perpetrator, he is also preventing HIV.”

 

Youth Sector

Interview with Nditsheni Mungoni, Chairperson, SANAC Youth Sector
Although there has been a decline in the HIV prevalence of young people (ages 15 to 24) from 8.7% in 2008 to 7.1% in 2012, this group still requires special attention in the HIV response. The HIV prevalence in this age group is particularly important, as it serves as a proxy for HIV incidence (new infections). The targeted HIV prevalence for this age group from 2008 to 2016 is 3.55%.
“The NSP only provides us with a framework of how to address youth-related HIV, STIs and TB. It does not provide us with a specific strategy on what activities need to be implemented (including details such as by whom or where) in order to achieve its targets for young people,” explains Mungoni.
“As the Youth Sector, we are advocating for young people to be regarded as a key population driving the HIV epidemic in the country, and the most vulnerable group to becoming infected or transmitting the virus.”
Key populations are seen as specific groups, including sex workers, lesbians, gays, bisexual, transgender and intersex (LGBTI) people, people who inject drugs, and migrant workers, who have increased vulnerability to becoming infected with HIV or STIs and developing TB.
Although there are many biomedical prevention methods available for young people, such as condoms, voluntary medical male circumcision (VMMC), post-exposure prophylaxis (PEP) and antiretrovirals, it is crucial that the broader social and structural issues affecting young people are addressed. These include peer expectations, sexual coercion, lack of employment opportunities and substance use.
“We need to strengthen the young person at an individual level so that they can navigate the social and structural barriers which make them vulnerable to HIV,” says Mungoni. This will require youth-friendly psychosocial support and services. The Youth Sector is also advocating for Life Skills Orientation in schools to be revised, as it is currently ‘old, tiring and boring’.

“Young people are too risk-tolerant. We need to address this beyond the policy level and speak to young people about what they think would change their behaviours.”

The Youth Sector is also calling for an HIV and TB Strategy targeted specifically at the youth. “If we want to win the fight against HIV, we need to focus on the youth,” says Mungoni. This strategy could direct all government departments, implementing partners and funders with concrete steps and programmes for young people, specifically, based on evidence of what strategies work to prevent and treat HIV in young people.
“What are we creating that is speaking to the dreams and aspirations of young people? We need young people to take a lead in driving the strategy.”

 

Children’s Sector

Input from Yezingane Network, SANAC Children’s Sector
Although South Africa’s mother-to-child transmission rate of HIV had decreased in 2012 according to the report, South Africa still has a high prevalence rate of children living with HIV. This group of children is made up of those who were infected as an infant and those who become infected later on in their lives through other ways. Supporting these children is critical in the South African HIV collective response.
Mother-to-child transmission of HIV is usually characterised by perinatal infection (transmission occurring at or before birth) or postnatal infection (transmission after birth, usually through incorrect breastfeeding).
Since the launch of the PMTCT programme in 2000, South Africa has demonstrated commitment to eradicating vertical transmission of HIV, by keeping up with new policy developments based on the latest available scientific evidence. The prevention of mother-to-child (PMTCT) guidelines were updated in accordance with international good practice in March 2013. The updated guidelines advocate for a standardised triple-drug regimen – including a fixed-dose combination (FDC) – to be administered to women (regardless of CD4 count or clinical stage) during pregnancy and breastfeeding. ART is continued after breastfeeding for women with CD4 counts less than 350 cell/mm3. The PMTCT guidelines also recommend integration of TB and syphilis screening and treatment, which also contributes to the elimination of syphilis in infants.
An assessment of the effectiveness of the national PMTCT programme, conducted by the Medical Research Council (MRC), revealed that the rate of MTCT of HIV at six weeks after birth fell from 3.5% in 2010 to 2.7% in 2011. The 2012/13 District Health Barometer indicates a further reduction, to 2.4%, in 2012.
While the latest surveys have measured HIV transmission at around six weeks, it has been observed that the sensitivity of the PCR used for testing for HIV may be compromised if the infant is receiving nevirapine prophylaxis. The six-week transmission level could therefore be underestimated, as nevirapine is routinely given to infants for HIV prophylaxis.
According to the report, all estimation methods suggest a dramatic decline in perinatal transmission rates in recent years, with declines of 23-36% over the period from 2010 to 2011. For children 2 to 14 years there has been a downward trend in HIV prevalence since 2002, decreasing from 5.6% in 2002 to 2.4% in 2012. This reflects the success of the scale-up of South Africa’s PMTCT programme.

However, there is still more work to be done in order to reach the goal of reducing transmission of HIV from mother to child to less than 2% at six weeks after birth, and reducing MTCT to less than 5% at 18 months of age, by 2016.

This includes strengthening the management, leadership and coordination of the PMTCT programme, and ensuring its integration with maternal and child health programmes for TB and syphilis screening; and treatment for pregnant women also needs to be included in the care they receive.

 

Lesbian, Gay, Bisexual, Transgender and Intersex (LGBTI) Sector

Interview with Dawie Nel, Chairperson, SANAC’s LGBTI Sector

Although there has been some progress in South Africa’s HIV response for lesbian, gay, bisexual, transgender and intersex people, the report itself makes little mention of issues and progress relating to the group, other than those relating to Men who have Sex with Men (MSM). It has been estimated that almost 10% (9.2%) of all new HIV infections in South Africa are related to MSM.
Although SANAC worked with partners to plan and expand the prevention, care and treatment programming for MSM through its work on the Global Fund for AIDS, TB and Malaria application, Dawie Nel, SANAC’s LGBTI Sector Chairperson, says critical challenges remain in addressing the health needs of LGBTIs and the specific HIV interventions that they require.
“South Africa’s health system is increasingly struggling to cope with delivering the most basic services for people in the general population. How realistic is it to expect such a government to accommodate specialised services for a minority group, such as LGBTIs, who have specialised health needs?” asks Nel. These health needs include screening and treatment for anal STIs, taking a proper sexual history within the limited time a health worker has the opportunity to spend with each client, and addressing behaviours that make LGBTI people vulnerable to HIV.
Although LGBTIs (especially MSM) are being included in Operational Guidelines, such as the Key Populations Operational Guidelines on HIV, STIs and TB, there are key gaps when it comes to the implementation of these recommendations.
For example, currently there exists no national large-scale inclusive programme for lesbian, gay, bisexual, transgender or intersex people. The programmes which do exist are run in parallel structures and are run by a “select few implementing partners”, who – according to Nel – receive all the funding that is available, time and time again. This excludes smaller LGBTI community groups, who are not empowered and need capacity-building, training and funding.
SANAC has not played a leadership role in addressing this, according to Nel. “There needs to be a structured development programme for LGBTI community groups. The capacity of these groups is often weak, but they are very connected to the community, which can facilitate delivering services to large areas.

 

Sex Worker Sector

Interview with Sally Shackleton, Chairperson, SANAC Sex Worker Sector

On progress towards achieving Goal 4 of the NSP of ensuring a legal framework that protects human rights in order to support implementation’, the report states there has been demonstrated growth in programmes for key populations, including sex workers.
“While there has been progress, the greatest barrier for sex workers in protecting themselves from gender-based violence and HIV is that sex work is still criminalised. Both NSPs have called for the decriminalisation of sex workers. We know that decriminalisation is protective for sex workers with regard to HIV— there is vigorous research which demonstrates this and all the normative international institutions such as the World Health Organisation and UNAIDS unequivocally advocate for the decriminalisation of sex workers. However, the report mentions nothing about decriminalisation of sex workers and what progress has been made towards this,” says Shackleton.
The report also comments that the rights of sex workers are being addressed. However, according to the Sex Worker Sector, this is not so in reality. Sex workers are continuously discriminated against, especially by the South African Police Service (SAPS) who arrest sex workers when they find condoms on them.

“How are sex workers meant to protect themselves from HIV, when the police themselves are using prevention methods as a reason to arrest sex workers while working?” asks Shackleton.

Although SANAC cannot address police abuse and decriminalisation on their own, as the coordinating advisory body to government on South Africa’s HIV and TB response, “SANAC should be taking a leadership role in making a strong evidence-based recommendation for the decriminalisation of sex workers and coordinate a public and multisectoral consultation to ensure that this recommendation can be a reality, which will result in a decrease in HIV prevalence amongst sex workers and consequentially their clients,” according to Shackleton.
The Sex Worker Sector also recommends that SANAC urgently call a high-level meeting – including ministers – with the police and the departments of Justice and Health to present the evidence on the benefits of decriminalising sex work, especially in relation to HIV. Police officers who discriminate against sex workers, must be dealt with authoritatively if South Africa wants to succeed in its HIV response regarding sex workers.
Some strides have been made regarding sex workers and HIV. These include the establishment of a national programme of health and HIV services for sex workers within the public sector and an improvement in sex workers’ access to condoms. A number of human rights and sensitisation workshops have been held for healthcare workers and a national toll-free helpline for sex workers has been set up. However, implementation gaps still exist and there is a lack of formal recognition of sex workers’ rights to healthcare and HIV services.
Although the report recognises the success of the National Strategic Plan for HIV Prevention, Care and Treatment for Sex Workers in addressing HIV in sex workers, the Sex Workers Sector points out that this plan has not yet been officially recognised and has created confusion among healthcare workers and programme staff.

 

<h1>NSP Review sent SANAC a copy of the article, and offered them an opportunity to respond. This was their response. </h1>

The South African National AIDS Council (SANAC) welcomes the dialogue and debate that has been generated by the first-ever progress report on the National Strategic Plan (NSP). SANAC hopes that the issues raised by this report will provide the impetus for a more inclusive response to the country’s HIV and TB epidemics.

The report and its findings demonstrate the importance of regularly monitoring and tracking the implementation of the NSP.

They also highlight that a critical component of the NSP is to ensure that human rights and access to justice are addressed within the HIV and TB response. In the first year of the NSP, a tangible agenda has been set, with specific attention being paid to addressing vulnerable key populations such as sex workers, men who have sex with men, and prison inmates.

However, the report notes that there may be a need for programmatic indicators relating to key populations, and recommends that SANAC should work with relevant stakeholders and propose amendments to indicator definitions and targets.

The SANAC Secretariat has re-established a Technical Working Group on Sex Workers to address the issues raised, including improving the National Sex Worker implementation plan; clarifying the status of the national programme, and laying out a roadmap of legal reforms.  The Secretariat will also formally table the national sex worker programme to SANAC and government.

In addition, the report points out some of the challenges and areas requiring further attention in the HIV response. Although there has been a four-fold increase in the use of ART during breastfeeding, modelling suggests that postnatal transmission during breastfeeding may still be high. Meanwhile, the target of keeping 94 percent of patients on treatment is not being met; and the quality of services will have to be addressed to reach a higher rate of retention of patients in care.

“One of the reasons we have monitoring and evaluation is so that we have precise feedback from stakeholders about how well South Africa and SANAC are doing with the full implementation of the National Strategic Plan. The honest and thoughtful feedback provided by the sector leaders is important to us at the Secretariat, as it helps us to improve our response and to advise government about what is working and what is not,” said SANAC CEO Dr Fareed Abdullah. •