Last year we published an article responding to the so-called “draft zero” of South Africa’s new National Strategic Plan for HIV, TB and STIs. We have now received an updated document marked “draft 1”. It can be downloaded here and comments can be submitted to nsp@sanac.org.za. The finalised NSP is expected to be launched on World TB Day (24 March) this year.

 

Many positives

The NSP draft 1 contains a number of good and ambitious targets. On the prevention side it seeks to “reduce new HIV infections by more than 60% – from 270 000 in 2016 to below 100 000 by 2022” and to “cut TB incidence by at least 30%”. On the treatment side it sets out to reach at least 6.1 million people with antiretroviral therapy by 2022 and to ensure that at least 5.5 million of those people achieve HIV viral suppression. For drug resistant TB, the target is at least a 90% treatment success rate and for multi-drug resistant TB at least 65%. The key circumcision target is to medically circumcise 2.5 million men by 2022.

It is encouraging to see significant attention being given in the NSP draft 1 to the need for more active case-finding and contact tracing for TB – these critical, but human resource intensive, interventions have not received sufficient attention in South Africa’s TB response. The document states: “we will roll out post-exposure TB management to at least 90% of eligible household contacts and at least 90% of eligible people receiving antiretroviral therapy”. Yet, whether these welcome targets will be met will depend largely on whether government makes the necessary investments in human resources – an issue that is not sufficiently addressed.

The NSP draft 1 also contains a welcome endorsement of home testing for HIV and announces a very promising new HIV testing campaign – something we’ve argued for in previous articles. It states: “A new national HIV testing campaign will be launched to decentralise testing and expand testing delivered in and outside health facilities (e.g., workplaces, and in community settings); specific efforts will be made to close testing gaps for men, younger people, key populations and other groups that are not currently accessing HIV testing at sufficient levels; self-screening will be rolled out and actively promoted…”

While the NSP draft 1 contains a welcome focus on the gathering of quality, geographically specific  healthcare data, it is disappointing that more is not made of ensuring that the public has access to this data. As we have previously argued, both to increase accountability and public involvement, the general public should be able to access viral load coverage and viral load suppression rates for all healthcare facilities and for all districts. The required technology is mostly in place, it is simply a matter of setting the data free in a responsible manner.

The broad-ranging NSP draft 1 document touches on a wide range of important issues including the need for a unique patient identifier, regular viral load testing, monitoring of HIV drug resistance, availability of new HIV and TB treatments, TB infection control, mental health services, and much more. As a listing of sensible things that should generally be done as part of the HIV and TB response, the NSP draft 1 ticks most boxes.

 

Where draft 1 falls short

Ideally the NSP would use evidence, solid arguments, and well-chosen targets to push government and society to implement interventions or policy changes that would not otherwise have taken place. It is thus of concern that in certain critical areas the NSP draft 1 is somewhat lacking in substance and makes its case rather half-heartedly.

Case in point is the NSP draft 1’s relative lack of substance on the question of human resources. While the issue is acknowledged in the section on so-called “enablers” (quite deep into the document), it is low on detail and does not get into any hard numbers. We can probably all agree that meeting the NSP’s ambitious targets will depend largely on having enough appropriately qualified and committed doctors, nurses, community healthcare workers (CHWs), peer-educators, pharmacists and pharmacy assistants. For the NSP not to fully connect the dots and not to aggressively force the issue on human resources by setting ambitious targets for things like “number of CHWs employed” would be a major missed opportunity.

One ray of light however, is the recognition at last that, “community health workers need to be formalized as a cadre, appropriately trained and supported, and fully integrated into the health system”.

The NSP draft 1 is also not very strong regarding access to condoms in schools. Draft 1 ambiguously mentions “condom promotion, provision” in a variety of settings, including school-based settings but it is explicitly endorsed in only one relatively general line under the heading “routine approach”: By contrast, there are various and much more extensive reference made to comprehensive sex education (CSE) – which, while also critically important, is only half the battle. For example, while there is an explicit target to “implement CSE programmes in at least 90% of schools in 27 high burden districts”, there is no similar target for ensuring access to condoms specifically in schools.

Whether we like it or not, the fact is that many young people are sexually active. It is a moral imperative, and quite likely a Constitutional obligation, that we provide these young people with all the tools they need to protect themselves from HIV infection and to prevent unwanted pregnancies. Failure to address this issue more explicitly and to set ambitious targets for condom availability in schools will make the NSP’s talk of a “substantially stronger focus on adolescent girls and young women” ring somewhat hollow.

On the decriminalisation of sex work (an issue that has been extensively covered in Spotlight) the NSP draft 1 is also surprisingly weak. While it does state “the NSP calls for steps to decriminalise sex work.”, it is disappointing that it does not then go on to outline these “steps” and attach strict timelines to them. While an NSP that broadly supports the idea of decriminalisation is useful, an NSP that is serious about its concern with human rights and with the rights of sex workers would go beyond just broad support and force the issue with specifics.

Finally, one of the most interesting aspects of the NSP draft 1 is its pre-exposure prophylaxis (PrEP) targets. In the document these targets are summarised as follows:

“We will offer PrEP to 1.4 million people (including 200 000 young women ages 20-24, 500 000 adolescents of both sexes, 450 000 sex workers, 175 000 MSM and 60 000 people who inject drugs.”

These targets may or may not be good targets – it is hard to tell without more information on how they were calculated. The final NSP will hopefully provide an explanation of why these exact targets were chosen.