Welcome detail in Mpumalanga HIV and TB plan

The National Strategic Plan (NSP) for HIV, TB and STIs 2017 – 2022 is supposed to guide South Africa’s response to HIV and TB. While this national plan sets out broad targets and strategies, the implementation of this plan depends on provinces. To this end, each province had to develop a provincial NSP implementation plan (PIP).

Mpumalanga’s plan is called the Mpumalanga Provincial Implementation Plan for HIV, TB and STIs 2017 – 2022 (the Mpumalanga PIP). (Spotlight previously published analysis of the KwaZulu-Natal PIP.)

Broadly speaking, the Mpumalanga PIP stands out for including a series of well-chosen concrete implementation targets. While most provinces include targets in their plans, targets tend to be broad and to relate to indicators such as new HIV infections, rather than to the specific interventions that will help reduce new HIV infections. Mpumalanga is thus one of the relatively few provinces whose implementation plan goes beyond just broad statements of intent and engages seriously with implementation. Below we analyse the PIP more closely. 

The context

Around 7 100 people died because of HIV in Mpumalanga in 2018. This is much lower than the peak of 31 000 in 2006. Around 19 300 people became HIV positive in the province in 2018. Since more people are becoming infected than are dying, the absolute number of people living with HIV in the province is still rising.

As in other provinces, the dramatic decline in AIDS deaths is driven by the increased availability of antiretroviral therapy. By 2018 there was in the region of 470 000 people on treatment in the province – more than ten times as much as 10 years ago. 

Around 700 000 people in the province are living with HIV – This amounts to 15.4% of the population. This makes Mpumalanga the province with the second highest HIV prevalence in the country behind only KZN.

Regarding the first of the UNAIDS and NSP 90-90-90 targets, Mpumalanga is tied with the national estimate of 90.5% of people living with HIV knowing their status. Regarding the second 90 – percentage of diagnosed people on treatment – Mpumalanga is estimated to be on 73.5%, ahead of the national estimate of 68.4%. On the third 90 – percentage of people on treatment who are virally suppressed – Mpumalanga is on 88.1%, just below the national estimate of 88.4%. (This is using the UNAIDS definition of <1000 RNA copies/ml – <400 RNA copies/ml is also used sometimes).

While the performance on the 90-90-90 targets is decent when compared to other provinces, it should be considered in the context of the province’s extremely high HIV prevalence. In this light it is at least as urgent in Mpumalanga as elsewhere to improve on the second 90 by taking concrete steps to help more people to start treatment and to stay on treatment.

The Mpumalanga PIP

As with most PIPs, the Mpumalanga PIP contains useful information on the state of the HIV and TB response in the province. Various problems in the response are identified, often with specific districts or sub-districts identified as focus areas. Two of the province’s three districts, Gert Sibande and Ehlanzeni, are of the hardest hit by HIV and TB in the country. 

In some instances the PIP’s recognition of the problems in the province is refreshingly frank and honest. In relation to TB it states: “The provincial challenges to address mortality and morbidity were largely linked to inaccessible TB treatment services due to drug stockouts, inadequate care provision and poor adherence models.”

Like most PIPs, the Mpumalanga PIP is good on the broad solutions. For example, in relation to TB screening it states: “Testing for TB will be intensified at facility level to amplify TB case finding in high burden areas such as mines, correctional services, mining communities, etc. A provincial drive to promote household symptom screening and the use of a combination of Xpert MTB/RIF and culture tests will be initiated. Ward-based outreach teams will be used to initiate TB positive clients on IPT (TB preventive therapy) and track and trace TB contacts.”

As a general statement on TB detection and TB prevention this ticks many of the boxes one would want to see ticked in the PIP. 

So far, so good. But implementation plans need to go beyond such broad statements of intent if they are to have any impact on implementation. The KZN PIP, for example, generally does not – fortunately the Mpumalanga PIP often does.

More detail than most

A problem with some PIPs is that it sets targets to reduce new HIV infections but does not contain much planning on how the reduction will be brought about. While the Mpumalanga PIP suffers from this to some extent, it also contains some well-chosen targets that get at the “how” and not just the “what”.

So, for example, the Mpumalanga PIP contains a target to increase the number of facilities providing voluntary medical male circumcision in the province from 64 to 85. This may not seem a particularly ambitious target, but it is achievable and provides a concrete means by which to reduce the rate of new infections in the province. In addition, the Department of Health is identified as being responsible for meeting this target. Ideally, the Provincial AIDS Council will ask the Department of Health to report on their plans and progress in this regard every time the council meets. Since it is such a clear and simple-to-track indicator, the Department of Health can have no excuse for not reporting.

Similarly, the PIP sets a target of increasing the number of youth and adolescent friendly accredited healthcare facilities from two to 36 over the period of the PIP. Again it is a concrete and implementable target that the Department of Health can be held accountable for. As discussed later in this article, the PIP falls short in other respects when it comes to young women and girls, but this target at least proposes another concrete and measurable intervention.

But some short comings

The Mpumalanga PIP nevertheless leaves some crucial areas insufficiently addressed. Despite a professed focus on HIV prevention and a “substantially stronger focus on adolescent girls and young women” there are no specific targets on providing PrEP and the condom distribution targets are roughly in line with current levels and does not include the specific targeting of young people and the provision of condoms at schools. Instead, the PIP’s focus is on incremental improvement of interventions that are already being implemented.

This tendency not to contain much ambitious thinking beyond the status quo is unfortunately very common in provincial planning. One can only speculate, but it seems likely that this relative conservatism is due to the relative weakness of civil society representation in many PIPs – which often means PIPs end up reflecting the trajectory government is already on. Ideally though, forums like AIDS councils and planning documents like PIPs should be places where civil society can pressure government to be more ambitious in its response to HIV and TB.

In addition, while the PIP proposes various useful interventions, it arguably relies too heavily on community dialogues and other forms of meetings. Dialogues are important, but, once you have empowered people with information you need to back it up with concrete interventions such as the provision of PrEP or condoms.

As in other provinces, there are questions to be asked about the implementation of the PIP. Two years into the plan, the PIP has not yet been costed – although we understand that a costing is in progress and should be completed soon. Questions we sent the contact person for the Provincial AIDS Council regarding the finalisation and adoption of an M&E framework for the PIP went unanswered.

Finally, the PIP states: “The province will develop a Provincial Social and Behaviour Change Communication Strategy under the leadership of the department of Social Development in order to assist individuals and communities to implement communication strategies that reduce HIV, TB and STI risk behaviours.”

We asked the Provincial AIDS Council’s contact person whether the communications strategy has been developed but received no answer despite various follow-ups.

The way forward

With a costing expected soon and with a number of useful indicators, Mpumalanga has some of the building blocks in place that can set the stage for real progress against HIV and TB in the province. Whether or not this potential is realised will depend largely on whether or not the political will exists in the province to make implementation of the PIP a reality and to improve the functioning of the public healthcare system.

Mpumalanga faces severe HIV and TB epidemics and, as with a number of other provinces, is struggling with widespread dysfunction in the public healthcare system. The challenge ahead of Premier Refilwe Mtsweni and MEC for Health Sasekani Manzini to build a more capable state in the province is daunting.

Arguably the most critical element of this challenge is to ensure enough appropriately qualified healthcare workers and other staff are employed in the province’s public healthcare system. The PIP has the following, among others, to say about the province’s human resource needs:

•  “Given the ambitious nature of the PIP’s service targets and the imperative to expand efforts to address social and structural drivers, human resource needs under this PIP undoubtedly will grow and further diversify.”
• “The PIP requires an increase in the number of primary health care nurses who have the skills to administer antiretroviral therapy, manage drug-resistant TB, and address STIs beyond syndromic management, as well as a sufficient number of doctors to support services.”
• “Linking with national processes that facilitate the formalization of community health workers as a cadre, appropriately trained and supported, and fully integrated into the various systems would be critical.”
• “Under this PIP, Mpumalanga will invest more resources and effort in the training and mobilisation of peer educators, lay counsellors and support personnel.”  

Maybe the biggest question facing healthcare in Mpumalanga, and the question upon which implementation of the PIP hinges, is whether the necessary investments of funds and political capital will be made to meet these human resource requirements in a way that is sustainable.

Note: Figures used in this article are taken from the recently published Thembisa 4.2 model outputs. Thembisa is the leading mathematical model of HIV in South Africa.