Opinion: Return of the quacks

By Anso Thom, Spotlight Editor

For a long time, South Africa has been a country where charlatans are able to flourish and peddle dangerous remedies for all kinds of ailments.

Take a trip on a public train or a walk down a road in our city centres and you will easily find pamphlets marketing remedies for anything, from enlarging penises to bringing back lost lovers. Even more seriously, the city lamp poles are plastered in posters offering cheap pregnancy termination services. Poor people stand on street corners for hours offering pamphlets and directions to the closest ‘doctor’. All illegal, all dangerous, but almost all operating with impunity.

The reasons these quacks proliferate are many. Not so long ago we had a president and health minister who created an enabling environment for them. President Thabo Mbeki questioned the efficacy of lifesaving anti-AIDS medication, told people they were toxic, and dragged his feet when it came to signing into policy the rollout of these medicines for the thousands who were suffering and dying.

His Health Minister, a medical doctor, Dr Manto Tshabalala-Msimang spoke often and passionately about the so-called healing properties of beetroot, garlic, lemon and olive oil. People sniggered, referred to her as Dr Beetroot and shook their heads.

But what Mbeki and Tshabalala-Msimang had done successfully, was to sow seeds of doubt. Many, many people living with HIV, desperate for a remedy not only to control the virus, but to exorcise it from their battered bodies, turned to the quacks, who promised to do so. What was criminal was that these ‘doctors’ were operating with the tacit support of the leaders who had the power to close them down.

They included the likes of German multi-vitamin peddler Matthias Rath; KwaZulu-Natal truck driver and seller of a concoction called uBhejane (the recipe of which he said was revealed to him in a dream by his ancestors) Zeblon Gwala and the likes of Tine van der Maas a barefoot Dutch nurse who pushed lemon, garlic, beetroot and olive oil concoctions at the behest of the health minister, or Belgian eccentric Kim Cools who continues to claim that he had injected himself with the HI virus but remains negative due to his remedies (see previous Spotlight).

Activists told stories and journalists wrote articles of the heartache these people had caused – the undignified deaths of mothers who left families orphaned as they dumped their antiretrovirals for Rath vitamins, the fatal and excruciating suffering of the much-loved DJ Khabzela after the health minister sent Van der Maas to heal him, or the illegal Rath clinical trials conducted on poor people, made to strip, have their photographs taken and give their blood.

And then there was Virodene – a powerful chemical detergent peddled by a bunch of crazy scientists as a cure for AIDS, which had as its cheerleader President Mbeki.

Mbeki and Tshabalala-Msimang were not alone in the rejection of proven treatments. Tshabalala-Msimang’s MECs either turned a blind eye to the fact that people were being used as guinea pigs, or did everything in their power to deny poor people access to lifesaving drugs.

Sibongile Manana was the MEC of Health in Mpumalanga at the height of the denialism years from 1999 to 2003. Now she is a Member of Parliament. As MEC she gave the Greater Rape Intervention Project (GRIP) in Nelspruit hell. She bullied Rob Ferreira Hospital’s Dr Thys von Mollendorff, a gentle caring doctor whose only crime was to try and help rape survivors. He offered them a dignified, safe space in his hospital where they were given the option of accessing legal, tested antiretrovirals to prevent infection. But Manana hounded Von Mollendorff and GRIP out of the hospital and treated them like criminals, dragging them to court and evicting them from the hospital.

Penny Nkonyeni, MEC for Health in KwaZulu-Natal during the Manto years, often rolled out the red carpet for her Minister. She printed quack pamphlets for distribution, hounded doctors who dared to offer pregnant mothers the option of treatment to prevent transmission of HIV to their babies, and she was a willing partner in finding crooked NGOs prepared to run illegal clinical trials using quack concoctions. Nkonyeni was later the speaker in the provincial parliament and Education MEC before being removed in a Cabinet reshuffle earlier this year. She indicated she was joining the private sector.

The examples are many and for those who were there, these memories are painful. Those who were there made a pact saying, never again.

Fast forward to 2016 

Dr Benny Malakoane is a medical doctor and was until recently Health MEC in the Free State. Over a three-and-a-half year period he oversaw the collapse of the public health-care system in the province, and turned the state machinery on elderly community health workers who were asking inconvenient questions, while facing multiple charges of fraud and corruption (these cases are still ongoing due to continued delays).It now appears that, much like Manana and Nkonyeni, Malakoane enabled a quack to operate with impunity in a state hospital, using unsuspecting state patients as guinea pigs in an illegal stem cell trial. In fact, this operation had been signed and sealed in a three-year contract which was due to further impoverish the Free State health system and enrich the shareholders of ReGenesis Health with millions of rands.

Questions must be asked over the enthusiasm of the MEC in signing this contract and personally overseeing its implementation. One has to ask how the MEC could be so enthusiastic in rolling out an untested stem cell intervention in the Pelonomi hospital’s orthopaedic department while his health system is collapsing and failing to get basic medicines to clinics and hospitals.

The Medicines Control Council led by Professor Helen Rees intervened within days of health minster Dr Aaron Motsoaledi becoming aware of this contract. It is refreshing and heartening to know and see in action the difference an ethical, incorruptible and no nonsense health minister and medical doctor can make. If only we had someone like Dr Motsoaledi in the early 2000s.

The MCC swiftly closed the ReGenesis operations at Pelonomi and have made it clear that according to the information they have, an illegal trial was being conducted, using an untested intervention.

For now, the operations have been brought to a halt and the Free State Department of Health has cancelled the contract. The MCC has sent ReGenesis a comprehensive list of questions, and Free State Premier Ace Magashule has been left with the task of holding his MEC accountable. Don’t get your hopes up.

Within a day of the information being revealed by Spotlight and the investigative television show, Carte Blanche, Free State premier Ace Magashule shifted his Health MEC to Economic and Small Business Development, Tourism and Environmental Affairs, and installed his former Police, Roads and Transport MEC Butana Kompela as the health custodian.

However, we cannot allow another quack enabler to get away without being held accountable.

The Free State Department of Health and Premier Magashule have to provide answers to some very serious questions. For instance, why did the Free State Department of Health publish a tender for stem cell therapy in the first place? On what basis was ReGenesis appointed in June? Why was Malakoane so closely involved with the project, chairing the board that would provide oversight of the work and research done by ReGenesis?

Simply shifting Malakoane to another post doesn’t make these questions go away. For there to be any accountability we need answers to these questions. The people of the Free State are not guinea pigs. They are not pawns in an alleged scam to enrich charlatans.

Not on our watch. The ball is in your court Premier Magashule.

 

A vision without a plan: In-depth analysis of SA’s new HIV and TB plan

By Marcus Low

On 11 May 2017 South Africa’s National Strategic Plan (NSP) for HIV, TB and STIs 2017 – 2022 was finally published after multiple delays. The NSP is meant to coordinate and guide a coherent response from government, business, organised labour and civil society to the HIV and TB epidemics in South Africa.

That such a master plan is of critical importance seems obvious. There are still around 270 000 new HIV infections in South Africa per year. According to what is written on death reports, TB is the number one killer in the country. If death reports are combined with other sources of information, experts conclude that HIV is the number one killer in South Africa – with around 150 000 deaths per year. Meanwhile, rates of drug-resistant forms of TB are increasing at alarming rates and reports from the Office of Health Standards Compliance (OHSC) and others paint a picture of a healthcare system that is often severely dysfunctional.

It may not make the headlines as it used to, but HIV and TB remain at crisis levels in South Africa. The NSP should be judged by the seriousness, ambition, and realism with which it addresses this crisis. With that guiding principle, we will start by considering the context in which the NSP is to be implemented. After that we will evaluate the content of the NSP in a number of key areas. Then, we will try to map some potential ways forward.

The NSP and the realities of our public healthcare system

In November 2016 the Business Day newspaper obtained data from the OHSC showing that only 89 of 1427 inspected clinics and hospitals met the OHSC’s 70% pass mark. Not one of 53 clinics inspected in the Free State obtained a pass mark. In all 9 provinces in the   country, the average performance outcome of district hospitals inspected fell below the pass mark. Some of this data was later presented to parliament and eventually published in a devastating report.

While the establishment of the OHSC is certainly one of the most notable achievements under Dr Aaron Motsoaledi’s tenure as Health Minister, it is deeply concerning that the data was only made available after Business Day had filed a request in terms of the Promotion of Access to Information Act (PAIA). The affair does however highlight the tendency from government and government-linked entities to sweep healthcare system problems under the carpet – as is arguably also done in the NSP.

While the OHSC data provides probably the most compelling evidence of widespread dysfunction in the healthcare system, there is no shortage of other red lights. From the Life Esidemini tragedy in Gauteng where at least 94 people died, to the unconscionable decay in cancer services in KwaZulu-Natal, to a Treatment Action Campaign (TAC) survey that found only 15 of 158 clinics across seven provinces had sufficient TB control measures in place, to the reports of the Stop Stockouts Project, to the terrible conditions in the Free State healthcare system and a collapsing roof at Charlotte Maxeke Hospital in Gauteng, there can be no doubt that there is widespread dysfunction in the public healthcare system in South Africa.

It is in the context of this widespread dysfunction that the NSP is to be implemented. Yet, when one reads the NSP one finds no recognition of this crisis, nor of the fact that the failure to engage with this crisis may render the NSP essentially unworkable. As argued in a recent TAC and SECTION27 media statement: “This is an NSP that seems reasonable when considered in the abstract, but that risks falling apart when confronted by the realities of the public healthcare system in South Africa and the political context in which this healthcare system exists.”

Underlying the dysfunction in our healthcare system are at least two key factors, a lack of funding and a political crisis that is undermining the public service. The funding crisis in relation to healthcare is most obvious in what amounts to the freezing of posts – something for which the recent health budget offered no relief. The OHSC report was also clear on this, stating that “indeed budget constraints has had direct impact on adequate funding of vacant clinical and allied professional  posts, inadequate  infrastructure and maintenance budget, medical equipment, medical supplies,  consumables including pharmaceuticals have been reported but there is no funding available.” Though the final NSP touches on the lack of funding, it does not go into much detail on this or on the accompanying human resource crisis and certainly does not connect the dots to make a powerful case for increased funding as one would have hoped it would.

On the political side, the NSP is even further removed from the realities of the fraught context it is to function in. The NSP justifies its own vagueness by arguing that it will be up to provinces to develop implementation plans. While this seems fine in principle, the reality is that this model has failed badly over the last five years since most provinces simply do not engage meaningfully with either the NSP or AIDS councils. There is no evidence in the new NSP that this failure has been reflected on with any seriousness and we thus seem doomed to repeat the same pattern of national-level policies or strategies being sent to provinces to die. One would at the very least liked to have seen annual provincial-level targets on all key indicators highlighted in the NSP and clear guidance for provinces as to which interventions to prioritise given resource constraints.

This dynamic of the breakdown between national and provinces of course cannot be disconnected from our wider politics and the culture of cadre deployment, corruption, and capture that has come to dominate public discourse in South Africa. Essentially, too many MECs for health are still untouchable because of their loyalties to particular factions within the ruling party. In addition to this ongoing accountability deficit, South Africa’s political crisis has also lead to rating agency downgrades and a recessionary economy which seems set to further shrink an already insufficient health budget. It may have been too much to expect the NSP to make an explicit statement on South Africa’s political crisis, but it could certainly have more forcefully and concretely made the case for the good and transparent governance of provincial healthcare systems and for greater political accountability.

HIV prevention in the NSP

One of the most remarked upon short-comings in the NSP is the very low targets set for pre-exposure prophylaxis (PrEP) in the final NSP – 18 000 people receiving PrEP by 2019, and 85 000 people by 2022. These low targets are particularly disappointing given that earlier drafts of the NSP contained much higher targets. Draft 1 of the NSP set a target of 1.4 million, 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”. The 1.4. million target may or may not have been a good target – we never saw a specific justification for it – but at least it was ambitious.

The NSP sets a target of reducing new HIV infections to under 100 000 per year by 2022. This is a very ambitious target given that the rate is currently around 270 000. While substantial reductions seem likely (Thembisa model outputs published last year projected around 170 000 by 2022), getting as low as 100 000 would require aggressive use of all available interventions. An important  modelling study by Dr Leigh Johnson and colleagues published in June last year, suggested that while not the most important factor in HIV prevention, PrEP aimed at youth and the general population may nevertheless have an important role to play in reducing new infections – incidentally, PrEP in sex workers was projected to have less impact on overall infection rates, although a moral case could still be made for providing PrEP to sex workers. In addition, as pointed out by Professor Linda-Gail Bekker in a plenary at the recent SA AIDS conference, one of the risks of limiting PrEP to sex workers is that it socially stigmatises PrEP, making later expansion of the programme difficult. Either way, the low PrEP targets in the NSP are baffling.

As former SANAC CEO Dr Fareed Abdullah  has been quoted as saying at the closing of the recent SA AIDS Conference, the “toolbox” provided in the NSP “doesn’t match the impact that we’re looking for”.

To have a chance of getting down to 100 000 new HIV infections per year by 2022 would require aggressively using all tools at our disposal. This will, amongst others, require a renewed focus on condom distribution and correct condom use and a drive to conduct more safe and voluntary medical male circumcisions. The NSP sets a target of 700 000 VMMCs performed in 2016/2017, reducing by 50 000 in each subsequent year. It sets a target of distributing 850 million male condoms per year and 40 million female condoms. These may or may not be good targets – it is hard to tell since the NSP provides no motivation for these specific numbers. It is also of interest that the NSP’s somewhat weak recommendations on access to condoms at schools has been superseded by a much stronger policy from the Department of Basic Education.

The study by Johnson and colleagues is particularly valuable for thinking about the NSP since it weighs up in a sophisticated way the relative impact different interventions (such as condoms, PrEP and VMMC) could be anticipated to have on the rate of new HIV infections. In a conclusion that might be surprising to some, they found that for the purposes of reducing new HIV infections the “most important epidemiological parameter to target will be the infectiousness of patients receiving ART”. They explained that this will mean “promoting adherence interventions such as adherence clubs, patient supporters, and SMS contact”. In other words, the most important intervention for reducing new infections is helping people already on treatment to stay on treatment and become and remain virally suppressed. The NSP’s distinction between prevention (goal 1) and treatment (goal 2) is thus somewhat problematic since the most important prevention intervention is not in the prevention section.

Either way, the NSP does generally say the right things regarding viral suppression, although there are some puzzling elements. For example, a sensible target is set to “ensure that 90% of all patients receiving antiretroviral therapy are virologically suppressed”. But then the NSP also says that “at least 90% of all ART patients will receive viral load testing in accordance with clinical guidelines compared to the 52% to 75% who do so now”. Though the current rates quoted are shockingly low, the 90% target for viral load coverage by 2022 is unacceptably low. Surely every single person who is receiving ART can also be offered a viral load test given that these are by definition people who are already interacting with the healthcare system. Getting one viral load test per year is not optional, it has been part of local and WHO guidelines for some time and a basic part of decent quality of care. In addition, the guidelines recommend viral load tests for all people on ART, not just 90% of people on ART. Of course, and as recognised in the NSP, adherence and viral suppression will depend on much more than just viral load testing.

The NSP and workers in the healthcare system

There is a welcome recognition in the NSP that we need “strategies to strengthen adherence to treatment and care” and that “adherence is a key element of reaching the 90-90-90 targets”. In broad terms the right things are said about the employment of community healthcare workers, primary healthcare nurses, and other types of healthcare workers. There seems to be at least a conceptual understanding that the success of the NSP will depend on the people employed in the healthcare system.

In fact, the NSP at times seems positively utopian in its outlook, as for example in this quotation:

“All people living with one or more of the three diseases covered by this NSP will have access to differentiated service delivery, including facilities that are friendly and suitable for children, adolescents, young people, men, people with disabilities and survivors of sexual assault. Services provided will be people-centred, integrated and comprehensive in scope. They will not only address HIV, TB and STIs, but also non-communicable diseases and other health conditions experienced by individuals, including access to palliative care. Services will include treatment and support for functional limitations or disabilities that people living with HIV and TB may increasingly experience as they age. People with HIV and TB will have access to age-appropriate psychosocial and treatment adherence, counselling and support, mental health screening and treatment.”

While ambition is welcome, the NSP generally fails to provide a realistic road-map as to how these ideal conditions will be reached – especially given the current state of the public healthcare system as reflected in the OHSC report. While the rough costing that was provided in the final NSP provides some indication that at least some attempt has been made to connect the dots in terms of cost, the costings are still too general and avoids critical issues like the employment of CHWs. It is alarming that even with the current costings – that we suspect may exclude some human resource costs – the NSP is underfunded by more than R6 billion per year.

It is also notable that the NSP never specifies the numbers of CHWs and other healthcare workers that would be needed to implement the plan. Side-stepping a critical issue like this brings into question the plausibility of the entire NSP. This is particularly disappointing since plans to fund an expanded CHW programme have recently been turned down at the Medium Term Expenditure Committee (the committee that makes decisions relating to what programmes are included in the budget). Unfortunately, there is very little in the NSP that would strengthen the Department of Health’s hand when going back to MTEC on this issue. Then again, apart from some high level comments, the pedestrian way in which CHW policy has progressed over the last decade suggests that the Department of Health itself has little appetite for an expanded CHW programme.

Good news on HIV testing

The NSP sets a target of 10 million people receiving an HIV test every year. This will be achieved through an ambitious programme described as follows:

“A new national HIV testing effort to find the remaining people who don’t know their status and those who become newly infected will be strategically focused on optimising testing yield. Testing will be decentralised and expanded testing services will be delivered in and outside health facilities, e.g. in workplaces and community settings. Specific efforts will be made to close testing gaps for men, children, adolescents, young people, key and vulnerable populations and other groups that are not currently accessing HIV testing at sufficient levels. The importance of at least annual HIV testing will be emphasised, especially for young people. Self-screening will be rolled out as part of the strategy to expand HIV testing and to close testing gaps. A major push will be made to ensure 100% birth testing of newborns exposed to HIV and of provider-initiated counselling of mothers and testing for all children up to 18 months to identify those that have acquired HIV through breastfeeding. All children of HIV positive parents will be tested for HIV. Every person that is tested for HIV will also be screened for other STIs as well as for TB.”

In our view the vision set out here is exactly what is needed in terms of HIV testing. The critical question however is whether we will see the necessary political will to drive this campaign – for example by taking it to workplaces and through ensuring sufficient funding for HIV self-testing and making sure referral networks are functional and easy to use for people who test positive. Fortunately, if we do the right things, the prospects are good in as far as HIV testing goes. While Johnson and colleagues’ model shows low likelihoods of reaching the second and third 90s, they project that South Africa is on course to reach the first 90 (90% of people with HIV know their status) by 2020.

As an aside, it is concerning that the NSP is inconsistent on whether the 90-90-90 targets in South Africa are to be met by 2020 or 2022. On page 15 under Goal 1, it states that in order to achieve the objective, it must prioritise “Achieving 90-90-90 by 2020 for HIV and TB” and it also includes an explanation as to why 2020 was the adopted timeline for South Africa. However, later, on page 19, it states; “To reach the 90-90-90 HIV target by March 2022, the end of the period that this NSP covers…” and later, “As this NSP covers the years 2017-2022, Goal 2 objectives and activities aim to reach the 90-90-90 target by 2022…” To further confuse things, a recent Bhekisisa news article quotes Deputy Director General of Health Yogan Pillay as saying that “by 2025, the health department aims to have 90% of all people diagnosed with HIV on treatment” (the second 90).

Moving these targets back to 2022 or 2025 would constitute a significant retreat from the ambitious 2020 goals set by UNAIDS.

Two thirds of a TB plan

Like much of the NSP, the TB sections are superficially very good. There is for example a commitment to rapidly implement new treatments and diagnostics. This could be particularly important given that changes to diagnostic tests and algorithms and further changes to the treatment regimens for drug-resistant forms of TB and for latent TB are likely within the period of this NSP. Given South Africa’s good track record regarding the introduction of new TB diagnostics (e.g. Gene Xpert) and treatments (e.g. bedaquiline), we can expect this aspect at least to go well.

The more difficult thing to fix in our TB response is ensuring that many more people get screened and tested so as to get people on to treatment quicker and to reduce the time that people are infectious. As in other areas, the NSP’s stated intent here is spot-on:

“Every person who is tested for HIV must also be screened for TB, as must all TB contacts. Tracing of TB contacts is especially urgent for DR-TB and will be prioritised. This Plan envisages intensified TB case-finding in key populations, including household contacts of people with TB disease, healthcare workers, inmates, and people living in informal settlements. People with diabetes and every child contact of an adult TB patient will be screened. All patients suspected to have TB will receive appropriate diagnostics, including GeneXpert MTB/RIF as an initial diagnostic and rapid confirmation of results.”

If this vision could be fully realised, it could have a dramatic impact on TB in South Africa. Again though, such a screening drive will be extremely labour intensive and require thousands of community healthcare workers and other healthcare workers to implement. The reality however is that there is an HR and funding crisis across the healthcare system and as yet no clear policy on the employment of CHWs. The NSP should have made it clear that its ambitious TB screening plans are fully dependent on certain human resource requirements being met – and then gone on to precisely outline and cost those human resource requirements. As it is, we have a great vision, but not much of a plan of how to realise that vision.

Decriminalisation of sex work

Earlier drafts of the new NSP, as well as South Africa’s previous NSP,  contained some, though insufficient, language on the decriminalisation of sex work. Even that language was eventually stripped from the new NSP. This is somewhat hard to understand given that the SANAC Sex Worker HIV Plan launched last year took a progressive position on the rights of sex workers and seemed to set a course toward decriminalisation. During the NSP development process, there was very strong support for the inclusion of a recommendation on decriminalisation from a number of civil society groups, including Sonke Gender Justice, SWEAT, Sisonke, and the Treatment Action Campaign. No explanation has been provided to these groups as to why decriminalisation was cut from the NSP at the last minute.

The removal of sex work from the NSP is likely one of the clearest examples of how the governance crisis at SANAC impacted the NSP. Under Dr Fareed Abdullah’s leadership SANAC has in recent years taken very progressive positions on decriminalisation – supported by a number of civil society organisations and by the published evidence on sex work and HIV. However, with his removal as CEO and from the NSP drafting team, one of the most outspoken and influential supporters of decriminalisation was side-lined. It is after his departure that decriminalisation was completely removed from the NSP. Spotlight sources also report that civil society representatives who were part of the drafting team did not oppose the removal of decriminalisation – despite the views of the civil society organisations above being known to them.

Better use of data

If the NSP’s ambitions regarding the better collection and use of data are met by 2022 South Africa’s healthcare system would have taken a significant step forward. Firstly, the NSP commits to the implementation of a unique patient identifier, which is welcome even though it is long overdue. This means patients will have their records stored electronically and these records could then be accessed at any healthcare facility. This should make it much easier for people to move between clinics or for people leaving correctional facilities to transition to clinics on the outside. Ensuring that this network is secure and that confidential patient information is not leaked will be a significant challenge – but not a reason not to implement the system.

Secondly, the NSP imagines routine and efficient data collection across the healthcare system. Having more geographically specific but, where appropriate, personally deidentified, data should help to spot trouble areas and better target interventions. If such data is routinely made available to AIDS councils, hospital boards and clinic committees, it could help inform more effective problem-solving. If shared publicly, which the NSP unfortunately does not explicitly suggest, it could make it easier for people to hold local healthcare managers accountable.

It is telling that with this focus on data, the NSP does not make more of the data already being generated by the OHSC. This data already provides very useful insights on the state of the healthcare system in specific districts and specific facilities. More explicitly integrating the OHSC data into NSP-related monitoring would have helped to more effectively root the NSP in the reality of our struggling healthcare system. In addition, there may be a cautionary lesson for NSP-related data in the fact that OHSC data only became public after a PAIA request. In an unrelated case, Spotlight recently also had to file a PAIA request to access information held by the Department of Health. While the data revolution picture painted by the NSP is promising, it will come up against a deeply ingrained culture at the Department of Health whereby most bad news is buried.

The way forward

How one responds to the NSP is at least in part a question of strategy. While hardly anyone would be entirely happy with the plan, most people should find at least some elements they could agree with. How one weighs up those positive elements against the various flaws in the plan will likely depend on who you are and what your interests are.

The most convincing argument for rejecting the NSP is that made by TAC and SECTION27 – that the NSP is fundamentally flawed and unimplementable since it does not take the current state of South Africa’s public healthcare system into account. In late March, the two groups said that they could not accept the NSP in the form it was then (referring to the then draft of the NSP and a summary document). The two groups said that they would only endorse the NSP if certain conditions were met. The conditions were as follows:

  1. If an addendum to the NSP is developed and published that provides detailed and realistic guidance to provinces and districts on NSP implementation. This must include provincial sub-targets on all key NSP targets and introducing smarter indicators as outlined by Doctors without Borders (MSF).
  2. If an addendum to the NSP is published setting out all the HR requirements for the various interventions and how this increased HR capacity is to be funded. This must include a budgeted and quantified plan and policy on community healthcare workers. Without such a plan we cannot endorse the NSP since we cannot endorse an unrealistic NSP.
  3. If all of the key interventions in the NSP are costed and funding sources identified.
  4. If all provincial AIDS councils are chaired by their respective provincial Premiers and if all provinces produce realistic, costed and fully-funded implementation plans.

these conditions have not been met so far – although some progress was made in the final NSP on condition 3. A key decision for activists is whether or not to hold out for all these conditions to be met, or to accept a flawed NSP and try to make the best of it.

A rejection of the NSP will be a step too far for some people or organisations or may not make strategic sense for some. In such a case, one way forward is to identify some of the positive elements in the NSP and to advocate for their implementation. It could, for example, be very important to pressure and hold government accountable for implementing the HCT campaign envisaged in the NSP or to use the NSP to advocate for the rapid introduction of new TB diagnostics and treatments. As described above, there are quite a number of positive commitments in the NSP that can be used to hold government accountable and to drive implementation.

Another possible position is simply to accept that the NSP has only limited influence since most key decisions regarding HIV and TB are ultimately made by government irrespective of what is written in the NSP. One could for example decide to ignore the NSP and simply attempt to engage with government directly as needed on specific policy issues. The difficulty with such a position is that one would essentially be forfeiting the good things that are included in the NSP. The NSP is after all endorsed by cabinet and as such presents official government policy – and in theory at least, such policy commitments are binding.

Finally, one cannot divorce the NSP from the structures of AIDS councils from local, district, provincial, to national level. Unfortunately AIDS councils across the country have mostly – with a few exceptions – been dysfunctional. The ongoing governance crisis at SANAC itself is particularly alarming and there is a real question as to whether SANAC should continue to exist in its current form. It is possible though that a radically reformed SANAC could help save the NSP by filling in the gaps and bringing together the right people. (Spotlight will soon be publishing an article on the crisis at SANAC and the potential for reform. The issues at SANAC are too complex to discuss fully in one article together with the NSP.)

  • Thank you to Kristanna Peris and Sasha Stevenson for help with this article. Thank you also to the many others who have shared their views and analysis of the NSP in recent weeks and months. I take sole responsibility for all errors in this article.

Note: Spotlight is a joint publication of SECTION27 and the Treatment Action Campaign. The Spotlight editorial team does however have substantial editorial independence – which it guards jealously.

The madness and evil of Manto and Thabo meets the madness and evil of Bathabile and Jacob

By Anso Thom

Having reported with many journalist colleagues on the darkest days on former President Thabo Mbeki and his health minister Dr Manto Tshabalala-Msimang’s distressing, fatal and quite mad HIV-denialism, the latest saga around social grants did bring back a sense of déjà vu. The denialism of the very real crisis and potentially devastating impact on the poor, spearheaded by President Zuma and his Social Development Minister Bathabile Dlamini, brought back some painful memories.

Once you start joining the dots and making the links, the similarities in some instances are remarkable.

Under Mbeki and Tshabalala-Msimang we had the following:

  • A President in denial and gone rogue on science, medicine, the Constitution and human rights.
  • A morally corrupt Minister who for various reasons allowed herself to become the President’s henchwoman
  • A President who not only denied that lifesaving drugs needed to be made available, but also denied that these medicines were actually efficacious.
  • A Minister who with great zeal not only became the President’s denialist spokesperson, but took his denialist rambling to the next level, by adding garlic, lemon, beetroot and olive oil to the mix.
  • Bewildering press conferences where the health minster even resorted to speaking Russian and chastised the media when she did not feel like dealing with tough questions.
  • Corrupt individuals and companies circling like salivating hyenas, desperate to make a quick buck with all kinds of untested quack potions as a replacement for anti-retrovirals. Some unethical like Virodene, others shady charlatans like Matthias Rath.
  • A Cabinet who failed to hold either the President or the Minister accountable, or not until many had died or suffered.
  • A President happy to sit in the shadows and let the Minister take the body blows.
  • Showing a middle-finger to the Constitution by failing to honour the Right to Healthcare.
  • Tacit support of views that harmed mostly poor people.

We ended up with a poisonous concoction which not only made us the laughing stock of the world (a quick google of the 2006 Toronto AIDS conference will offer enough evidence), but also spread terror, confusion and heartache among poor people who could not afford the lifesaving medicine. These vulnerable people were on the receiving end of so many conflicting messages from their leaders, people who they looked up to for guidance.

Fast forward a couple of years to 2017 and again we have a similar recipe albeit with slightly different ingredients.

  • A President in denial and gone rogue on administrative procedure, social good, the Constitution, his responsibilities as a custodian and human rights.
  • A morally corrupt Minister who becomes the President’s henchwoman.
  • A President who denied there was a crisis (no crisis until there is a crisis, he told Parliament).
  • A Minister who with great zeal spread the message of confusion and stubborn denial with no thought for the poor who deal with the uncertainty of not knowing whether or not their grants will come.
  • Bewildering press conferences where the Minister and her spokesperson at times refused to speak English, take legitimate questions from the media, opting to rather chastise them for doing their jobs.
  • Corrupt individuals circling like hyenas, knowing that the social grants contract in this country is worth Billions.
  • A Cabinet who failed to hold either the President or the Minister accountable.
  • A President happy to sit in the shadows and let the Minister take the body blows.
  • Showing a middle-finger to the Constitution by failing to implement a Constitutional Court order to stop Cash Paymaster’s contract.

But perhaps that is where the similarities end. Many have tried to understand how Mbeki, by all accounts an intelligent man, became so swayed by the denialist theories that he was willing to risk his legacy, to reject science, science that actually saves people’s lives. Tshabalala-Msimang, a medical doctor by training, went from a poster child of good health to a pariah who did not miss an opportunity to promote her vegetable remedies. Whatever motivated their deadly denialism, it seems unlikely that corruption had much to do with it.

In this regard Jacob Zuma and and Bathabile Dlamini are not quite the same as their earlier Comrades in that one cannot but think that the absolute chaotic handling of the social grants matter, has a stench of corruption. A stink of lining the pockets of friends and ensuring that money, lots of it, ends up in the right or wrong places, depending on which team you back.

But corrupt or not, the past and present again converge when both the Mbeki and the Zuma teams, chose then and again choose now, to turn their backs on the cries of the poor. To block their ears and continue to operate in a “lala-land” where there is “no crisis” and we live in a “funny” democracy.

But now, as then, there is nothing funny when a President turns his back on the poor. There is nothing funny when Ministers, heading up Departments which  exists to serve the poor, are prepared to laugh off legitimate concerns and play silly buggers with semantics.

How galling it was to receive a graphic on Whatsapp last week, Minister Dlamini grinning in the one corner. A massive hashtag in bold, red letters #SASSACARES screaming at the receiver.

A line which reads” All social grants will be paid out from the 01 April 2017 as promised by our caring Government”.

“Caring” Government? Not then, not now. Now as then, government has lost touch with the reality faced by poor people in South Africa. For this, Zuma and Dlamini will pay the price as Mbeki and Tshabalala-Msimang did – only this time, another decade further into ANC rule, they will also likely drag the party down with them.

Prisons and the New NSP: Nobody left behind?

by  Ariane Nevin[1] and Thulani Ndlovu[2]

Evidence has shown that prisons are a key battleground in the fight against HIV and TB. Prison populations are transient, and inmates are released back into their communities, taking with them all of the infections and unhealthy behaviours learned in prison. This means that any HIV and TB plan that doesn’t address the drivers of HIV and TB in prisons will fall woefully short of achieving its goals. And sadly, the latest draft of the NSP, with its inadequate prison-focused interventions, looks set to do just that.

The first draft of the NSP, released in November 2016, was cause for some jubilation for prisoners’ rights activists, for the first time including inmates as an HIV key population and incorporating important human rights language and interventions for prisons. However, we may have celebrated too soon, as two drafts later, following a far from transparent or inclusive political process, the prison-focused language has been markedly stripped down.

Although inmates remain a key population for both HIV and TB, and recipients of a core package of services targeting key populations, the NSP is missing interventions directed at addressing the causes of the TB and HIV epidemics in prisons: insufficient infection control, non-implementation of the Policy to Prevent Sexual Abuse of Inmates, dismal levels of overcrowding , inadequate ventilation, and insufficient re-integration support or linkage to care for ex-inmates upon release, to list but a few.

The latest draft includes as an objective, ‘Train correctional and detention centre staff regarding the prevention and health care needs and human rights of detainees and inmates living with or at risk of HIV and TB.’ However, sexual violence and overcrowding in prisons, which are key drivers of HIV and TB respectively, do not feature in any objectives. Surely any plan directed at training correctional centre staff on the prevention of HIV should look first to existing policies, of which the Policy to Prevent Sexual Abuse of Inmates is an excellent one. Why not include the implementation of this policy as an objective? Likewise, if we are to reduce TB infection rates, the plan should at the very least include amongst its objectives a strategy to reduce overcrowding.

The Departments of Correctional Services and Health receive plenty of money to fund their TB and HIV response, which they are using to test and screen inmates. However, they can counsel and screen as much as they like; until plans are developed and fully implemented to address the drivers of the epidemics, attempts to contain and beat them back will continue to have minimal impact.

International donors need to push DCS for a more comprehensive approach, greater transparency and better data. We cannot continue simply to roll out treatment blindly. If we are going to win this fight, we need to cut off these diseases at the knees.

Inmates and ex-inmates would have been the most qualified to suggest effective strategies for preventing TB and HIV in prisons, and effective support for reintegration of ex-inmates into their communities. However,  the inclusion of key populations in NSP consultations was made difficult, if not impossible by SANAC’s dismal organisation and planning that left important participants stranded and ultimately not consulted. Not only this, but the processes through which provisions are included or left out was entirely opaque, leaving stakeholders frustrated and in the dark, and SANAC, unaccountable.

So, what should the targets be?

  • Full implementation of the DCS Policy to Prevent Sexual Abuse of Inmates in DCS Facilities: Sexual abuse is prevalent in prisons, and is a recognised driver of the spread of HIV inside prisons. Unless urgent steps are taken to detect, prevent and respond to sexual violence in prison, transmission of HIV will continue.
  • Full implementation of a TB infection control policy: Prevention is better than cure and raising awareness among inmates that windows should be left open is not adequate. Steps need to be taken to decrease overcrowding, to ensure that cells have sufficient cross-ventilation and to allow inmates to spend more time spent outside of their cells. The NSP must set more concrete targets in this regard.
  • Urgent steps need to be taken to address extreme overcrowding in prisons: TB and HIV infection control policies will continue to have limited impact until overcrowding is decreased. Studies show that implementation of national cell occupancy recommendations could reduce TB transmission risk by 30%. The NSP must set concrete and measurable targets in this regard and map out a clear and workable strategy to eliminate overcrowding as soon as possible.
  • An effective prison oversight body with sufficient independence and powers to investigate and refer complaints needs to be established to replace the Judicial Inspectorate for Correctional Services: this will ensure that DCS policies are adhered to, and their obligations met. It will also provide a safe avenue through which inmates may submit complaints. Improved linkage to care between prisons and communities, and support groups for ex-inmates: Inmates need to receive counseling, a copy of their medical file and a referral to a clinic accessible to their community to enable adherence to treatment once they leave prison. They also need ongoing support to avoid re-offending. These services are currently lacking. In order for this to happen simple systems need to be put in place, and the DCS, DOH and DSD need to work together to ensure that there is no loss to care in the transition between incarceration and freedom.
  • An effective collaboration in real time between the DCS and NDOH to ensure that new NSP policies, like Universal Test and Treat and condom distribution are implemented with no delay.

We hope that the final NSP 2017-2022 will take heed of this advice, and look forward to an NSP that is actually strategic and truly leaves nobody behind.

[1] Sonke Gender Justice

[2] Zonk’izizwe Odds Development

HIV docs win quack HIV gel case

By Lauren Jankelowitz, CEO SA HIV Clinicians Society

The South Gauteng High Court this week ruled in favour of the SA HIV Clinicians Society in its legal battle with a doctor who promoted a product marketed as Dr Hugh’s Dermo Blue Pre-sex Protection Gel, which claimed to prevent HIV infection.

The Society previously informed clinicians and patients that the gel was untested and not proven to work, and explained the steps it had taken to ensure that the product was withdrawn from the market. This ultimately led to the doctor suing the Society for defamation.

The Society has an evidence-based approach to all its work and this is what was used when we considered the product in question. Part of the work of the Southern African HIV Clinicians Society includes constant efforts to debunk non-proven HIV “cures” and emphasise the importance of offering patients therapies that have been tested according to rigorous standards.

We are relieved and satisfied with the outcome. Part of the Society’s mandate is to provide doctors with the evidence that they need to give patients the best possible quality of care. Part of safeguarding patients is preventing the sale and use of untested products.

Such products, whether they are marketed as HIV cures or ways of preventing HIV infection, could encourage people to feel safe under false pretenses and thus put them at risk, and even cause harmful side effects. The Society reiterates the importance of taking HIV medication or using HIV prevention methods that have been thoroughly evaluated according to the highest scientific standards. This is the only way to ensure that those who seek medical care are protected.

“People who feel that they are at risk or fear for their health can be very vulnerable and thus fall prey to those selling quick-fixes or untested remedies. The Society plays a crucial role in ensuring that these patients aren’t taken advantage of and receive the best care possible,” says Society board member Professor Yunus Moosa.

Society President Dr Francesca Conradie agrees: “The Society aims to advance evidence-based interventions, whether for prevention or treatment. We will continue to work as advocates for those affected by HIV. This ruling is fantastic news for us.”

 

Sex Work and the new NSP

By Marlise Richter[1], Thuli Khoza[2] and Katlego Rasebitse[3]

Sex Work and the ‘National Strategic Plan on HIV, STIs and TB 2017-2022’ – time to be brave!

No HIV plan or response will be wholly successful if it does not candidly address the context in which sex work takes place, and do so from within a human rights framework.  South Africa’s HIV programmes have taken the lead in acknowledging the need to partner with sex workers and sex work advocacy groups.  Some AIDS plans have even be so wise as to recommend the decriminalisation of sex work – this means that all criminal laws that apply to sex work are removed, and sex work is dealt with as ‘work’.  Modelling research has shown that decriminalisation will reduce HIV transmission by 33%-46% among female sex workers and clients within a decade. In fact, South Africa is one of the first countries to have a sex work-specific plan in the form of the South African National Sex Worker HIV Plan 2016-2019, and it specifically endorses decriminalisation.

There is much to be proud of – but it is not yet enough.

Meme produced by Zia Wasserman

The drafting and consultation process for the NSP 2017-2022 has been a tricky one, with drafts radically changing from one month to the next.  One draft would have a robust human rights chapter, only to be followed by a version where there is none, which will catalyse strong push-back from civil society.

The last version of the NSP we studied was dated 24 February 2017.  It had remedied many of the issues raised by consultations and submissions including a clear commitment towards human rights, and should be applauded.

We would however like to see much more robust sections on the structural factors that impact on sex work, and submit the following key recommendations:

  • Strong call for the decriminalisation of sex work with clear indicators. The last NSP draft calls for “steps to be taken towards the decriminalisation of sex work”, which we applaud and support as this form of law reform is absolutely key to protect sex workers and their clients from HIV and other illnesses. However SANAC and the Department of Health should take the lead in pushing for law reform, and these efforts should be measured and monitored in the careful log frames that are included in the drafts.
  • Eliminate the police practice of ‘Condoms as Evidence’: The sub-objective on sensitising law makers and law enforcement agents should include an explicit statement on the elimination of the police practice of using possession of condoms, lubricant, ARVs or any other legal commodity as evidence of sex work and grounds for confiscation or arrest . In shorthand, called the ‘Condoms as Evidence’ practice, some police undermine public health principles by harassing sex workers carrying condoms, or destroying them.  This has to stop.
  • Remove ideology-based funding restrictions: The Department of Health and SANAC should petition US agencies for the removal of the so-called PEPFAR ‘Anti-Prostitution Pledge’ from funding agreements between US donors and SA NGOs and agencies that prohibit funding recipients for advocating for law reform on sex work. This is currently the case, and is causing organisations working with sex workers to remain silent on the human rights abuses experienced by sex workers.  Law reform is urgently needed on sex work to reduce the violence and abuse of sex workers, and the voices of organisations providing services to sex workers need to be heard.
  • Include the Social Impact Bond: Social Impact Bonds should be included under the discussion of innovative funding mechanisms, and be supported.  The SIB is an exciting intervention that we need to watch carefully as it could support the empowerment of sex workers and the reduction of their vulnerability to HIV and other illnesses. SANAC has been collaborating with Social Finance (UK) to explore if some components of the funding for the Sex Worker HIV Programme 2016-2019 could be raised through an outcomes-based financing model that could be an SIB.
  • Include a migration focus: There are strong links between migration and sex work in South Africa and the region, and it is regrettable that this NSP makes almost no provision for migration-aware health services or responses in its text.

We look forward to seeing the final NSP 2017-2022, and we trust that it will be the best one South Africa has ever had.

 

[1] Sonke Gender Justice

[2] SANAC Sex Work Sector leader

[3] SANAC Sex Work Sector leader

 

SA’s new AIDS plan falls short on community health workers

By Sasha Stevenson

South Africa’s new National Strategic Plan (NSP) on HIV, TB and STIs will be launched on March 24. It presents a unique opportunity to start correcting the rudderless management of community health workers (CHWS) in the South African public healthcare system in recent years. (For in-depth background on CHWs, see Spotlight’s recent special investigation.)

The draft of the new NSP states: “HIV, TB and STI prevention, treatment and care is labour intensive and requires diverse cadres of human resources from multiple sectors.” And, “Community health workers need to be formalized as a cadre, appropriately trained and supported, and fully integrated into the health system.”

These are promising statements on human resources for health in general, and community health workers in particular, being key enablers for NSP 2017-2022. The question, however, is how far the new NSP goes in advancing the discussion around and demand for the development and integration of community health workers as a vital cadre of health care worker for the implementation of the NSP and strengthening of the health care system. The answer, unfortunately, is not far enough.

Focus on prevention

The new NSP puts prevention at its centre. In doing so it supports the new ‘test and treat’ policy which is aimed at reducing HIV-related morbidity and mortality and significantly reducing TB incidence and TB mortality. It envisages a comprehensive multi-sectoral prevention programme focused on high incidence hot spots in the hope of changing individual risky sexual behaviour. It sets ambitious targets and lays out detailed indicators.

Disease prevention, health promotion, and linkage to care are at the core of CHW programmes the world over. Health behaviour and social welfare promotion, preventive health care service and commodity distribution, diagnosing and management of common illnesses, assistance during birth, and community organising are all traditional CHW functions.

Despite the broad statements made, and despite what would appear to be the natural alliance between the needs of the new NSP and the need of the health system more broadly for the employment and integration of CHWs, the NSP is low on detail and does not get into any hard numbers in relation to CHWs.

Important targets missing

The NSP 2017-2022 should set targets for the number of CHWs employed or WBPHCOTs developed. It should set targets on CHW capacitation for TB case detection and for preventing loss to follow up for HIV and TB patients. It does none of this.

Goal 2 of the NSP expressed the need for guidelines on the role of, and tools for the use of, CHWs in HIV testing and counselling, linkage to care, and initiation on ART. The implementation and expansion of “community and peer-led programming” is aimed for under Goal 3, without acknowledgement of the direct role of CHWs in such programming. Clinics will open for longer hours – undoubtedly positive – but it is not clear that CHWs will be appropriately supported in the ongoing provision of home based care.

At a time when CHW policy has stalled; when posts for other health care workers are being frozen; but when there is a renewed focus on HIV and TB and the need to treat 5.5 million people, the incorporation of a properly trained, managed and integrated CHW cadre into the HIV and TB programme is vital. Unfortunately, it looks as if the drafters of the latest NSP are missing this opportunity.

Fly by night tenders: A Spotlight special investigation into aeromedical service in South Africa

By Marcus Low and Ntsiki Mpulo

Aircraft have been used effectively to provide emergency medical services and to transport medical specialists and other supports services to deep rural and underserved areas in South Africa since 1960. However, an investigation has revealed that the provision of such aeromedical services has become mired in questionable tenders. Now, a relatively unknown Free State emergency medical services company, new to aeromedical services, is rapidly winning government contracts in the so-called Premier League provinces and two others.

The tender for aeromedical services in South Africa is called RT-79. It is run by the National Treasury – and not the Department of Health, although the latter does play an important role. RT-79 has been advertised and awarded three times – in 2009, 2012 and 2015.

However, the 2015 RT-79 tender was cancelled at short notice in mid-2016 without a new tender to replace it. This created a vacuum in a number of provinces that was soon filled by a newcomer to aeromedical services – a company called Buthelezi EMS, owned by Thapelo Buthelezi.

Spotlight previously reported on Buthelezi EMS allegedly providing sub-standard ground ambulance services to the Free State Department of Health. The Democratic Alliance has also questioned the Free State government’s decision to outsource ambulance services to a private company providing poor service. Attempts to get comment from Buthelezi has been unsuccessful. Their website is still under construction, their Facebook page not regularly updated and some numbers listed on their Facebook page are were not working at the time of writing this article. An e-mail with questions sent to an address an unidentified woman who answered one of the phone lines supplied, went unanswered.

For years, Buthelezi EMS provided only ground ambulance services in the Free State. However, in 2015 they started providing aeromedical services in the Free State.
When the 2015 national RT-79 tender was cancelled, Buthelezi EMS entered into a joint venture with a company called Halo Aviation. Halo previously worked with ER24 and has a proven track record providing aeromedical services. Together, Buthelezi and Halo soon were awarded contracts in Mpumalanga and Limpopo in the following months. They also won a tender in the North West Province. Farhaad Haffejee of a competitor, the non-profit Red Cross Air Mercy Service (AMS) says they were not aware of the North West tender until after it was awarded. Buthelezi EMS also provide services in Gauteng.

However, the process by which Buthelezi EMS has come to be awarded these contracts is currently being challenged in the North Gauteng High Court by AMS. While the cancelation of the RT79-2015 contract meant new business for Buthelezi and Halo, it also meant that AMS were suddenly out of business in Limpopo and Mpumalanga in spite of providing an undisputed quality of service.
According to Haffejee AMS had to retrench staff in both Limpopo and Mpumalanga. “In addition,” he says, “the AMS has taken significant losses because aircraft, hangars, offices, etc that were acquired for the three year duration of RT79-2015 are now supernumerary in the AMS system. As such, the AMS has had to put aircraft on the market for sale and have had to deal with the closure of two bases in Mpumalanga and Limpopo.”

AMS has argued in ongoing court proceedings that proper procedure were not followed when new service providers were appointed in the wake of the cancelation of RT-79. They claim that they were not invited to or asked to bid for the new contracts in Mpumalanga and Limpopo.
“Perhaps what is worrying about all of this is that when the tender was cancelled, National Treasury advised the Provinces not to do business with the AMS,” says Haffejee. “What happened was that both the Mpumalanga and Limpopo provinces were advised to piggyback on a tender (as allowed for by the Public Finance Management Act) of the Free State Department of Health which had been awarded to Buthelezi EMS and Halo. Even though the AMS was already operating in the provinces, providing a service without any operational issues and at a lower cost, the AMS was not considered to continue, even on a month to month basis until such time that all the legal issues had been settled.”

“Further to this, the Mpumalanga Provincial Department of Health went against the written advice of the Mpumalanga Provincial Treasury which instructed them that they were only able to grant Buthelezi a contract for 6 months as per the PFMA and instead gave Buthelezi a tender for a period of 3 years,” says Haffejee. “What is even more surprising is that the rates charged by Buthelezi EMS for this new contract is significantly more than what the AMS was charging under the RT79-2015 contract.”

Spotlight asked National Treasury about the alleged failure to include AMS in bidding processes in these provinces. Treasury did not provide a direct answer to this question. Treasury also claimed that there was nothing wrong with the Mpumalanga tender as alleged.
Treasury did however explain that they provided interim guidance to provinces stating as follows:
“The departments are hereby authorised to acquire the above services in accordance with the following prescripts:

Paragraph 4.7.5.1 of the Guide to Accounting Officer which stipulates that “In urgent and emergency cases, an institution may dispense with the invitation of bids and may obtain the required goods, works or services by means of quotations by preferably making use of the database of prospective suppliers, or otherwise in any manner to the best interest of the State”

Paragraph 16.A6.4 of the Treasury Regulation stipulates that “ if in a specific case it is impractical to invite competitive bids, the accounting officer or accounting authority may procure the required goods or services by other means, provided that the reasons for deviating from inviting competitive bids must be recorded and approved by the accounting officer or accounting authority.”

The reasons for the urgency/emergency and for dispensing of competitive bids, should be clearly recorded and approved by the accounting officer/authority or his/her delegate.”
Commenting on this issue, Ryan Horsman of Halo told Spotlight that “all participating provinces were advised by National Treasury to deal directly with approved service providers to ensure continuation of the provision of an aero medical service within each respective province.” According to Horsman the majority of the provinces preferred this approach “as the general consensus was that the National Tender did not address the unique individual challenges each Province experienced”.

We also put the following question to Treasury: “When the 2015 RT-79 tender was cancelled in mid- 2016, why were well-functioning services that were already in place (such as those provided by AMS) not allowed to continue until such time as a new tender could be concluded?”
The rather puzzling response from treasury was simply that “The tender award prejudiced suppliers that should have been in contention for award of business on the contract.”
It appears services to patients were impacted by the abrupt cancelation of the tender. According to Haffejee Provinces went without an aeromedical service for some time before Buthelezi EMS and Halo was able to set up operations in these Provinces.

Follow up questions we sent to treasury were not answered. Attempts to get comment from the Free State, Limpopo, Mpumalanga and national departments of health were also unsuccessful.

 Why was the 2015 RT-79 tender cancelled in the first place?

Leading up to the award of the 2015 RT-79 tender, AMS wrote to treasury about various concerns regarding the tender specifications. These initial concerns appear to have been ignored by treasury which went ahead with the award of the tender to, amongst others, AMS and a newly formed company called FlyFOFA. AMS doubted FlyFOFA’s ability to deliver and raised its concerns with National treasury. The Kwazulu-Natal Department of Health also doubted FlyFOFA’s ability to deliver and kept AMS under contract – even though FlyFOFA won the tender for fixed-wing services in the province. (We previously reported on the Kwazulu-Natal situation here.) There were additional concerns about the management of FlyFOFA (discussed in the next section), but they appear not to have impacted the cancelation of the tender.

”When RT79-2015 was awarded to Air Mercy Service and FlyFOFA, ER24 as the lead partner approached the Public Protectors office to investigate the award of the tender to these parties as criteria utilised for the award to AMS and FlyFOFA did not match tender requirements,” says Ryan Horsman of Halo. “HALO supported the approach to the Public Protectors Office.”
In line with this complaint, the eventual cancelation of the 2015 RT-79 tender was justified by treasury by the fact that a so-called “utilization factor” had not been disclosed in the tender documents. (A utilization factor is an estimate of how much a service will be utilised and accordingly how much it will cost the state at a quoted rate) Whether it is in fact necessary to disclose utilization factors in tender documents is one of the issues that the court has been asked to consider. AMS argues that non-disclosure of this number in tender documents does not make the tender unlawful and that National Treasury did not follow due process in the cancellation of the tender.

The court battle also involves a dispute regarding the cost implications of the utilization factor that was used. Treasury argues that the number used prejudices the State to about R30million. AMS disputes this and includes in their court papers compelling comparisons indicating that AMS provides the full service required at roughly the same or lower cost than competitors at a higher technical level. In fact, it seems likely from the AMS estimates that the state is getting less value for money by using Buthelezi EMS.

When asked by Spotlight, treasury provided only the following explanation for the cancelation of the 2015 RT-79 tender: “The contract was not in line with the Special Conditions of Contract of the Tender. Evaluation criteria was used that were never part of the evaluation criteria as specified in the tender document. Hence the contract was awarded on an unlawful basis.”
Haffejee is suspicious of the motives behind the cancelation of the tender. “Why was this tender only cancelled nine months after the award?” he asks. “Why did National Treasury never respond to the objections lodged by the AMS immediately after the award of the Fixed Wing portion of the RT79-2015 tender to a non-qualifying operator (FlyFOFA) without any due diligence having been done?”

  A history of questionable tenders

The RT-79 tender was introduced in 2009 at the behest of FIFA, who wanted an aeromedical service meeting certain specifications to be in place in time for the 2010 Soccer World Cup hosted by South Africa. Rhett Davis, Deputy Director for Disaster Management at National Health, was involved with the 2009 tender from the Department of Health’s side. In April 2010, Davis left his job at the department and was appointed Procurement Manager at ER24, a private medical service owned by Mediclinic International (or Mediclinic Southern Africa). Shortly after Davis left the Department of Health, ER24 put in a bid together with a company called Halo and in March 2012 they won the rotor wing (helicopter) tender for the Free State, NorthWest and Mpumalanga. While the movement of individuals from government to companies that subsequently win government contracts is of concern, we stress that we have no evidence of wrong-doing by Mr Davis,  (nor by Mr Theu or Mr Fisha mentioned below).

The Northern Cape tender in 2012 was awarded to a company called Flying Ambulance Pty. The Director of Flying Ambulance Pty was at the time Krause Steyl. Steyl is also director of a company called Aerocare that also provides aeromedical services. According to reports Steyl was involved with Executive Outcomes – a mercenary group that planned a coup in Equatorial Guinea in 2004. The coup failed. Steyl turned state witness and testified against the other conspirators. When asked about the award to Steyl and Flying Ambulance Pty, treasury responded that “National Treasury was not and is not aware of such.”

Prior to Flying Ambulance Pty winning the tender the province had an excellent outreach service which had been developed by the AMS together with the Northern Cape Department of Health over a period of 16 years (started in 1996) which ensured that patients in small outposts received regular visits from top specialists. Not only did it serve the patients it also relieved the pressure on the referral hospitals in the urban centres especially Kimberley. This service saw the eradication of dental and eyecare backlogs in the Northern Cape, infact the NC Province received recognition at the time from National Health for the Province that had made the most significant progress in eradicating backlogs of cataract blindness.

The 2015 RT-79 tender wasn’t any better. As in 2012, people previously involved with the award of tenders won parts of the new tender. A newly formed company called FlyFOFA won the fixed-wing air ambulance and outreach tenders for the Northern Cape and Kwazulu-Natal. The Executive Managing Director at FlyFOFA is Charles Theu – previously the Director of Emergency Medical Services at the National Department of Health where he was the department’s person responsible for RT-79.

In addition, the Chief Operating Officer at FlyFOFA, Thabo Fisha, had in September 2015 been dismissed from a senior position at the South African Civil Aviation Authority (CAA). The CAA told journalist Erika Gibson that the dismissal was not linked to FlyFOFA. The CAA did however state on the record that there were irregularities with the issuance of an air operating certificate to FlyFOFA in January 2015. There are also claims from industry sources that FlyFOFA was issued with an operating license in record time. The CAA told Spotlight that FlyFOFA does not presently have a valid license to provide air ambulance services.

FlyFOFA did not respond to questions sent by Spotlight.
The 2015 tender was unusual for other reasons as well. Originally due to come into effect on 1 April 2015, the award date was delayed multiple times, and with no compelling reason given. The award was eventually made in September. Then, having started late, the tender was abruptly and controversially (as described above) cancelled mere months later in July 2016.

 

Correction and apology

This article was amended on 3 March 2017. According to Mr Rhett Davis his job title at the National Department of Health was “Deputy Director — Disaster Management” and not “Deputy Director of Emergency Medical Services” as originally stated. Additionally, Mr Davis left the Department of Health on 12 April 2010 and not 2011 as originally stated. We also initially wrote that Davis was responsible for “driving” the Department of Health’s involvement with the 2009 RT-79 tender – we have amended this to simply indicate that he was involved with the tender. We also added Mr Davis’s job title at ER24 and a comment stating that we have no evidence of wrong-doing by Mr Davis.
Spotlight did not obtain comment from Mr Davis prior to the initial publication of this article. This was a serious journalistic error. Spotlight apologises to Mr Davis for this error. Spotlight takes sole
responsibility for this error.

South Africa: Sexual violence in Platinum Mining Belt a major driver of HIV

Press Release

By Medecins Sans Frontieres

Seattle/Rustenburg – New analysis of data detailing the extent of sexual violence in the Rustenburg area indicates that one in five HIV infections (approximately 6,765 of all female cases) and one in three cases of depression among women (5,022 cases) are attributable to rape and intimate-partner violence (IPV), while one in three women inducing abortion (1,296 cases) was pregnant as a result of sexual violence.

These startling findings, presented at in Seattle at the annual Conference on Retroviruses and Opportunistic Infections, follow from an in-depth 2015 survey conducted by MSF among more than 800 women living in communities along the mining belt where the health consequences of sexual violence remain largely unaddressed and demand urgent action.

Much additional suffering could have been prevented if survivors had been able to access a basic package of healthcare services, but according to MSF epidemiologist Sarah-Jane Steele, “Opportunities are missed each day to prevent HIV infection, psychological trauma, and unwanted pregnancy for victims of sexual violence in on the platinum mining belt, because there are too few health facilities with the capacity to provide essential care.”

As South Africa finalizes its next five-year National Strategic Plan (NSP) on HIV, TB and STIs (2017-2022), MSF is calling for the inclusion of ambitious targets for increasing sexual violence survivors’ access to medical and psychosocial services at health facilities. Key interventions include providing post-exposure prophylaxis (PEP) to prevent HIV and other sexually transmitted infections, psychosocial support including trauma counselling,emergency contraception, other basic medical services (e.g. first aid), and the option of forensic examination.

“It is not unrealistic to expect, at a minimum, that every sub-district in the country has a health centre that can provide an essential package of care to mitigate the consequences of rape and other sexual violence,” Steele says.

Alongside increased access to services there is also a need for health promotion within communities, as half of the women MSF surveyed in 2015 did not know that HIV can be prevented after rape if PEP is received within 72 hours. The situation could be helped by a two-pronged approach of establishing more health facilities as points of entry for sexual violence care services, while raising awareness in communities about the benefits of accessing care.

A note on research methodology:

MSF’s 2015 survey of more than 800 Rustenburg women between the ages of 18-49 established that one in four have been raped in their lifetime, whereas approximately half have experienced some form of sexual or intimate partner violence. Initial findings from this survey were released in the report Untreated Violence in August 2016. Having established the prevalence of sexual violence, MSF aimed to determine the attributable burden of disease. This was achieved by using World Health Organization estimates of disease risk to determine population attributable fractions (PAFs). The PAFs were then applied to the population distribution figures for the area, as well as local disease prevalence estimates obtained through literature review.

About MSF in Rustenburg
MSF has been present in Rustenburg since July 2015, when the organization began supporting the North West Department of Health (DoH) to expand access to care for survivors of sexual violence living in the shadows of the area’s platinum mines. Services offered at primary healthcare facilities called “Kgomotso Care Centres” (KCCs) include PEP to prevent HIV and other sexually transmitted infections, and psychosocial support and counselling for survivors. Patients requiring more advanced medical, psychosocial or legal services are referred to hospitals, other government departments and/or community support structure.

This Press Release was published at MSF

New TB and HIV science from CROI 2017

By Marcus Low

The Conference for Retroviruses and Opportunistic Infections (CROI) was held in Seattle this week. Below are some of the research findings and presentations that stood out for us. CROI is a big conference and it is impossible to get to everything. We no doubt left out some important new findings in the below and there are whole areas – especially basic research – that we did not cover at all.

An XDR-TB breakthrough and more TB news

At present most people who get Extensively Drug-Resistant (XDR) TB die – with mortality estimated to be as high as 75%. However, in the still ongoing NIX-TB trial indications are that most patients are being cured.

NIX-TB is testing the use of a six-month course of treatment consisting of the medicines bedaquiline, pretonamid and linezolid for the treatment of XDR and pre-XDR TB. It is a single arm trial  given that there is no standard of care for XDR TB to constitute a control arm. Some interim data from the trial was previously reported, but the data presented at CROI is the most up-to-date data from the trial available in the public domain.

Of 72 XDR and pre-XDR TB patients enrolled so far, 40 have completed the treatment – and of these 31 have also completed six months of follow-up. There have been only four deaths in the trial – a remarkably low number given the poor prognosis these patients would have in the public healthcare system. There has been only two cases of relapse or reinfection. All patients who completed the treatment were cured – all having culture converted by four months.

While it is becoming increasingly clear that the NIX regimen is the best available option for people with XDR or pre-XDR TB, access to this regimen is currently limited to people taking part in clinical trials. While access to two of the drugs, linezolid and bedaquiline, is possible in a number of countries, the third drug, pretonamid, has not yet been registered in any countries. The onus is on the TB Alliance, who controls the development of pretonamid to ensure that more people can access the drug while these studies continue.

In other important TB news, details of the performance of an updated version of the Xpert MTB/RIF TB test was presented this week. One of the weaknesses of the old test is that when testing a hundred people with both HIV and TB it would fail to detect TB in around 30 of those people. The new version of the test, called the Xpert Ultra, is 12% more sensitive – which would take the sensitivity from around 70% to around 78% (which means it would miss 22 people in a hundred rather than 30). It was also announced that the cartridges for the new test will be sold at the same price as the old cartridges.

Compelling new evidence was also presented at CROI that TB preventative therapy using isoniazid saves lives in people living with HIV with high CD4 counts whether or not they are also taking antiretroviral therapy. A total of 86 deaths were observed in the 2 056 people followed in the study – 34 in the preventative therapy arm and 52 in the arm that did not get preventative therapy. The study was an extension of the landmark TEMPRANO study – a study that in 2015 both confirmed the value of TB preventative therapy and earlier antiretroviral treatment for HIV.

There was also some disappointing news from  a study testing whether it is safe to use a newer form of TB preventative therapy – the so-called 3HP regimen  (once weekly rifapentine and isoniazid) – together with the critically important new ARV dolutegravir. The small safety study unfortunately had to be stopped early due to serious adverse events. It is widely expected that dolutegravir will in a few years become part of the standard first line treatment for HIV in South Africa and many other countries. This study suggests that it will not be possible to use the 3HP regimen with dolutegravir.

Some new ARVs and ARV combinations

Many investigational HIV treatments in various stages of development were presented and discussed at CROI. One of the most interesting is GS-CA1 – a drug in a new class called capsid inhibitors. The capsid is the protein shell of a virus. It is thought that by targeting the capsid, capsid inhibitors can prevent HIV integration and replication at various stages – unlike other antiretroviral drugs that typically target only one specific part of the HIV life-cycle. Human trials have however not yet begun and the expected date for phase I trials is next year (2018).

In more immediately relevant results from the phase III SWORD 1 and 2 trials (reported together), it appears that certain people healthy and stable on three or four drug antiretroviral therapy can safely be switched to a two drug regimen consisting of dolutegravir and rilpivirine. People receiving dolutegravir/rilpivirine dual therapy in the two studies had very good viral suppression and similar outcomes to the control group on most measures. The two SWORD studies together have 1 024 participents and the data presented was for 48 weeks – 144 week data will be presented in future.

Integrase inhibitors are playing an increasingly important part in HIV treatment with dolutegravir looking set to become a key part of standard first-line treatment in coming years. A phase II study reported at CROI suggested that a new integrase inhibitor called bictegravir may be as safe and as effective as dolutegravir. Planned phase III trials should help to tease out the differences between these two drugs.

Finally, a new analysis from the TasP trial conducted in KwaZulu-Natal found that of 1 340 participants for which resistance tests were done, 8.4% had significant levels of drug resistance to one of the three first line drugs before they started taking antiretroviral therapy – with resistance to efavirenz being most common. Rather surprisingly, viral suppression was as good in people with pre-existing resistance as in those without. This suggests that in most of these cases two drugs were enough to achieve viral suppression. The factors most strongly correlated with poor viral suppression were high initial viral loads and poor treatment adherence.

This article has not considered the wealth of HIV cure research presented at CROI, nor the substantial amount of pre-exposure prophylaxis research. We will return to those issues in future Spotlight articles.

Some recommended presentations you can watch online

All presentations from CROI are made available online a day or so after the session takes place. Thanks to this people from across the world can benefit from some of the excellent presentations at the conference. Below we highlight just three that stood out for us.

  1. Jintanat Ananworanich of the US Military HIV Research Program presented a fascinating overview on research toward an HIV cure.
  2. Francesca Conradie of the University of the Witwatersrand presented an excellent summary of the state of treatment for MDR TB and prospects going forward.
  3. Catharina C Boehme of the Foundation for Innovative New Diagnostics (FIND) provided an overview of the state of MDR TB diagnostics.