New SANAC CEO responds to questions about his past

By Ufrieda Ho

Dr Sandile Buthelezi was recently appointed as the new head (CEO) of the South African National AIDS Council. His appointment follows the suspicious non-renewal of the previous CEO’s contract Dr Fareed Abdullah and unsuccessful attempts to lure Eastern Cape head of health Dr Thobile Mbengashe to the post. The success of the new National Strategic Plan implementation and the long-term survival of a robust, relevant and ethical SA National AIDS Council will depend on the new CEO. Spotlight put a range of questions to Buthelezi regarding his involvement in the Tara KLamp debacle, the persecution of doctors at Manguzi Hospital in 2008, and allegations of corruption.

Dr Sandile Buthelezi was recently appointed as the new Chief Executive Officer (CEO) of the South African National AIDS Council (SANAC). Buthelezi’s appointment comes as a surprise, given that it was expected that the position would go to Thobile Mbengashe – who Spotlight understood to have been the preferred candidate of key members of the SANAC board of trustees. However, we understand the Eastern Cape made Mbengashe a counter offer, which made it hard for him to leave for the SANAC job.

Buthelezi’s appointment also surprised activists who are concerned about his involvement in the rollout of an unsafe circumcision device (the Tara KLamp) in Kwazulu-Natal and the persecution of doctors at Manguzi Hospital in 2008. The doctors were providing dual antiretroviral therapy to pregnant women with HIV. At the time providing dual therapy was deemed to be against the government policy of AIDS denialist President Thabo Mbeki and Health Minister Manto Tshabalala-Msimang.

Highly charged atmosphere

Buthelezi is stepping into a highly charged atmosphere with recent news reports describing SANAC as being in disarray and various civil society organisations considering a withdrawal from SANAC. Some of the concerns regarding governance at SANAC relate to the process of appointing a new CEO. For reasons that have not yet been explained, an initial recruitment process was stopped halfway and the post was readvertised early this year. In February this year the trustees, then led by Dr Gwen Ramakgopa, who is now Gauteng MEC for health, announced that Dr Malega Constance Kganakga had been appointed acting CEO for three months while interviews were being completed. It would be another four months (after those initial three months) before Buthelezi took office at the beginning of September 2017.

The board controversially decided in February not to extend the CEO contract of Dr Fareed Abdullah or to allow him to continue as interim CEO. This move was met with widespread condemnation from activists and the Democratic Alliance. Abdullah is credited by some for transforming SANAC into an independent Council that for the first time had five straight years of clean audits and better checks and balances in place to ensure good governance.

Buthelezi told Spotlight he wishes to thank his predecessors “for building SANAC into the credible organization that it is”. “SANAC operates against the backdrop of people’s perception of government institutions and hence our first duty will be demonstrating good corporate governance,” says Buthelezi. “This is a critical obligation that we at SANAC need to uphold, and it will be the hallmark of my tenure.

Persecution of Manguzi doctors

In 2008 Buthelezi was head of HIV and AIDS in KwaZulu-Natal where he played a role in the persecution of doctors at Manguzi Hospital. Dr Colin Pfaff, acting medical manager at Manguzi Hospital at the time, and colleagues broke rank from official Department of Health policy to introduce dual-therapy treatment for HIV-positive pregnant women at a time when official government policy was to provide only monotherapy.

The science at the time was clear that dual therapy was superior to monotherapy in reducing mother-to-child transmission of HIV. Pfaff raised funds from donors to pay for the introduction of dual therapy at Manguzi. Pfaff was suspended for this and faced disciplinary action – that was later withdrawn.

Buthelezi admits he worked closely with doctors in the district at the time and adds: “I believe it is unfair to expect a junior official to act out of sync with national government policy.” At the time Buthelezi was quoted making a similar argument in the New York Times saying “I am wary of us undermining national just because of what other provinces are doing (referring to the rollout of dual therapy in the Western Cape)”. At the time Buthelezi was working under controversial KwaZulu-Natal MEC for Health Peggy Nkonyeni – who was a close ally of AIDS denialist Health Minister Dr Manto Tshabalala-Msimang.

No regrets regarding Tara KLamp

In 2010, Two years after the Manguzi scandal, with government-sanctioned AIDS denialism having meanwhile “ended” under the leadership of first Health Minister Barbara Hogan and then her successor Dr Aaron Motsoaledi, the Kwazulu-Natal Department of Health was involved in another high-profile controversy. The department started providing circumcisions with an unsafe plastic circumcision device called the Tara KLamp. The device caused a number of serious injuries and eventually became the subject of a Treatment Action Campaign complaint to the Public Protector. Questions about alleged kickbacks relating to the procurement of the Tara KLamp remain unresolved seven years later.

While Buthelezi wrote letters and was quoted in the media in relation to the Manguzi scandal, it appears he was less directly involved with the Tara KLamp rollout. Another Sandile, Sandile Tshablalala, was in charge of the circumcision programme in the province. As with Manguzi, the Tara KLamp had high-profile political backing  this time in the form of MEC for Health Sibongiseni Dhlomo, then Premier of Kwazulu-Natal Zweli Mkhize, and King Goodwil Zwelithini.

Yet, as head of HIV and AIDS in the province Buthelezi would have almost certainly been party to decisions made regarding the rollout of the Tara KLamp. We can find no evidence that he opposed the rollout in any way – this while he admits involvement in the circumcision programme. “I am proud of my contribution to the roll-out of medical male circumcision in KwaZulu-Natal,” says Buthelezi, wwhich included (…) Rallying all stakeholders including His Majesty, in advocating for MMC.”

“The implementation of medical male circumcision in the province remains a watershed moment in the country’s HIV response,” he says. “A province where circumcision was not routinely practised, took the lead in including medical male circumcision as part of a combined package of prevention methods. This is a significant achievement and I have no regrets.”

Corruption allegations

In late 2010 Buthelezi left the KZN Department of Health. A source suggested to Spotlight that Buthelezi’s departure was related to allegations that he awarded a catering contract to a family member.

While Buthelezi does not dispute that the allegations were made, he insists that they are baseless and untested. “The issue relates to a tender that was dealt with at a district where I was not involved in any of the bid committees,” he says. “I only received paper work to approve payment after the district committees and management had signed that they received the goods and/or services.”

Buthelezi says he left the KZN Department of Health because he received a better job offer and that he continued to have a good relationship with the department after he left. He took up a position as country director of ICAP, a University of Columbia initiative to strengthen health systems around the world. From there he left to work at HLSP- Mott MacDonald, as senior technical lead with the health sector consultancy. In 2014 he was reappointed to the ICAP role.

“He will have to build trust”

Several of Buthelezi’s previous colleagues, members of the SANAC board and people he had professional dealings with at his previous positions were contacted to comment on Buthelezi’s appointment. Some didn’t respond and some declined to comment on record. Professor Wafaa El-Sadr the director of ICAP, based in New York, did comment, saying that in the last three years that he reported to her that Buthelezi did meet specific implementation targets and successfully built important linkages and partnerships within his team. “He had a good understanding of the lay of the land. He had the experience and he did understand South African realities.

“The challenges for a strong SANAC will be about never losing sight of the core of what we do and that is to change the lives of people. He will have to build trust and be able to bring along with him even those people who are not supportive of him,” says El-Sadr.

“He was on the wrong side”

Anele Yawa, General Secretary of the Treatment Action Campaign, says that Buthelezi’s past cannot be ignored. “He was on the wrong side – he was an AIDS denialist, like Manto Tshabalala-Msimang and Thabo Mbeki, he wasn’t for the people,” he says.

“We don’t just want a warm body in the position of CEO and we still don’t know what happened with the process of appointing a new CEO,” says Yawa. “Buthelezi must be able to add value. He can start with audits of the organisations that are part of the SANAC civil society sector – he can even start with TAC, this will make it clear who should be part of SANAC and who should not.”

Yawa says SANAC has to return to the grassroots – the face of HIV/AIDS, not be fixated on “meetings and conferences held in fancy hotels”.

Even with his outspoken criticism, Yawa says that for now TAC remains committed to staying within SANAC. “We want to fix the problems because we have come a long way. But when we ring the bell Buthelezi must come. We give him three months to get his house in order,” says Yawa.

“I believe in service”

Buthelezi says his vision for SANAC will become clearer once he settles into the role. But he says he’s up to the job. “I come from rural eShowe where humility, respect and ubuntu define human relations,” he says. “We’ve fought HIV for too long – we must see results.”

“I believe in service and I am results-driven and work well with teams. I hope we shall be an organisation that listen actively, prioritises what’s important, adapts readily and empowers others.”

 

TAC congress elects new leaders, sets priorities

The Treatment Action Campaign’s (TAC) 6th National Congress held in

Deputy President Cyril Ramaphosa accepts the iconic HIV positive t-shirt from TAC Deputy General Secretary Vuyokazi Gonyela, while General Secretary Anele Yawa looks on. Photo: Joyrene Kramer

Sterkfontein, Gauteng  concluded today with the re-election of Anele Yawa as General Secretary and the election of Sibongile Tshabalala as Chairperson. Vuyokazi Gonyela was elected as Deputy General Secretary and Patrick Mdletshe was re-elected as Deputy Chairperson.

“The second phase of TAC’s struggle is for quality healthcare delivered through a well-functioning healthcare system where the dignity of all is respected and nobody is excluded,” read a TAC statement. It also said that “In 2017, the HIV and TB epidemics are far from over in South Africa and in many other countries. To bring an end to these epidemics we will require more healthcare workers and properly functioning healthcare systems. We will require a movement that politicises access to healthcare and that refuses to accept that some people can get quality treatment while others cannot”.

The congress, attended by representatives from close to 200 TAC branches from seven of South Africa’s nine provinces, made a long list of resolutions that will guide the organisation’s work over the next three years. Amongst others, the congress resolved to recommit to the empowerment of TAC branches and the reinvigoration of the organisation’s treatment literacy programme. It was also resolved that each of TAC’s branches must adopt a clinic and a school which they should monitor and engage with.

Earlier the congress was addressed by Deputy President of South Africa and chair of the South African National AIDS Council (SANAC) Cyril Ramaphosa. Ramaphosa said that “we must acknowledge that our health system is under great strain and that it is struggling to meet the needs of our people”. He also urged TAC to not to disengage from the SA National AIDS Council. The congress eventually resolved that TAC will remain in SANAC, but that the organisation will leave SANAC should its concerns regarding SANAC governance not be addressed with sufficient urgency and transparency. (Ramaphosa’s speech can be read in full here.)

The congress also earlier heard from Minister of Health Dr Aaron Motsoaledi who presented government’s plans on National Health Insurance. TAC resolved to continue its support of NHI while also raising concerns regarding certain aspects of NHI, such as the exclusion of foreign nationals and the exclusion of civil society from six of the seven recently announced NHI committees. TAC also undertook to assist patients who could not access appropriate treatment and care in the public sector to seek such treatment in the private sector. It was stressed that this would be done in a dignified and non-disruptive way.

The full list of TAC national leaders elected at the congress are as follows:

  • Chairperson – Sibongile Tshabalala
  • Deputy Chairperson – Patrick Mdletshe
  • General Secretary – Anele Yawa
  • Deputy General Secretary – Vuyokazi Gonyela
  • PLHIV Sector Representative – Andrew Mosane
  • Women’s Sector Representative – Thandi Maloka
  • LGBTQIA+ Sector Representative – Philemon Twala
  • Youth Sector Representative – Amelia Mfiki
  • Men’s Sector Representative – Pule Goqo

A full list of congress resolutions is available on the TAC website here.

Note: Spotlight is a joint publication of the Treatment Action Campaign and SECTION27. We have been granted substantial journalistic independence – which we guard jealously.

 

Mental health and pill-taking: Getting beyond HIV

By Professor Francois Venter

Recently, I took part in a chat show on Radio 702 to discuss how to disclose one’s HIV status to one’s sex partners. Hosted by Eusebius McKaiser, the show was vibrant, entertaining and challenging – made more so by the other guest, Thula Mkhize. Thula is an HIV-positive, heterosexual man in a discordant relationship (his wife is HIV-negative). Thula speaks openly and passionately about his sex life, and we chatted about the ethics of disclosing on the first or second or third date, among other things.

Dating when HIV-positive can be very tricky. When do you disclose your status to a new sex partner? How do antiretrovirals impact on your sex life? Why do we sometimes take risks that don’t seem rational? Relationships are hard, but can be so much harder when you have a background condition that is sexually transmitted.

The show went well; but I found some of the callers talking about their experience of disclosure surprisingly moving and upsetting. People were calling in, talking about the enormous impact of HIV on their sex lives, and of partners slowly pushing them away due to their status. This was not the violent, ignorant stigma that we easily identify and loudly denounce, but a more subtle, much more personal rejection. It reminded me of a good friend who is HIV-positive, who when she is about to engage in sex with a guy, says he often behaves as if he were doing her a huge favour, despite her being completely non-infectious on treatment. These little and not-so-little indignities can be devastating, and can prick holes in your self-esteem. Getting reliable support after disclosure is far from guaranteed.

A few weeks ago we lost Prudence Mbele, a beloved long-time activist living openly with HIV, who died of TB. Prudence was famous for her ‘pill holidays’ – a big no-no in HIV-land, as it leads to further immune damage. The idea of someone stopping their life-saving tablets – even temporarily – boggles the minds of most health providers. Her death triggered an intense media and Facebook/Twitter reaction, filled both with criticism at her choices as well as empathy, as people shared their own hard stories about taking antiretrovirals. Yet this notion of ‘pill fatigue’ affects lots of people in the HIV field and beyond, and generates a lot of chatter on social media.

Pill fatigue is a difficult concept to swallow, as a health professional. The daily tablet we use for HIV is small and getting smaller, has very few side effects, and is becoming safer all the time. Public health guidelines in South Africa recommend that a huge proportion of our population need tablets for diabetes, hypertension and cholesterol, among other ailments, especially as people get older. Pills are a part of normal life for everyone as they get older – so why should HIV-positive people complain of pill fatigue?

Some of those reasons relate to anxiety and depression and stigma, now strongly linked to delayed presentation for treatment, as well as adherence to their meds. Sadly, mental health issues are more associated with medical hot air than with any content; very few resources are allocated specifically to this area in either the public or the private sector, despite tons of data suggesting they are important. We have some very spirited and smart mental health professionals trying to change this, but there is in inertia in the current health system. This is also coupled with harsh societal views around mental health – depressed people are told to pull themselves together, think positive thoughts, be grateful – which are less than helpful to people experiencing sometimes devastating physical symptoms as a result of mental ill health. The truth is that mental ill health is probably just as stigmatised as HIV.

What does all of this mean, for someone with HIV? There are no magic bullets; but this is the best advice I can offer:

Identify your mental health symptoms

It’s a good idea to pay attention to your mental health, as well as your physical health. The first step is noticing whether you are feeling different – do you have feelings of hopelessness, persistent sadness, a lack of energy to get through your normal routine, or disrupted sleep or eating patterns? If so, and if these persist for more than a couple of weeks, you may be becoming depressed.

Do you have persistent and repetitive thoughts, worrying about your life or other problems? Do you notice physical symptoms such as shortness of breath, churning stomach or nausea, dizziness or rapid heartbeat, fear of new situations or people? If so, and these persist for more than a couple of weeks, you may be experiencing anxiety.

Get support

The best thing you can do is ask for support. It is sometimes very hard to reach out, especially when you may be afraid of people’s reactions. My experience though is that families and friends can be remarkably compassionate; and studies have shown that people who are open about their HIV status tend to get more support, have fewer issues with adherence, and generally appear to be happier. In one study, people with HIV who had good social support mechanisms reported the same quality of life, once they were on successful antiretrovirals, as people without HIV. Disclosing your HIV status can be scary, but it can also keep you healthy. Similarly, if you notice your mental health is wobbling, disclosing this to your friends and family can help keep you healthy.

Of course, this does not hold true for everyone. The world can be brutal and violent, families may use stigmatising diseases to play out internal politics, and not every spouse is going to be supportive. Use common sense, and choose your support network carefully. Equally, this does not mean you need to rush out and disclose to everyone the moment you get your diagnosis – I’ve seen quite a lot of people treating this period as a kind of confessional. Learning you are HIV-positive can be a huge shock; give yourself time to think it through, and decide when and who you want to disclose to.

American sex therapist Dan Savage famously says that disclosure on a date (or in any other situation) tells the other person only a small thing about you; whereas their reaction tells you everything you need to know about them. While it can be a shock to hear from a friend or loved one that they have HIV, or depression, or any other scary condition, there is no excuse for casually offensive opinions or hurtful comments. You do not have to stand for it, and you can be clear in deciding whether to continue a relationship with an individual who is rejecting or judgemental about your physical or mental health.

You can often find support groups through local churches, NGOs and community organisations. These don’t work for everyone, but can be of huge benefit. You might find that sharing your experiences and finding out more about HIV will be empowering, and this will help keep you both physically and mentally well. Also, you could talk about your mood; and if you are feeling low or anxious, it can be enormously helpful just to tell someone about it.

So pay attention to your friendship circle, family and community; and invest time and energy in these relationships.

Speak to your health professional

It is likely that you will receive very little clinical help concerning your mental health. Many health professionals are woefully under-trained around mental health, and you might find yourself brushed off if you try to talk to your doctor, nurse or even counsellor about this. If you feel strong enough, you can ask questions and insist that your health worker answer them; or if they can’t, that they do their own research and come back to you.

You have a right to mental health care, even though the reality is that South Africa is very under-resourced in this field. Your raising it could be helpful in transforming your own health worker’s understanding, too, and could contribute towards changes in broader mental health policy for everyone, over time. Also, challenge people on social media and in public, when they post trite messaging on mental health issues (the most annoying I have seen is a meme saying that people with depression don’t need tablets – just a pair of running shoes and a forest). They will be more careful next time.

Take your medication

Taking tablets every day for ‘conditions’ when you’re healthy is fast becoming a fact of life for everyone, for everything from high blood pressure to diabetes. Getting onto antiretrovirals, developing habits around swallowing tablets and staying on treatment, and finding the easiest system possible for getting your tablets, will move this aspect to ‘habit’ rather than being a constant reminder of the virus. If you acknowledge to yourself that pill fatigue might actually be systems fatigue – weariness around a health system that remains largely inefficient and unfriendly, and wastes so much of your time – this might help you to address your own negative thought patterns about taking your meds, and help you to stick to the regime. If you can, try to find a clinic that has good systems and helpful, competent staff. This will help you stay mentally healthy too.

If you are persistently depressed, it might also be possible to obtain anti-depressant medications on prescription. Primary healthcare clinics have access to anti-depressant drugs, and these can be a valuable addition to other counselling support. If you have the means, shop around for a professional you relate to – one who is sympathetic to mental health issues.

There are many similarities between taking anti-depressants and taking antiretrovirals. You need to take your meds consistently, without interruption, in order to achieve the best results. You may experience some side effects; but these can often be mitigated by changing the dose slightly, or just waiting for your body to get used to them. Many people take anti-depressants for months or years in order to keep their mood stable and enhance their mental health. There is nothing to fear from these drugs.

Get activated

Use activism to get behind organisations advocating for better health services, for both HIV and mental health. In a recent study we did on truck drivers (most of whom were HIV-negative), rates of anxiety and depression were very high; we see similar prevalence among carers, low-income families living in poor housing, and inner-city dwellers. If you can, donate money to help them campaign, and to hire good staff. Become a vocal supporter of better mental health initiatives, wherever they exist. Challenge your health provider to take mental health seriously, and be bold about opening conversations with your friends and family about mental health. The World Health Organisation estimates that one out of every four people suffers mental illness at some point in their lives, so you are not alone.

You might find useful mental health information and support through one of the smartphone apps or personalised telephonic support lines that are becoming increasingly available. These may involve a cost, but there have been enough studies to show that they can be valuable. Watch this space to learn more about which ones are reliably effective.

What should HIV-negative people and healthcare workers be doing? I guess trying to avoid the trite ‘support’ statements – from ‘Well, at least you’re alive’, to the hideous ‘We will all die one day’ – would be a start. I have been at dinners in white, middle-class suburbia where someone is loudly opining about morality and its connection with HIV, not knowing that the couple across from me are my patients. The same holds for mental health issues – think before saying some stupid, stigmatising thing. There needs to be much more community awareness about the importance of unconditional acceptance and support of people on any kind of chronic medication.

If you’re a health professional, the best thing you can do is to educate yourself around mental health – and learn, firstly, how to accurately diagnose someone with depression or anxiety; and secondly, how best to work out a treatment plan. Mental ill health is rarely healed only through drugs, but more usually involves a comprehensive strategy encompassing talking therapies, good lifestyle interventions, removing stress, treating other health conditions, and prescription medications. Compassion, empathy and the ability to ask the patient questions about their unique experience of living in their own body are crucial. The last thing you should be doing is adding to stigma by putting your foot in your mouth. It is not a moral failing to suffer mental ill health, just as it is not a moral failing to be HIV-positive, or have any sexually transmitted infection.

As South Africans, there are many things that grind us down: corrupt politics; lack of jobs; increasing living costs; high rates of violent crime; poverty and poor service delivery; alcohol abuse; and family and relationship break-ups. If you also take into account the reality that too many of us experienced trauma because of the brutalising effects of apartheid, it is no wonder that mental ill health is so prevalent in our society. Sadly, we have been slow to acknowledge this and implement adequate policies to help mitigate mental illness.

Just as with HIV, every single one of us knows another person who is experiencing mental ill health. However, this may be hidden – due to stigma, shame, lack of understanding, and lack of adequate treatment. As a country, we achieved a lot when we started taking HIV seriously: through activism, scientific research, transformed health delivery systems and a lot of hard work at all levels, we managed to turn the epidemic around and make HIV a manageable condition. We can do the same with mental health, if we are motivated to do so.

Professor Francois Venter is a medical doctor who has been involved in HIV patient care, as well as guideline development and studies on new HIV treatments, for many years. He had lots of support from work colleagues and friends in editing this article.

For more information and resources on mental health, go to:

* This article was first published in a special print edition of Spotlight published ahead of the Treatment Action Campaign’s 6th National Congress held in August 2017. A PDF of that print publication can be downloaded here.

Opinion: Will we get the NSP right this time?

By Marcus Low, Spotlight Editor

At the end of this year South Africa’s big plan to fight HIV and tuberculosis (TB) comes to an end. The National Strategic Plan (NSP) for HIV, TB and STIs 2012-2016 will be replaced by the 2017-2021 NSP. It is vital that the new NSP avoids the mistakes of the past and fully incorporates new scientific evidence. It is also critical that it sets an ambitious and realistic course that all of South Africa can get behind, not just people working in health care.

What went wrong with the previous NSP?

While there was a lot that was good in the previous NSP, we need to be honest about the problems with the Plan and how we implement it. A great plan on paper is of little use if we do not have the systems or political will to use it effectively. Looking back over the past five years, two problems stand out.

Firstly, there was so little effective tracking of our progress against NSP targets that we only occasionally got an idea of how we were performing against the targets. The NSP would have been of much more value if every single district or provincial AIDS council meeting had up-to-date data on a series of key indicators for their area. In the absence of such data, much of the work relating to the current NSP was done in a vacuum. This contributed to a lack of focus and direction.

Secondly, the lack of coordination between government and AIDS councils meant that the NSP often ended up feeling irrelevant when it came to the actual implementation of TB and HIV programmes. Few people seem to understand that at all levels, the NSP and the work of AIDS councils are supposed to set the course for our collective AIDS response. Instead, government, local and national, appeared to do what it wished irrespective of the work done in AIDS councils, KwaZulu-Natal at times being a notable exception. This tendency of government to forge ahead with little regard to AIDS councils undermined the vision of a wider societal AIDS response drawn together by the NSP and AIDS councils.

Top six priorities in the next NSP

To deal with these problems and to provide for a more focused and effective NSP, the following should be considered for the NSP 2017-2021:

  • We need real-time monitoring of the health-care system

Rather than creating long lists of targets, the NSP must set fewer targets that we know we can track. It is essential that these indicators must regularly be shared with AIDS councils at all levels. When a district AIDS council meets, it must have fresh stats for the entire district as well as for each facility in the district. This will help focus our response in the areas where it is most needed. Often this data is already available to the Department of Health or the National Health Laboratory System, but is not shared timeously with AIDS councils or the wider public. If the new NSP is to revitalise society’s response to TB and HIV, the Department of Health will have to start sharing more data with society.

  • We need a roadmap to treatment for all

The landmark START (Strategic Timing of AntiRetroviral Treatment) trial showed us that all people living with HIV should be offered antiretroviral treatment. In line with these findings and with World Health Organisation guidelines, all people living with HIV in South Africa will be eligible for treatment from September this year. But merely making more people eligible is not enough. As shown by the recent TasP (Treatment as Prevention) trial, much of the challenge will be to test people and then to get people who test positive to start treatment. Making a success of such a campaign will require a very ambitious new test-and-treat campaign – as well as employing the thousands of community health workers and lay counsellors required to make such a campaign work. All this must be carefully planned, budgeted and coordinated through SANAC. The document that must bring all that planning together in one place is the new NSP.

  • We need an ambitious plan for TB

While the new NSP will undoubtedly have good and aspirational targets for TB, it should also provide clear guidance on how those targets could be reached. For example, it should set South Africa on a course for dramatically scaled-up contact tracing and active case-finding. Since these are human resource-intensive activities, government has shied away from them; the NSP has to break this impasse. Similarly, the NSP should show the way toward addressing infection control both in the public and private sector so that we can reduce TB transmission in schools, correctional facilities, taxis, hostels, shops, the mines, and all other places where TB is transmitted. As with HIV testing and linking to care, the TB response will not succeed if we can’t grow it outside of the health-care system.

  • We need to implement an ambitious and evidence-based HIV prevention plan

All indications are that the rate of new HIV infections in South Africa is still very high (around 280,000 per year). Rightly, much of the talk at the recent International AIDS Conference in Durban focused on prevention, especially prevention in women and girls aged 15 to 24. It is clear that we urgently need to ensure that all young people in this age group have easy access to condoms, and comprehensive sex education. Yet, between the Department of Health and the Department of Basic Education, government seems incapable of getting its act together in any meaningful way. The new NSP must help break this deadlock. It must launch a serious, focused, sustained, HIV prevention campaign, driven and endorssed by the Presidency, targeting schools and children of school-going age.

The NSP must also ensure that proven HIV prevention interventions, like condom provision and voluntary medical male circumcision, are scaled up aggressively. Promising initiatives such as the provision of pre-exposure prophylaxes to sex workers must be continued and expanded to other groups of people who are at high risk of HIV infection.

  • We need concrete plans to bring in business and labour

Ensuring more people are tested and then started on treatment will require taking our AIDS response beyond the health-care system. Many people, especially men, simply never go near a clinic and we have to find other ways of reaching them. The solution, however, is not to hold talk shops in Sandton every six months. Instead, the NSP must outline concrete ways in which business and labour can play a part in the HIV and TB response by, for example, facilitating HIV testing in the workplace. It must be a key part of the work of district AIDS councils to invite and involve local business and labour to be part of our TB and HIV response in concrete ways. There are already good examples out there. We must learn from them and replicate them.

  • We need to reform SANAC

One of the elephants in the room is the severe dysfunction in many SANAC sectors. Unfortunately, these sectors are often little more than talk shops. Where it matters, for example in relation to medicine stockouts and the ongoing crisis in the Free State public health-care system, SANAC leadership is often missing. Leaders should be keeping government on its toes and pushing a progressive agenda if SANAC is to have any relevance going forward and if SANAC is to help mobilise wider civil society in our collective TB and HIV response.

Part of the change will have to be in leadership, but a large part of it will have to be in the way SANAC is structured. Unpopular as such a move might be, all SANAC sectors should be disbanded. It is deeply disappointing, but for various reasons they simply haven’t delivered as many of us hoped they would. Instead, a single SANAC task force of no more than 15 people, including the Minister of Health and the Deputy President, should be established and should meet at least once a quarter. Business, labour, health-care worker groups and membership-based civil society organisations must all be represented in this task force. Critically, no individuals who are not accountable to substantial constituencies should be on this task force. In addition to the task force, SANAC should also convene a technical task team made up of appropriately qualified experts to consider technical scientific issues and to provide advice to the SANAC task force and the Minister and the Presidency.

Top eight indicators for the new NSP

It is critical that we monitor our TB and HIV response in as close to real-time as we can. It is also essential that we get data sliced up by district and facility so that we can see where the trouble spots are and respond to them effectively. Ideally, all of the indicators below should be available to every ward, district, and provincial AIDS council in the country. This data should also be available to all members of the public. (Note, these suggested indicators include monitoring against the UNAIDS 90-90-90 targets – By 2020, 90 percent of all people living with HIV will know their HIV status, 90 percent of all people with diagnosed HIV will receive sustained antiretroviral therapy, 90 percent of all people receiving antiretroviral therapy will have suppressed viral load.)

  1. Number of people tested for HIV in the last three months by facility, district, province, and nationally.
  2. This statistic should also be expressed as the percentage of HIV-positive people who know their status (the first 90) if possible. Number of people on antiretroviral treatment by facility, district, province, and nationally. Ideally, this statistic should also be expressed as the percentage of people who know their status that are on treatment (the second 90).
  3. Viral load coverage by facility, district, province, and nationally. Viral load coverage must be expressed as the percentage of people on treatment who have received at least one viral load test in the last 12 months.
  4. Viral load suppression rate by facility, district, province, and nationally. This should be expressed as the percentage of people on antiretroviral treatment who are virally suppressed (the third 90).
  5. Number of people with a confirmed diagnosis of Drug-Sensitive-TB and Drug-resistant TB by facility, district, province, and nationally.
  6. Percentage of people with DS-TB or DR-TB who have started TB treatment by facility, district, province, and nationally.
  7. DS-TB and DR-TB cure rate by facility, district, province, and nationally.
  8. HIV vertical (mother-to-child) transmission rate at six weeks and 18 months by facility, district, province, and nationally.

 

Opinion: Dear Deputy President Ramaphosa

I am writing this letter to you in your capacity as the Chairperson of the South African National AIDS Council (SANAC), as it reaches a crucial stage in the development of the next National Strategic Plan (NSP) on HIV, TB and STDs.

‘Deputy President, AIDS is not over’ – Mark Heywood

Deputy President, a few days ago I received the following text message from a friend:

‘Two funerals today of family/friends that died of AIDS. One kept it secret from the family; found CD4 results under mattress of 34. She attended a church that preaches believers don’t take ARVs. In the other case, he defaulted on treatment and died. Late 40s/early 50s. Free State and Limpopo.’

This sad message probably indicates something we would rather not consider, that there are a growing number of people dying from AIDS and TB again – despite the availability of antiretrovirals. Statistics reveal to us that a high proportion of adolescents are dying of TB and HIV, both diseases that can be prevented and either cured or managed. I hear that the rates of vertical HIV infection (mother to child transmission during and after birth via breastfeeding) are higher than we admit. These facts point to the heart of the challenges we face, challenges that must be brought to the fore as SANAC, under your leadership, finalises a new strategic plan on HIV for the next five years.

This will be our country’s fifth national AIDS plan since democracy. It is certainly the most critical. This is the do-or-die plan. Literally. I’ve been involved in all five so please allow me to reflect on why this one is so important.

The first plan, drawn up by the National AIDS Convention of SA (and known as the NACOSA plan), covered the years 1994-1999. It was drafted with the full involvement of civil society and in close cooperation with ANC leaders. It was strong on human rights, but did not include ARV treatment because in 1994 treatment was unproven. It failed not because it was not a good plan, but because, tragically, it coincided with the first years of our liberation. Our nation had other pressing priorities. There was little political will to implement it.

The second 2000-2005 plan was a poor plan. It was largely ignored; that was the period of AIDS denialism, the period of Manto Tshabalala-Msimang and Thabo Mbeki, a time when SANAC was chaired by a disinterested then Deputy President Zuma. SANAC was so dysfunctional we didn’t even bother with it.

The third NSP, 2007-2011, was the plan that broke the back of AIDS denialism. It was ambitious and expansive, it set a target of ‘appropriate packages of treatment, care and support to 80 percent of HIV positive people and their families by 2011’, it strengthened programmes to prevent mother-to-child transmission, it introduced the idea of a programme of voluntary male circumcision. NSP 2007-2011 was an omnibus, a bumper edition. It had to be. It was strategically necessary to pack it with every programme we knew had some efficacy because AIDS denialism had placed us seven years behind the AIDS epidemic and there was total disarray in the national response.

However, to be honest, NSP 2007-2011 wasn’t very strategic. The strategic focus came from something that is not even mentioned in the plan; it was the Treatment Action Campaign’s (TAC) mobilisation to popularise the plan and to focus the government to continually expand access to ARV treatment that made sure it remained relevant to the national discourse. It was the health workers who were desperate to start saving lives again.

The fourth plan, 2012 to 2016, is about to expire. Nobody will miss it. Very few people knew about it in the first place. It was too complex, too unfocused. It came out of a process, much like the one going on at the moment, that allowed everyone to throw in their pet project and didn’t distinguish clearly enough what were the priority projects. It dodged the difficult issues. Cabinet’s only contribution before it approved it in late 2011 was to delete a firm commitment to decriminalise sex work from the plan. Are you therefore surprised we have such high rates of HIV among sex-workers?

In recent months an extensive consultation has taken place again about the next NSP. However, I would strongly recommend to you that now you entrust the development of the plan to an expert team. Their job is to distill the ideas, insights and learnings they have heard, into a strategy. They must do what they must do – but my unsolicited advice to them would be as follows:

Keep it short and simple

We can’t afford another 500-point strategy that’s read only by experts and which is unintelligible to the people who need to know the plan.

Avoid jargon

Avoid reference to UNAIDS’ confusing jargon that means nothing to an ordinary person – and actually causes confusion. ‘Test and Treat’, ‘Treatment as Prevention’, ‘Decanting’, ‘90-90-90’, ‘Getting to Zero’, ‘KPs’, ‘VPs’ and ‘MSM’, and so on…

Keep it focused 

Leave things out rather than stuff everything in. In my view a strategic Strategic Plan should now focus all its efforts (or rather our efforts) around two keys questions:

How to massively cut the number of new infections, particularly in young women and among what AIDS experts call ‘key populations’. It is scary, outrageous, shocking that 2,000 young women are infected with HIV every week. If we could cut this by 75 percent – and we have to believe that we can – we would be on a winning streak.

How to improve the quality of care for the 3.5 million people now on ARV treatment and how to find our way to the missing 3.5 million who need to be on HIV and TB treatment.

To address these two challenges, DP, you have been entrusted to provide leadership. You must force us to square up to the things that can’t be said. You must help us to do the things ‘that can’t be done’. They can.

We must throw the kitchen sink at these two critical challenges and leave the rest to take care of itself. We can do this because many of the other necessary programmes and activities of the AIDS response are now reasonably well entrenched. The message is that they must continue.

So what could we do about prevention? There are 25,741 schools in our country. These should be the sites where we concentrate the struggle against HIV. We should say that within six months every school should offer continuous quality sexuality education, especially about gender and sex, voluntary male circumcision, male and female condoms, Pre Exposure Prophylaxis (PreP, but please don’t call it that), HIV and TB testing, access to HIV and TB treatment and support for adherence. If we did this, we would win.

So what could we do about treatment? There are 3,182 clinics and 331 Community Health Centres (CHCs) in our country. These need to be the sites of our struggle against AIDS and TB, co-ordinating salvoes into schools, shebeens, churches, football clubs, burial societies. But to do that they need better management, empowered clinic committees, resources, and properly employed, paid and supervised community health workers as the backbone of ward-based outreach teams.

Is this impossible? No it is not. Would it make a difference? Yes, it would.

And finally a word of warning, or rather exhortation. There are a number of risks that we must counter.

The first is that many of those who represent ‘civil society’ in SANAC and Provincial AIDS Councils are pretenders; they are out of touch and disconnected from real people, they are their own insular civil society, they have formed a world in a parasitic eco-system that feeds and flies them. If these people continue to guard the gates of the AIDS response, we are in trouble. You, DP, need to once more insist on accountability and evidence, volunteerism and sacrifice.

Measure people by their actions not their words.

Finally, DP, a special appeal. We can’t implement the NSP outside of the public health system. And here’s the rub: At the moment the NSP is being developed without any reference to the desperate state of our clinics and hospitals, or the exploitation of our health workforce. This might seem odd, but my guess is that hardly any of the people busy making proposals about the NSP, or being consulted about it, either have HIV or have HIV and use the public health system. This means that they do not appreciate the obstacles created by drug-stockouts, poor quality information, rushed HIV testing, and treatment illiteracy from the treaters. It is half-true that AIDS ‘is not a health issue’. But without a solid health system, the response has no backbone. At the moment that backbone is broken.

It does not need to be part of the NSP, DP, but it is critical that we empower Health Minister Motsoaledi to fix the health system in the provinces.

Deputy President, AIDS is not over. Millions of lives depend on your leadership of this process. Please get it right.

Mark Heywood
Activist
Former deputy Chairperson of SANAC

 

Editorial: The new hiv & TB plan – Three months to get it right

Delays at the South African National AIDS Council (SANAC) has meant that the new NSP (National Strategic Plan) will now only be ready in March 2017. While the delay itself is not of any great concern, the kind of plan that will be produced by an unsettled SANAC and a weakened, unrepresentative civil society is concerning and brings into question the very idea of SANAC and the NSP. Already we are hearing rumours of a back-track on various things contained in draft zero of the NSP – including a back-track on the recommendation to decriminalize sex work.

There is a risk that over the next three months an NSP will take shape that will lack many of the targets and deadlines it needs to make an impact. It is understandable that government doesn’t want what they see as an external plan to interfere with their internal plans. But civil society should not accept this. We need leaders who can stand up to government, when needed work with them, but ultimately demand we do better on key issues such as sex work, condoms in schools, active case-finding for TB and community healthcare workers. Unfortunately, from what we’re hearing, civil society is capitulating on these issues without much of a fight.

Even though many critical issues will be mentioned in the eventual NSP, mere mentions are not enough. We need plans, timelines and budgets. We need an NSP that is highly focused and concrete. The decriminalization of sex work, for example,  has been on the agenda for years – but simply having it on the agenda is not enough. We need to have a roadmap from where we are now to an actual amendment in our laws. Without such a roadmap, we do not in fact have a plan.

Similarly, setting targets for providing more people with HIV treatment and helping people adhere to treatment is all good and well, but targets are not a plan. How do we improve treatment adherence? Do we need to employ more community healthcare workers to provide adherence support and to trace patients who default? We think we should. How do we provide differentiated care through adherence clubs, if we don’t pay people to run those adherence clubs? How do we ensure there are no drug stockouts which endanger trust in the health system. How do we build a Medicines Control Council that can cope with the workload or registering new drugs and investigation unlawful treatment and activities? These are the issues the NSP must map out in detail and force action on. It should make the case so clearly and convincingly that the Department of Health and treasury has no option but to fund it.

In the same way, we can say whatever nice things we wish about active case-finding for TB (possibly the most critical TB intervention we are not implementing), but if we don’t map out what that means in the real world then it will be just an another aspirational target. The NSP has to make it explicit that we can’t do active case-finding without people and that we need to train and pay people to start doing active case-finding. In two words Community Health Workers.

Another  critical area on which the new NSP must move the dial is HIV and pregnancy prevention in schools. We need a programme that is explicit about the right to comprehensive sex education and the right to access condoms – the latter being a right in terms of the right to access healthcare services.  But again there appears to be no clear plan on the table on how we get from here to there.

If the new NSP doesn’t deliver on these critical issues with detailed  timelines and budgets then it will be hard for us to support it. As has become clear in recent issues of Spotlight (previously NSP Review), our HIV and TB response is at code red. Our public healthcare system is in crisis. We need a plan that deals with this emergency seriously and based on the best available evidence. Anything less is not good enough.

A difficult political environment

The development of the new NSP comes at a very difficult time in South Africa’s history. Amid the Public Protector’s State Capture Report, the various scandals relating to the Gupta family, spurious charges against Finance Minister Pravin Gordhan and widespread calls for President Jacob Zuma to stand down, Deputy President and SANAC chair Cyril Ramaphosa has had a lot on his plate. In this fraught political context the new NSP has hardly elicited the national conversation or leadership that is needed – that it is needed is clear from the fact that around seven million people in South Africa now live with HIV and tens of thousands still die of tuberculosis every year.

To some extent, our HIV and TB response is also falling victim to the wider crisis in our politics. It is thus very encouraging that Health Minister Dr Aaron Motsoaledi and deputy Minister Joe Phaahla took a public stand against corruption when late in October they publically declared their support for Minister Gordhan. The spurious charges against Minister Gordhan has since been withdrawn. We trust that these leaders will not lose their jobs or be victimised for having taken this correct and principled stance. We will watch closely.

While the fight against corruption and state capture in South Africa is urgent and critical, the development of the new NSP is also critical. We urge the Deputy President, the Minister of Health, the rest of the national cabinet and all provincial cabinets to engage with both these urgent issues. Just like corruption, HIV and TB impacts the lives of millions of people in this country.

While the big picture politics are deeply concerning, there are also some signs that all is not what it should be at SANAC. The position of SANAC CEO Dr Fareed Abdullah was recently advertised amid rumours of a campaign to replace him with a person more compliant to the whims of some in government. Whether there is any veracity to these rumours we do not know, but it has reached us from various sources.

What is clear though is that in the current political context we need SANAC to be stronger than ever. Abdullah has done well in steering SANAC over the last five years and much of what concerns us at SANAC is beyond his control. Removing him now will threaten operational continuity at SANAC – something we cannot afford.

Civil society leadership crisis

While operational continuity is critical at SANAC, we urgently need new energy and ideas on the political side. This political energy has to come from civil society leaders at SANAC. Many people we have spoken to have expressed their disappointment with the failure of the current civil society representatives to raise critical issues impacting on ordinary people living with HIV and/or TB over the last five years.

Activists in SANAC have expressed their unhappiness with that is currently happening in SANAC, or more specifically in SANAC civil society.

There is a strong feeling that SANAC needs a civil society that is fully representative, that speaks with the voices of the marginalized, speaks with the voices of the poor and that the only way in which this can happen is if the current civil society is disbanded.

The new NSP provides an opportunity to make a clean start where we avoid the pit-falls of the past and ensure that people living with HIV and TB in South Africa feel they are properly represented. One way to avoid these pit-falls is to set some guidelines of what we expect from our civil society representatives.

To start with, we should insist that civil society leaders must represent constituencies and not just themselves (academics and other technical experts can of course contribute in their personal capacities to technical questions). Ideally, we want people who have been elected by affected people and who must account back to those people on what they have or have not done at SANAC.

Secondly, we should insist on transparency regarding the financial affairs of all civil society representatives. Where people represent NGOs, the finances of those NGOs should be open for public scrutiny – as is the case with all NGOs. If people do business with government, then that potential conflict of interest should be disclosed.

Looking back, there is much to be proud of, but what lies ahead is what matters now and what we do in the next three months will set the course of the next five years.

 

Modernising ART

By Dr Michelle Moorhouse

South Africa, like many lower and middle-income countries, follows the World Health Organization (WHO) recommended public health approach, using standardised drug regimens to treat HIV. This along with task shifting from doctors to NIMART (Nurse initiation and management of antiretroviral therapy) trained nurses has enabled more than 3.9 million people living with HIV (PLWH) to access life-saving antiretroviral therapy (ART) since 2003. ART is undeniably one of the biggest successes of modern medicine, along with vaccines and antibiotics

While we have some pretty great treatments already, there is still room for

improvement. Current first-line ART is a big pill to swallow, it has some unpleasant side effects, resulting in poor adherence and virological failure, and resistance develops quite easily; it will not get any cheaper over time. From the more logistical aspect, the high dose of the drugs that make up first-line ART means they use more ingredients meaning they cost more, and is the reason the pill is so big, which in turn means the packaging is big, and takes up more space in the pharmacy. Clearly, we need treatments which are easier to take in terms of size and are cheaper. And if you compare first-line ART in lower middle income countries (LMIC), some of the drugs being used are no longer recommended in better resourced settings.

Current first line ART

So, let’s look a little more closely at our current first-line ART. According to our

ART is undeniably one of the biggest successes of modern medicine, along with vaccines and antibiotics

national guidelines, most people living with HIV (PLWH) will receive a combination of efavirenz (EFV), tenofovir (TDF) and emtricitabine (FTC) or lamivudine (3TC) as first-line ART. FTC/3TC, which are structurally almost identical, really contribute very little in the way of toxicity generally and are usually continued through subsequent lines of therapy so I am not going to say much more about them here, and going to confine my deliberations to EFV and TDF.

What is great about this combination is that millions of PLWH around the world have been treated with it for years so there is a wealth of experience with it – a bit like that comfortable T-shirt we like to sleep in, for us as prescribers, but perhaps not so much for PLWH. The regimen has proven virological efficacy, is generally well tolerated, is simple to take as it is dosed once daily and is co-formulated into a single tablet fixed-dose combination (FDC).

What are the problems with EFV? It comes with some unpleasant side effects (abnormal dreams, nightmares, hallucinations even and other neuropsychiatric type symptoms mainly; occasionally rash); has a very low resistance barrier; and requires a high dose. Its safety in pregnancy has been established despite a bumpy start in early development and it plays relatively well with most other drugs, including TB drugs (but not all, for example some contraceptives such as implantables). EFV is an example of one of the first-line drugs which has disappeared from first-line treatment in many wealthier countries.

Alternatives to EFV

So how do we improve on EFV? There are a number of alternatives to EFV to consider which are currently available in South Africa. Rilpivirine (RPV) is one option, from the same class of ARVs as EFV, and is dosed at 25 mg (compared to 600 mg of EFV which contributes significantly to the size of the FDC). RPV is much better tolerated than EFV and is incredibly cheap, which is always good news in a drug which could be potentially be used to treat millions of people. The downside is that it is not yet available in any FDCs in South Africa, can’t be used with rifampicin-based TB treatment or in anyone with a high viral load when starting treatment, and in the public sector we don’t do viral loads at treatment initiation, so it too has its warts. However, it is being studied in some interesting new combinations so let’s not completely set it aside just yet. Certainly as a switch option RPV is a very good choice in patients who don’t tolerate EFV, and there are studies which support this.

Dolutegravir (DTG) is another option already available in South Africa. Again, another low dose drug at 50 mg. In registrational first-line studies no one with virological failure developed any DTG resistance which means this drug is incredibly robust. DTG was also the first drug to ever beat EFV in a head-to-head study, where pretty much all others had previously tried and failed, and this was probably a lot to do with the fact that DTG is more tolerable than EFV. And as the saying goes, if it sounds too good to be true… In fact, there are emerging data suggesting there may be some side effects which include dizziness and anxiety. But this is coming mainly from European cohorts, which do not have the same genetic diversity of African populations. Currently a massive study called ADVANCE that compares DTG to EFV is underway in South Africa and includes screening for these types of symptoms. DTG is also available already co-formulated in SA with abacavir (ABC) and 3TC, but it is not practical to roll out this particular FDC programmatically as ABC is very expensive.

But as DTG requires only a 50 mg dose, if it were to be introduced into the public sector programme, produced by a generic manufacturer with South Africa’s buying power as the largest consumer of generic ART in the world, DTG would be an affordable option for first-line ART, and is currently an alternative option in the WHO guidelines. With regard to DTG and TB drugs there is an interaction, which can be overcome by adjusting the dosing of the DTG, but this might not be necessary – some studies are underway to look into this. One of the current challenges with DTG is at this stage we don’t know a lot about DTG in pregnant women. Botswana made the bold move of introducing DTG into their HIV treatment programme in June 2016, including for pregnant women and it is anticipated that they will present data on the first pregnancies at the IAS conference in Paris in July 2017 which will start to fill this gap. So, we have a very robust drug that is well tolerated and can be co-formulated into a small inexpensive pill – looks promising.

Then there are also other future third-drug options which are not available in South Africa (or indeed anywhere else) as yet. These include doravirine and bictegravir. Doravirine is from the same class of drugs as EFV and RPV. It is still in phase 3 of development (registrational studies) and whether or not it will ever hit our shores is unknown. Bictegravir, also in phase 3, is a drug which is very similar to DTG and is co-formulated with tenofovir alafenamide fumarate (TAF), which I will discuss a little more below, and FTC.

An alternative to TDF

So, moving on to TDF. The problems with TDF are in some ways similar to those with EFV. The high dose means a high active pharmaceutical ingredient requirement which drives the pill size and the cost. And it also has some toxicity associated with it. Currently, we do not have any alternatives available in South Africa  that are any better but there is one which should be available soon, namely TAF (tenofovir alafenamide fumarate). TAF, like the TDF in current first-line ART is a pro-drug of tenofovir. TAF is given at a much lower dose (approximately 10-fold lower) than TDF. TAF is associated with much less kidney and bone toxicity than TDF. The ADVANCE study will also compare TAF and TDF, as most studies of DTG used ABC as the backbone, and also would not have included many African participants. TAF has not been studied with TB drugs or in pregnant women as yet, but these studies are underway. Once we have a better understanding of this, on account of the better safety profile and the lower dose which will result in significant reductions in cost, TAF is set to be a favourable option to replace TDF.

And in fact, if DTG, FTC and TAF are co-formulated potentially we are looking at a future first-line regimen, to quote Prof Francois Venter, “smaller than an aspirin” which is incredibly potent, incredibly robust, incredibly well tolerated, all while being incredibly cheap – incredible isn’t it?

ART does not exist in a vacuum

All of this is very important, while we have such tough targets to chase – the famous 90-90-90. And to achieve that third 90 we need to modernise treatments so that PLWH can adhere to them. When there are so many other challenges to overcome within a healthcare system, optimising ART to be as simple, safe, efficacious and robust as possible facilitates safer task shifting to other cadres of staff which may help alleviate some of the human resource shortages faced within healthcare facilities.

But no matter how good the drugs are, ART does not exist in a vacuum, and ART alone will not achieve the three 90s. ART will not fix the healthcare system. ART will not address stigma. ART will not help us achieve that first 90 – 90% of PLWH knowing their status. ART will not find the missing in action to test them – the men, the key populations, the adolescents, girls and young women – and then link them to care to achieve the second 90. ART will not then retain them in care, and measure their viral load so we can see if we are reaching that third 90.

Massive investment in infrastructure and development of systems backed by political will is critical. Civil society must remain engaged and all of this must be backed by a National Strategic Plan (NSP) that is realistic, detailed, and embodies the principles of equity and access. There is a massive amount of work to be done to conquer HIV in South Africa, but optimised ART is certainly a great step in the right direction.

Dr Michelle Moorhouse – Wits Reproductive Health and HIV Institute and Southern African HIV Clinicians Society

No Need to Embellish our Achievements or to Diminish our Challenges when it comes to HIV

By Fareed Abdullah

When I joined government in 1994 there was not only an openness to dissenting opinions; it was encouraged. When we met, month after month, as the Health MINMEC (meeting of Ministers, MECs and senior staff) with the then Minister of Health in the chair, there was uniform acceptance that finding solutions to the tasks that faced us in the complex health function required debate, discussion, disagreement. It was encouraged.

These days a different opinion is labelled disloyalty. This new culture has creept up on us slowly over the last twenty years but now public service has become synonymous with blind loyalty to the political head and those who are the most loyal bureaucrats become the most powerful. Intellectual honesty and competence fly out the window.

The medium of this loyalty are words of praise of government and ministers consistently belted out by civil servants who have become adept at spinning a good story. The most skilled bureaucrats master the art of doing this and wrap it up in lofty language and references to science and evidence but only when this suits them. The political chicanery and subterfuge of the last few days has been met with disbelief yet it has been a long time coming. And it is this culture that permeates all the factions in government, including those who are now presenting themselves as the ‘unsullied,’ that undergirds the sycophancy that overpowers the work of government.

This is the world in which the recently launched National Strategic Plan to fight HIV, TB and STIs (NSP 2017 – 2022) has been written. A technical team was contracted to review progress and the latest evidence and make recommendations and a Steering Committee was established to provide a higher level strategic view to guide the technical work. Instead of seeing this process through, we had a political commissariat cherry picking technical work with the aim of making government look good whilst at the same time giving just enough airtime to the latest evidence to avoid criticism from technical constituencies inside and outside the country. This is also why important stakeholders such as the Treatment Action Campaign have not endorsed the NSP. So, let’s look at the facts.

We have performed well as a country when it comes to the roll out of ARVs and the prevention of mother-to-child transmission of HIV. Of this there can be no doubt. There is also no doubt that the Minister of Health, Dr Aaron Motsoaledi, has been ‘on point’ with upgrading our treatment policy first to start ART at 350 then 500 cells/µL. He has also been quick to announce in parliament in 2016 that any South African testing HIV positive would be started on ART without delay as this was now the gold standard for antiretroviral treatment across the globe.

It is not disloyal to point out that his officials have not yet issued the revised guidelines for ‘test and treat.’ Neither is it disloyal to point out that whilst we are very privileged to have access to viral load testing compared to our neighbouring countries, almost half of our patients do not have the test or get their results.

It is laudable that the NSP 2017 – 2022 makes a commitment to have 6.1 million people on ART by 2022. That will be no mean feat. Yet it is wise to think that unless there are sweeping reforms of the health services, including the widespread use of private GPs, this will be difficult to achieve. It is widely held that doubling the number of patients on ART will require additional clinics, more nurses, doctors, pharmacists and lab techs and ensuring adherence will require finances, NGOs and employing more lay counsellors and community health workers. This is little evidence that this is intended in the new NSP.

It is also not disloyal to point out that when the NSP is stripped off its verbiage when it comes to the scale up of treatment, what remains is the United States governments plan for test and start in this country. That plan was written more than a year ago, and is already being implemented. South African super-NGOs, also known as the PEPFAR partners, have been contracted to scale up test and treat in public sector facilities in 27 high-burden district municipalities in the country. Of course, this is in partnership with the Department of Health at national and provincial level but the driving force is the US government, its agencies in South Africa and its contracted NGO partners. The NSP merely endorses the PEPFAR plan, and therefore does not have any intention to address the remaining 20 districts where PEPFAR will not be engaged and that yet remain the government’s responsibility. Whilst PEPFAR, as a donor, has the freedom to select 27 high burden districts to optimise its investments, the NSP does not enjoy that luxury as it must serve persons living with HIV irrespective of where they reside. The new NSP does not even offer a minimum package for persons outside the 27 high burden districts for any HIV prevention or treatment services.

While there is still room when evaluating how well we have done in the case of antiretroviral treatment to vacillate between two debating sides – is the glass half full…is the glass half empty, no room exists for this vacillation when it comes to HIV prevention. We have failed miserably and we should start by accepting our failures in a brutally self-reflective and honest manner. HIV is coming down globally and in South Africa over the last decade. This is fact. But the decline in HIV globally and in South Africa has been very slow in the last five years. The UNAIDS Spectrum model estimates that that there are still 370 000 new HIV infections (2015) in South Africa each year with marginal declines over the last five years. The University of Cape Town’s Thembisa modelling outputs show the declines of around 27% over the last five years (with 270 000 new infections in 2016 alone) but even this team of modellers do not think that the declines are due to any successful prevention programmes. Thus, it is disingenuous for the drafters of NSP 2017 – 2022 to claim the decline in new infections as a country success.

The truth is that countries such as Zimbabwe, Namibia and Zambia have had much bigger declines in HIV incidence than South Africa. We know that we have not performed well when it comes to prevention. Our interminable debate on male medical circumcision delayed the start of the programme for more than two years. Our life skills programme in schools has been a monumental failure and the HIV testing and condom distribution collapsed during 2013 and 2014, only recovering in 2015 and 2016. The government mass communications programme (Khomanani now Phila) was shut down for 6 years from 2010 to 2016 with a noticeable absence of basic HIV messaging to the public leading to a significant decline in basic HIV knowledge in the country with the largest epidemic in the world.

The effects of this parlous effort at prevention was documented by the Human Sciences Research Council, which found that condom use was going down in South Africa and multiple sexual partnerships and early sexual debut were on the rise.

The new NSP approaches HIV prevention with an awkward triumphalism. On the one hand, it claims successes like a decline in incidence and the ‘She Conquers’ Programme. On the other, it cannot escape the facts and highlights 270 000 new infections in 2016 and 2000 new infections in young women per week. It then does the right thing by setting a target to reduce these new infections to below 100 000 by 2022. This is a 63% reduction over five years. The technical team debated this as it was clearly aware of the fact that this was an ambitious target. How can you set a target of 63% when you could not achieve a prevention target of 50% in the NSP of the last five years?

The answer to this is that we have more prevention interventions than we have ever had before and we have better knowledge of the drivers of new infections than ever before. We are certain that putting everyone who tests positive on ART will reduce transmission to uninfected contacts. Leigh Johnson at UCT’s modelling made a compelling case for optimising viral suppression in those already on treatment as the most effective prevention intervention. We also know that biomedical interventions work. These include PrEP, PEP and circumcisions and managing STIs. And we know through Gesina Meyer-Rath’s Investment Case Study that if we did it right and to scale, then condoms, reducing multiple concurrent partnerships and decreasing early sexual debut are both effective and cost-effective interventions.

What has also become clearer with each new study is the impact we can have by keeping girls in schools, child support or conditional cash transfers, reducing binge drinking and alcohol/substance abuse and addressing sexual assault and child abuse. These are the structural drivers of HIV and our prevention efforts will be more effective if we can do more of the smart and cost-effective interventions to address these structural drivers.

It is certainly possible to achieve such an ambitious prevention target to reduce new HIV infections to below 100 000. The NSP 2017 – 2022 contains the full list of these interventions but it lacks strategy and organisation. It contains all the right words but does not put on the table an outgoing or forthright plan to tackle prevention. There is no game plan. There is no strategy to connect a wish list of disparate, siloed interventions run by different departments. There are no resources or financing plans to reallocate resources. Nor is there an ambitious fundraising strategy. There is no planning methodology, no surveillance system and most importantly, there are no implementation arrangements. The NSP is so indolent in its approach that it does not even break down the national target into provincial targets. South Africa needs a prevention agency and the NSP 2017 -2022 would have been the perfect medium to make a call for the policy makers to seriously address this major shortcoming in our HIV response. De facto, the new NSP retains the same arrangements for prevention that has existed for the last decade. Anyone who expects a different outcome with the same failed strategy is misjudging the need.

The Health Department is not able to coordinate the prevention response. It is not well suited to this task, does not have the expertise nor the enthusiasm and will do well to stick to its knitting. It has the challenge to doubling the size of its treatment programme in a system with multiple challenges. It must rebuild its TB programme from scratch – imagine missing 37% of all the TB patients in the country – and it has to rebuild the STI treatment platform that has been completely decimated over the last twenty years.

The failure to address the implementation arrangements for prevention is a missed opportunity in this NSP and this may very well its Achilles’ heel. Perhaps it is a symptom of the malaise we describe at the beginning of this article. Perhaps the NSP was there only for the day of the launch of the document. Perhaps the very thorough technical exercise was trumped by a couple of bureaucrats from government who cherry picked the words and phrases that their political bosses would have liked and muffled the real issues that had to be addressed by the new NSP.

This would certainly be in keeping with the times.

Fareed Abdullah is the former CEO of the South African National AIDS Council where he championed HIV prevention and programmes for key populations such as sex workers. He is a medical doctor and specialist in Public Health Medicine who is well-known for implementing the first public sector PMTCT and ART programmes in the Western Cape where he was Deputy Director General and head of the AIDS Programme from 1994 to 2006. 

 

 

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.

Measuring up to the task of tackling HIV and TB in the new NSP

By Julia Hill

What gets measured gets done and, ideally, gets improved. As the South African National AIDS Council (SANAC) nears completion of the next National Strategic Plan (NSP) on HIV, TB, and STIs (2017-2022), lofty ambitions for positive outcomes are in place. However, what provinces and districts are expected to measure in order to track implementation and incremental steps toward these goals is—at this point—completely absent from the NSP.

Correctly, the NSP aims to achieve substantial reductions in HIV infections to fewer than 100,000 per annum by 2022, and reach UNAIDS 90-90-90 targets by 2020 for HIV testing, retention in care, and viral suppression. Biomedical and social service approaches to HIV prevention are also prominent, including tackling the national epidemic of sexual violence. On the TB front, the NSP similarly seeks to close the gaps in prevention, diagnosis, treatment initiation, and treatment success, and specifically notes the special attention that must be paid toward bringing the drug-resistant TB (DR-TB) epidemic under control.[i] The wish-list of goals in the NSP leaves out very little. But these targets are expected outcomes—and outcomes do not evolve from a programmatic void.

The resulting pie-in-the-sky document makes it difficult for communities most affected by HIV and TB to hold to account AIDS Council governance structures and government departments. National success depends on smaller programmatic successes at district, sub-district, and service provision level. Monitoring and evaluation (M&E) standards must therefore be put in place at these system levels to ensure people are able to access services intended to lead to achievement.

For example, the intention to put half a million adolescents on PrEP by 2022 is overdue and welcome. But where is the breakdown for what districts are expected to contribute to that national total? High-burden districts like King Cetshwayo (formerly uThungulu) in KwaZulu-Natal have HIV incidence rates among adolescent girls that skyrocket to 6.2% by age 19[ii] –far exceeding the WHO threshold for PrEP eligibility. These districts should have very specific targets for the number of adolescents that should start and be retained on PrEP. But districts and sub-districts should also have ambitious targets in place for the proportion of schools offering HIV testing services and referrals to preventative services such as PrEP, or for the proportion of facilities implementing youth-friendly services—such as staying open after-hours on some days of the week. It is through monitoring these types of indicators that we can ensure that districts are offering services that put them on track to meet targets.

At the 21 February 2017 consultation on Draft 1 of the NSP, interested parties were invited to participate in shaping indicators and targets for the provincial implementation plans. A long list of possible indicators was shared with this group. Some indicators were intended to be aggregated at the national level to measure major outcomes—such as the number of people on antiretroviral therapy—but a number of process indicators were also proposed that, if well-designed, could be used to measure programmatic implementation progress down to the sub-district level.

It was not clear if provinces were required to report on any of these process indicators, or if they are merely expected to select those they find interesting or convenient. Outcomes of this meeting were—to our knowledge—never published online or shared, making it extremely difficult for provinces to incorporate programmes and M&E support into their implementation plans.

However, it is not too late for provinces and high-burden districts to be offered guidance on what to prioritize. Not everything must be done everywhere, but certainly a bare minimum must be universally required across the country, and high-burden districts must be required to implement additional interventions beyond the minimum.

So what type of interventions should be prioritized as the essential minimum required from all districts, and implemented with urgency in high-burden districts? At Doctors Without Borders (MSF), our short-list includes the following:

  • Proportion of sub-districts offering a package of school-based services (including HIV testing, TB and STI screening, pregnancy tests, condoms, and referrals for PrEP, VMMC, and referral to further HIV/TB services) in 100% of schools – Target 80% of sub-districts by 2019; ≥90% by 2022
  • Targets (proportionate to disease burden) at sub-district level for the number of PrEP courses distributed to adolescents and youth – National target of 200 000 adolescents and 75 000 women age 20-24 initiated on PrEP by 2019; 500 000 adolescents and 200 000 women age 20-24 by 2022
  • Targets (proportionate to disease burden) at sub-district level for the number of free HIV self-testing kits distributed in public sector – National target of 3 million tests per year by 2019; 10 million per year by 2022
  • Proportion of sub-districts with primary health care (PHC) facilities (including community health centres (CHC)) offering essential services for sexual violence survivors (forensic examination, PEP, emergency contraception, psychological counseling, social assessment), linked into interdepartmental referral network for more advanced services – Target 100% of designated PEP facilities in all HIV high-burden sub-districts capacitated by 2020; 100% of all sub-districts with minimum one facility by 2022
  • Proportion of CHC/district hospitals and PHC facilities in high-burden settings providing comprehensive DR-TB services (diagnosis, treatment initiation, continued management –Target 100% of PHC facilities in high-burden settings; target minimum one facility per sub-district in lower-burden settings. Total of 800 facilities by 2019; total of 1000 facilities by 2022.
  • Proportion of PHC facilities not providing 3-month ART refills to stable ART patients – Target <5% of facilities by 2019; 0% of facilities by 2022.
  • Proportion of PHC facilities per sub-district achieving ratio of one lay health worker: 800 people within community (with 25% of lay workers facility-based; 75% community-based – Target 80% of facilities by 2019; 100% by 2022.
  • Proportion of treatment sites (including community pick-up points serviced by Central Chronic Medicine Dispensing and Distribution) experiencing stock outs of ARV or TB meds –  Target: <10% by 2019; <5% by 2022.
  • Proportion of PHC facilities in HIV high-burden districts and CHC in all districts offering after-hours/Saturday services for ART initiation and/or ART refill collection – Target 75% by 2019; 90% by 2022.

This approach will require strengthening data capturing and M&E systems, and the public must have access to data if those responsible for action are to be held to account. It is mandatory to invest in requiring and measuring programmes if we are to avoid frittering away the next five years. When sub-districts receive specific guidance, they are inclined to implement it—this is evident in the massive uptick in numbers enrolled on HIV treatment, or registered to receive their medicines at community pick-up points. And if government departments or other stakeholders do not implement programmes, or do not run them well, then a robust M&E system makes it obvious where intensified efforts should be directed to improve the quality and availability of HIV and TB services.

South Africa knows what it wants to accomplish in reducing the national burden of HIV and TB over the next five years. The major question remaining is whether or not it will measure up to the task before it.

Julia Hill is Deputy Head of Mission, Doctors Without Borders/Médecins Sans Frontières South Africa

[i] SANAC. Draft 2: South African National Strategic Plan on HIV, TB and STIs 2017-2022. Accessed 27 March 2017. Available at: http://sanac.org.za/wp-content/uploads/2017/03/NSP-Draft-2_24-February-2017.pdf

[ii] Grebe E, Huerga H, van Cutsem G, Welte A. (2016) “Cross-sectionally estimated age-specific HIV incidence among young women in a rural district of KwaZulu-Natal, South Africa” presented at the 21st International AIDS Conference. July 18-22 (2016), Durban, South Africa.