Welcome detail in Mpumalanga HIV and TB plan

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

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

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

The context

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

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

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

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

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

The Mpumalanga PIP

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

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

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

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

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

More detail than most

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

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

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

But some short comings

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

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

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

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

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

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

The way forward

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

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

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

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

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

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

KZN’s HIV and TB plan: Good on structure, low on detail

The National Strategic Plan (NSP) for HIV, TB and STIs 2017 – 2022 is supposed to guide South Africa’s response to HIV and TB. While this national plan sets out broad targets and strategies, the implementation of this plan depends on provinces. To this end, each province had to develop a provincial NSP implementation plan (PIP). KwaZulu-Natal’s (KZN) PIP is called the Multi-Sectoral Response Plan for HIV, TB and STIs for KwaZulu- Natal Province 2017-2022 – but in this article we will refer to it just as the KZN PIP.

Broadly speaking, the KZN PIP’s engagement with the governance and consultative structures required to implement a plan like this is refreshingly realistic and shows an awareness of the very real risk that PIPs can become inconsequential processes parallel to existing government planning processes. The plan also does a good job of using data to define the particular problems in the province and flagging, in general terms, the kind of interventions that are required. Unfortunately, the KZN PIP is very low on detail when it comes to implementation – which is deeply disappointing in an implementation plan.

Some context

KZN is at the epicentre of South Africa’s HIV epidemic, if not the world’s. Annual AIDS deaths in the province peaked at 87 000 in 2005 and fell to around 17 000 in 2017. In 2019 there was probably around 15 000 deaths, although there is significant uncertainty regarding the 2019 figures. The decline in AIDS deaths in the province is driven largely by the provision of antiretroviral therapy – in 2005 there were 27 000 people on treatment in the province, today there is around 1.4 million.

One major concern however, is that growth of the HIV treatment programme in the province has slowed significantly in recent years. In 2014 around 230 000 people in the province were newly started on treatment. That number has dropped every year since and is now estimated to be under 100 000.

While AIDS deaths have declined dramatically, the rate of new HIV infections remains stubbornly high in the province. While the estimated 61 500 new infections in 2017 is much better than the 160 000 per year seen around the turn of the century, it is nevertheless high and means that the absolute number of people living with HIV keeps going up. Just over a third of the new infections in 2017 (around 21 000) were in women and girls aged 15 to 24. Around two million people in the province are living with HIV.

The KZN PIP

Probably the most important target in the KZN PIP is to reduce new HIV infections to below 20 000 by 2022 – roughly a third of 2017 levels. Modelling suggests that this very ambitious target will not be met and that by 2022 levels would still be in the high 40 000s. According to the PIP “interventions revolve around expanded and intensified provision of biomedical services, sexual and reproductive health and the provision of pre-exposure prophylaxis to high risk groups.”

While specific mention of PrEP is welcome, the PIP rather confusingly says that PrEP should be provided “as part of a prevention package for the general population and key population groups e.g. sex workers” and elsewhere it refers to providing PrEP to “high risk groups”. Who exactly should be offered PrEP is never made much clearer than this. The plan does not specifically set out to provide PrEP to women and girls aged 15 – 24, as one might expect given the high infection rate in this group. It also doesn’t set any concrete targets or make any meaningful commitments regarding PrEP.

Some might argue about the cost effectiveness of PrEP, but even if the cost-effectiveness case is not as strong as that for say medical male circumcision, one could argue that the state has an obligation to nevertheless provide young women and girls at very high risk of contracting HIV with the means to protect themselves. Either way, if ambitious PrEP targets were rejected based on cost-effectiveness grounds, then the PIP should state that explicitly.

Given the high rate of infection in young women and girls, one would also expect a strong focus on the promotion of safe sex and condom use. As is recognised in the PIP: “While the province achieved its condom distribution targets, these were not adequate when calculated at number of condoms per eligible male.” One would expect such an admission to result in ambitious new condom distribution targets. Maybe more importantly, given the high rates of HIV in young women and girls, one would expect an unequivocal commitment to making condoms available at schools. Yet, while the PIP does not prohibit it, it certainly does not make a strong case for increased condom distribution or making condoms available in schools.

DREAMS and various specific interventions are mentioned, but unfortunately the KZN PIP does not break any new ground in plotting how the province will address HIV infection in young women and girls.

Touches on key issues

Though lacking in detailed planning and concrete commitments, the KZN PIP does nevertheless touch on a lot of the key interventions required at this stage of South Africa’s response to HIV and TB and provides useful district by district breakdowns of some key indicators. It is to be welcomed, for example, that HIV self-testing and same day initiation are both endorsed. With some help and guidance from national or the province, these are issues that districts can run with.

While increased testing is relatively easy to do, many other interventions require the province to play a greater role and for districts to be given more guidance. The KZN PIP could, for example, have set targets for how many adherence clubs would be needed in each of the province’s districts and included an estimate of the additional human and financial resources that would entail. Without such guidance and support from a provincial level, many of the good things mentioned in the KZN PIP might not be implemented, or not be implemented with sufficient ambition. It could be that these issues will happen through other channels, but the PIP should at least contain some thinking on it if it is to meaningfully impact implementation.

The PIP identifies some serious problems in the province’s HIV response. For example, it states that “information indicated that only 55.7% of those on ART had viral loads done”. Identifying and admitting problems like this is positive. It is not clear however from the PIP what will be done to address this problem. Ideally, a serious problem like this would have triggered the commissioning of research to understand why viral load testing rates are so low – and that research would then have been used to inform the PIP.

Reduce TB incidence by 50%

The KZN PIP sets a target of reducing TB incidence by 50% by 2022 when compared to 2017 levels. According to the KZN PIP: “Currently TB incidence is way above the World Health Organisation threshold of 200 per 100 000 population. Earmarked interventions relate to increasing the uptake of TB preventive therapy using various strategies including mass screening.”

The PIPs endorsement of interventions like mass TB screening and intensify contact tracing is to be welcomed. But whereas the intent is good, the lack of actual planning here too is concerning. There is no sign in the KZN PIP of serious engagement with the human resource requirements of expanding screening and contact tracing – and without the people to expand these services the expansion simply won’t happen. We had similar concerns with the NSP at a national level. The explanation then was that this kind of grappling with the nitty gritty of implementation would be addressed in the PIPs.

It is true that the KZN PIP does include a matrix of which departments and sectors or organisations would be responsible for various interventions, but it does not go much further than this. The background is good, the general ideas are good, but in the final analysis there is no real plan to implement.

Serious about structure

Some of the short comings with the KZN PIP outlined above might be explained by the disconnect that often exists between AIDS council and Department of Health planning processes. An AIDS council might set laudable goals, but the Department of Health controls most of the relevant resources. For this reason, the NSP and PIPs should ideally be taken into account in departmental planning processes and budgets. The odd thing is that, unlike most provinces, KZN seems actually to have put some real effort into making these various processes talk to each other. In fact, much of the KZN PIP engages with just this kind of structural problem.

The PIP states: “This plan has to the extent possible incorporated issues relating to HIV, TB and STIs as mentioned in other departmental and sector plans to enhance mainstreaming and multi-sector participation. It further presents a platform for participation in the response by departments and sectors that may not have HIV, TB and STIs activities in their current plan. They should use this plan as a reference document to inform their implementation in line with the departmental mandate. The activities can then be incorporated into departmental strategic plans when the opportunity arises.” And, “The PCA through its secretariat will be required to facilitate the process of ensuring that all departmental plans support the goals and objectives of this plan.”

The above should be in every PIP – with a premier using his or her clout both as premier and head of the PCA to enforce it.

In KZN the Premier has for years been chairing the Provincial AIDS Council and Spotlight sources report that the council meets regularly and is functional. In addition to the PCA, the PIP indicates that the province has 11 District AIDS Councils and 43 Local AIDS Councils. It seems however that leadership at PCA level has not filtered down. The PIP itself states: “While functionality of the PCA was impressive, that of AIDS Councils at the other spheres of government was generally poor especially, at local municipality and ward level. In some cases ward AIDS Committees were non-existent. More broadly all AIDS councils face the challenge of effective stakeholder participation with few stakeholders from different departments, organisations and civil society participating in AIDS councils. This affects governance and mutual accountability of the response.”

The problem of ensuring greater functionality at district or local AIDS council level is certainly not unique to KZN. It is also not something that can be solved in a PIP. For it to be flagged and grappled with in a PIP is welcome.

According to the KZN PIP “6 districts and 21 local municipalities had AIDS coordinators that were exclusively assigned to HIV.” Ideally all districts will have such AIDS coordinators, and all district-level councils will be chaired by mayors.

The plan also shows a good understanding for the fact that health crises of the scale of HIV and TB cannot be stopped by the Department of Health alone. It reads: “Government organisations, non-government organisations, civil society, the private sector, development partners, traditional leadership and the religious sector all have individual and complementary roles in implementing this plan and ensuring delivery.” It is arguably at district and local level that these “individual and complementary roles” are most important. More guidance on how to turn these good intentions into actual shared programmes and shared responsibilities may be useful.

 

No costing and no communications strategy

 

One area that the PIP gives a lot of attention to is communications. It goes as far as to commit that a “comprehensive provincial multi-media HIV, TB and STIs communication strategy will be developed”. This strategy is mentioned time and time again in the PIP in different contexts and in relation to various specific interventions.

The idea of a single communications strategy around HIV and TB in the province is not a bad one. While some HIV communications projects in South Africa have had only limited success, that is not to say that a properly conceived and executed strategy might not be more successful in KZN.

Unfortunately, according to Bonolo Pududu of the HIV and AIDS Directorate in the office of the KZN Premier, by mid-2019 this communications strategy has not yet been developed.

Another concern is that by mid-2019 the KZN PIP, which is a 2017 – 2022 plan, has not been costed. According to Pududu, this is not the province’s responsibility. “The costing of the Provincial Implementation Plans (all provinces) is/was the responsibility of national (i.e. SANAC),” says Pududu. “Initial processes commenced to cost the plans, however, the finalisation of this process is yet to be communicated.”

The PIP refers to a monitoring and evaluation framework document. A draft of this framework was shared with Spotlight. According to Pududu, “final consultations” with “provincial stakeholders” have not yet taken place and the PCA has not yet adopted the framework.

The lack of a costing of the PIP, the fact that the communications strategy has not been developed, and the fact that the M&E framework is only now being adopted are all worrying signs.

Though the KZN PIP is low on detailed plans, there is also some indication that some of the good things in it are not being implemented. Under goal 4 “Social and structural drivers” the PIP sets out to “implement and scale up a package of harm reduction interventions for alcohol and substance use”. Yet, for much of 2018 a needle-exchange programme in Ethekwini was shut down by the authorities, ostensibly because needles were not being disposed of appropriately.

What is to be done

With a new Premier in the province and a new MEC for Health, there is significant potential for change in KZN. The various good things in the PIP can and should be built on.

Ensuring district and local AIDS councils meet and are given sufficient guidance is one urgent priority. Making this happen will require strong political leadership together with clear thinking on what roles district and local AIDS councils can and should play.

A second urgent priority would be to flesh out some of the ideas in the KZN PIP into fully fledged implementation plans. How should new infections in young women and girls be addressed? Should the province embark on a massive scaling up of PrEP for young women and girls? Should there be a new safe sex and condom distribution campaign? Will these campaigns be funded and who will implement them?

Thirdly, whatever revised plan is made must be costed and, if a communications strategy remains central to the plan, then such a plan must be developed. If the PCA and the Premier is serious about the KZN PIP, then they must show that seriousness by executing the plan and integrating it into government planning and service delivery in the province.

Note: The KZN PIP uses estimates from the Thembisa model version 3.2. In this article we use more recent estimates from Thembisa version 4.1.)

 

 

New HIV estimates shows too many people are still not on treatment

South Africa has made great strides in scaling up HIV testing and increasing HIV suppression in patients receiving antiretroviral treatment (ART), but is still struggling to reach ART coverage targets and is falling short of HIV prevention goals. This is according to new findings from the Thembisa model of HIV in South Africa presented today at the 9th South African AIDS Conference held in Durban.

Overall, the model estimates that in 2018 there were 7.39 million people in South Africa living with HIV – equivalent to 12.9% of the population”, said a press release from the University of Cape Town. Around 4.57 million of these were receiving ART.

Around 80 000 people are estimated to have died of AIDS in South Africa from mid-2017 to mid-2018.

Progress against 90-90-90

The model painted a mixed picture regarding South Africa’s progress against UNAIDS and National Strategic Plan (NSP) targets of diagnosing at least 90% of people with HIV, treating at least 90% of those diagnosed with HIV, and achieving suppression of the virus in 90% of those on treatment (the so-called 90-90-90 targets).

According to the model around 90.5% of people living with HIV in South Africa have received a positive HIV diagnosis, 68.4% of those diagnosed are receiving treatment, and 88.4% of those treated had viral suppression (according to the UNAIDS definition of <1000 RNA copies/ml – <400 RNA copies/ml is also used some times).

Of all people living with HIV in South Africa (including undiagnosed cases and people not on treatment), only around 54.7% are virally suppressed. This figure is important since people with viral suppression do not transmit HIV.

Still too many new infections

Although South Africa has been making progress in reducing the rate of new infections, the statement expressed concern that the progress may be too slow. “Over the period from mid-2017 to mid-2018, Thembisa estimates there were 249 000 new HIV infections in South Africa – a 36% reduction on the 388 000 new infections that occurred between mid-2010 and mid-2011. However, the UNAIDS target is to achieve a 75% reduction in the annual number of new infections between 2010 and 2020. To meet this target, South Africa would need to reduce its annual number of new infections to less than 100 000 within the next year, which appears unlikely given the slow pace of decline to date.”

Dr Leigh Johnson, lead developer of the Thembisa model, identified two factors that were hampering progress towards the HIV incidence reduction target: “Firstly, ART coverage is lower in South Africa than in other southern African countries, and we need to do better in linking HIV-diagnosed individuals to care and retaining them in care. Secondly, there is increasingly strong evidence of reductions in condom use, relative to the levels we would expect in the context of high levels of HIV diagnosis.”

The model estimates that adolescent girls and young women (ages 15-24) account for 31% of all sexually-acquired HIV infections. It is estimated that around 22% of women and girls in this group used condoms the last time they had sex. This percentage appears to have been falling steadily from a high of around 30% in 2005-2007.

Although the rate at which new infections is coming down is too slow, the statement points out some success stories. “KwaZulu-Natal, the province with the most severe HIV epidemic, has succeeded in reducing its total annual number of new infections by 49% over the period from 2010-11 to 2017-18. Thembisa also estimates that the annual number of new infections in children declined from 29 000 in 2010-11 to 13 000 in 2017-18, a reduction of 55%.”

Apart from a variety of other sources, the latest version of the Thembisa model also takes into account data from the 2016 Demographic and Health Survey. Work on the model is funded by UNAIDS and from 2017 Thembisa has been the source on which official UNAIDS estimates for South Africa are based.

Spotlight will in the coming weeks be publishing more in-depth analysis of the new Thembisa estimates.

 

Minister: We must have communities, especially people living with HIV tell us what is needed

ADDRESS BY THE MINISTER OF HEALTH DR ZWELI MKHIZE AT THE OPENING OF THE 9th SOUTH AFRICAN AIDS CONFERENCE

INKOSI ALBERT LUTHULI INTERNATIONAL CONVENTION CENTRE, DURBAN, KWAZULU-NATAL

11 JUNE 2019

Programme Director

The Conference Chair, Prof Refilwe Phaswana-Mafuya

Premier of the KwaZulu-Natal, Mr Sihle Zikalala,

Ministers, Deputy Ministers and MECs present

The Mayor of eThekwini, Ms Zandile Gumede and other leaders from the local government

The UNAIDS Deputy Executive Director, Dr Shannon Hader,

Representatives of Multilateral and Bilateral Development Partners

SANAC Trust Board members

The Deputy Chair of SANAC and Chair of the Civil Society Forum, Ms Steve Letsike and other Civil Society Leaders

Senior Officials

Scientists, Researchers and Activists

Distinguished guests

Ladies and Gentlemen,

We meet during Youth Month, a few days before June 16th – a historic day in history of our country when thousands of young people took on the might of the apartheid regime. We salute the youth of 1976 and all young people who fought against the evils of oppression and we thank those that paid the ultimate price that they paid for our freedom.
Unfortunately, since then too many young people have succumbed to a preventable disease – HIV and AIDS! Every year for the past 9 years, South Africans gather here in the ICC to discuss ways to prevent HIV transmission as well as how to ensure that we initiate and keep people who are living with HIV on treatment.
The theme of this year’s conference is: Unprecedented Innovations and Technologies: HIV and change. Lest we forget, we have an estimated 7.1 million South Africans who are HIV positive with 4.6 million on treatment. This means that we must move rapidly to ensure that everyone living with HIV is on treatment. Equally we must ensure that those of us who are HIV negative remain negative! This needs innovation and change as the theme of this conference suggests!
For such a conference to succeed in its objectives we must have communities, especially people living with HIV tell us what is needed, researchers and scientists tell us what works and what does not work and government and its implementing partners who are implement with a great sense of compassion, passion and urgency all working together to defeat this epidemic!
This conference epitomises collaborative excellence where science, activism, government, and medicine come together in our responses to the HIV/AIDS epidemic and its twin – tuberculosis. This community has again come together, during this week, to rise to the enormous challenges the response to the epidemic continues to require. These include:
• The eradication of stigma and discrimination around HIV and calling out the prejudice that has fuelled it;
• The hard work of research and of ensuring that the research is relevant, puts the rights of people first and community voices are heard when planning and implementing the research;
• And importantly to ensure that government and its partners are responsive to the epidemic and that programmes are implemented effectively, efficiently and with quality.
This conference is where we dedicate our energy to share innovative plans to end the HIV epidemic. Today, we also pay tribute to the researchers and activists who have devoted their lives to finding solutions to end AIDS as a public health threat. In addition, we are reminded of the bravery and courage of late activists like Gugu Dlamini, Nkosi Johnson, and Prudence Mabele, who fought from the front to ensure that this epidemic does not define our destiny as a country. This day also brings to memory our global icon and the first President of democratic South Africa, Tata Nelson Mandela – who fought against the discrimination of people infected with HIV and TB and rallied behind the campaign for expanding ARV treatment.

Such gatherings remind us that we need to understand the needs of the person who lacks access to information and services so that we can provide them with information and services, including key populations, the LGBTI community, rural communities and people living with disabilities. These gatherings also remind us to harness the huge potential of people living with HIV to guide the response and delivery of services and the campaign against stigma and discrimination. The day also reminds us to create platforms for young people to shape and direct the programmes that are meant to empower them to stay HIV free and for those that are infected to live longer and reach their full potential so as to contribute to the development of the country.

Although our country is applauded globally for having progressive legislation and policies that promotes access to health services, evidence has identified stigma and discrimination, including self-stigma, and the negative attitudes of healthcare workers, as key barriers to accessing HIV and TB services.

The 2014 People living with HIV Stigma Index Survey, conducted by SANAC in partnership with the National Association of People living with HIV and AIDS (NAPWA), the Treatment Action Campaign (TAC and Positive Women’s Network (PWN), found the following:

• Over one-third of respondents (36%) reported experiencing some form of stigma in either their personal or social environments, including being gossiped about, experiencing verbal and physical harassment and assault.
• That over one-third (36%) of respondents reported being teased, insulted or sworn at because of their TB status.
• 27% harboured feelings of uncleanliness or dirtiness in relation to their TB diagnosis.
It is not surprising that people are discriminated against because they have tuberculosis – even though TB is a very old disease and has been around for hundreds of years – because it is airborne and anyone can contract TB.

A more recent survey, in 2018, conducted by the University of KwaZulu-Natal also found that stigma and discrimination affected access to health care services, creating barriers to access to and adherence to ART and deterred individuals with TB from accessing services for fear of breaches of confidentiality.

Let me be clear as the newly appointed Minister of Health, stigma and discrimination has no place in the provision of health services. We will take action against any health professional that discriminates against anyone on the basis of their illness, gender orientation, social status or any other characteristic!

In addition, to address these issues and to give effect to the objectives of goal 5 of our National Strategic Plan for HIV, TB and STI 2017-2022, I am pleased to announce that we have just launched a 3-year Human Rights Plan for HIV and TB, which aims to set out a comprehensive response to human rights and gender-related barriers to HIV and TB services in South Africa for people living with HIV, people living with TB, and vulnerable and key populations. This plan will focus on the following:

1. Stigma and Discrimination reduction
2. Train health and other frontline workers to provide care that is non-discriminatory
3. Sensitize and train Law makers and law enforcement agencies
4. Campaigns that focus on legal literacy and rights
5. Strengthening legal support services
6. Monitoring, reviewing laws and policies
7. Reducing gender inequality and gender based violence

I would like to take this opportunity to thank the SANAC Human Rights and Legal Task team under the leadership of the Deputy Minister of Justice, Mr John Jeffrey for overseeing the development of this plan. In working with the Chairperson of SANAC, I will ensure that the implementation of this plan becomes a standing item in all SANAC InterMinisterial committee meetings and in SANAC plenary meetings.

The response to the HIV and TB epidemics needs resources. We are grateful that our government is the main funder of our responses. In addition, we wish to thank the Global Fund for their support which was recently announced ($369 million over the next three years) and the President’s Emergency Fund for AIDS Relief (PEPFAR) which will provide $730 million in funding in the 2019/20 financial year. I want to encourage everyone that benefits from these funds to ensure that the funds are used as effectively and efficiently as possible. We have to use these scarce resources to reach the target that President Ramaphosa announced in the 2018 State of the Nation Address of 6.1 million people living with HIV on treatment by December 2020! We dare not fail to achieve this target if we wish to reach epidemic control!

In closing, I would like to thank the Conference Planning Committee under the leadership of Prof Refilwe Phaswana-Mafuya for all the hard work of planning such a big conference and wish everyone fruitful deliberation over the next 3 days.

I thank you.

Hepatitis C in South Africa: A primer for civil society on the need for action

By Maria Stacey, Tim Lane, Anton Ofield-Kerr and Carlos Orte

OPINION: When the topic of Hepatitis comes up in conversation amongst people involved in the HIV response, people often confess they know very little about the illness. And yet, globally, viral hepatitis currently causes more deaths than HIV; and while the number of HIV-related deaths are falling, those associated with hepatitis are increasing yearly. Our National Strategic Plan for HIV, TB and STIs 2017-2022 recommends integrating viral hepatitis vaccination, screening and treatment into our comprehensive HIV response. Yet, there are significant barriers to making this a reality, including lack of awareness amongst health professionals, lack of public education, a lack of registration of life-saving medicines, and stigma and discrimination towards people at high risk for viral hepatitis, including people who inject drugs (PWID).

 Viral Hepatitis basics

The most common forms of viral hepatitis are Hepatitis B (HBV) and Hepatitis C (HCV). There are an estimated four million people with Hepatitis B and 400,000 with Hepatitis C in South Africa. Hepatitis C, in particular, affects key populations, especially people who inject drugs (PWID). Like HIV, Hepatitis C is a blood-borne virus, but is able to survive and remain infectious outside of the body longer than the HIV-virus. Although it can be sexually transmitted, the most efficient, and common, mode of transmission, is through re-used or shared needles and razor blades, or direct contact with infected blood.

Prior to the 1990s, most HCV transmission occurred iatrogencially, that is, unintentional transmission through medical procedures, including medical injections using unsterile needles, and blood transfusions before the blood supply was screened for HCV. Most of the up to 400,000 South Africans with chronic HCV infection acquired HCV through these means. Most of these are likely unaware of their HCV infection unless it has caused liver disease (see “Symptoms of Hepatitis C” below). Thankfully, iatrogenic infection is now extremely uncommon and preventable through many of the same precautions through which health care professionals prevent HIV transmission in medical settings, including the use of gloves, sterile needles, and safe disposal of medical waste products.

Nevertheless, South Africa is currently facing a significant viral hepatitis epidemic challenge. Recent epidemiological studies reveal rapidly growing hepatitis outbreaks among South African PWID populations. HCV prevalence estimates among PWID range between 45% and 94%; as many as half of all PWID may be co-infected with HIV and HCV; and around 5% of PWID have chronic HBV infection. PWID in the national capital of Tshwane appear to carry the highest burden of viral hepatitis: two separate, independent studies by the national NGO TB HIV Care and the University of California San Francisco in 2018 found three-quarters or more of PWID with an untreated viral hepatitis infection.

The structural and human rights challenges which make PWID a key population for HIV apply to Hepatitis C as well: high levels of stigma, discrimination, violence, criminalization of drug using behaviour and police harassment, low access to health services, high rates of homelessness, and high rates of incarceration.

 Symptoms of Hepatitis C

Like HIV, people who are infected with Hepatitis C may be unaware of the infection, as they can be symptom-free for years. Infection has an acute phase – the first six months after becoming infected – during which as many as 20% of infected people may naturally clear the virus. For the remaining 80%, infection will become chronic.

Some people with chronic Hepatitis C will progress to develop fibrosis and cirrhosis (scarring) of the liver, liver cancer or end stage liver disease, while others experience very little liver damage, even after many years. In cases where there is an absence of symptoms many people do not discover that they have HCV until some time after they have been infected. Heavy alcohol use and co-infections, including HIV and HBV, can exacerbate and accelerate progression of chronic HCV infection to cirrhosis or liver cancer.

Another reason that Hepatitis C goes undiagnosed for many years is that its symptoms are often non-specific and are frequently attributed to other illnesses. These include depression, fatigue, difficulty concentrating, skin problems, insomnia, pain and digestive disorders. In fact, often hepatitis C infection is picked up by doctors when they do a liver function test while monitoring for another medical condition; hepatitis C infection is then confirmed with HCV antibody and viral RNA testing. For these reasons Hepatitis C is often referred to as the ‘Silent Epidemic’.

New drugs bring eradication within our reach

In the past, the only HCV treatment option available was weekly injections of interferon, combined with daily oral ribavirin, for up to one year. Interferon-ribavirin treatment was associated with high rates of unpleasant chemotherapy-like side effects, including anaemia, flu-like symptoms including severe fatigue after interferon injections, and psychological side effects including irritability, severe depression, and suicidal thoughts. Even for those who could endure the full course of treatment, cure rates were only around 50%.

However, now, finally, new solutions exist to treat Hepatitis C. New direct acting antiviral drugs (DAAs) provide a safer, more effective, orally administered cure over a shorter time period (either an 8 or a 12-week course) that is well-tolerated with none of the severe side effects associated with interferon-ribavirin treatment. South Africa has recently approved National Hepatitis Guidelines, in line with the latest WHO recommendations for DAA treatment. A National Hepatitis Action Plan (NHAP) is being finalised, for launch in mid-2019. As many as 96% of chronic HCV infections in South Africa can be cured by DAA therapies. It may even be possible to eradicate HCV in South Africa by 2030.

Yet, South Africa faces significant barriers to scaling up Hepatitis C screening and treatment for all. These include lack of awareness amongst both healthcare providers and the general population who may have been exposed through medical procedures before the 1990’s, as well as high-risk groups such as PWID; the current lack of availability of DAAs except through a special Section 21 named patient procedure; failure by the South African Health Products Regulatory Authority (SAHPRA) to register any of the new medications; lack of treatment activist engagement in the silent epidemic; overwhelmed public health infrastructure; and a lack of ambition to plan and implement an eradication strategy based on mass case-finding, screening, treatment and cure.

What are the barriers and what needs to happen?

For South Africa’s NHAP strategy to be effective, a few things need to happen:

  • Increased awareness among healthcare providers. At the moment, awareness of Hepatitis C amongst health professionals is very low, and expertise is highly centralised within tertiary hospitals. There is a dire need to increase expertise amongst health professionals at primary and secondary level, so that they become alert to the symptoms of Hepatitis C, and are competent in the diagnosis and treatment of the condition.
  • Multi-sectoral cooperation to reach key populations. Partnerships between public health facilities and NGOs, especially those working with key populations, will create synergies. NGOs can engage with key population communities, raise awareness, conduct social mobilisation, refer for treatment, and provide sensitisation training for health facility staff.
  • Registration of DAAs. Direct acting antiviral drugs have been awaiting registration by the SAHPRA for up to five years. These drugs will address a large unmet public health need and must be processed and approved by SAHPRA urgently.
  • Human-rights affirming HCV prevention, care, and treatment for PWID. Punitive law and drug enforcement policies and programmes targeting PWID drive people away from health services, contribute to the growing HCV epidemic outbreak, and ultimately, cost lives. Programmes and policies to assist PWID should all be guided by WHO-recommended harm reduction best practices, including access to sterile needles, and opioid substitution therapies (OST) to treat heroin addiction.
  • Needle and Syringe Programmes (NSP). PWID often do not have access to clean and sterile needles despite peer-based NSP outreach to PWID. For example, in eThekwini, the municipality shut down a civil society NSP. PWID need a continuous supply of adequate quantities of needles and syringes, otherwise even if people are treated for HCV, they can become re-infected.
  • Cost-effective Opioid Substitution Therapy (OST) access and scale up. OST is currently out of reach for most PWID due to its high retail cost. For example, the OST drug Methadone is currently approximately 30-40 times more expensive in South Africa than in other countries. Public health emergency strategies must be invoked to decrease the cost, including encouraging introducing competition into the market through new applications to SAHPRA.

Civil society advocacy has the power to unlock the hepatitis response in South Africa and save hundreds of thousands of lives, as it did with HIV. It is time for civil society to educate ourselves, talk openly about hepatitis, advocate for integration of hepatitis screening into primary health care and sexual and reproductive health services, and to reduce barriers to care and treatment, especially among PWID and other key populations. It is also time for government to lead the hepatitis response, with an ambitious strategy aimed to eradicate hepatitis through mass screening, treatment and cure.

  • The authors are Directors of Equal International, a niche consultancy group focused on supporting multi sectoral partnerships to ensure marginalised groups are not ‘left behind’, and would like to thank the PITCH programme (a strategic partnership a strategic partnership between Aidsfonds, Frontline AIDS and the Dutch Ministry of Foreign Affairs) for supporting multi-stakeholder engagement around Hepatitis C and PWID in South Africa.

 

Donor shift threatens adherence clubs in the Free State

Mosamaria’s Connie Motsoeng addressing an adherence club at Pelonomi Hospital in Bloemfontein Photo by Khothatso Mokone

A shift in donor funding for HIV has endangered the continued existence of successful and effective antiretroviral adherence clubs in the Free State.

The Mosamaria project, an NGO-run adherence club project based in Mangaung, has in the last five years reached 25 000 people through 21 health facilities and achieved a 98% patient retention rate. The clubs operated on a R4 million a year budget, which translates into about R161 per patient, per year.

These gains are in danger of being reversed as donor support from the Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM) shifts to other programmes.

Right to Care (a large national NGO), which for five years has been a primary recipient of money from the GFATM, has been distributing funds to Mosamaria. The GFATM distributes funds to a series of so-called primary recipients in South Africa, who then distribute it to specific projects.  Right to Care is no longer a principal recipient of GFATM funds and none of the new primary recipients will be stepping in to fund the Mosamaria Project. The key reason for this appears to be that South Africa’s country coordination mechanism (CCM – a committee that submits funding applications on behalf of the country) decided last year that no further application to the GFATM to support community adherence clubs would be undertaken. The CCM is administered by the South African National AIDS Council (SANAC).

Mosamaria’s funding for adherence clubs came to an end on 30 March 2019.

As a result, the Mosamaria project is in the process of being shifted to the Free State health department, a risky move in a province with a poor track record when it comes to health and more especially HIV.

That adherence clubs are part of the solution to South Africa’s HIV epidemic is now widely accepted. The clubs have been a model of successful HIV management since they were first piloted by MSF (Medicins Sans Frontieres) in Khayalitsha in the Western Cape in 2007. By filtering stable HIV positive patients into the clubs it helped patients receive their medicines on a fixed schedule and helped them save time by avoiding regular long hospital or clinic queues. Peer support is also a key part of adherence clubs.

As a result of successful pilot projects, adherence clubs as a model was adopted, along with CCMDD (Centralised Chronic Medicine Dispensing and Distribution) and Fast Lane dispensary services as part of the National Department of Health’s ARV adherence policy.

What clients say

Patients’ adherence club logbooks Photo by Khothatso Mokone

Bloemfontein local Margaret Baratang is one of the Mosamaria patients at Pelonomi Hospital in Bloemfontein. On the morning of her last club meeting with the Mosamaria team, Baratang was angry and deeply anxious.

“These people [Mosamaria facilitators] treat us nicely. I’ve been coming to the club for three years. Every time I’m here 30 minutes then I can go. Now if we must go back to the hospital queue and we will have to wait for two or three hours, I’m telling you,” she says.

She talks as she shuffles up the rows of seats. The queue moves fast. In her hand is her club booklet. It’s covered in decorative wrapping paper. Most of the patients have done the same – they are a support group after all. The foil wraps, the prints of flowers and butterflies represent their care and respect for a club model that’s come to represent service and significance in their lives.

Others in the queue with Baratang include a man who works as a driver. He’s juggling car keys and says he is irritated. His HIV status is his private business and the club model respected this he says, by allowing him to arrive every second month, have a basic medical screening, receive his medicines and still arrive at work on time. Now he will have to explain to his employer and colleagues why he has to take a whole morning off every second month to be at the hospital.

Another patient, Boitumelo Mokeane, launched a petition to the Free State MEC for Health. In representing “concerned people living with HIV”, she said in her petition that patients deserve access to quality healthcare. She raised fears that the Mosamaria facilitators’ expertise would be lost and that CHWs would not be able to cope. Over time Mokeane also said people would default because collecting medicines would become too much of a hassle.

“We don’t want the situation where we have to start from scratch in adjusting with new people and new systems,” she says.

Mosamaria workers host one of their final adherence club meetings. Photo by Khothatso Mokone.

CHWs assigned to take over

With the absorption of the project into the Free State Department of Health, community healthcare workers (CHWs) have been assigned to take over the running of the clubs. Mosamaria facilitators spent the last few weeks while they were still employed, training the CHWs. It was a scramble against time as the Free State’s Chief Director of district health service and health programmes only sent out an internal memo on 6 February. It was a memo to the three affected districts of Fezile Dabi, Mangaung Metro and Xhariep to identify two CHWs per facility to be trained to run adherence clubs. It was also only in February that the Department met with NGOs for a “transitioning meeting”. This was less than two months before Mosamaria was scheduled to wrap up its operations.

Thapelo Mabule, Mosamaria’s outgoing programme manager for the adherence clubs, says often CHWs didn’t show up for training sessions in those weeks.

“CHWs are being paid a stipend by the department of health, not salaries so maybe they don’t care enough to come for training. The clubs as we know them will collapse the minute we hand them over,” he says.

His seems a realistic assessment, because without the structure, that includes salaried facilitators trained in record keeping, monitoring and evaluation and managing patient loads and communicating with the pharmacy for filling pre-packing scripts, the club model has a slim chance of succeeding.

Free State Department of Health spokesperson Mondli Mvambi however, is confident there will be few disruptions. He says: “The transitioning of Mosamaria will not negatively influence the patients as the clubs will continue using the principles outlined in the National Adherence Guideline Standard Operating Procedure. When the project was started the Free State Department of Health was aware that funding was only for a limited period of time, hence the province has worked on a transitioning plan for when funding comes to an end.”

He adds that in addition to the two CHWs assigned to each club, each facility will have a nurse and an operational manager for continued implementation of the clubs and other differentiated care interventions.

“Patients trusted us”

Mosamaria’s Connie Motsoeng Photo by Khothatso Mokone

For Connie Motsoeng, a Mosamaria club facilitator, walking away is tough. She says: “We are losing something that we love. Patients trusted us and now we worry that they will suffer without properly run clubs.”

She’s also worried because she has a baby on the way – her second child. She’s one of 39 facilitators and administrators who are now jobless as their posts were funded through Right to Care funding.

According to Mabule, communication with Right to Care has been minimal. Mosamaria were notified that their funding would be discontinued in mid-October last year and they had a close-out meeting with Right to Care in Johannesburg, but not much else has been communicated.

According to Right to Care discussions with Mosamaria were initiated in October 2018 to indicate that the funding will come to an end in March 2019. “Representation to the CCM were undertaken to indicate that adherence clubs will require continued support.  The Department of Health indicated that transition plans would be made,” Right to Care said in response to questions from Spotlight. Going forward, Right to Care will provide adherence club services in Ehlanzeni and Thabo Mofutsanyane districts in the Free State with support from the United States government.

By the beginning of December Mosamaria fired off hopeful funding proposals to new Global Fund South African principal recipients and also notified the provincial department of health of the situation.

Trudie Harrison, a Mosamaria co-ordinator, says one local principal recipient didn’t respond, another told them to wait till February to submit proposals. A month after that they were told HIV adherence clubs would not be funded.

“Five months is not enough time to close out a project like this. We did assume that one of the other local principal recipients would continue funding the clubs because they have proven to work so well.

“We are a small organisation but instead of being in the field, we end up spending more time writing proposals, stuck in meetings and following up with would-be funders,” says Harrison.

She adds: “International donors do not consult sufficiently, if at all, with the people who are actually implementing programmes in communities. We just get told by principal recipients ‘the Global Fund has decided …’ without any reasons why this has happened.

Government’s responsibility

Lynne Wilkinson, a differentiated service delivery consultant with the International AIDS Society, says closing out plans need to be properly and effectively managed so there is seamless transfer and patients are not put at risk or under any anxiety over the future of their care.

Wilkinson, who was involved with MSF’s first clubs launched in the Western Cape (that now are run by the Western Cape Department of Health), says it remains government’s responsibility to ensure that adherence club models are not compromised, even as outside funders’ priorities shift.

“The national adherence policy guidelines are in place to ensure that stable patients can access their medication as easily as possible throughout the cycle of lifelong treatment,” Wilkinson says.

She adds too that it’s adherence clubs that have over time proven to be the cheapest most effective model of keeping patients on treatment. She says: “The government’s target is to get another two million people on ARV treatment by 2020, it means we need to use every resource we have. So when an organisation like Mosamaria has successfully built up clubs that have proven to be successful and cost effective, they should be supported and funded, not allowed to fall away.”

South African National Aids Council (SANAC) CEO Dr Sandile Buthelezi drives home the point that donor funding is finite. He says: “Principal recipients [like Right to Care] are aware that their funding is for three years. It is therefore imperative that sustainability plans and transition plans are part and parcel of the application, and the Oversight Committee of the Country Co-ordinating Mechanism ensures that these plans are followed and implemented. In addition, the main reason for the Department of Health to always be part of principal recipients is to ensure that this transition takes place.”

He says SANAC, through its Resource Mobilisation Committee, will canvas for more domestic and donor funding to ensure that ARV adherence is implemented and that South Africa continues to wean itself off foreign donor funding.

New guides to advocating in AIDS councils

Spotlight has developed two new advocacy guides for members of provincial or district AIDS councils. One focuses on TB prevention and the other on retention in care of people living with HIV.

These are practical advocacy guides that we hope will be useful to members of AIDS councils who wish to find district or provincial-level solutions to these two critical problem areas in the HIV and TB response in South Africa.

The guides can be downloaded for free by clicking on the links below. The guides have been designed to be printed on A4 pages that can be folded after printing.

Let’s Make AIDS Councils Work – HIV

Let’s Make AIDS Councils Work – TB

 

Let us know what you think about the guides in the comment section below.

In-depth: The problem of stopping or not starting HIV treatment

By Thania Gopal

South Africa has the largest HIV epidemic in the world. The United Nations Programme on HIV/AIDS (UNAIDS) estimates that there are approximately 7.2-million South Africans living with HIV, with 270 000 new HIV infections in 2017. South Africa also has the largest antiretroviral therapy (ART) programme with more than four million people estimated to be on treatment. Despite progress in getting people onto treatment, recent evidence indicates that the country is still experiencing significant numbers of people developing and dying from advanced HIV-disease. This is as result of people who either do not start treatment, start treatment late, or stop and re-start treatment. There is, therefore,  an urgent need to not only prioritise HIV-testing but to ensure that once people start treatment, they remain on life-long care.

As part of its National Strategic Plan for HIV, Tuberculosis and STIs 2017 – 2022, South Africa has adopted the UNAIDS 90:90:90 targets which aims to achieve the following HIV-related goals by 2020: (1) 90% of all people living with HIV should know their HIV status (2) 90% of all people with diagnosed HIV infection should receive sustained antiretroviral therapy, and (3) 90% of all people receiving ART should be virally suppressed.

Deputy Director-General of Health, Dr Yogan Pillay, says that while South Africa is not doing too badly with regards to testing people for HIV and keeping them virally suppressed while on ART (the first and third targets), the main challenge is keeping people on treatment.

Estimates from Thembisa (the leading mathematical model of HIV in South Africa) indicates that South Africa has already achieved and surpassed the first 90, with an estimated 90% of people living with HIV knowing their status in 2017. Although South Africa appears to be performing well in terms of HIV-testing, this progress will need to be sustained given the large amount of new infections annually.

In addition, the testing of specifically men and young people remains a problem. According to Professor Francois Venter, Deputy Executive Director at the Wits Reproductive Health and HIV Institute, the 90:90:90 targets for men are an “absolute disaster” compared to women. “Men test late, they don’t link to care, they are less likely to suppress, they are more likely to fall out of care, they are also more likely to come to treatment much later. So, it’s a really big challenge at the moment”, he says. Similarly, Pillay says that even when men are tested and test positive, there is a reluctance to initiate treatment.

Dr Laura Trivino-Duran, Medical Coordinator for Médecins Sans Frontières in South Africa cautions against thinking about 90:90:90 targets as a linear model in which people who “start on treatment will stay on treatment forever” and says the cyclical nature of the treatment journey in which people start care, exit care and restart  care – for a number of different reasons – should be recognised.

Poor performance on second 90

With regards to the second UNAIDS target of having 90% of HIV-diagnosed individuals on ART, based on the Thembisa model, South Africa only had around six out of every 10 (61.9%) of HIV-diagnosed people receiving ART in 2017, with the provincial rate varying between about half (54%) in Gauteng and North West, about six out of every 10 (64%) in Western Cape and eight out of every 10 (81%) in the Northern Cape.

The model estimates less than half (40%) of people with HIV were still not on treatment in 2017, this is roughly three million people at risk of progressing to advanced HIV-disease.

For the third 90, the model estimates that almost eight out of every 10 (77.8%) HIV-positive people who were receiving treatment in 2017 were virally suppressed, meaning the virus could not be detected in their bodies. According to the model, well below half (43.3%) of all people living with HIV in South Africa were virally suppressed. This is important because people who are virally suppressed do not transmit the virus.

Dr Leigh Johnson, from the Centre for Infectious Disease Epidemiology and Research at the University of Cape Town and lead developer of the Thembisa model, says there has been “a slower than expected growth in the ART programme” with the number of patients initiating ART peaking at around 720 000 in 2010 and steadily declining to approximately 479 000 per annum in 2016.

The big controversy

“I think the big controversy is really around where are we failing, are we failing to diagnose people, are we failing to link people to care after that initial diagnosis or is the problem that we actually just aren’t retaining people in care?”, says Johnson.

Pillay says there are two challenges: “The one is that patients are still shopping around even after being diagnosed positive with the rapid test and there’s also a delay to treatment. The other reason for delay to treatment is that patients are not always offered same day initiation and when they don’t initiate on the same day, we find it very difficult to get them back into care”.

In 2016, following results from the landmark START trial, government expanded eligibility criteria for ART by introducing a “Test-and-Treat” policy which called for all people diagnosed with HIV to be initiated onto treatment as soon as possible, irrespective of their CD4 count. According to Venter, the policy has been surprisingly effective: “I used to be a bit sceptical about it, just thinking that people need time to get ready, but in fact, for many people, just taking that first step immediately, and not having to sit around thinking about it is probably quite a healthy thing”, he says.

There are many factors which contribute to patients not starting ART, says Professor Catherine Orrell, from the Desmond Tutu HIV Foundation. “It’s often personal reasons, there’s a lot of stigma, there’s a lot of non-disclosure because people are afraid of what their family and friends will say about their HIV status”. She adds that South Africa is still “suffering from the side-effects” of AIDS-denialism, during which certain groups denied that HIV even existed. South Africa is still a conservative society, despite living in a country where one in eight people have HIV, there are very few public figures such as sports stars, radio celebrities or politicians that have openly disclosed their status, says Venter.

High drop-out rate

Another major issue is keeping people on treatment with suppressed viral loads once they have started treatment. At the Gugulethu Clinic, in Cape Town, where Orrell works, around one in five  (20%) of people who have started treatment at the clinic have left care by week 16.

“Within four months, 20% of people have left care, of those that come to start care, so there’s definitely a retention issue as well. There’s a very steep drop off in numbers in that first four months and then there’s an ongoing slow trickle of drop off,” she says.  Similar results were seen in a larger study1 in Khayelitsha using clinic data of 39 884 patients who had visited one of 13 Khayelitsha ART clinics during 2013/2014. The study found that just over one in five (22.6%) of patients disengaged from care at least once during 2013/2014 and an additional number (2.5%) transferred to a different clinic from the one in which they had originally started on ART. While a third of patients in the study returned to care after stopping, an additional quarter were alive but not in care.

Pillay said around 20% of patients default at six months after starting ART and up to 30% of patients default at twelve months after initiating treatment.

Trivino-Duran says that in the past, advanced HIV-disease was predominantly seen in people who had not started on ART and who became ill. Currently, the majority of people with advanced disease have been on ART before and have stopped or interrupted treatment.

Two recent studies highlight a worrying trend of people who already have advanced HIV-disease, starting treatment late. One study2 (based on countrywide laboratory data) found that of 654 868 patients starting care in 2016, almost one third (32.9%) had advanced HIV-disease. Another study3, using Western Cape provincial data of all HIV patients receiving CD4 count testing, found that an increasing proportion of patients with very advanced HIV-disease had previously been on ART. Between 2006 and 2016, patients with advanced HIV-disease getting treatment for the first time dropped from 60.9% to 26.7% whereas the proportion who had previously been on ART increased from 14.3% to 56.7%. This points to a major problem of patients not remaining on continuous care.

Trivino-Duran is also concerned about a potential blind spot in missing patients who are discharged after being treated for advanced HIV-disease and who may be lost to follow-up again. “What happens when they are discharged from hospital, and they have to go back to the health facility, that’s a very crucial period of time where I think we need to strengthen our follow-up of those patients – once they are discharged and not completely well, they are still a bit fragile.”

According to Professor Graeme Meintjes, from the Institute for Infectious Disease and Molecular Medicine, based at the University of Cape Town, the costs of treating patients who require hospital admission for advanced disease is enormous compared to people who are stable and doing well on ART as an outpatient. Ideally, the ART programme should work in such a way that it is keeping people healthy and preventing people from developing advanced HIV, says Meintjes.

No effective tracking system

A major obstacle to keeping people on treatment in South Africa is the high rates of mobility of the population with no consistently reliable method of tracking patients across different health facilities.

“Each province has different systems, and different ways of doing things, and to have a unique tracking system across the country would be immensely valuable”, says Orrell. The absence of a reliable tracking system makes it difficult to know if patients are receiving treatment at a different facility or if they have truly stopped treatment altogether.

According to Venter, “If you don’t have a single patient identifier you don’t know what you are fixing, you don’t have proper data. It would help governance and programmes immeasurably being able to track how people are using services and who is and who isn’t included… and it will make things smarter, cheaper, more effective, and it allows us to understand how our health care service needs to operate”.

However, Pillay says the problem of a unique identifier has been resolved both “conceptually and practically”. He says there are currently around 26-million South Africans who are linked to the Health Patient Registration System (HPRS) via a Health Patient Registration Number (HPRN). Instead, the main challenge is internet connectivity at health facility-level and linking the different systems that manage patient-linked data.

Patients also experience difficulty transferring from one clinic to another due to the way that the public health system is structured, says Orrell. She says that patients who do attempt to return to care may be given a hard time by clinic staff if they do not have the proper documentation. “…you have to come get an appointment, you have to get a long letter, you have to go to the other clinic and present the letter, and if you don’t get the letter then it’s hard to get into the next clinic, but people do cycle all the time,” says Orrell.

Healthcare worker attitudes

There are many reasons why individual patients stop treatment including psychological issues, life events, disruptions to their daily schedules, job instability or psychological distress, according to Meintjes.

Another barrier for patients who want to return to care is the attitude of healthcare workers, with patients often complaining about being “shouted at”, according to Trivino-Duran. “I think staff attitude and even the way we talk about the patients, we call them ‘defaulters’, we call them ‘treatment failures’, and those are very punitive words that we use to describe patients”.

Patients who have been on treatment may also suffer from treatment fatigue. “I think the kind of unforgiving attitude of health care workers is very damaging, its completely normal and human to stop, to get tired of therapy, to have life issues, especially for young people, and one can understand that”.

We should be designing a healthcare system where patients can easily access care outside of traditional health facilities, says Venter. “If you educate patients, and you give them power, make them knowledgeable about their condition, they are very, very good at managing themselves”. The Central Chronic Medicines Dispensing and Distribution (CCMDD) programme, for example,  enables more than two million patients in South Africa to receive their ART medication at various pick-up points, such as churches and libraries, closer to their homes. “It’s just much closer and the queues are much shorter, so I think that has been really exciting, that we are starting to look at different models of medication delivery that doesn’t mean you have to spend hours waiting,” says Venter.

The NDoH is also trialling a bicycle system to courier medication over the ‘last mile’ from designated pick-up points directly to patient’s homes. This is currently being piloted in two townships in KwaZulu-Natal (KZN) and Johannesburg and is modelled on an initiative in Khayelitsha. “While it is in early discussion, we think it’s something that will also make life easier for patients and therefore increase adherence. Also, because of the distribution of patients, the cyclists who courier the drugs to them can also alert them to when their next appointments are in case they forget” says Pillay.

The role of adherence clubs

An ongoing strategy, forming part of the NDoH’s adherence policy to keep patients motivated and on treatment, is the use of adherence clubs, which brings together groups of patients at a health facility or other community venue to facilitate quick pick-up of pre-packaged ART and to receive counselling and support, usually facilitated by community health workers or lay health workers.

“The clubs cater for the majority of people that are stable on treatment and that have a suppressed viral load. They provide peer support, and they produce that social fabric that is very good for many patients”, says Trivino-Duran.

While adherence clubs have been successful, they also face a number of problems given the rapidly expanding number of people on ART. One problem is that adherence clubs are only allowed to supply medication for two months which is regarded as insufficient and should be extended to up to six months, says Trivino-Duran. Patients who do not require regular peer support, especially those who have been on treatment for a long period, also prefer having a “fast lane” to collect their medication, rather than having to sit through counselling each time.

Another issue in Khayelitsha – where around half (50%) of the HIV-cohort are using adherence clubs – is that the size of the clubs have grown so much that finding an appropriate space to accommodate them is becoming a big problem. In addition, patients with other chronic diseases, are still required to visit health facilities to collect their other medication so “it’s not a single stop service for them,” says Professor Orrell.

“Basically, the message is that we need to have a variety, a number of models of care that caters to everybody and doing only clubs is not the way forward. Clubs are good for a certain population but not for everybody,” says Dr Trivino-Duran.

With regards to adherence clubs, Dr Pillay says the NDoH’s plan is to move toward “peer-led clubs rather than clubs led by community health workers”. He says government has partnered with three organisations managed by people living with HIV and will be working with them to look at how they can support the programme with respect to adherence and treatment literacy.

The role of Community healthcare workers

There is also a lack of clarity with regards to the role of community health workers (CHWs) under the new Policy Framework and Strategy for Ward Based Primary Healthcare Outreach Teams 2018/2019 – 2023/2024, released last year. CHWs are involved in all aspects of HIV-management including prevention, testing, treatment, linkage to care and retention in care.

According to Donela Besada, Senior Research Scientist at the South African Medical Research Council, there appears to be a consolidation of the roles of community health workers, lay health workers and caregivers and an increase in the scope of work which includes HIV/AIDS, tuberculosis, child and maternal health, and non-communicable diseases. “What we had before is a lay health worker that worked in the facility and then we had another community health worker that was out in the community and now what we are trying to find out is what’s going to happen when they put it all under one overall umbrella”.

Another concern is the introduction of a Grade 12 qualification for CHWs under the new policy and what will happen to CHWs who have been working in the system for years.

Going forward, Dr Pillay says CHWs will focus on encouraging people to test and on tracking and tracing patients lost to follow-up.

Treatment closer to home

Many programmes aimed at improving linkage to care and retention in care centre around community-based interventions which bring treatment and support closer to people’s homes.

So, for example, MSF has piloted ‘Welcoming Services’ which is based on making people feel more welcome when returning to treatment after stopping ART. According to Trivino-Duran, this involves utilising a more effective triage system to identify people who may be returning to care outside of their allocated appointments and trying to prioritise or fast-track them, enhancing systems at the health facility, and improving staff attitudes toward patients who are returning to care.

Given that around 20% of patients have defaulted six months after starting ART, Pillay says patients should be followed up immediately after missed appointments via SMS or telephonically. However, he admits that this is often ineffective because patients may change their contact details, provide incorrect details or not respond. When this happens, ward-based outreach teams (made up of CHWs) are given lists of patients to trace their physical locations, which is also challenging.

Trivino-Duran says another pilot, which involves the use of social media platforms such as Facebook, may provide an alternative in areas where smart phone penetration is high. This is being used to encourage people to return to health services without fear of being “blamed” if they have disengaged from treatment for a long time and also to provide them with more information on where to go and what to do.

The NDoH, in partnership with MSF is also piloting interventions aimed at encouraging men to use health services in KZN (Pinetown, KwaMashu) and Cape Town (Khayelitsha). These include providing a package of services customised towards men’s health issues (such as STI screening and erectile dysfunction) rather than offering stand-alone HIV-services, providing a male nurse and fast-track queues for men on Saturdays.

No magic bullet

The use of HIV self-screening tests (using an oral self-testing kit) has also been trialled, particularly among men and sex workers. Current pilots conducted by MSF in Eshowe in KZN and in Khayelitsha in Cape Town have shown promising results. Trivino-Duran said these tests should be distributed on a massive scale, along with further access to information on how to understand the results and access further care. A mobile application is also available which guides people through the self-testing process, and directs them to the nearest facility.

One of the disadvantages of self-testing is that it does not automatically link people to care after testing positive. “What we do know for sure is that people use it, it is accepted, and it doesn’t seem to produce errors and it is easy to do but what we cannot really say, is what people do after getting the results” says Trivino-Duran. An interesting finding from the study was that many patients who used the test already knew their status and used self-testing to “confirm” the results. Therefore, an important learning from the study was to make patients who were already on ART aware that self-testing results would not be the final word, since it could provide false negative results for patients who were taking ART.

A range of different interventions focussed on young people are also being implemented by the DTHF in Cape Town in partnership with the Western Cape government and funded by the Global Fund to Fight AIDS, Tuberculosis and Malaria. Some of these interventions, such as Zimele, provide healthcare services as well as strong educational support and social empowerment, according to Orrell. The Women of Worth (WOW) project is a research study described as a “social protection intervention that will address a range of biomedical, socio-behavioural, structural and economic vulnerabilities” in 10 000 young women between the ages of 19-24 years using twelve “empowerment workshops”.

In addition to the way that the health system is structured and services are delivered, there are also changes to the actual treatment guidelines that should help keep more people healthy. An example, from Meintjes, is the introduction of a new treatment regimen which will be introduced in South Africa later this year, which involves moving patients from Efavirenz to Dolutegravir, as part of a triple therapy regimen. This change in treatment has been shown to result in patients developing less resistance even if they stop and re-start the treatment, “so having a drug that is very resilient in terms of resistance will also help to prevent advanced HIV,” he says.

Ultimately, there is no magic bullet and it boils down to getting the basics right, says Venter. This includes “ensuring that people  can walk into a clinic and get decent care, that there are no drug stocks-outs, that the staff know what they are doing, that facilities are clean and safe” and that patients’ needs are being prioritised by being able to access care in the evenings and over weekends.

1 Kaplan SR, Oosthuizen C, Stinson K, Little F, Euvrard J, Schomaker M, et al. (2017) Contemporary disengagement from antiretroviral therapy in Khayelitsha, South Africa: A cohort study. PLoS Med 14(11): e1002407. https://doi.org/10.1371/journal.pmed.1002407

2 Carmona S, Bor J, Nattey C,  et  al. Persistent high burden of advanced human immunodeficiency virus (HIV) disease among patients seeking care in South Africa’s national HIV program: data from a nationwide laboratory cohort. Clin Infect Dis 2018; 66:S111–7.

3 Osler M, Hilderbrand K, Goemaere E, et al. The continuing burden of advanced HIV disease over 10 years of increasing antiretroviral therapy coverage in South Africa. Clin Infect Dis 2018; 66:S118–25.

 

 

Provinces make progress with AIDS plans

All nine of South Africa’s provinces have finalised their NSP provincial implementation plans, according to the South African National AIDS Council (SANAC). These nine implementation plans are meant to guide implementation of South Africa’s National Strategic Plan (NSP) for HIV, TB and STIs 2017 – 2022.

In total, 46 out of 52 districts in the country have finalised their district implementation plans. The six that are missing are from the Western Cape, where district implementation plans will not be implemented due to the fact that the province does not have district AIDS councils – but similar structures called Multi-Sectoral Action Teams (MSATs).

Of the nine provincial plans we managed to find only the Limpopo plan online. After contacting provincial AIDS councils we managed to get hold of a total of six of the nine plans – with the Eastern Cape, North West, and Northern Cape not sending us their plans after multiple requests – although provincial AIDS council representatives in the Northern Cape did indicate that a print copy could be collected in Kimberley. (Future Spotlight articles will engage with the content of the plans)

SANAC says they view provincial implementation plans as public documents that should be freely available. “however the provinces and the districts have custody of these plans,” SANAC told Spotlight. “A new SANAC website is currently being developed and provinces/districts will be encouraged to share formatted and designed documents for upload. At a provincial and district level, we encourage AIDS councils to print and distribute the documents.”

Six of nine provincial councils chaired by premiers

According to SANAC all provincial AIDS councils are chaired by the Premiers except for Gauteng, Western Cape and the Eastern Cape. “The Premier in North West is currently leading the reestablishment of the PCA in the province and wants the council re-established by 28 February 2019,” SANAC told Spotlight.

Activists have argued that provincial AIDS councils should be chaired by premiers so as to ensure high-level political buy-in into the AIDS response and to ensure the AIDS response involves not only the provincial department of health. “Provincial AIDS Councils have a huge role to play in coordinating the HIV response and from national to local level they have not been successful in doing this. Their functionality signifies a crisis as they are mostly measured by the number of meetings held instead of the production of fundamental plans and or commitments agreed on at meetings that will improve the response,” says Vuyokazi Gonyela, of the Treatment Action Campaign and SECTION27.

“The directive from the previous Deputy President, Cyril Ramaphosa, to the Premiers that requires the full resourcing of AIDS Councils has not been implemented to the same level across all provinces”, SANAC told Spotlight. “This hampers their capacity to function adequately, including the development and monitoring and evaluation of implementation of the PIPs and DIPs and the capacity building and inclusion of civil society sectors in subnational AIDS council structures.”

Capacity to draft good plans

One of the criticisms previously made in Spotlight of the NSP was that it does not provide enough guidance on how the plan is to be implemented. Spotlight understands that the process of developing provincial implementation plans has been difficult and slow. Various factors may have contributed to this, including a lack of political prioritisation, a lack of capacity in provincial AIDS councils, and a lack of funding.

SANAC did however step in to provide assistance to provinces. As SANAC explains: “A national steering committee was established to guide and review the draft multi-sectoral provincial and district implementation plans. This committee provided guidance and oversight, review and alignment roles in terms of their development. In addition a project management team was established within SANAC to provide technical assistance to provinces and districts by supporting the writing, facilitating workshops and calculating targets for the M&E plans.”

The NSP steering committee was comprised of a multi-sectoral team that included key donor representatives from PEPFAR and the Gates Foundation, explains SANAC. UNAIDS and the World Health Organization were also part of the NSP steering committee. Some funds were made available by donors for technical assistance to provinces and districts and some costing support currently for Mpumalanga.

We asked SANAC whether there were any common problems or difficulties in the development of specifically district implementation plans, since districts are often where the least data is available and the least planning capacity is in place. SANAC identified the following five issues:

  1. Availability of data for baselines was often a challenge – as information is not collected routinely or in the required disaggregation (especially for NSP goals 3,4,5).
  2. In addition, information on private sector and community responses was difficult to know/access if constituencies were not part of the AIDS council structures.
  3. Developing plans and targets at sub-national level which may have different targets from existing APPs (annual performance plans) was a challenge to overcome with government departments as it meant some activities in the PIPs and MDIPS would be included without having committed funding for implementation.
  4. Participation of civil society was correlated to the strength of the civil society leadership within the provincial aids council and their influence and role in the provincial steering committee.
  5. The contribution of NGOs to the achievement of targets is not always fully reflected

Municipal involvement

In one of its many aspirational undertakings, the NSP commits that “Steps will be taken to ensure that  municipal mayoral committees work together alongside  civil society and the private sector to institutionalise an inter-and multi-sectoral approach.” We asked SANAC to describe what steps have been taken in this regard.

SANAC explained that in partnership with SALGA and through the support of UNAIDS and IAPAC, they are implementing a fast track programme, which focuses on fast tracking local responses to HIV and TB, as well as strengthening local leadership for the local AIDS response. “19 high HIV/TB burden municipalities were identified and have also been assisted to identify their own fast track priorities. The municipalities are currently being supported to develop response plans linked to the PIPs and MDIPs.”

“During the December 2018 conference of the South African Local Government Association (SALGA) Members Assembly – which is the highest decision making body at SALGA – all mayors attending signed a Pledge to lead, institutionalise and support the AIDS response in their districts and local municipalities,” SANAC told Spotlight.

The above responses were sent to Spotlight by Kanya Ndaki on behalf of SANAC.

 

Is South Africa on track to meet NSP targets?

On World AIDS Day 2018 we assess how South Africa is faring against 10 key targets set in the National Strategic Plan (NSP) on HIV, TB and STIs 2017 – 2022. The current picture is mixed, with areas of impressive progress, such as HIV testing,  offset by some serious red flags, such as retention in care.

Of the 10 targets, we have assessed two as “Appears target will be reached”, two as “Target is within reach”, four as “Reaching the target will be difficult”, and two as “no sufficiently reliable figures”.

In future articles we will assess progress against other important issues in the NSP not covered here such as stigma, availability of data, and accountability in the public healthcare system. Accountability for the development of implementation plans and actual implementation is an ongoing problem with the NSP – although there are now signs that it may be addressed. The South African National AIDS Council (SANAC) reports that it is currently “developing an NSP Accountability framework and scorecard for accountability to achieve the goals of the NSP 2017-2022 for HIV, TB and STIs”.

“The accountability framework will assist in ensuring commitment to set priorities by individual role players in the current and subsequent NSPs,” SANAC explained in response to questions from Spotlight. “The Framework will nationally determine who should be accountable, for what, why and how. The development of the accountability framework will require extensive consultations to ensure ownership in the national response.”

SANAC also indicated that its mid-term review of the NSP will be published by August 2019. The mid-term review is expected to include up-to-date estimates for all the indicators covered in this article.

1.Reduce new HIV infections to less than 100 000 by 2022 (or 88 000 by 2020)

According to the Thembisa model (a sophisticated mathematical model of HIV in South Africa) there were around 275 000 new HIV infections in South Africa in 2017. This number is higher than the 231 000 estimated in the South African National HIV Prevalence, Incidence, Behaviour and Communication Survey 2017 (the HSRC survey).

Either way, given the current trajectory it seems highly unlikely that South Africa will get new infections down to below 100 000 by 2022. The Thembisa model projects that new infections will only drop to around 198 000  by 2022 (with the low end of the 95% confidence interval around this estimate at 184 000).

According to SANAC, the target for New infections has now changed to 88 000 by 2020, an even more ambitious, and arguably more unreachable, target.  “The change/adjustment has been made in line with  the global UN Prevention road map to accelerate HIV prevention strategies and reach national and global goals to end the threat of AIDS by 2030,” SANAC explained in a response to Spotlight. “The NSP Steering Committee agreed that the change in the targets according to the Prevention Revolution will be incorporated into the NSP M&E Plan (rather than in the NSP programme narrative).  The NSP M&E Plan will be available once approved by all SANAC structures.”

Verdict: Reaching the target will be difficult

2. Reduce annual new HIV infections in women and girls aged 15 to 24 to 30 000 by 2022

The targets section of the NSP lists the 30 000 target, while earlier in the NSP reference is made to bringing the infection rate in young women and girls down to less than 800 new infections per week (which works out to around 41 000 per year). Either way, it is widely agreed that reducing new infections in young women and girls is of critical importance.

According to the Thembisa model there was around 81 000 new infections in women and girls aged 15 to 24 in 2017 (this works out to just over 1 500 per week, rather than the more widely quoted 2 000 per week.). Thembisa projects annual infections in this group only dropping to around 58 000 by 2022 – almost double the target.

Verdict: Reaching the target will be difficult

3. The rate of mother-to-child transmission of HIV at 18 months must be below 2% by 2022

According to the Thembisa model the mother-to-child transmission (MTCT) rate was 4.81% in 2017. The model projects this dropping to around 3.5% by 2022. This number however includes transmission that occurs after 18 months, and the 18 month number might thus be very slightly lower. While there are other sources for MTCT rates, we prefer quoting the Thembisa estimates since the model factors in MTCT cases where the mother is not aware of her status – likely the majority of MTCT cases.

For the MTCT rate to come down further will require that a higher percentage of HIV-positive women of child-bearing age take antiretroviral therapy and achieve viral suppression. It will also require that we help more breastfeeding women who are not living with HIV to stay HIV negative – since women who become HIV-positive in the months they are breastfeeding account for a large proportion of onward transmission to children.

Verdict: Reaching the target will be difficult

Implement the 90-90-90 strategy for HIV

The 90-90-90 targets first proposed by UNAIDS were adopted in South Africa’s current NSP. There was previously some uncertainty regarding whether the three targets (described below) are to be met by 2020 (as per UNAIDS) or by 2022 (the end date of the NSP). Our understanding is that the agreed target date for South Africa is 2020.

4. 90% of all people living with HIV know their HIV status

The Thembisa model estimates that South Africa has already reached the first 90, with an estimated 90% of people living with HIV knowing their status in 2017. By contrast, the HSRC survey suggests that South Africa is just below the target, with around 85% of people aged 15-64 in South Africa who are living with HIV knowing their HIV status.

While South Africa appears to have done well on the first 90, maintaining a high score on the first 90 will require sustained testing efforts given that over 200 000 people are newly infected every year (and obviously do not know their status until testing). Thembisa projects that South Africa will reach around 92.4% by 2020.

Verdict: Appears target will be reached

5. 90% of all people with diagnosed HIV infection receive sustained antiretroviral therapy

According to the Thembisa model, South Africa is doing much poorer on the second 90, with only around 61.9% of people diagnosed with HIV receiving antiretroviral therapy in 2017. The HSRC survey paints a slightly rosier picture, estimating that around 71% of people aged 15-64 with diagnosed HIV infection are receiving sustained antiretroviral therapy. According to the Thembisa model projections South Africa will reach only around 70.4% by 2020.

South Africa’s poor performance on the second 90 is arguably the biggest red flag in the set of indicators examined in this article.

Verdict: Reaching the target will be difficult

6. 90% of all people receiving antiretroviral therapy are virally suppressed

In terms of the third 90, the Thembisa model estimates that around 77.8% of HIV positive people who were receiving treatment in 2017 were virally suppressed (the virus was so successfully suppressed in their bodies that it could not be detected with standard tests). Again the HSRC survey paints a more positive picture than Thembisa, estimating that 86% of people aged 15-64 receiving antiretroviral therapy have viral suppression.

Even though these figures are relatively high and may well go up with the introduction of dolutegravir-based antiretroviral therapy in South Africa, it is by no means certain that it will rise to 90 in the coming years and then be maintained above 90 (Thembisa projects around 86% by 2020).

Verdict: Target is within reach

A related indicator that does not directly form one of the three 90s, is the percentage of all people living with HIV who are virally suppressed (not just those on treatment as per the third 90). The Thembisa model estimates that 43.3% of all people living with HIV in South Africa were virally suppressed in 2017 (the implicit target based on the 90-90-90 target is 73%). Compelling scientific evidence shows that people who are virally suppressed do not transmit HIV.

Implement the 90-90-90 strategy for TB

As with HIV, TB also has a set of 90-90-90 targets that have been integrated into the NSP. Given that TB figures are harder to find than HIV figures, Spotlight twice wrote to the Department of Health to request the most recent estimates they have for these indicators. While the department did acknowledge our request, we did not receive any figures by the time of publishing. SANAC also failed to provide Spotlight with estimates regarding the 90-90-90 targets for TB.

Below we use the targets as they are presented in the final NSP. It is notable however that the 90-90-90 targets for TB has been taken to mean different things in different contexts. A recent Health Systems Trust publication describes the targets as “90% of people with TB will be screened, 90% will be initiated on  treatment, and 90% will successfully complete treatment” – which is not the same as the targets from the NSP used below. Where we found targets unclear we have attempted to clarify them with reference to the WHO’s version of the 90-90-90 targets for TB.

7. Find 90% of all TB cases and place them on appropriate treatment

The WHO’s version of this target is formulated as follows: “Reach at least 90% of all people with TB and place   all of them on appropriate therapy: first-line, second-line and preventive therapy, as required.”

In our understanding the indicator that most closely tracks whether we are finding people with TB is the case detection rate. According to figures available from the WHO’s TB data portal South Africa’s case detection rate was 68% in 2017. But the WHO also has the case detection rate at 68% for each of the last six years – something which does not inspire much confidence in this number. Neither the Department of Health or SANAC provided figures for this indicator despite various requests from Spotlight.

Recent testing campaigns in mining and other high-burden areas have been an important step in the right direction. Indications are that we are most likely still failing to diagnose many thousands of TB cases – one recent study found that most people with active TB who attend clinics in the Eastern Cape were not properly screened and tested. In addition to improving the quality of screening that should be happening at primary healthcare facilities, rapid and widespread implementation of the increased contact tracing and active-case-finding efforts described in the NSP will be critical if this target is to be met.

Verdict: No sufficiently reliable figures

8. Treat at least 90% of those diagnosed with DS TB and 75% of those with DR TB.

We understand “treat” here to refer to successful treatment as per the WHO version of this target. The WHO states it as follows: “Achieve at least 90% treatment success for all   people diagnosed with TB through affordable   treatment services, adherence to complete and   correct treatment, and social support.”

According to WHO figures around 82% of people with drug-sensitive TB and 55% of people with drug-resistant (MDR or Rifampicin Resistant) TB in South Africa were successfully treated in 2017. Neither the Department of Health or SANAC provided figures for this indicator despite various requests from Spotlight.

While reaching the 90% treatment success target for DS TB is within reach, reaching the target cannot be taken for granted given the many challenges facing the public healthcare system in South Africa. The introduction of better and less toxic treatments for drug-resistant forms of TB should help push the DR TB treatment success numbers up in the coming years.

Verdict: Target is within reach

9. Find at least 90% of the TB cases in key populations (the most vulnerable including people living with HIV with low CD4 counts, under-served, at-risk) and place them on appropriate treatment. Successfully

We have not been able to find reliable figures for this indicator. Neither the Department of Health or SANAC provided figures for this indicator despite various requests from Spotlight.

Verdict: No sufficiently reliable figures

10. Reduce TB incidence by at least 30%, from 834/100,000 population in 2015 to less than 584/100,000 by 2022

According to the 2018 World Health Organization (WHO) World TB Report, TB incidence in South Africa was 567 per 100 000 in 2017. At first glance it thus seems that we have already achieved the NSP target of less than 584 per 100 000. The reality is however more complicated. In 2018 the WHO made major adjustments to its TB estimates for South Africa. This included recalculating the estimate for 2015 as 759 per 100 000. A 30% reduction of this figure would set a target for 2022 of 531 per 100 000. The estimate of 567 per 100 000 is still above this level, but by 2022 South Africa will be well below this adjusted target if the downward trend suggested by the WHO’s figures  continues.

That said, there is significant uncertainty regarding TB incidence in South Africa and the picture might well change substantially as new information becomes available in the coming years. While the 567 per 100 000 figure may be the figure most often quoted, the WHO estimates that the real figure could be anywhere between 406 and 754 per 100 000.

Verdict: Appears target will be reached

Conclusion

  • Regarding HIV, the good news is that South Africa is doing well when it comes to HIV testing and where people living with HIV are on treatment the treatment is generally working and saving lives.
  • The bad news is that many people who are living with HIV are not on treatment – either never having started or having quit. Arguably the biggest challenge facing the public healthcare system today is to support many more people living with HIV to start and stay on treatment. Doing this in an often dysfunctional healthcare system will not be easy.
  • Regarding TB, the good news this year is that South Africa’s TB epidemic appears not to be quite as large as previously thought. TB rates appear to be coming down slowly, although it is hard to say with any certainty exactly how fast – chances are not fast enough.
  • The bad news is that even in 2018 many people in South Africa with TB do not get diagnosed. Again the available figures cannot be trusted, but even if the real figure is only half of the estimated 90 000 to 100 000, we are still facing a very serious situation.
  • Either way, it is clear that in addition to gathering better data on TB, as is being done with South Africa’s first TB prevalence survey, South Africa also needs better epidemiological models of TB along the lines of what we have for HIV.