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

By Julia Hill

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

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

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

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

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

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

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

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

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

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

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

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

[i] SANAC. Draft 2: South African National Strategic Plan on HIV, TB and STIs 2017-2022. Accessed 27 March 2017. Available at:

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

The Achilles Heel of the new NSP: Accountability and Equity

By Russell Rensburg

As we move towards the release of South Africa’s latest National Strategic Plan for HIV/AIDS, TB and STI’s it is important to celebrate the successes achieved since the end of AIDS denialism and the introduction of a revitalised AIDS response in 2006. Getting there and sustaining the response has required significant political will and herculean effort to harness the combined energy of all sectors. The results are undeniable: we have seen over 3 million people initiated on treatment (something almost inconceivable at the start of the journey), the near elimination of mother to child transmission.

Successes aside, significant challenges remain: our performance on TB is less than spectacular and the rate of new infections among key populations—such as young woman, men who have sex with men and commercial sex workers—remains unacceptably high.  We are almost there, but not quite.

The new NSP, which is deeply rooted in the global AIDS movement, heralds the end of AIDS by 2030. This belief is premised on the 90 90 90 strategy, which a lot like the offside rule in football, is deceptively simple but often difficult to explain. All things considered, the goal is to test 90 % of people, initiate 90% of those who test positive on treatment, and ensure that at least 90 % of those on treatment have suppressed viral loads, which will lower the risks of HIV transmission and prevent new infections. The idea is well articulated in the new NSP which proposes several innovative strategies to realise these goals. Some strategies target key populations, those directed at young women and girls, and strategies aimed at high transmission districts.

So, we have a good plan in hand? Not quite, we are afraid.

What makes a good plan is a plan that promotes equity and a plan that is informed by the people most affected. A good plan is a plan that we know will be implemented due to robust accountability mechanisms. These in our view are the Achilles’ heels of the new NSP.

Community consultation

There are complaints from different sectors as to the integrity of the consultation process. As with our own submission, there are allegations that the input of critical stakeholders, most especially community groups, have not been taken sufficiently into account. It would strengthen the plan’s standing if it could make fully transparent the consultation process and how key concerns have been addressed; or if not, why not.

Crumbling rural Building Blocks

Our second major concern regards the feasibility of the plan. Don’t get us wrong, we  am not advocating for a less ambitious plan – but for a realistic, equitable plan.  The World Health Organisation in their framework for strengthening health systems identifies six building blocks that are essential to a truly functional health system. These building blocks include leadership, human resources for health, service delivery platforms, sustainable financing, medical technologies and health information system. Looking at the plan through this lens, the feasibility of the new strategic plan is indeed exposed. To illustrate the challenge that lies ahead, it may be useful to reflect on a few of these concerning the goals presented in the NSP.

For instance, the NSP recommends a rapid expansion of the country’s treatment program by focusing on high-risk groups with the hope to more than double the number of people on treatment. Logically, it follows that the expansion in treatment will require concurrent investment in improving the functionality of the district health system. The reality, however, is that the NSP kicks off at a time when resources for health are diminishing, a weak currency is contributing to significant increases in drug prices, and there is a deepening crisis in human resources because resources are insufficient to meet basic HR needs. The system is close to collapse.

The picture is particularly bleak in rural areas where more than 40% of our population currently reside. Rural facilities, which have always struggled to attract health professionals, are further threatened by staffing moratoria. Infrastructure problems and neglect and the lack of investment in dignified and family-friendly accommodation for rural health care workers are other disenablers for the recruitment and retention of health care workers so critical to implementation of the NSP in the rural areas. Investment in HR is being channelled to larger urban centres, placing at risk millions of rural woman and girls who continued to be left behind.

The Role of SANAC

This brings us to the very critical role of the South African National AIDS Council (SANAC). Against the above context, it is obvious that SANAC needs to ensure that the NSP speaks to these rural realities for if not, it is a plan doomed to fail on Government’s mandate to plan and deliver for all who live in South Africa. Secondly, SANAC ought to advocate robustly for these rural realities to be turned around: for strong, firm building blocks to be put in place and for these to be protected in rural South Africa. Beyond more nurses, doctors and pharmacists in rural areas, what we need are sufficient community health workers to reach the most impoverished communities at household level; and Clinical Associates to upscale the Medical Male Circumcision drive and to support the minimal numbers of doctors in many small rural hospitals at the brink of collapse.

While the NSP continues to advocate for a multi-sectoral response that includes all stakeholders, it provides little guidance on how the various sectors will interact nor does it provide an accountability framework against which the custodians of SANAC can be assessed. This is particularly important when you consider that beyond the development of the NSP, SANAC has little influence on how the strategy is implemented. What is required is a strong SANAC that has the support of all stakeholders. A strong SANAC that can lead, direct and accelerate the response. We fear SANAC in its current state does not meet this muster.

To ensure the success of this NSP urgent attention to the governance and accountability frameworks are needed. As a start, the current leadership vacuum has to be addressed. Secondly, there should be a robust review of existing governance structures at national provincial and district levels. Finally, it is time for fresh elections of all SANAC office bearers, ensuring that we have the right people in place with the courage and commitment to coordinate and oversee the implementation of an equitable NSP that brings quality HIV and TB services to all.

Russell Rensburg – RHAP Programme Manager: Health Systems and Policy

Prisons and the New NSP: Nobody left behind?

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

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

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

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

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

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

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

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

So, what should the targets be?

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

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

[1] Sonke Gender Justice

[2] Zonk’izizwe Odds Development

HIV docs win quack HIV gel case

By Lauren Jankelowitz, CEO SA HIV Clinicians Society

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

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

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

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

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

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

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


Sex Work and the new NSP

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

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

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

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

Meme produced by Zia Wasserman

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

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

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

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

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


[1] Sonke Gender Justice

[2] SANAC Sex Work Sector leader

[3] SANAC Sex Work Sector leader


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

By Sasha Stevenson

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

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

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

Focus on prevention

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

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

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

Important targets missing

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

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

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

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

By Marcus Low and Ntsiki Mpulo

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

  A history of questionable tenders

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

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

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

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

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

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


Correction and apology

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

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

Press Release

By Medecins Sans Frontieres

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

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

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

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

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

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

A note on research methodology:

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

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

This Press Release was published at MSF

New TB and HIV science from CROI 2017

By Marcus Low

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

An XDR-TB breakthrough and more TB news

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

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

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

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

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

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

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

Some new ARVs and ARV combinations

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

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

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

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

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

Some recommended presentations you can watch online

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

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

NSP Draft 1: Good Enough?

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


Many positives

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

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

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

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

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


Where draft 1 falls short

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

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

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

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

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

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

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

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

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