A print and online publication monitoring South Africa's response to TB and HIV, the state of our health systems and the people that use it and keep it going.
Note: This is the editorial from a special print edition of Spotlight guest-edited by young people.
Every week in South Africa, around two thousand young women and girls
Thuthukile Mbatha, guest editor on this special youth edition of Spotlight
between the ages of 15 and 24 become HIV positive. More than one in ten women and girls in this age group are living with HIV.
On the back of these shocking statistics, many targeted programmes have
been launched in South Africa. Whether these programmes are what is needed, and whether the state is fulfilling its duties to young women and girls, are key questions we discuss in this youth-focused and youth-edited issue of Spotlight.
On paper, the rights of women and girls in South Africa – or that subset of rights we call sexual and reproductive health and rights (SRHR) – are relatively well protected. The Constitution enshrines the right to bodily integrity, the right to access healthcare services, the right to education, the right to dignity, and the right not to be discriminated against.
Specific laws such as the Sexual Offences Act and the Choice on Termination of Pregnancy Act provide specific protections and affirm specific rights. Policies such as the Department of Basic Education National Policy on HIV, STIs and TB, and strategies such as the National Strategic Plan on HIV, TB and STIs 2017-2022 further guide the implementation of state programmes aimed at the realisation of these rights.
And yet, despite this generally enabling legal framework, the reality in South Africa is that most young women – and young men, for that matter – grow up poor, and with limited education. Only around 40% of young people matriculate by age 20. Around two thirds of youth 25 and younger are unemployed (under the expanded definition that includes people who have stopped looking for work).
Most girls grow up in highly patriarchal communities, often communities with high rates of gender-based violence. The criminal justice system is often unresponsive and downright dysfunctional when it comes to prosecuting gender-based violence.
Doctors without Borders (MSF) estimates that one in four women in the Rustenburg area has been raped at least once in their lives, and that the vast majority of them did not tell a healthcare worker about the rape. Reliable national figures are hard to find, but it seems many rapes are not reported; and even when they are, dockets often go missing, or police bungle the investigation.
The 2014 Khayelitsha Commission of Inquiry, led by Advocate Vusi Pikoli and Judge Kate O’Regan, grew out of frustration with exactly this kind of dysfunction. Despite the excellent work of the commission and its impressive report, four years later the criminal justice system remains severely dysfunctional in areas where mainly poor people live.
It is within this dire socio-economic context that we should consider that many women and girls struggle to access the tools that may protect them against unwanted pregnancy and HIV infection. Making condoms and other contraceptives easily available to learners remains taboo in many schools.
Youth-friendly healthcare services remain the exception to the rule. While we know that young women at high risk of becoming HIV positive can benefit from oral pre-exposure prophylaxis (PrEP), the rollout of PrEP to young women has been stalled by a lack of political will, and an overly cautious public-health approach that pays scant regard to the rights of young women.
It is not surprising that in such socio-economic conditions, and with such
Teenage girls on their way to school in Soweto, Gauteng. The best time to teach young people about sexual and reproductive health is when they are at school. (Image: Rosa Irene Betancourt, Alamy)
limited access to available prevention methods, as many as six per cent of girls aged 15 to 19 fall pregnant every year – according to one report, that amounted to around 15 000 pregnancies among girls in school in 2015. The two thousand new HIV infections in girls aged 15 to 24 every week are also not all that surprising, given the context sketched above.
Though the personal cost to young women is clearly very high, there is surely also a high societal cost. While most women living with HIV can live perfectly normal lives thanks to antiretroviral therapy, the infection does still require lifelong treatment and care – which come at significant cost, either to the state or to individuals. The minority of women who develop serious secondary infections such as tuberculosis or crypto will face additional costs. Possibly even more disruptive to a young woman’s prospects is an unwanted pregnancy – something that could mean an end to one’s formal education, or which could make it harder to hold down a job.
Together, unwanted pregnancies and HIV infection constitute a kind of poverty trap: poor people are more likely to experience unwanted pregnancies and to contract HIV, and this then makes them and their children more likely to be poor in future. The struggle for SRHR is not a struggle for some abstract ideal, but a struggle to help women break out of this cycle of poverty and disease.
Faced with such a complex set of socio-economic factors, one should be sceptical of supposed quick fixes for the dual problems of HIV and unwanted pregnancy. For example, while anti-sugar daddy campaigns might provide convenient scapegoats, there are real questions as to whether such campaigns will make any difference without addressing the underlying social and economic realities.
Fortunately, however, we do have programmes that are approaching these complex issues with seriousness, and a more sophisticated understanding of the complexities involved. Perhaps foremost among youth-focused interventions is the innovative work done by the Desmond Tutu Foundation in and around Cape Town – see our article on page 35 about their youth-friendly clinics, the Tutu truck, and their trial of conditional cash transfers.
Confirming what works in programmes such as that of the Desmond Tutu Foundation and then scaling that up, as well as addressing the ongoing crisis of South Africa’s dysfunctional education system, must be a national priority in the coming years. In his response to replies to the State of the Nation Address in February, new South African President Cyril Ramaphosa said that “we must confront the social and economic factors that prevent young women from completing school, entering higher education and graduating”, and that “we must all work together to tackle the chauvinism experienced by women in the workplace and other social settings”.
The president identified the She Conquers campaign as government’s key programme in this regard (see our article on DREAMS and She Conquers on page 22). While such big programmes are welcome, as are the donor dollars that often fund them, there are questions to be asked as to whether these programmes really meet the needs of young women.
But along with these longer-term and overarching solutions, there are things that can be done right now – such as ensuring that condoms are freely available at all schools, and dramatically expanding access to PrEP. Whether these interventions will be implemented is mainly a question of political will. And whether the political will is there to follow through on President Ramaphosa’s welcome words on the role of women in our society remains an open question.
Ultimately, we can measure the state and President Ramaphosa’s response to the dual crises of HIV and unwanted pregnancy by the answers to a few simple questions:
Do all young women and girls in South Africa have easy access to comprehensive sex education?
Do all young women and girls in South Africa have easy access to condoms and other forms of contraception?
Do all young women and girls in South Africa have easy access to professional termination of pregnancy services?
Do all young women and girls in South Africa at significant risk of contracting HIV have easy access to pre-exposure prophylaxis (PrEP)?
Do all young women and girls in South Africa have access to high-quality secondary and tertiary education?
Do all young women and girls in South Africa have safe and easy access to appropriate police and medical services in cases of rape or other forms of sexual violence?
At present, the state is failing abysmally at most of these measures. Look at the lives of young women in Khayelitsha, in Rustenburg, in Lusikisiki, in Ermelo. It is there in our dilapidated schools and in our dangerous and poorly-lit streets, for all to see.
While this remains the case, all the positive rhetoric and advertising campaigns about empowering young women will ring hollow. The large-scale infringement of the sexual and reproductive rights of young women and girls in South Africa will continue; and the poverty trap fuelled by HIV and unwanted pregnancy will ride roughshod over our futures.
Thuthukile Mbatha has been a researcher at SECTION27 since 8 January 2014.
“In a sector that is scarce and expensive to begin with, corruption can mean the difference between life and death.” – Viva Dadwal, Deputy Editor of Globalisation and Health
“Making corruption a research subject and a responsibility of health systems
“All constitutional obligations must be performed diligently and without delay.” Section27
researchers in South Africa and elsewhere allows us to name the problem, measure it, and develop and test ideas about how to address it. Such research also allows the global community of health system researchers to contribute towards improved efficiency, effectiveness and social accountability of health systems.” – L Rispel et al, ‘Exporting corruption in the South African health sector’, Health Policy and Planning, 2015, 1–11
In 2017, a debate raged at the Treatment Action Campaign’s (TAC) National Congress about how to respond to corruption across the country. As the levels of scandal and shock around President Jacob Zuma’s behaviour have risen, TAC’s allies have often called on it to take to the streets and join organisations such as the Save South Africa campaign that are calling for Zuma to step down.
However, within TAC, some activists have asked: ‘What does health have to do with party politics?’ They argue that TAC should stick to its mission – the right to health – and avoid being caught in a morass of political mudslinging. There is a level of truth in this argument; however, the very birth of organisations such as TAC was in response to a failing political strategy, government and healthcare service, responsible for the deaths of millions of people when they refused to provide adequate treatment for patients with HIV.
Our struggle for the right to health has always been political, and will always remain political. Everywhere in the world, the quality of health has everything to do with politics. South Africa is no exception.
Under apartheid, the majority of the population were denied access to quality health services. When apartheid ended in 1994 there were gross inequalities in health outcomes. That is why “access to health care services” was included as a right for “everyone” in our Constitution.
Today, the Constitution is our supreme law. But South Africa’s Constitution started its life as a political agreement between parties to mark the dawn of democracy. The Constitution is like a finely woven tapestry; it has many threads and many strands. Each one weaves in and out of another. Looked at from afar, they compose a picture that promises everyone in our country equality, dignity and social justice.
However, very few of the threads can exist independently. The right of access
to healthcare services, for example, cannot be realised in a silo. It is dependent in many ways on good governance, accountability, and a government that is diligent in the performance of public functions. These too are parts of the Constitution. For example, Section 195 of the Constitution says that:
“Public administration must be governed by the democratic values and principles enshrined in the Constitution, including the following principles:
A high standard of professional ethics must be promoted and maintained.
Efficient, economic and effective use of resources must be promoted.
Public administration must be development-oriented.
Services must be provided impartially, fairly, equitably and without bias.
People’s needs must be responded to, and the public must be encouraged to participate in policy-making.
Public administration must be accountable.
Transparency must be fostered by providing the public with timely, accessible and accurate information.”
Section 237 says: “All constitutional obligations must be performed diligently and without delay.” What this means is that where government is bad, access to health services fails. Without access to healthcare services, people’s health will deteriorate.
Very few people now deny that we have a very bad government. In the last two years our country has been in the throes of a crisis caused by what is now known as ‘state capture’. Theft by people such as the Gupta family has been facilitated by President Zuma and other Cabinet members.
Unfortunately, the story of state capture has been told in a one-sided way. Most of the focus has been on institutions such as SARS, Eskom, SAA, PRASA and now the Treasury. But with the combined budget of the national and provincial health departments now around R190 billion per year, the health system also offers rich pickings for those intent on theft. In this context, the capture of big health tenders, ambulances and institutions such as hospitals is also common.
How corruption manifests itself in the healthcare system
Corruption is a serious threat to the majority of the population who rely on public hospitals and clinics. Not only does it make it difficult for them to receive proper treatment when they are vulnerable and cannot pay a bribe, but when funds, medicines and equipment are stolen or misused by officials, it can have devastating effects on communities at large.
Type of corruption
Examples
Informal payments
Unofficial payments given to healthcare providers which are more than the official cost of a service, or for services that are supposed to be free
Selling of government posts
A senior official in a position of power demands a payment from government agents to secure or keep their positions
Moonlighting
Healthcare professionals abusing leave policies or conducting their private practice during work hours
Bribes
Money or something of value promised or given in exchange for an official action
Procurement corruption
Includes many types of abuse, such as bribes, kickbacks, fraudulent invoicing, collusion among suppliers, failure to audit performance on contracts, etc.
Theft or misuse of property
Theft or unlawful use of property such as medicines, equipment or vehicles for personal use, for use in a private medical practice, or for resale or renting out
Fraud
Includes false invoicing, ‘ghost’ patients or services (billing for patients who do not actually exist or services that were not rendered), and diversion of funds into private bank accounts
Embezzlement of funds
Officials, healthcare providers or other individuals stealing or deliberately diverting national funds allocated for healthcare services
Nepotism
Employment opportunities are given to friends and family members based on personal connections instead of merit
Improper healthcare accreditation
Individuals or groups approve a healthcare professional’s qualifications due to personal or political connections with the professional or the receipt of a bribe
Inappropriate healthcare facility certification
Officials provide unwarranted certification to a healthcare facility, due to personal or political connections with the facility operators or the receipt of a bribe
Inappropriate healthcare training facility certification
Officials provide unwarranted certification to a healthcare training facility, due to personal or political connections with the college owners or the receipt of a bribe
Source: Corruption Watch/SECTION27
However, while we can point to specific instances of corruption in the health system (as I do below), there has not been enough investigation of the overall levels of corruption – or its impact. But it is large. In 2011, for example, SECTION27 and Corruption Watch commissioned research (Corruption in the South African Health Sector, Benguela) that concluded that up to R20 billion a year was being lost to corruption in the public and private health sector. It warned that: “If the current corruption risk remains and is not appropriately addressed, it will inflate the cost of health care, limit access to services, and negatively impact on the quality of care.”
More recently, research by Laetitia Rispel and others recorded that the majority of people they interviewed “were of the opinion that corruption is pervasive, particularly in the public health sector. For example, commenting on corruption in the public sector, respondents note that it is ‘rampant’ (Private Hospital Manager) and has ‘reached uncontrollable levels’ (Provincial Department of Health Director).”
Rispel et al attempt to quantify the cost of corruption in health by studying levels of “irregular expenditure” that are recorded in reports of the Auditor General. Irregular expenditure is money that is spent without proper authorisation and outside of the legal framework. It is not automatically corrupt – but a very large part of it is. They found, for example, that in four financial years between 2009 and 2013, the total amount of irregular expenditure within provincial health departments was over R24 billion.
This is a huge amount of money! It is the equivalent of the annual budget for the HIV conditional grant, or twice the amount currently spent on Emergency Medical Services (which we know to be woefully inadequate).
Below are some examples of corruption that have been confronted by SECTION27 and TAC.
Gauteng Health Department: a rogue unit
The Gauteng Health Department is possibly one of the most corrupt provincial health departments in the country. Its irregular expenditure for the period of 2010/2011 to 2016/2017 was calculated by the Auditor General to be a massive R6.9-billion.
The rot appears to have started about ten years ago, with then-MEC for Health Brian Hlongwa. Hlongwa is facing charges of corruption. Due to the capture and collapse of our criminal justice system, Hlongwa has not yet faced the consequences of his corrupt behaviour. Hlongwa is currently facing charges of corruption and money laundering relating to two tenders worth R1.4-billion. It is alleged that in 2007, Hlongwa fraudulently rigged two tenders so that they could be awarded to 3P Consulting and Boaki Consortium, and that he received various kickbacks in return. 3P was initially paid R120 million to establish a project management unit for the department, but they ended up earning R392 million by the time their contract was cancelled in 2009. Boaki was awarded a tender worth R1.2 billion to set up a health information and health records system. By the time their contract was cancelled in 2008, they had been paid R400 million, but no infrastructure had been set up.
In 2010, the Special Investigating Unit (SIU) was given a mandate to investigate these matters by a Presidential Proclamation. It has been seven years, and still no-one has been brought to book. Hlongwa is currently serving as the ANC Chief Whip in the Gauteng Legislature, and has continued to operate with impunity. He recently noted: “I was once a minister, an MEC of health from 2006 to 2009 in Gauteng. There is a cloud hanging over my head. I am supposed to be somebody who is corrupt as well. It has been nine years. But there is no case.” Looking at the current state of affairs and the political puppets in charge of the National Prosecuting Authority, it seems unlikely that Hlongwa will be brought to justice for crippling the GDoH.
In 2009 Hlongwa was replaced by disgraced MEC Qedani Mahlangu. Between the two of them they have managed to bankrupt the GDoH.
As a result the price of corruption is being felt in collapsing services; community health workers go unpaid because of corruption; babies die or are disabled because there are not enough midwives and nurses; people acquire TB and MDR-TB because there are no systems for infection control. As we saw recently, hospitals treat dead bodies like the carcasses of animals.
The worst example of the results of corruption is the Life Esidimeni disaster, which caused the death of at least 143 mental-health patients. The arbitration currently under way aims to find the truth. At this point, the real reasons patients were moved out of Life Esidimeni and dumped into unregistered ‘NGOs’ where most of them died must still come out. But some of the evidence seems to suggest that senior officials such as Dr Makgabo Manamela, the head of mental-health services, may have had corrupt relationships with some of the ‘NGOs’ to which they sent patients.
These ‘NGOs’ profited from patients the GDoH sold them to care for, several of them making hundreds of thousands of rands. There is also some evidence that they benefited from the patients’ disability grants and life insurance.
But Life Esidimeni is not just about a few corrupt individuals. The Gauteng healthcare system has been corrupted. Instead of being managed as a system for health care, it is seen by politicians and public servants as a get-rich-quick scheme. And the most senior officials in government – like president Zuma – turn a blind eye to this, because the individuals involved are usually part of a political faction whose support they depend upon.
One significant casualty of corruption in the GDoH is the National Health Laboratory Services (NHLS). The NHLS can be thought of as being the arteries of the public-health system, and particularly of the response to HIV and TB. It is like the Eskom of health. Controlling AIDS and TB is totally dependent on laboratory tests for HIV such as CD4 count and viral load, and on technologies such as GeneExpert. However, the GDoH owes over R2.5 billion to the NHLS… but says it can’t afford to pay its bill.
To make matters worse, people who work in the NHLS allege that there is rampant corruption and mismanagement by senior officials. In the latest financial year, the NHLS incurred nearly R1 billion in irregular expenditure. If the NHLS collapses as a result of its burden of debt and corruption, large parts of the health system will go under with it.
Corruption in the Free State Department of Health
But Gauteng is not the only provincial health system where thieves rule. For several years, TAC and SECTION27 have tried to spotlight corruption in the Free State Department of Health. Dr Benny Malakoane, who was the MEC for health between March 2013 and October 2016, had already learnt his thieving ways by the time he became MEC. He is on trial for charges of corruption related to his past employment, but every time he is due in court he and his accused seem able to engineer a postponement.
In 2015 a whistle-blower contacted SECTION27 to tell us that Benny Malakoane had introduced a programme for unproven stem-cell treatment of geriatric patients at two hospitals in Bloemfontein. The programme was costing the Free State DoH R3 million a month, and would run for three years. It was alleged that Malakoane had a direct relationship with the company that was providing the ‘service’. Fortunately, on the basis of the information provided by the whistle-blower SECTION27 was able to inform the Director General in the DoH, who quickly investigated and then closed the programme down. Tens of millions of rands were saved from theft.
Theft of medicines
As we know, South Africa now has the biggest anti-retroviral (ARV) programme in the world. Billions of rands are spent on medicines every year. This is also an area vulnerable to corruption. For example, when the issue of major stock-outs first became a concern in 2013, one of the reasons was rampant theft at provincial medicine depots such as that in Umtata. A report produced by TAC and MSF at the time noted that at any one time, the Umtata depot would have medicines in stock worth up to R40 million – and noted how much of this was at risk of being stolen. In recent years – in part because of TAC and SECTION27’s activism, and the monitoring of the Stop StockOuts Project (SSP) – the management of provincial medicine depots has improved, reducing the risk of corruption.
Conclusion: AIDS activists must be anti-corruption and social justice activists!
The examples I have given above are reasons that AIDS activists must also be political and social justice activists.
Politicians are the gatekeepers of the resources allocated to and spent on healthcare services. When their greed supersedes the needs of the people, and results in the crippling of our health institutions – and in many instances, leads to the deaths of our most vulnerable – we must then admit that we are indeed a sick society. The president might not have had direct involvement in cases such as Life Esidemeni and the crumbling of the NHLS; but the system of thievery that festered under his leadership allows for a Qedani Mahlangu, and makes the call for his removal all the stronger.
The fact that access to healthcare services is a constitutional right does not mean we should think that health is automatically protected. It is contested by the everyday behaviour of officials who steal from funds intended to realise that right. If we don’t root out corruption in the public-health system, the health system will collapse. According to Rispel and others: “Poor governance and corruption share a reciprocal relationship and negatively impact on the morale of healthcare providers, the majority of whom are committed to service excellence”. They go on to say that:
“Although legislation seems adequate, initiatives by government to identify and ameliorate vulnerabilities to corruption within the health sector need to be further developed. Proactive mechanisms to detect corruption and the enforcement of negative sanctions against those found guilty of corruption are important interventions to create disincentives for engaging in corrupt activity.”
Unfortunately, it doesn’t seem that the national and provincial health departments take corruption seriously, or that it is being seriously investigated by bodies such as the Hawks or the NPA. Their responses are usually reactive to reports by civil society and the media, rather than part of a proactive plan to root out corruption in the health sector. Until there is political commitment to really fighting corruption, civil society will have to fill the gap by exposing and reporting corruption.
On a day-to-day basis this requires strengthening of community oversight through participation in hospital boards and clinic committees. It means organisations that monitor health-service delivery (such as the Stop Stock-outs Project) are vital. Re-establishing bodies such as the Budget, Expenditure and Monitoring Forum (BEMF) is also essential.
Civil society needs to constantly monitor institutions such as SANAC, from where there have been reports of corruption involving civil society leaders. We also need to investigate tenders worth hundreds of millions of rands, such as that given to the controversial company Sadmon for a health communications strategy that is mostly invisible and ineffective.
Finally, on a political level it means that TAC should join forces with those challenging corruption at the highest level, including that of the President and the ruling party.
If state capture and corruption is not investigated and punished, South Africa will end up with a public-health system as broken and dysfunctional as that in other African and Asian countries. That, surely, is something we must do everything we can to avoid.
Dr Sandile Buthelezi was recently appointed as the new head (CEO) of the South African National AIDS Council. His appointment follows the suspicious non-renewal of the previous CEO’s contract Dr Fareed Abdullah and unsuccessful attempts to lure Eastern Cape head of health Dr Thobile Mbengashe to the post. The success of the new National Strategic Plan implementation and the long-term survival of a robust, relevant and ethical SA National AIDS Council will depend on the new CEO. Spotlight put a range of questions to Buthelezi regarding his involvement in the Tara KLamp debacle, the persecution of doctors at Manguzi Hospital in 2008, and allegations of corruption.
Dr Sandile Buthelezi was recently appointed as the new Chief Executive Officer (CEO) of the South African National AIDS Council (SANAC). Buthelezi’s appointment comes as a surprise, given that it was expected that the position would go to Thobile Mbengashe – who Spotlight understood to have been the preferred candidate of key members of the SANAC board of trustees. However, we understand the Eastern Cape made Mbengashe a counter offer, which made it hard for him to leave for the SANAC job.
Buthelezi’s appointment also surprised activists who are concerned about his involvement in the rollout of an unsafe circumcision device (the Tara KLamp) in Kwazulu-Natal and the persecution of doctors at Manguzi Hospital in 2008. The doctors were providing dual antiretroviral therapy to pregnant women with HIV. At the time providing dual therapy was deemed to be against the government policy of AIDS denialist President Thabo Mbeki and Health Minister Manto Tshabalala-Msimang.
Highly charged atmosphere
Buthelezi is stepping into a highly charged atmosphere with recent news reports describing SANAC as being in disarray and various civil society organisations considering a withdrawal from SANAC. Some of the concerns regarding governance at SANAC relate to the process of appointing a new CEO. For reasons that have not yet been explained, an initial recruitment process was stopped halfway and the post was readvertised early this year. In February this year the trustees, then led by Dr Gwen Ramakgopa, who is now Gauteng MEC for health, announced that Dr Malega Constance Kganakga had been appointed acting CEO for three months while interviews were being completed. It would be another four months (after those initial three months) before Buthelezi took office at the beginning of September 2017.
The board controversially decided in February not to extend the CEO contract of Dr Fareed Abdullah or to allow him to continue as interim CEO. This move was met with widespread condemnation from activists and the Democratic Alliance. Abdullah is credited by some for transforming SANAC into an independent Council that for the first time had five straight years of clean audits and better checks and balances in place to ensure good governance.
Buthelezi told Spotlight he wishes to thank his predecessors “for building SANAC into the credible organization that it is”. “SANAC operates against the backdrop of people’s perception of government institutions and hence our first duty will be demonstrating good corporate governance,” says Buthelezi. “This is a critical obligation that we at SANAC need to uphold, and it will be the hallmark of my tenure.
Persecution of Manguzi doctors
In 2008 Buthelezi was head of HIV and AIDS in KwaZulu-Natal where he played a role in the persecution of doctors at Manguzi Hospital. Dr Colin Pfaff, acting medical manager at Manguzi Hospital at the time, and colleagues broke rank from official Department of Health policy to introduce dual-therapy treatment for HIV-positive pregnant women at a time when official government policy was to provide only monotherapy.
The science at the time was clear that dual therapy was superior to monotherapy in reducing mother-to-child transmission of HIV. Pfaff raised funds from donors to pay for the introduction of dual therapy at Manguzi. Pfaff was suspended for this and faced disciplinary action – that was later withdrawn.
Buthelezi admits he worked closely with doctors in the district at the time and adds: “I believe it is unfair to expect a junior official to act out of sync with national government policy.” At the time Buthelezi was quoted making a similar argument in the New York Times saying “I am wary of us undermining national just because of what other provinces are doing (referring to the rollout of dual therapy in the Western Cape)”. At the time Buthelezi was working under controversial KwaZulu-Natal MEC for Health Peggy Nkonyeni – who was a close ally of AIDS denialist Health Minister Dr Manto Tshabalala-Msimang.
No regrets regarding Tara KLamp
In 2010, Two years after the Manguzi scandal, with government-sanctioned AIDS denialism having meanwhile “ended” under the leadership of first Health Minister Barbara Hogan and then her successor Dr Aaron Motsoaledi, the Kwazulu-Natal Department of Health was involved in another high-profile controversy. The department started providing circumcisions with an unsafe plastic circumcision device called the Tara KLamp. The device caused a number of serious injuries and eventually became the subject of a Treatment Action Campaign complaint to the Public Protector. Questions about alleged kickbacks relating to the procurement of the Tara KLamp remain unresolved seven years later.
While Buthelezi wrote letters and was quoted in the media in relation to the Manguzi scandal, it appears he was less directly involved with the Tara KLamp rollout. Another Sandile, Sandile Tshablalala, was in charge of the circumcision programme in the province. As with Manguzi, the Tara KLamp had high-profile political backing this time in the form of MEC for Health Sibongiseni Dhlomo, then Premier of Kwazulu-Natal Zweli Mkhize, and King Goodwil Zwelithini.
Yet, as head of HIV and AIDS in the province Buthelezi would have almost certainly been party to decisions made regarding the rollout of the Tara KLamp. We can find no evidence that he opposed the rollout in any way – this while he admits involvement in the circumcision programme. “I am proud of my contribution to the roll-out of medical male circumcision in KwaZulu-Natal,” says Buthelezi, wwhich included (…) Rallying all stakeholders including His Majesty, in advocating for MMC.”
“The implementation of medical male circumcision in the province remains a watershed moment in the country’s HIV response,” he says. “A province where circumcision was not routinely practised, took the lead in including medical male circumcision as part of a combined package of prevention methods. This is a significant achievement and I have no regrets.”
Corruption allegations
In late 2010 Buthelezi left the KZN Department of Health. A source suggested to Spotlight that Buthelezi’s departure was related to allegations that he awarded a catering contract to a family member.
While Buthelezi does not dispute that the allegations were made, he insists that they are baseless and untested. “The issue relates to a tender that was dealt with at a district where I was not involved in any of the bid committees,” he says. “I only received paper work to approve payment after the district committees and management had signed that they received the goods and/or services.”
Buthelezi says he left the KZN Department of Health because he received a better job offer and that he continued to have a good relationship with the department after he left. He took up a position as country director of ICAP, a University of Columbia initiative to strengthen health systems around the world. From there he left to work at HLSP- Mott MacDonald, as senior technical lead with the health sector consultancy. In 2014 he was reappointed to the ICAP role.
“He will have to build trust”
Several of Buthelezi’s previous colleagues, members of the SANAC board and people he had professional dealings with at his previous positions were contacted to comment on Buthelezi’s appointment. Some didn’t respond and some declined to comment on record. Professor Wafaa El-Sadr the director of ICAP, based in New York, did comment, saying that in the last three years that he reported to her that Buthelezi did meet specific implementation targets and successfully built important linkages and partnerships within his team. “He had a good understanding of the lay of the land. He had the experience and he did understand South African realities.
“The challenges for a strong SANAC will be about never losing sight of the core of what we do and that is to change the lives of people. He will have to build trust and be able to bring along with him even those people who are not supportive of him,” says El-Sadr.
“He was on the wrong side”
Anele Yawa, General Secretary of the Treatment Action Campaign, says that Buthelezi’s past cannot be ignored. “He was on the wrong side – he was an AIDS denialist, like Manto Tshabalala-Msimang and Thabo Mbeki, he wasn’t for the people,” he says.
“We don’t just want a warm body in the position of CEO and we still don’t know what happened with the process of appointing a new CEO,” says Yawa. “Buthelezi must be able to add value. He can start with audits of the organisations that are part of the SANAC civil society sector – he can even start with TAC, this will make it clear who should be part of SANAC and who should not.”
Yawa says SANAC has to return to the grassroots – the face of HIV/AIDS, not be fixated on “meetings and conferences held in fancy hotels”.
Even with his outspoken criticism, Yawa says that for now TAC remains committed to staying within SANAC. “We want to fix the problems because we have come a long way. But when we ring the bell Buthelezi must come. We give him three months to get his house in order,” says Yawa.
“I believe in service”
Buthelezi says his vision for SANAC will become clearer once he settles into the role. But he says he’s up to the job. “I come from rural eShowe where humility, respect and ubuntu define human relations,” he says. “We’ve fought HIV for too long – we must see results.”
“I believe in service and I am results-driven and work well with teams. I hope we shall be an organisation that listen actively, prioritises what’s important, adapts readily and empowers others.”
Delays at the South African National AIDS Council (SANAC) has meant that the new NSP (National Strategic Plan) will now only be ready in March 2017. While the delay itself is not of any great concern, the kind of plan that will be produced by an unsettled SANAC and a weakened, unrepresentative civil society is concerning and brings into question the very idea of SANAC and the NSP. Already we are hearing rumours of a back-track on various things contained in draft zero of the NSP – including a back-track on the recommendation to decriminalize sex work.
There is a risk that over the next three months an NSP will take shape that will lack many of the targets and deadlines it needs to make an impact. It is understandable that government doesn’t want what they see as an external plan to interfere with their internal plans. But civil society should not accept this. We need leaders who can stand up to government, when needed work with them, but ultimately demand we do better on key issues such as sex work, condoms in schools, active case-finding for TB and community healthcare workers. Unfortunately, from what we’re hearing, civil society is capitulating on these issues without much of a fight.
Even though many critical issues will be mentioned in the eventual NSP, mere mentions are not enough. We need plans, timelines and budgets. We need an NSP that is highly focused and concrete. The decriminalization of sex work, for example, has been on the agenda for years – but simply having it on the agenda is not enough. We need to have a roadmap from where we are now to an actual amendment in our laws. Without such a roadmap, we do not in fact have a plan.
Similarly, setting targets for providing more people with HIV treatment and helping people adhere to treatment is all good and well, but targets are not a plan. How do we improve treatment adherence? Do we need to employ more community healthcare workers to provide adherence support and to trace patients who default? We think we should. How do we provide differentiated care through adherence clubs, if we don’t pay people to run those adherence clubs? How do we ensure there are no drug stockouts which endanger trust in the health system. How do we build a Medicines Control Council that can cope with the workload or registering new drugs and investigation unlawful treatment and activities? These are the issues the NSP must map out in detail and force action on. It should make the case so clearly and convincingly that the Department of Health and treasury has no option but to fund it.
In the same way, we can say whatever nice things we wish about active case-finding for TB (possibly the most critical TB intervention we are not implementing), but if we don’t map out what that means in the real world then it will be just an another aspirational target. The NSP has to make it explicit that we can’t do active case-finding without people and that we need to train and pay people to start doing active case-finding. In two words Community Health Workers.
Another critical area on which the new NSP must move the dial is HIV and pregnancy prevention in schools. We need a programme that is explicit about the right to comprehensive sex education and the right to access condoms – the latter being a right in terms of the right to access healthcare services. But again there appears to be no clear plan on the table on how we get from here to there.
If the new NSP doesn’t deliver on these critical issues with detailed timelines and budgets then it will be hard for us to support it. As has become clear in recent issues of Spotlight (previously NSP Review), our HIV and TB response is at code red. Our public healthcare system is in crisis. We need a plan that deals with this emergency seriously and based on the best available evidence. Anything less is not good enough.
A difficult political environment
The development of the new NSP comes at a very difficult time in South Africa’s history. Amid the Public Protector’s State Capture Report, the various scandals relating to the Gupta family, spurious charges against Finance Minister Pravin Gordhan and widespread calls for President Jacob Zuma to stand down, Deputy President and SANAC chair Cyril Ramaphosa has had a lot on his plate. In this fraught political context the new NSP has hardly elicited the national conversation or leadership that is needed – that it is needed is clear from the fact that around seven million people in South Africa now live with HIV and tens of thousands still die of tuberculosis every year.
To some extent, our HIV and TB response is also falling victim to the wider crisis in our politics. It is thus very encouraging that Health Minister Dr Aaron Motsoaledi and deputy Minister Joe Phaahla took a public stand against corruption when late in October they publically declared their support for Minister Gordhan. The spurious charges against Minister Gordhan has since been withdrawn. We trust that these leaders will not lose their jobs or be victimised for having taken this correct and principled stance. We will watch closely.
While the fight against corruption and state capture in South Africa is urgent and critical, the development of the new NSP is also critical. We urge the Deputy President, the Minister of Health, the rest of the national cabinet and all provincial cabinets to engage with both these urgent issues. Just like corruption, HIV and TB impacts the lives of millions of people in this country.
While the big picture politics are deeply concerning, there are also some signs that all is not what it should be at SANAC. The position of SANAC CEO Dr Fareed Abdullah was recently advertised amid rumours of a campaign to replace him with a person more compliant to the whims of some in government. Whether there is any veracity to these rumours we do not know, but it has reached us from various sources.
What is clear though is that in the current political context we need SANAC to be stronger than ever. Abdullah has done well in steering SANAC over the last five years and much of what concerns us at SANAC is beyond his control. Removing him now will threaten operational continuity at SANAC – something we cannot afford.
Civil society leadership crisis
While operational continuity is critical at SANAC, we urgently need new energy and ideas on the political side. This political energy has to come from civil society leaders at SANAC. Many people we have spoken to have expressed their disappointment with the failure of the current civil society representatives to raise critical issues impacting on ordinary people living with HIV and/or TB over the last five years.
Activists in SANAC have expressed their unhappiness with that is currently happening in SANAC, or more specifically in SANAC civil society.
There is a strong feeling that SANAC needs a civil society that is fully representative, that speaks with the voices of the marginalized, speaks with the voices of the poor and that the only way in which this can happen is if the current civil society is disbanded.
The new NSP provides an opportunity to make a clean start where we avoid the pit-falls of the past and ensure that people living with HIV and TB in South Africa feel they are properly represented. One way to avoid these pit-falls is to set some guidelines of what we expect from our civil society representatives.
To start with, we should insist that civil society leaders must represent constituencies and not just themselves (academics and other technical experts can of course contribute in their personal capacities to technical questions). Ideally, we want people who have been elected by affected people and who must account back to those people on what they have or have not done at SANAC.
Secondly, we should insist on transparency regarding the financial affairs of all civil society representatives. Where people represent NGOs, the finances of those NGOs should be open for public scrutiny – as is the case with all NGOs. If people do business with government, then that potential conflict of interest should be disclosed.
Looking back, there is much to be proud of, but what lies ahead is what matters now and what we do in the next three months will set the course of the next five years.
South Africa, like many lower and middle-income countries, follows the World Health Organization (WHO) recommended public health approach, using standardised drug regimens to treat HIV. This along with task shifting from doctors to NIMART (Nurse initiation and management of antiretroviral therapy) trained nurses has enabled more than 3.9 million people living with HIV (PLWH) to access life-saving antiretroviral therapy (ART) since 2003. ART is undeniably one of the biggest successes of modern medicine, along with vaccines and antibiotics
While we have some pretty great treatments already, there is still room for
improvement. Current first-line ART is a big pill to swallow, it has some unpleasant side effects, resulting in poor adherence and virological failure, and resistance develops quite easily; it will not get any cheaper over time. From the more logistical aspect, the high dose of the drugs that make up first-line ART means they use more ingredients meaning they cost more, and is the reason the pill is so big, which in turn means the packaging is big, and takes up more space in the pharmacy. Clearly, we need treatments which are easier to take in terms of size and are cheaper. And if you compare first-line ART in lower middle income countries (LMIC), some of the drugs being used are no longer recommended in better resourced settings.
Current first line ART
So, let’s look a little more closely at our current first-line ART. According to our
ART is undeniably one of the biggest successes of modern medicine, along with vaccines and antibiotics
national guidelines, most people living with HIV (PLWH) will receive a combination of efavirenz (EFV), tenofovir (TDF) and emtricitabine (FTC) or lamivudine (3TC) as first-line ART. FTC/3TC, which are structurally almost identical, really contribute very little in the way of toxicity generally and are usually continued through subsequent lines of therapy so I am not going to say much more about them here, and going to confine my deliberations to EFV and TDF.
What is great about this combination is that millions of PLWH around the world have been treated with it for years so there is a wealth of experience with it – a bit like that comfortable T-shirt we like to sleep in, for us as prescribers, but perhaps not so much for PLWH. The regimen has proven virological efficacy, is generally well tolerated, is simple to take as it is dosed once daily and is co-formulated into a single tablet fixed-dose combination (FDC).
What are the problems with EFV? It comes with some unpleasant side effects (abnormal dreams, nightmares, hallucinations even and other neuropsychiatric type symptoms mainly; occasionally rash); has a very low resistance barrier; and requires a high dose. Its safety in pregnancy has been established despite a bumpy start in early development and it plays relatively well with most other drugs, including TB drugs (but not all, for example some contraceptives such as implantables). EFV is an example of one of the first-line drugs which has disappeared from first-line treatment in many wealthier countries.
Alternatives to EFV
So how do we improve on EFV? There are a number of alternatives to EFV to consider which are currently available in South Africa. Rilpivirine (RPV) is one option, from the same class of ARVs as EFV, and is dosed at 25 mg (compared to 600 mg of EFV which contributes significantly to the size of the FDC). RPV is much better tolerated than EFV and is incredibly cheap, which is always good news in a drug which could be potentially be used to treat millions of people. The downside is that it is not yet available in any FDCs in South Africa, can’t be used with rifampicin-based TB treatment or in anyone with a high viral load when starting treatment, and in the public sector we don’t do viral loads at treatment initiation, so it too has its warts. However, it is being studied in some interesting new combinations so let’s not completely set it aside just yet. Certainly as a switch option RPV is a very good choice in patients who don’t tolerate EFV, and there are studies which support this.
Dolutegravir (DTG) is another option already available in South Africa. Again, another low dose drug at 50 mg. In registrational first-line studies no one with virological failure developed any DTG resistance which means this drug is incredibly robust. DTG was also the first drug to ever beat EFV in a head-to-head study, where pretty much all others had previously tried and failed, and this was probably a lot to do with the fact that DTG is more tolerable than EFV. And as the saying goes, if it sounds too good to be true… In fact, there are emerging data suggesting there may be some side effects which include dizziness and anxiety. But this is coming mainly from European cohorts, which do not have the same genetic diversity of African populations. Currently a massive study called ADVANCE that compares DTG to EFV is underway in South Africa and includes screening for these types of symptoms. DTG is also available already co-formulated in SA with abacavir (ABC) and 3TC, but it is not practical to roll out this particular FDC programmatically as ABC is very expensive.
But as DTG requires only a 50 mg dose, if it were to be introduced into the public sector programme, produced by a generic manufacturer with South Africa’s buying power as the largest consumer of generic ART in the world, DTG would be an affordable option for first-line ART, and is currently an alternative option in the WHO guidelines. With regard to DTG and TB drugs there is an interaction, which can be overcome by adjusting the dosing of the DTG, but this might not be necessary – some studies are underway to look into this. One of the current challenges with DTG is at this stage we don’t know a lot about DTG in pregnant women. Botswana made the bold move of introducing DTG into their HIV treatment programme in June 2016, including for pregnant women and it is anticipated that they will present data on the first pregnancies at the IAS conference in Paris in July 2017 which will start to fill this gap. So, we have a very robust drug that is well tolerated and can be co-formulated into a small inexpensive pill – looks promising.
Then there are also other future third-drug options which are not available in South Africa (or indeed anywhere else) as yet. These include doravirine and bictegravir. Doravirine is from the same class of drugs as EFV and RPV. It is still in phase 3 of development (registrational studies) and whether or not it will ever hit our shores is unknown. Bictegravir, also in phase 3, is a drug which is very similar to DTG and is co-formulated with tenofovir alafenamide fumarate (TAF), which I will discuss a little more below, and FTC.
An alternative to TDF
So, moving on to TDF. The problems with TDF are in some ways similar to those with EFV. The high dose means a high active pharmaceutical ingredient requirement which drives the pill size and the cost. And it also has some toxicity associated with it. Currently, we do not have any alternatives available in South Africa that are any better but there is one which should be available soon, namely TAF (tenofovir alafenamide fumarate). TAF, like the TDF in current first-line ART is a pro-drug of tenofovir. TAF is given at a much lower dose (approximately 10-fold lower) than TDF. TAF is associated with much less kidney and bone toxicity than TDF. The ADVANCE study will also compare TAF and TDF, as most studies of DTG used ABC as the backbone, and also would not have included many African participants. TAF has not been studied with TB drugs or in pregnant women as yet, but these studies are underway. Once we have a better understanding of this, on account of the better safety profile and the lower dose which will result in significant reductions in cost, TAF is set to be a favourable option to replace TDF.
And in fact, if DTG, FTC and TAF are co-formulated potentially we are looking at a future first-line regimen, to quote Prof Francois Venter, “smaller than an aspirin” which is incredibly potent, incredibly robust, incredibly well tolerated, all while being incredibly cheap – incredible isn’t it?
ART does not exist in a vacuum
All of this is very important, while we have such tough targets to chase – the famous 90-90-90. And to achieve that third 90 we need to modernise treatments so that PLWH can adhere to them. When there are so many other challenges to overcome within a healthcare system, optimising ART to be as simple, safe, efficacious and robust as possible facilitates safer task shifting to other cadres of staff which may help alleviate some of the human resource shortages faced within healthcare facilities.
But no matter how good the drugs are, ART does not exist in a vacuum, and ART alone will not achieve the three 90s. ART will not fix the healthcare system. ART will not address stigma. ART will not help us achieve that first 90 – 90% of PLWH knowing their status. ART will not find the missing in action to test them – the men, the key populations, the adolescents, girls and young women – and then link them to care to achieve the second 90. ART will not then retain them in care, and measure their viral load so we can see if we are reaching that third 90.
Massive investment in infrastructure and development of systems backed by political will is critical. Civil society must remain engaged and all of this must be backed by a National Strategic Plan (NSP) that is realistic, detailed, and embodies the principles of equity and access. There is a massive amount of work to be done to conquer HIV in South Africa, but optimised ART is certainly a great step in the right direction.
Dr Michelle Moorhouse – Wits Reproductive Health and HIV Institute and Southern African HIV Clinicians Society
When I joined government in 1994 there was not only an openness to dissenting opinions; it was encouraged. When we met, month after month, as the Health MINMEC (meeting of Ministers, MECs and senior staff) with the then Minister of Health in the chair, there was uniform acceptance that finding solutions to the tasks that faced us in the complex health function required debate, discussion, disagreement. It was encouraged.
These days a different opinion is labelled disloyalty. This new culture has creept up on us slowly over the last twenty years but now public service has become synonymous with blind loyalty to the political head and those who are the most loyal bureaucrats become the most powerful. Intellectual honesty and competence fly out the window.
The medium of this loyalty are words of praise of government and ministers consistently belted out by civil servants who have become adept at spinning a good story. The most skilled bureaucrats master the art of doing this and wrap it up in lofty language and references to science and evidence but only when this suits them. The political chicanery and subterfuge of the last few days has been met with disbelief yet it has been a long time coming. And it is this culture that permeates all the factions in government, including those who are now presenting themselves as the ‘unsullied,’ that undergirds the sycophancy that overpowers the work of government.
This is the world in which the recently launched National Strategic Plan to fight HIV, TB and STIs (NSP 2017 – 2022) has been written. A technical team was contracted to review progress and the latest evidence and make recommendations and a Steering Committee was established to provide a higher level strategic view to guide the technical work. Instead of seeing this process through, we had a political commissariat cherry picking technical work with the aim of making government look good whilst at the same time giving just enough airtime to the latest evidence to avoid criticism from technical constituencies inside and outside the country. This is also why important stakeholders such as the Treatment Action Campaign have not endorsed the NSP. So, let’s look at the facts.
We have performed well as a country when it comes to the roll out of ARVs and the prevention of mother-to-child transmission of HIV. Of this there can be no doubt. There is also no doubt that the Minister of Health, Dr Aaron Motsoaledi, has been ‘on point’ with upgrading our treatment policy first to start ART at 350 then 500 cells/µL. He has also been quick to announce in parliament in 2016 that any South African testing HIV positive would be started on ART without delay as this was now the gold standard for antiretroviral treatment across the globe.
It is not disloyal to point out that his officials have not yet issued the revised guidelines for ‘test and treat.’ Neither is it disloyal to point out that whilst we are very privileged to have access to viral load testing compared to our neighbouring countries, almost half of our patients do not have the test or get their results.
It is laudable that the NSP 2017 – 2022 makes a commitment to have 6.1 million people on ART by 2022. That will be no mean feat. Yet it is wise to think that unless there are sweeping reforms of the health services, including the widespread use of private GPs, this will be difficult to achieve. It is widely held that doubling the number of patients on ART will require additional clinics, more nurses, doctors, pharmacists and lab techs and ensuring adherence will require finances, NGOs and employing more lay counsellors and community health workers. This is little evidence that this is intended in the new NSP.
It is also not disloyal to point out that when the NSP is stripped off its verbiage when it comes to the scale up of treatment, what remains is the United States governments plan for test and start in this country. That plan was written more than a year ago, and is already being implemented. South African super-NGOs, also known as the PEPFAR partners, have been contracted to scale up test and treat in public sector facilities in 27 high-burden district municipalities in the country. Of course, this is in partnership with the Department of Health at national and provincial level but the driving force is the US government, its agencies in South Africa and its contracted NGO partners. The NSP merely endorses the PEPFAR plan, and therefore does not have any intention to address the remaining 20 districts where PEPFAR will not be engaged and that yet remain the government’s responsibility. Whilst PEPFAR, as a donor, has the freedom to select 27 high burden districts to optimise its investments, the NSP does not enjoy that luxury as it must serve persons living with HIV irrespective of where they reside. The new NSP does not even offer a minimum package for persons outside the 27 high burden districts for any HIV prevention or treatment services.
While there is still room when evaluating how well we have done in the case of antiretroviral treatment to vacillate between two debating sides – is the glass half full…is the glass half empty, no room exists for this vacillation when it comes to HIV prevention. We have failed miserably and we should start by accepting our failures in a brutally self-reflective and honest manner. HIV is coming down globally and in South Africa over the last decade. This is fact. But the decline in HIV globally and in South Africa has been very slow in the last five years. The UNAIDS Spectrum model estimates that that there are still 370 000 new HIV infections (2015) in South Africa each year with marginal declines over the last five years. The University of Cape Town’s Thembisa modelling outputs show the declines of around 27% over the last five years (with 270 000 new infections in 2016 alone) but even this team of modellers do not think that the declines are due to any successful prevention programmes. Thus, it is disingenuous for the drafters of NSP 2017 – 2022 to claim the decline in new infections as a country success.
The truth is that countries such as Zimbabwe, Namibia and Zambia have had much bigger declines in HIV incidence than South Africa. We know that we have not performed well when it comes to prevention. Our interminable debate on male medical circumcision delayed the start of the programme for more than two years. Our life skills programme in schools has been a monumental failure and the HIV testing and condom distribution collapsed during 2013 and 2014, only recovering in 2015 and 2016. The government mass communications programme (Khomanani now Phila) was shut down for 6 years from 2010 to 2016 with a noticeable absence of basic HIV messaging to the public leading to a significant decline in basic HIV knowledge in the country with the largest epidemic in the world.
The effects of this parlous effort at prevention was documented by the Human Sciences Research Council, which found that condom use was going down in South Africa and multiple sexual partnerships and early sexual debut were on the rise.
The new NSP approaches HIV prevention with an awkward triumphalism. On the one hand, it claims successes like a decline in incidence and the ‘She Conquers’ Programme. On the other, it cannot escape the facts and highlights 270 000 new infections in 2016 and 2000 new infections in young women per week. It then does the right thing by setting a target to reduce these new infections to below 100 000 by 2022. This is a 63% reduction over five years. The technical team debated this as it was clearly aware of the fact that this was an ambitious target. How can you set a target of 63% when you could not achieve a prevention target of 50% in the NSP of the last five years?
The answer to this is that we have more prevention interventions than we have ever had before and we have better knowledge of the drivers of new infections than ever before. We are certain that putting everyone who tests positive on ART will reduce transmission to uninfected contacts. Leigh Johnson at UCT’s modelling made a compelling case for optimising viral suppression in those already on treatment as the most effective prevention intervention. We also know that biomedical interventions work. These include PrEP, PEP and circumcisions and managing STIs. And we know through Gesina Meyer-Rath’s Investment Case Study that if we did it right and to scale, then condoms, reducing multiple concurrent partnerships and decreasing early sexual debut are both effective and cost-effective interventions.
What has also become clearer with each new study is the impact we can have by keeping girls in schools, child support or conditional cash transfers, reducing binge drinking and alcohol/substance abuse and addressing sexual assault and child abuse. These are the structural drivers of HIV and our prevention efforts will be more effective if we can do more of the smart and cost-effective interventions to address these structural drivers.
It is certainly possible to achieve such an ambitious prevention target to reduce new HIV infections to below 100 000. The NSP 2017 – 2022 contains the full list of these interventions but it lacks strategy and organisation. It contains all the right words but does not put on the table an outgoing or forthright plan to tackle prevention. There is no game plan. There is no strategy to connect a wish list of disparate, siloed interventions run by different departments. There are no resources or financing plans to reallocate resources. Nor is there an ambitious fundraising strategy. There is no planning methodology, no surveillance system and most importantly, there are no implementation arrangements. The NSP is so indolent in its approach that it does not even break down the national target into provincial targets. South Africa needs a prevention agency and the NSP 2017 -2022 would have been the perfect medium to make a call for the policy makers to seriously address this major shortcoming in our HIV response. De facto, the new NSP retains the same arrangements for prevention that has existed for the last decade. Anyone who expects a different outcome with the same failed strategy is misjudging the need.
The Health Department is not able to coordinate the prevention response. It is not well suited to this task, does not have the expertise nor the enthusiasm and will do well to stick to its knitting. It has the challenge to doubling the size of its treatment programme in a system with multiple challenges. It must rebuild its TB programme from scratch – imagine missing 37% of all the TB patients in the country – and it has to rebuild the STI treatment platform that has been completely decimated over the last twenty years.
The failure to address the implementation arrangements for prevention is a missed opportunity in this NSP and this may very well its Achilles’ heel. Perhaps it is a symptom of the malaise we describe at the beginning of this article. Perhaps the NSP was there only for the day of the launch of the document. Perhaps the very thorough technical exercise was trumped by a couple of bureaucrats from government who cherry picked the words and phrases that their political bosses would have liked and muffled the real issues that had to be addressed by the new NSP.
This would certainly be in keeping with the times.
Fareed Abdullah is the former CEO of the South African National AIDS Council where he championed HIV prevention and programmes for key populations such as sex workers. He is a medical doctor and specialist in Public Health Medicine who is well-known for implementing the first public sector PMTCT and ART programmes in the Western Cape where he was Deputy Director General and head of the AIDS Programme from 1994 to 2006.
On Friday 31 March 2017 South Africa’s National Strategic Plan (NSP) for HIV, TB an STIs 2017 – 2022 was launched in Mangaung, Free State. However, as of noon on Monday 3 April the final plan has not yet been made public. Most commentary is thus based on almost-final versions of the plan and/or a summary of the plan published by the South African National AIDS Council (SANAC).
At the launch, Deputy President of South Africa and head of the South African National AIDS Council (SANAC), Cyril Ramaphosa, said that “this is a pivotal moment in our fight against the epidemics because, despite our successes, we need to significantly expand and accelerate our efforts.” He said that the new NSP “emphasises the need for leadership participation and accountability at all levels to achieve the 90-90-90 targets.”
“We should, at minimum,” said Ramaphosa, “reach the 90-90-90 targets for HIV and TB by 2020.” He said that “this must be the commitment of government, business, labour and every formation within civil society.”
NSP not endorsed by TAC and SECTION27
On the night of March 30, lobby groups the Treatment Action Campaign (TAC) and SECTION27 released a joint media statement in which they said that they cannot endorse the NSP in its current form. They argued that the NSP falls short in four areas: lack of accountability, human resources, funding, and the NSP’s “weakness” on a number of specific issues – of which they identified access to condoms in schools and the decriminalization of sex work as key examples.
TAC and SECTION27 did however indicate that they would consider endorsing the NSP should certain additional implementation plans be developed and costed. Amongst others, they wish to see an addendum giving detailed guidance to provinces on NSP implementation, an addendum that sets out the additional human resources required to implement the interventions identified in the NSP, and a full costing of the NSP and a realistic assessment of where the needed funds will be found.
The two groups also indicated that they are “deeply concerned” by what they describe as the “ongoing governance crisis at SANAC”. “Serious questions about governance at SANAC remains unanswered despite various letters from TAC and meetings with key individuals,” the statement read. “We are particularly concerned by the lax way in which SANAC has handled conflicts of interest and the process of appointing a new CEO.”
Comment from MSF, RHAP, Sonke and others
Previously, writing on Spotlight, Julia Hill of Medecins Sans Frontieres (MSF) argued that we need to take the NSP to local, community level otherwise we only have a “pie-in-the-sky document” which makes it difficult for communities most affected by HIV and TB to hold to account AIDS Council governance structures and government departments. National success, she says, 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. In this regard, she argued, the NSP falls short.
Russell Rensburg of The Rural Health Advocacy Project (RHAP), also writing on Spotlight, pointed out that 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.”
He cautioned that the reality 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. He also called for a “strong SANAC that can lead, direct and accelerate the response. Rather damningly, they conclude that, “We fear SANAC in its current state does not meet this muster.”
Ariane Nevin of Sonke Gender Justice and Thulani Ndlovu of Zonk’izizwe Odds Development wrote 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, they 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.
Marlise Richter, of Sonke Gender Justice, and Thuli Khozaof and Katlego Rasebitseof the SANAC Sex Work sector, writing in Spotlight, also highlight the “tricky” drafting process of the NSP. They made the case for a much more robust section on the structural factors that impact on sex work. These include a strong call for the decriminalisation of sex work with clear indicators, the elimination of the police practice of ‘Condoms as Evidence’, removing ideology-based funding restrictions and including a migration focus.
Sasha Stevenson of SECTION27 argued that the NSP offers promising statements on human resources for health in general, and community health workers in particular, but that the question 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, she says, is “not far enough”.
NOTE: Spotlight is published by the TAC and SECTION27 – both of which are mentioned in this article. The editorial team has however been given editorial independence – which we guard jealously.
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
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.
It was business as usual at the International Aids conference in Durban in July 2016. The South African Minister of Health was about to address a plenary session when two young girls took to the stage. One made a beeline for the Minister and the microphone, while another stood with a placard about the effects of a lack of sanitary towels. Together, the Treatment Action Campaign’s (TAC) Ntombizodwa Maphosa and Tina Power set the agenda for young people at the international aids conference.
It was not a new conversation. For years, health activists have called for condoms and sanitary wear to be available in schools but their pleas have fallen on deaf ears. The only thing that changed were the numbers, and as the saying goes, numbers don’t lie.
The government’s National Strategic Plan (NSP) for 2012-2016 had envisaged an increase in male condom distribution from 492 million in 2010-11 to 1 billion, and 5.1 million female condoms in 2010-2011 to 25 million by 2016. Despite having set these goals four years ago, new infections are still on the rise.
Providing condoms in school has been a contentious issue within South African communities for a long time. Some argue that giving condoms to schoolchildren will only encourage them to become sexually active and therefore put learners at risk of teenage pregnancy as well as the transmission of diseases. Others have argued that creating easier access to condoms while including more in-depth sexual education within the life orientation curriculum, will help to curb the incidence of teenage pregnancy and HIV/AIDS infection rates among the youth.
The TAC has been at the forefront of the call for condoms and a comprehensive sexual education programme in schools. The TAC’s biggest concern, as explained by the National Women’s representative, Portia Serote, is that the law pertaining to the sexual rights of children is so contradictory that it is difficult to implement an effective plan to address the needs of learners for sexual education and access to contraception. One section of the Constitution, for example, defines a minor as being anyone under the age of 18, but another section states that having any sexual relations with anyone under the age of 16 is statutory rape.
The policy on condoms in schools gives power to school governing bodies (SGBs) to decide on whether or not they want condoms to be made accessible to learners. St Enda’s Secondary School in Johannesburg is one of those that has decided not to do so.
When interviewed by Spotlight, the principal, Moti, is somewhat dismissive of the idea, believing that it would be inappropriate, and should not even be promoted to children under the age of 18: ‛We wouldn’t want that,’ he says. ‛We are already dealing with a lot of external factors.’ The school is situated in the heart of Hillbrow and students and teachers are surrounded by drug dens and easy access to alcohol. For the principal, the last thing they want to do as a school is add to the long list of issues they battle with daily.
Although this is the official policy of the school, there are teachers who think providing access to condoms to pupils would not be a bad idea. One such educator is Afrikaans teacher Lenshur Abdul, who has also become the unofficial life orientation teacher.
‛At grade 11, there is no sexual education covered in the curriculum,’ she says. When students come knocking on her door, Abdul does her best to answer questions around sexuality, and sometimes refers them to the biology teacher.
According to Moti, the school also has the services of counsellors who engage with the learners in a general forum, to identify any issues that they may have. If necessary, children are referred to a social worker. The principal points out that although these programmes are available, he is not always privy to the information due to patient/counsellor confidentiality.
This year, reportedly, four girls have had babies, and two are currently pregnant. These numbers are, however, disputed by Moti, who believes that two girls fell pregnant this year and that one is currently pregnant. The principal confirms that learners who become pregnant are allowed to return to school.
‛How can we not talk to the children about these issues?’ asks Abdul. ‛In school we are trying to prepare them for the world ,which has HIV/AIDS, accidents and cancer,’ says Abdul.
Although debates continue about the morality and in some instances the feasibility of providing condoms in schools, the statistics continue to paint a worrying a picture. In South Africa, 2,000 schoolgirl pregnancies a week are reported – there is clearly a problem.
The MEC of Education, Panyaza Lesufi, says that recent statistics are enough to convince him that it is time to overhaul the entire approach to sexual education and access to contraceptives in schools. ‛We need to radically change whatever policy we had before, the statistics show that we are losing the battle, if 2,000 girls are newly impregnated, we cannot glorify such a policy,’ he says.
‛Pregnancy is not a scary thing anymore’
Sanele Zwane and his grade 11 friends, Lerato Ndlovu and Eva Malie, speak freely about pregnancy. Earlier this year a classmate of theirs fell pregnant. Zwane tells us, when she discovered she was pregnant, she started telling all the people in her grade not to be surprised if they didn’t see her later in the year, as she was going to having a baby. ‛She literally told everyone, even people she isn’t close to,’ Zwane recalls.
It is a reality they all face, and they are well aware of the various forms of contraception. ‛I think the Government just wants to cut down on the levels of teenage pregnancy, all they are really worried about is getting pregnant, but there is no counselling around sex,’ says Ndlovu.
‛Not talking about it (sex) is not helping us,’ adds Malie.
For these learners, what matters most is counselling that will provide them with emotional support, to prepare them to engage in sexual intercourse.
‛Nobody speaks to us about what it actually means [to have sex] with someone,’ says Ndlovu. Her beliefs around sex and abstinence are anchored in her religion. She believes that sex is sacred: ‛You can’t just go around giving everyone a piece of your soul,’ she explains.
Despite having different reasons for wanting to abstain from sex, the group is united in their view that a lot more should be done to provide social and emotional support about sex and teenage pregnancy. For most children, it is not easy to have a conversation about sex with their parents, there are questions that cannot be asked.
‛You know how our parents are, if you even try and bring these issues up, you are shut down immediately,’ says Zwane.
The generational gap between youngsters and parents is also evident between learners and the creators of the educational curriculum. ‛Our ministers and the MEC are from the 80s – they actually need to connect more with the youth,’ says Zwane.
‛I feel like the people who create these textbooks don’t even consult the youth,’ Malie adds.
Although Zwane and his peers are well aware of contraceptive methods, they have not thought as far ahead as the prevention of HIV/AIDS. For these 16-year-olds, pregnancy is a bigger scandal and an even bigger shame. ‛People can see your tummy, but nobody will ever know you have HIV/AIDS.’
A focus on HIV/AIDS advocacy is an issue that Health MEC Panyaza Lesufi has also identified. ‛We cannot wait until the 1st of December to start talking about HIV/AIDS; no schools should go without having posters about HIV/AIDS,’ he observes.
For Lesufi, the question of condoms in schools is not a moral question. ‛This has nothing to do with morals, it’s about taking collective responsibility,’ he says. We need to discuss the use of alcohol, we need to discuss drugs and sexual intercourse as being channels through which our children find themselves faced with issues of teenage pregnancy and being infected with HIV/AIDS.
