Episode 8: How South Africa is performing against key NSP indicators

The National Strategic Plan (NSP) for HIV, TB and STIs 2017 – 2022
sets various targets for the country’s HIV response. In this episode
of the Spotlight podcast host Nomatter Ndebele chats to Spotlight
editor Marcus Low about how South Africa is performing against key NSP
indicators and what that tells us about the state of the AIDS
response.

Episode 8: How South Africa is performing against key NSP indicators
The Spotlight Podcast

 
 
00:00 / 19:30
 
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Let’s make AIDS councils work

by Vuyokazi Gonyela, SECTION27

Provincial AIDS Councils (PACs) should be chaired by Premiers, and District AIDS Councils (DACs) by mayors. All councils should meet at least once a quarter – but many do not. If your DAC or PAC is not meeting, write to your Premier or mayor to urge them to organise and chair these meetings. Once we are at the meetings, it is up to us to use them to ensure we get an effective, non-corrupt response to HIV, TB and STIs in our provinces or districts.

Send an e-mail to tell us about your PAC or DAC experiences.

Seven questions to ask at your PAC

Not sure what to say at Provincial AIDS Council meetings? Here are some ideas for questions you could ask

1.    South Africa’s new NSP envisages an ambitious new HIV Counselling and Testing Campaign. When are we starting to implement this HCT campaign in our province.

Here is the relevant part of the NSP, if you want to quote it in the meeting:

“A new national HIV testing effort to find the remaining people who don’t know their status and those who become newly infected will be strategically focused on optimising testing yield. Testing will be decentralised, and expanded testing services will be delivered in and outside health facilities, e.g. in workplaces and community settings. Specific efforts will be made to close testing gaps for men, children, adolescents, young people, key and vulnerable populations, and other groups who are not currently accessing HIV testing at sufficient levels.

“The importance of at least annual HIV testing will be emphasised, especially for young people. Self-screening will be rolled out as part of the strategy to expand HIV testing, and to close testing gaps. A major push will be made to ensure 100% birth-testing of newborns exposed to HIV, and of provider-initiated counselling of mothers and testing for all children up to 18 months to identify those who have acquired HIV through breastfeeding. All children of HIV-positive parents will be tested for HIV. Every person tested for HIV will also be screened for other STIs, as well as for TB.”

2.  The new NSP says that the tracing of TB contacts must be prioritised; and that it envisages intensified TB case-finding in key populations, “including household contacts of people with TB disease, healthcare workers, inmates, and people living in informal settlements.” What are we doing to step up contact tracing and active case-finding in our province?

Here is the relevant part of the NSP, if you want to quote it in the meeting:

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

3.    The NSP sets important national targets. What are our provincial targets relating to reducing new HIV infections and reducing new cases of TB?

Setting provincial targets is essential if we wish to create greater accountability in our province. It also helps focus and direct the work that needs to happen in the province. Yet most provinces do not have targets. Getting your province to set ambitious and concrete targets will be an important achievement.

Some key national targets in the NSP for which we require provincial equivalents are as follows:

  • Reduce new HIV infections to under 100 000 per year by 2022.
  • Reduce TB incidence by at least 30%, from 834/100 000 population in 2015 to fewer than 584/100 000 by 2022.
  • 10 million people should receive an HIV test every year.

4.   Can the Department of Health please provide us with detailed, up-to-date statistics for our province on our progress towards the 90-90-90 targets for HIV and the 90-90-90 targets for TB?

The 90-90-90 targets for HIV and TB are at the centre of the NSP. To create local accountability, and to identify areas that need work, we should track progress against these targets within our provinces, not only at national level. As members of AIDS councils, you have a right to this information.

For HIV, the 90-90-90 targets for provinces are:

  • By 2020, 90% of all people in the province living with HIV will know their HIV status.
  • By 2020, 90% of all people in the province with diagnosed HIV infection will receive sustained antiretroviral therapy.
  • By 2020, 90% of all people in the province receiving antiretroviral therapy will have viral suppression.

For TB, the 90-90-90 targets for provinces are:

  • By 2020, 90% of vulnerable groups in the province will have been screened for TB.
  • By 2020, 90% of people in the province with TB will have been diagnosed and started on treatment.
  • By 2020, 90% of people in the province on treatment will have been successfully treated.

5. What is the status of our provincial implementation plan (PIP)?

The PIPs may sound boring, but they are the plans that must make the goals and broad strategies of the NSP a reality in the communities across our provinces. By engaging in these plans, we can help improve the HIV and TB response in our provinces. Developing these plans is some of the most important work that AIDS councils will do. Once they have been developed, adapting these plans over time and monitoring their implementation will be just as important. In short, if you are on a PAC, part of your responsibility is to know exactly what is going on with your PIP.

In addition to the above question, here are some follow-up questions you could ask:

  • Is the implementation of the PIP in our province fully costed?
  • Where is the money going to come from to implement our PIP?
  • Do we have the human resources to implement our PIP?

6.  Can the Department of Health please provide us with detailed statistics on the best- and worst-performing districts in our province?

‘Best’ and ‘worst’ can be measured in different ways. For that reason, it might be worth asking for more specific indicators of how districts are performing. Here are some examples:

  • What are the viral load coverage rates for each of the districts in our province? (Viral load coverage tells you whether all people on HIV treatment are getting viral load tests, as they are supposed to. If a district has a low viral load coverage rate, then you know there is a problem in that district, because people are not getting the tests that they are supposed to get.)
  • What are the districts in our province with the most medicine stock-outs?
  • What are the TB treatment success rates for each of the districts in our province?

Six questions to ask at your DAC

Not sure what to say at District AIDS Council meetings? Here are some ideas for questions you could ask.

1. South Africa’s new NSP envisages an ambitious new HIV Counselling and Testing Campaign. When are we starting to implement this HCT campaign in our district?

Here is the relevant part of the NSP, if you want to quote it in the meeting:

“A new national HIV testing effort to find the remaining people who don’t know their status and those who become newly infected will be strategically focused on optimising testing yield. Testing will be decentralised, and expanded testing services will be delivered in and outside health facilities, e.g. in workplaces and community settings. Specific efforts will be made to close testing gaps for men, children, adolescents, young people, key and vulnerable populations, and other groups who are not currently accessing HIV testing at sufficient levels.

“The importance of at least annual HIV testing will be emphasised, especially for young people. Self-screening will be rolled out as part of the strategy to expand HIV testing, and to close testing gaps. A major push will be made to ensure 100% birth-testing of newborns exposed to HIV, and of provider-initiated counselling of mothers and testing for all children up to 18 months, to identify those who have acquired HIV through breastfeeding. All children of HIV-positive parents will be tested for HIV. Every person tested for HIV will also be screened for other STIs, as well as for TB.”

2.  The new NSP says that the tracing of TB contacts must be prioritised; it envisages intensified TB case-finding in key populations, “including household contacts of people with TB disease, healthcare workers, inmates, and people living in informal settlements.” What are we doing to step up contact tracing and active case-finding in our province?

Here is the relevant part of the NSP, if you want to quote it in the meeting:

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

3.  The NSP sets important national targets. What are our district targets relating to reducing new HIV infections and reducing new cases of TB?

Setting district and provincial targets is essential if we wish to create greater accountability in our districts and provinces. It also helps focus and direct the work that needs to happen at district level. Yet most districts do not have targets. Getting your district to set ambitious and concrete targets will be an important achievement.

Some key national targets in the NSP for which we require district and provincial equivalents are as follows:

  • Reduce new HIV infections to under 100 000 per year by 2022.
  • Reduce TB incidence by at least 30%, from 834/100 000 population in 2015 to fewer than 584/100 000 by 2022.
  • 10 million people should receive an HIV test every year.

4.  Can the Department of Health please provide us with detailed, up-to-date statistics on our progress towards the 90-90-90 targets for HIV and the 90-90-90 targets for TB in our district?

The 90-90-90 targets for HIV and TB are at the centre of the NSP. To create local accountability, and to identify areas that need work, we must track progress against these targets within our districts and provinces, and not only at national level. As members of AIDS councils, you have a right to this information.

For HIV, the 90-90-90 targets for districts are:

  • By 2020, 90% of all people in the district living with HIV will know their HIV status.
  • By 2020, 90% of all people in the district with diagnosed HIV infection will receive sustained antiretroviral therapy.
  • By 2020, 90% of all people in the district receiving antiretroviral therapy will have viral suppression.

For TB, the 90-90-90 targets for districts are:

  • By 2020, 90% of vulnerable groups in the district will have been screened for TB.
  • By 2020, 90% of people in the district with TB will have been diagnosed and started on treatment.
  • By 2020, 90% of people in the district on treatment will have been successfully treated.

5.  What is the status of our provincial implementation plan (PIP)? And if we have a District Implementation Plan (DIP), what is the status of that?

The PIPs and DIPs may sound boring, but they are the plans that must make the goals and broad strategies of the NSP a reality in our communities. By engaging in these plans, we can help improve the HIV and TB response. Developing these plans is some of the most important work that AIDS councils will do. Once they have been developed, adapting these plans over time and monitoring their implementation will be just as important. In short, if you are on a DAC or PAC, part of your responsibility is to know exactly what is going on with your DIP and/or PIP.

In addition to the above question, here are some follow-up questions you could ask:

  • Is the implementation of the PIP and DIP in our district fully costed?
  • Where is the money going to come from to implement our PIP (or DIP)?
  • Do we have the human resources to implement the PIP (Or DIP)?

6.  Can the Department of Health please provide us with detailed statistics on the best- and worst-performing clinics in our district?

‘Best’ and ‘worst’ can be measured in different ways. For that reason, it might be worth asking for more specific indicators of how clinics are performing. Here are some examples :

  • What are the five clinics in our district with the lowest viral load coverage rate? (Viral load coverage tells you whether all people on HIV treatment are getting viral load tests, as they are supposed to. If a clinic has a low viral load coverage rate, then you know there is a problem at that clinic, because people are not getting the tests that they are supposed to get.)
  • What are the five clinics in our district with the most medicine stock-outs?
  • What are the five clinics in our district with the worst TB treatment success rates?

 

Opinion: Will we get the NSP right this time?

By Marcus Low, Spotlight Editor

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

What went wrong with the previous NSP?

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

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

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

Top six priorities in the next NSP

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

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

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

  • We need a roadmap to treatment for all

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

  • We need an ambitious plan for TB

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

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

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

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

  • We need concrete plans to bring in business and labour

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

  • We need to reform SANAC

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

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

Top eight indicators for the new NSP

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

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

 

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

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

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

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

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

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

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

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

A difficult political environment

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

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

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

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

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

Civil society leadership crisis

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

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

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

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

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

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

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

 

Round-up of responses to SA’s new AIDS/TB plan

By Staff writer

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.

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

By Julia Hill

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

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

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

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

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

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

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

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

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

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

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

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

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

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

The Achilles Heel of the new NSP: Accountability and Equity

By Russell Rensburg

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

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

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

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

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

Community consultation

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

Crumbling rural Building Blocks

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

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

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

The Role of SANAC

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

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

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

Russell Rensburg – RHAP Programme Manager: Health Systems and Policy

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

By Sasha Stevenson

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

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

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

Focus on prevention

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

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

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

Important targets missing

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

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

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

NSP Draft 1: Good Enough?

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

 

Many positives

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

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

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

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

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

 

Where draft 1 falls short

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

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

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

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

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

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

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

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

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

Editorial: Three months to get it right

By Anso Thom and Marcus Low

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 have 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. There is a strong feeling that SANAC needs a civil society sector 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.