Buthelezi: SANAC to lead the prevention revolution

By Dr Sandile Buthelezi

Dr Sandile Buthelezi

In June 2017, at the end of the South African National AIDS conference, Deputy President Cyril Ramaphosa, who is also the Chairperson of SANAC, called for a Prevention Revolution to prioritize prevention, the same way we do with treatment. As I reflect on this as the newly appointed SANAC CEO, I see my appointment as an opportune moment for SANAC to take up this challenge.

In South Africa, we know that approximately 270 000 people are newly infected with HIV every year. What we also know is that almost 48 million South Africans are HIV negative. Our major task is therefore to keep these people negative.

We know what to do and how to do it: over the past few years, we have gained knowledge and appreciated the efficacy of new tools to prevent HIV, from pre-exposure prophylaxis (PrEP) to the knowledge that an undetectable viral load dramatically reduces the risk of transmission. SANAC’s urgent and immediate task will be to rally everyone behind a new prevention revolution that harnesses combination prevention approach, especially in communities hardest hit by HIV.

In a UNAIDS Discussion Paper on combination prevention, combination programming is defined as “rights-based, evidence-informed, and community-owned programmes that use a mix of biomedical, behavioural, and structural interventions, prioritized to meet the current HIV prevention needs of particular individuals and communities, so as to have the greatest sustained impact on reducing new infections.”

While we appreciate that the pace of decline in new infections is not fast enough, the reality is that we have not put prevention back at the top of our priority list. SANAC will have to take major strides to address this, which is why the new National Strategic Plan for HIV, TB and STIs (2017-2022) has placed prevention as the first goal with the bold target of reducing new HIV infections by more than 60 percent and cutting TB incidence by at least 30 percent.

South Africa has made significant progress: more than 10 million people now test for HIV each year; new HIV infections declined from 367 946 in 2011 to 266 618 in 2016, a 27.5% reduction against a target of 50%. We have also recorded major successes in the reduction of mother-to-child transmission of HIV from 3.6% to 1.5% (measured at 6 weeks postpartum), the lowest rate in Southern Africa. In addition, the number of infants born HIV positive has been reduced from 70 000 in 2003 to less than 6 000 in 2015, putting us on the road to eliminate mother-to-child transmission of HIV. But these gains could be reversed if we do not take urgent and immediate action to step up our prevention efforts.

What does a Prevention Revolution look like?

Everyone speaks of ‘combination prevention’, but we have not committed to specific programmatic priorities and actions. The referral pathway for HIV negative individuals, for instance, is poorly defined and implemented therefore an area that must be strengthened. Although targets for a multi-sectoral prevention response exist, they are not as memorable as the treatment targets. Every AIDS council must have a robust prevention plan and be capacitated and financed to monitor, track and review implementation progress.

Service providers also need guidance around the range of new combination prevention options that are now available. They are grappling with the rapidly changing landscape, and are faced with the challenge of conveying increasingly complex sexual health information in a way that resonates with key populations such as men who have sex with men, young girls and women. Furthermore, we need to create coherent and consistent prevention messages so that we don’t overemphasize one at the expense of others. We can’t afford to leave anyone behind.

To maximize impact and use resources optimally, HIV prevention interventions of proven high impact need to be delivered to key locations and priority populations. Protecting human rights, safeguarding gender equality and ensuring access to services for key and vulnerable populations remain pivotal in the HIV response. Social and structural drivers which place people at risk of infection must also be addressed earnestly by investing now for long term sustainable solutions.

We know that people at risk of HIV infection have a cascade of HIV prevention needs. They need to be aware of risk, to learn how to protect themselves (including knowing their HIV status) and to have the means to protect themselves. They also need the power to make informed decisions about HIV prevention options and to receive support for their choices.

Just as innovation has changed the landscape of HIV prevention in the past, innovation will remain critical. We can’t continue doing the same things hoping for different outcomes.

Combination prevention will only work if it is based on a genuine understanding of the nature of the epidemic in each community. Communities and local organizations are well placed to contribute their knowledge and expertise to highlight who and where to focus and what works. They should be at the forefront of the local prevention response.

Communities will need to use their power to push this new HIV prevention revolution and hold governments, donors and themselves accountable. Without community ownership, the target of reducing new HIV infections by 50% by 2022, and virtually eliminating them by 2030, will not be achieved.

I am also committed to making sure SANAC provides the leadership needed to achieve these goals. For SANAC to reach its full purpose and potential, it too must change. It is time for us to recognize our shortcomings and reform the way we work.

Let our actions count!

New SANAC CEO responds to questions about his past

By Ufrieda Ho

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

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

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

Highly charged atmosphere

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

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

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

Persecution of Manguzi doctors

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

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

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

No regrets regarding Tara KLamp

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

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

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

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

Corruption allegations

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

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

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

“He will have to build trust”

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

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

“He was on the wrong side”

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

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

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

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

“I believe in service”

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

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

 

TAC congress elects new leaders, sets priorities

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

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

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

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

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

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

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

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

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

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

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

 

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.

 

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

By Fareed Abdullah

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

This would certainly be in keeping with the times.

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

 

 

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.

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

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.

 

NSP 2017-2022: Our Fifth National AIDS plan presents SA’s greatest challenge yet

By Mark Heywood

 

Dear Deputy President Ramaphosa,

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

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

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

This sad message probably indicates something we would rather not consider, that there are a growing number of people dying from AIDS and TB again – despite the availability of antiretrovirals. Statistics reveal to us that a high proportion of adolescents are dying of TB and HIV, both diseases that can be prevented and either cured or managed. I hear that the rates of vertical HIV infection (Mother to Child transmission during and after birth via breastfeeding) are higher than we admit. These facts points to the heart of the challenges we face, challenges that must be brought to the fore as SANAC, under your leadership, finalises a new strategic plan on HIV for the next 5 years.

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

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

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

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

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

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

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

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

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

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

  1. How to massively cut the number of new infections, particularly in young women and amongst what AIDS experts call ‘key populations’. It is scary, outrageous, shocking that 2 000 young women are infected with HIV every week. If we could cut this by 75% – and we have to believe that we can – we would be on a winning streak.
  2. How to improve the quality of care for the 3.5-million people now on ARV treatment and how to find our way to the missing 3.5-million who need to be on HIV and TB treatment.

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

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

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

If we did this, we would win.

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

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

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

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

Measure people by their actions not their words.

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

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

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

 

Mark Heywood

Activist

Former deputy Chairperson of SANAC

 

 

 

New NSP by November: SANAC responds to questions on NSP process

By Marcus Low

We recently sent the South African National AIDS Council some questions regarding the process for developing South Africa’s new National Strategic Plan on HIV, TB and STIs. Below we reproduce their responses exactly as they were sent to us.

Spotlight: We know some consultations on South Africa’s next NSP were held in Durban. What future plans are there for civil society engagement in the process? (If you have a schedule of consultations we will be happy to publish that.) Please also share all details you can share regarding timelines.

SANAC: SANAC has embarked on a process of deep involvement of civil society to emerge with a Plan civil society has been involved in developing (not simply consulted on) and, with other stakeholders feels ownership of.

The development of the National Strategic Plan will go through the following stages: The initial stage is getting input from a diverse group of stakeholders, including civil society, on key questions. This will be followed by a national stakeholder engagement meeting where key issues will be debated before the NSP document is developed and then passed through the SANAC structures, where civil society will again be able to input, before being presented to the national Cabinet in early November.

We are engaging with various stakeholders, including the civil society forum, on the details of how they wish to be engaged. This process will be supplemented by opportunities for people to give their opinion through various media platforms including twitter, Facebook and the SANAC website.

Spotlight: Who is in charge of the process for developing and writing the new NSP?

SANAC: A Multi-stakeholder NSP Steering Committee, with civil society representation, has been established to lead the process. The SANAC secretariat with the support of consultants will be responsible for the writing up of the NSP based on the input of stakeholders and the guidance of the NSP Steering Committee.

Spotlight: What is the cost of developing the next NSP and who is paying? Please share as much detail as you can.

SANAC: SANAC has budgeted R1m for the development of the NSP. In addition, WHO, Gates, GIZ, the Global Fund and UNAIDS are providing consultant experts to assist with preparing the NSP and facilitating the consultations. The Secretariat is still fund raising as the budgeted funds will not be adequate. Developing a NSP requires consultation (conference costs, travel) and technical support to ensure development of a Plan that reflects the input of stakeholders and is strategically sound and based on recent reviews, changes in the epidemic and new evidence.

Spotlight: Will changes to the structure of SANAC be considered at any point during the process of developing the next NSP?

SANAC: All inputs from stakeholders will be considered as part of the process of developing the NSP. The main questions being asked will include: what of the current NSP needs to be expanded and what needs to be strengthened (and how), what is new and needs to be included, what are the game changers to set the scene for the achievement of the NDP goals of 2030?