National Strategic Plan on HIV, TB and STIs: SANAC briefing

Meeting report

Opening remarks

The Chairperson said that as much as South Africa has progressive legislation dealing with TB and HIV and AIDS there were still grey areas where members of Parliament have an obligation to interact with communities affected by these diseases. Black African communities are by their nature conservative in the discussion around sex and sexuality. We must find a way to create an enabling environment where members of communities can talk about these sensitive issues.

Briefing by the South African National Aids Council (SANAC) on the South African National Strategic Plan for HIV, TB and STI 2017 - 2022

Dr Sandile Buthelezi, CEO of the SANAC trust said that the SANAC Trust was a legal structure established by Cabinet to drive all SANAC related activities. The recent successes that were an inspiration were:

-There has been a huge drop in HIV-related deaths from 2006 to 2016 which was a drop of almost 400 000;

-The number of TB-related deaths also dropped significantly from 70 000 to 38 000 by 2015;

-The high rollout ARTs caused the HIV treatment patients was about 3.7 million in 2016, currently there is a million more than that; and

-New HIV infections are down from 410 000 in 2011 to 270 000 in 2016

 

The Key Challenges for HIV/TB Programmes in South Africa are:

-Although South Africa is less than 1% of the global population almost 20% of people living with HIV is in this country;

-15% of all new HIV infections globally is in this country, 34% are in young people between 16 and 24;

-15% of all HIV related deaths globally are in South Africa;

-20% of all HIV infected people on treatment are in South Africa; and

-South Africa treats more than 1 million new STI infections a year.

 

The National Strategic Plan (NSP) with a principle of “One country. One plan, One response” has eight goals:

Goal 1: Accelerate prevention in order to reduce new HIV and TB infections and new STIs;

Goal 2: Reduce illness and death by providing treatment, care and adherence support for all;

Goal 3: Reach all key and vulnerable populations with services that are tailored to their specific needs;

Goal 4: Address social, economic and cultural factors that add fuel to the HIV, TB and STI epidemics;

Goal 5: Ground the HIV, TB and STI programme in human rights principles;

Goal 6: Promote leadership at all levels and shared accountability for delivering this Plan;

Goal 7: Mobilise resources to support achievement of the NSP and ensure a sustainable HIV, TB and STI programme: and

Goal 8: Strengthen the gathering and use of information to make the NSP successful

 

The targets for 2020 can be achieved but SANAC needs to focus on a number of things namely:

-Evidence-based prioritisation

-Understanding drivers and risk at a local level. Most of these risks cannot be homogenous and they need to understand the epidemics at a local level and tailor make interventions to that level and then scale up. 

-Customising an approach appropriate for local epidemic- specific to the local drivers and risk

-Implementing change for the adoption of selected new behaviours and interventions

-Targeting and ensuring adequate coverage rates

-Strengthening data integration and reporting on biomedical, structural, socio-economic and behaviour change interventions

-Innovation to expand & enhance what we have

-Advocacy for progressive policy change and accountability

Key recommendations from AGYW (Adult, Girls, Young, Women) Summit were:

-There needs to be an inclusion of boys and young men in all HIV prevention programmes, including targeting social clubs places of work and identified hook-up spots. There is a feeling that young men have been neglected as a lot of focus has been put on adolescent girls.

-There needs to be better consultation of parent/guardians to receive buy-in and ensure consent is provided for participation in HIV prevention programmes.

-There is also an urgent need to increase knowledge about and access to sexual reproductive Health services, family planning and contraception use are low amongst AGYW. People are not using condoms and contraception as much as they should and this has resulted in an increase in teenage pregnancies and termination of pregnancies, both legal and illegal, which means that there is something they are not doing right.

-There needs to be an increase in the availability of pre-exposure prophylaxis (PrEP) beyond current initiations sites and universities to increase access and reduce stigma.

-There is a need to scale up comprehensive sexual education as levels of knowledge on HIV amongst AGYW are unacceptably low. There is a lot the Department of Basic Education is doing here working with various partners.

-Develop a condom distribution plan for condoms and lube in schools and higher education institutions. They distribute almost a billion condoms in the country but research has shown that there has not been an increase in the utilisation of thereof.

-Need to scale up the Department of Social Development’s SDCC programmes to address social and structural drivers of HIV, including those for mental health.

-Develop (jointly with youth) and implement a national communication strategy for HIV, TB and STIs with a particular focus on AGYW and male sexual partner targeting.

-Standardise M&E tracing system to measure the impact of all programmes dedicated to the HIV response targeted at AGYW.

-Empower political and community leaders with necessary information to champion programmes for AGYW on the ground and increase urgency on the ground in terms of eliminating new infections amongst AGYW

-Strengthen advocacy efforts for progressive policy change and hold each other accountable for implementing AGYW programmes according to what has been committed in the multi-sectoral district implementation plans.

Dr Buthelezi explained about PIPs and MDIPs. He said to attain the ambitious of the NSP 2017-2022, each province is responsible to align its provincial activities through its respective Provincial Implementation Plans (PIPs) and Multi-sectoral District Implementation Plans (MDIPs). The NSP will never be implemented at National level. Provinces needed to develop Provincial Implementation Plans (PIPs). There was an aggressive drive over the first year driven by the NSP Steering Committee to ensure that SANAC assisted Provinces in developing their PIPs. All Provinces have produced their plans though there are Provinces like Gauteng that are limping. 46 districts (excluding the Western Cape) have drafted annual multi-sectoral district implementation plans. The Western Cape only has a Provincial plan because they do not believe in a district based HIV approach. These have their own challenges in terms of how they align with Government planning processes.

 

Key findings from the HSRC (Human Sciences Research Council) were:

-The incidents of new infections has dropped by 44%. The largest decline was among females and there was actually a slight increase in the male population. This is currently being discussed in different research circles;

-There has been an overall HIV incidence among youth decline of 17%.  The decline in incidence was only among females (26%) and there was actually an increase incidence in males by 11%;

-In 2017 the overall HIV prevalence in South Africa was 14% which is an increase from what it was in 2012. This translates to 7.9 million people in South Africa which is a changed from 7.1 million people in 2016. This is an increase of approximately 1.6 million more new people than in 2012. In 2012           the prevalence of HIV among South Africans of all ages was 12.2%; and

-90% of those people living with HIV should know their status. 90% of those people who know their status should be on treatment. And 90% of those people should be virally suppressed. Being virally suppressed is essential because HIV infected will then not pass the virus to other people. As a             country in terms of 90-90-90 South Africa is not doing badly. 84.9% of HIV infected people know their status, 70.6% of those people are on treatment, and 87.5% of HIV infected people on treatment are virally suppressed.

 

National Wellness Campaign

Reverend Zwoitwaho Nevhutalu, Executive Manager for Stakeholder Management and Campaigns, said that one of the primary objectives of the National wellness campaign is to provide an enabling environment for health seeking behaviour. It also seeks to strengthen test and treat initiatives and strengthen HIV prevention interventions which includes condom use, medical male circumcision, prevention of mother to child transmission, PEP, PrEP. TB, and hypertension and diabetes communication.

Rev Nevhutalu said that the secondary objectives of the national wellness campaign includes increasing demand creation through community mobilisation, strengthening community testing including HIV self-screening and other modalities, improve referrals for diagnosis and treatment, and improve data collection, management and strengthen evaluation.

Campaign Targets

Rev Nevhutalu said that the campaign is targeting 2 million new clients on treatment by 2020, 14 million tested and screened for HIV, STIs, TB and 7 million for hypertension and diabetes. 10 million of the targeted 14 million will be in the 27 high burden districts and 4 million will be in the remaining 25 districts.

Package of Services

Rev Nevhutalu said that the package will include among other things the widespread distribution of condoms, the promotion of HIV self-screening among vulnerable and key populations and Pre-exposure prophylaxis among populations at high risk of contracting HIV.

Dr Buthelezi said that this campaign was supposed to be launched in June but it could not for certain reasons. They are awaiting a launch date which is to come very soon.

Discussion

Dr P Maesela (ANC) thanked SANAC for an interesting presentation. He said that it is futile to do the same thing over and over again and expect different outcomes. We need to look into that and see how we can shift the paradigm. Poverty is the greatest single driver of ill health. Efforts made by doctors through medicines are ill-fated if the patient is subject to poverty. Can some of the funding SANAC receives be diverted to diagnostic purposes? If you catch a disease earlier the possibility of successful treatment are very high. Interventions need to be based on evidence. The interventions need to focus on children and getting children out of these dangerous zones.

Mr T Nkonzo (ANC) said that South Africa has the biggest HIV epidemic, estimated at 7.1 million in 2016. At the same time South Africa has made progress in the last 10 years. He asked if SANAC is visible in Provinces and municipalities. Are there any successes in the different levels of Government? When did SANAC realise that it was doing so well in areas in the Western Cape and the Northern Cape? What was the situation like in those areas before SANAC got to those areas? How is SANAC tracking its performance on its planned activities? What measures is SANAC taking to implement awareness and information sharing on HIV? What is the distribution of the allocation of funds received from donors in respect of the Provinces?

Mr A Mahlalela (ANC) welcomed the presentation by SANAC. He said he would have expected the Department of Health to be a part of this meeting. In the presentation he could not locate the role of the Department of Health. He agreed with Dr Maesela that poverty is a big driver of ills and social challenges in South Africa. Any plans to address the HIV, TB and STI problem in South Africa needs to be done through an integrated approach. Does the donor funding received by SANAC address the problem of social challenges in South Africa? He cited the consumption of alcohol as a big contributor to the challenges facing the country. The consumption of alcohol by young people is contributing to the spread of these diseases. There is a view that HIV and Aids is no longer a topical matter in South Africa. If this is the case then it is no longer an issue of prevention but an issue of treating. The distribution of condoms is no longer working because it is not giving the desired results. Even when the Committee asked the Department of Health on this they could not give the Committee a proper answer based on a proper analysis. What are reasons for condoms not being used as much is it should be? He asked for clarification on the statistics dealing with the number of people living with HIV and the number of people on ARV treatment. Black Africans often choose to go to traditional healers before they go to health facilities. How does SANAC mobilise these traditional healers to be part of the bigger agenda? Females generally visit health facilities more regularly than males. On oversight visits to health facilities the Committee always saw much more females than males in health facilities. Does SANAC have a programme to mobilise males to know their HIV and other status? Does SANAC have a plan to target sexually active school girls? Are local HIV and AIDS councils being supported financially or otherwise to be able to perform their tasks? What are the elements of the “She Conquers” campaign? What is SANAC’s plan to deal with those HIV infected people who are not on ARV treatment?

The Chairperson asked if SANAC is confident in the reporting of SANAC’s one person per Province. How confident is SANAC that Civil Society is not being manipulated by funders? She told Mr Mahlalela that the Department of Health was invited to the meeting and they will follow up on that. She said that sex workers are not only females but males as well. Does SANAC have a programme in place to target children in basic education? She said she was taken aback when she found in an area a 13 year old girl who fell pregnant from intercourse with a peer. She was told that the boys in that community do not want to use condoms. The society in which we live in is conservative and SANAC must work at a ground level to inform and educate people on these topics. Has SANAC ever interacted with the people in the Higher education sector? She too raised her concern over the behavioural choices of young people with regards to sexual activity and alcohol consumption.

Dr Buthelezi said that if he had received these questions beforehand he would have done the presentation in a different way. This will help in future because now SANAC knows how the Committee wants their presentations to be structured.

Dr Buthelezi said that within the bigger structure of SANAC they include traditional leaders, traditional healers, women, labour, sports, arts, recreation and the religious sector. These are some of the sector whose leadership participates. In government they have 32 core IMC departments that participate with SANAC. So there is robust communications throughout SANAC with the main departments. SANAC is not an implementation agency but it is a coordination structure at a national level. SANAC collates and ensures that people do what they do either in Government, civil society or the private sector.

Dr Buthelezi said that sometimes the statistics can be very confusing. Given the nature of the HIV disease the statistic on HIV is based on a statistical model, and the current model being used is the Themisa model which is run by a team from the University of Cape Town. UNAIDS uses a different model. There are new tests which use biomarkers that can show the time around which an infection occurred. The statistics which Mr Mahlalela referred are estimated based on modelling which has been tried and tested and it has been accepted. The 7.1 million people living with HIV is an estimate and the real number cannot be known until people are actually tested and their status is officially confirmed. Also because HIV is not a notifiable disease it is very difficult to have accurate numbers on research.

Dr Buthelezi said that the ‘She Conquers’ campaign is a three year campaign which was launched two years ago and has five objectives. It brings together all programmes that are addressing young and adolescent girls in the country. One of the objectives is to reduce the HIV infection rates in young girls, the second is to reduce teenage pregnancy, and the third is to keep girls in schools at least until matric, four is to reduce gender based violence, and five is to increase economic empowerment opportunities.  There is a study that shows that condom usage among young and adolescent girls can be increased if they can be provided with some economic means. There is a programme that SANAC is piloting in the Western Cape and in KwaZulu Natal called a cash plus care programme. They are targeting 30 000 young girls to evaluate issues of entrepreneurship, providing some basic necessities to young girls and ensuring they have access to more economic opportunities.

Dr Buthelezi said that in terms of the HSRC survey the Western Cape and the Northern Cape are the two Provinces that are worrying because they have increased prevalence. He said in the next meeting they can provide more details on the Provincial and district levels because they do have that available.

Dr Buthelezi said that the SANAC trust has an Annual Performance Plan which gets approved by the Board and is reported on a quarterly basis; and there is an annual report available on SANAC’s website. This is in relation to tracking the performance of planned programmes.

Dr Buthelezi said that one of the key issues around liquor is that the licensing of liquor outlets is an exclusive provincial competence. Premiers of Provinces need to take responsibility with their MECs for economic development who gives out these licenses to look at how they are going to address the issue of giving out these licenses. The multi-sector aspect is very critical so that they can identify problematic areas and see how authorities are addressing the issues of managing liquor.

Recently SALGA has joined SANAC as a member and they had a big meeting over two days with SALGA bringing in mayors and starting with at least 19 municipalities that they call ‘fast track municipalities’. They will be working out key programmes for those municipalities where they will be getting some resources from UNAIDS and some other international organisations to put in some fast track programmes in problematic municipalities. This is important because most of their normal funders are more interested in biomedical issues, so if they do get areas where they can actually spend more money on social and structural drivers they will be able to address it. However, they have seen in municipalities where there is leadership that despite the lack of resources these municipalities are doing well. This happens when there is mainstreaming. SANAC’s role is to ensure that there is coordination at a leadership level and they are now developing this tool for Mayors to look at the statistics.

Dr Buthelezi said that in the first Plenary of the Chair that they had on the 29 June 2018, the main agenda item was for each of the Premiers to present how their councils are structured and supported. They have that report and can make it available to the Committee. Some Provinces are doing really well and have good structures in place.

Dr Buthelezi said that focus is given to the mining areas where the prevalence of TB is high. There is a programme called ‘TB in the mines’ which is funded by the global fund and it is run through Wits health as a principal recipient. This programme is beyond just running health programmes. At the end of the day the conditions down in mines ventilation is a big issue so they need to ensure that there is pre-screening and to ensure that people who contract TB get their compensation. The global fund will also be used for new technology which can diagnose disease better and the fund allows them to look forward with these new technologies.

Dr Buthelezi said that participation in SANAC is voluntary and the participation of Civil Society in SANAC does not take away their independence. SANAC hardly funds the Civil Society.

Dr Buthelezi said that the sex worker representative in SANAC is a male. SANAC is quite progressive and they are moving with that at a representational level.

Dr Buthelezi said that perhaps they can present on some of the programmes SANAC is engaged with Education when they get a chance at the next meeting with the Committee. In South Africa we run one of the strongest Department of Higher Education AIDS programmes which is called ‘HEAIDS’.

Dr Buthelezi said that they do have programmes for farm workers in farming areas.  

Dr Buthelezi concluded by saying that they had a lot to present but they could not put it all in one presentation.

Dr Nevilene Slingers, Executive Manager of Donor Coordination at SANAC, said that the ‘cash plus care’ programme started when Social Development came to SANAC and said that they are aware of the child support grant ending when a person is 18 and they are aware that women aged 20 to 24 are vulnerable. There is evidence that the child support grant makes a big difference, but the problem is what should be done for 20 to 24 year olds because they are vulnerable and there is no grant that covers that area. There is also evidence that people need more than just money. There was quite a lot of discussion with The National Treasury before this ‘cash plus care’ pilot was taken on to understand that it is not setting up an expectation that Government cannot meet. In piloting the ‘cash plus care’ they are already discovering, from women in that age group, that the financial challenges are larger than SANAC thought. The care element of the programme is about giving people information that is appropriate for their age and linked to what interests them. The other element is about looking at building economic opportunities. It has taken quite a lot of time to understand exactly how to do that because people struggle to understand how to deliver it, and there is some variability according to the area of focus, what people’s needs may be, and what would work for them. The basic idea is to give women basic financial literacy and linking people to three kinds of opportunities. One of those is to link people to jobs, the other one is to try to link people to opportunities to further education if they want that, and the last one is linking people to entrepreneurial opportunities and understanding what that is. What they have learnt with the first bit of the pilot was that although there are quite a few Government interventions out there for people, it is not coordinated and they are very specific. The cash is an incentive based on the fact that people must attend certain sessions. The sessions where they provide the care is the sessions they must attend to be able to get the funding. It is not huge amounts of money and the two government Departments have chosen slightly different ways of doing it. People are given R 300 a month, but it is dependent on them attending the sessions. They are learning a lot from the women and their needs and also what the communities are thinking. There is an initial assessment which looks at what needs to be improved, and this will be used for the next grant.

Dr Slingers said that in the National Strategic Plan it says that a key strategy for working out what people need is what was called the focus for impact. They are trying to help provinces understand exactly where to focus and on what to focus. The focus for impact consists of three main elements. One is a web-based platform that is set up to draw information from different information sources together. Another element of the programme is community profiling. Once they have identified areas that are highly burdensome it allows them to look at exactly in which ward in that district the challenge was located. Then they can work with communities to understand what the drivers and gaps are. For example, some communities say that where there is virginity testing a lot more anal sex happens. These people are not aware that anal sex is more risky in terms of HIV transmission than vaginal sex. So unless they can know this from the community and raise awareness about it they will not be able to truly address the issues. The third point is understanding what kind of programmes they need to provide to the populations at risk in that area. The response for farm workers is that they need each province and each district to understand what their needs are. They are in the process of implementing a paradigm shift where the approach in different communities varies according to the needs of those communities and they are going to need a multi-sector response to be able to do that.

There was an invitation to the Committee from SANAC to attend and participate in the extended SANAC Plenary in November 2018. It is a broad platform where all relevant stakeholders participated.

The Chairperson said the Committee will process that request accordingly.

Ms Steve Litsike, Co-Chair SANAC, said that the Civil Society forum which is an integral part of SANAC is a formal advisory body which was established in 2012 because there was not any forum where civil society came together. In this country there is a substantial number of NGOs. They have 18 sectors so the forum itself is also in various spheres including provincial and district level particularly because of the bottom up approach they took as a council in 2012 when they revitalised their own governance as a council. SANAC is a multi-sectoral body that aims to account, coordinate and monitor the HIV response. She was very clear that they have a crisis of funding where there is money, but it is not being reflected in communities who are recipients. She said that while there is interrogation of accountability, there should also be interrogation of the dissemination of financial resources.

The Chairperson thanked Ms Litsike for her words. At times it is not what is being raised but how it is being raised. We can never do away with Civil Society because they are the ears, eyes and mouths of ordinary people on the ground. 

The Chairperson requested the CEO to send information in writing about what is happening between SANAC and the Department of Basic Education.

The Chairperson thanked SANAC for their presentation.

The Chairperson said that the Committee has been granted a study tour. They will have to indicate which members will be going, four members from the ANC, Two from the DA, and one from the EFF. There is to be two males and two females from the ANC.

The meeting was adjourned.