2007-2011 National Strategy Plan for HIV / AIDS and STIs: Department briefing

HEALTH PORTFOLIO COMMITTEE
27 February 2007
2007-2011 NATIONAL STRATEGY PLAN FOR HIV / AIDS AND STDS: DEPARTMENT BRIEFING

Chairperson: Mr L V Ngculu (ANC)

Documents handed out:
Draft National Strategic Plan on HIV and AIDS & STI (2007-2011)

Audio Recording of the Meeting

SUMMARY

The Department of Health presented a draft version of the 2007-2011 National Strategy Plan for HIV & AIDS and STIs. This included a few changes from the 2000-2006 plan setting clearer targets and ambitious aims such as a reduction in the infection rate of 50%. Much of the plan remained the same but was restructured with some areas being expanded on.

The Committee asked questions regarding the policies around testing and treatment as well as some of the problems that were found during implementation of the last plan. The Committee resolved to be closely involved in the implementation phase of the new plan.

MINUTES

Department of Health presentation
Dr Nomonde Xundu (Director: HIV & AIDS and STIs, Department of Health) said that the old draft plan was being handed out as well as an assessment of the implementation of the previous National Strategy Plan (NSP). They will make the new draft available as soon as it is completed. The South African National AIDS Council (SANAC) still has to approve the plan and must agree on the structure. There had been a meeting in May 2006 to lead the process of creating a new framework. It was finished in September 2006. It was a useful assessment but had limitations. The 2000-2005 NSP did fulfil the task. A problem was the lack of reliable quantified data. She thought that business could contribute more. The first draft was created from extensive consultations with civil society, government departments and other stakeholders. The 8^th draft was completed in February 2007. There were no fundamental differences from the first draft. TB remains a serious concurrent disease with HIV & AIDS. The Department uses antenatal clinic (ANC) Surveillance which is the most reliable source of information. TB and STIs are the most important opportunistic infections. Drug resistant Gonorrhoea has also become a problem, especially in men in KwaZulu-Natal. The Department used Batho Pele as the biggest guiding principle for creating the framework for the plan. She outlined the goals of the NSP 2007 to 2011, especially a decrease in the rate of new infections. They did not have targets before but the new draft is more explicit in this way. It has four main targets including prevention, treatment and research. New sections that were included in the draft deal with costing and identifying the requirements for effective implementation. In summary it is a statement of intent and does not contain all the details of how implementation will take place.

Discussion
Mr G Morgan (DA) gave credit to Dr Xundu for her and SANAC’s wide consultation in creating the plan. There had been criticism in the past, especially from NGOs, that there had not been sufficient consultation. It was heartening to hear and will likely result in greater buy-in from such parties if they have been consulted. He asked whether in reformulating the plan they had considered their biggest successes and biggest failures.

Ms C Dudley (ACDP) asked for elaboration on private sector involvement, the approach to testing and environmental gaps.

Dr Xundu hoped that there would be wide agreement at the National Consultative Forum for the plan. The biggest success was at an outcomes level which is often not easily visible on a short time scale. The biggest failure is the lack of clear targets so the outcomes are very difficult to measure. They have changed this with the ambitious but attainable targets, especially with regards to prevention. The private sector must be leveraged because of their resources which the Department lacks. Testing is an emotive issue. They need to consider the stigma and the capacity for implementation. Most people who are testing are already symptomatic; they wanted to also reach asymptomatic people.

Ms M M Malumise (ANC) asked when the government social cluster would become involved, especially the Portfolio Committee. Is the 50% decrease in the rate of infection really possible? In controlling TB, is there intervention with MDR before it becomes XDR? How long will it take to get the drugs for Gonorrhoea?

Ms F Batyi (ID) asked how far studies on a vaccine for HIV had progressed.

Dr Xundu replied that the 50% reduction is very ambitious. Everyone needs to do something, especially with regards to mother to child transmission and in young women. They could intensify efforts, but should be cautious. They also need TB control and the problem with both is defaulting on treatment. The health system must be supportive and they did have a crisis plan for TB in place. The Gonorrhoea drugs are covered in the STD treatment guidelines. They have a monitoring system to check the levels of resistance. Not everyone is tested, but drugs are administered and this can create resistance. It is not as difficult to deal with as XDR TB. The vaccine is a case of optimism vs. realism. It is a complex virus and complex immune system. The Department is supporting the research out of hope.

Mr Thami Mseleku (Director General) apologised for being late and indicated that the Portfolio Committee should guide the Department as to how it wants to be involved. He asserted that planning is at an executive level and they require guidance on the involvement of the legislature.

The Chairperson said that the Director General had not understood the question. The Department was in the process of adopting the plan, but was talking about involving the Committee during implementation. The Committee wants to know how it will be involved between the current position and the implementation. They feel that they are already being involved quite late in the process.

Mr Mseleku repeated that they wanted guidance from the Committee.

Ms R J Mashigo (ANC) asked for clarity on the capacity increases at district level. Co-ordination at this level has been absent. What has the problem been? The draft plan aimed for 20% palliative care but they had achieved only 10%. Is that now a priority and are there systems in place to achieve it?

Ms M L Matsemela (ANC) commented that the plan is good. They need to cost it and to implement it fully to realise their ambitions. She is worried about the review being called by SANAC as the council had not met for two years. How is the Department going to implement the plan with a non-functional SANAC? Can the Committee be briefed on the strategy for implementation? With regards to medication for pregnant women, is Nevarapine relevant? Is there a new strategy for the CD4 counts required to obtain treatment?

Dr Xundu replied that she could not comment at this point how the strengthening of the district health system will be accomplished. The Department needs to change the plan into an action strategy. There are problems with human resources and with infrastructure. Palliative care has been mainstreamed with a specific programme. With regards to costing, they have investigated but it is difficult to have a specific figure before the National Consultative Conference. A specific figure will take 6-9 months to calculate. SANAC is being restructured. Dealing with HIV & AIDS must be multidisciplinary and cannot only be medical. The Director General would comment further on this. The question about Nevarapine is a technical one. During the previous plan, a few babies were saved. They learnt that where the health system is weak, Nevarapine did not achieve success. They are looking at evidence of the CD4 counts. If they treat people with higher counts, they risk not being able to reach all the people with lower counts because there will be too many people.

Mr Mseleku said he agrees that SANAC has not been functional for two years. Considering the new plan, it is evident that there is a new SANAC in place. The key structural changes have been with the leadership at a government level. The ministers meet with functionaries. The restructuring is at a leadership level. The IMC (inter-ministerial committee) has also been resuscitated. If the plan works, the problems will not be an issue. They are looking at the scientific evidence for Nevarapine. With the creation of policy, one must be sure about the evidence. Scientists often disagree. There must be a series of studies and debates before policy is made. The CD 4 count level is not a thumb suck. It is from the World Health Organisation. They do not exclude the possibility of changing or increasing this level. Resistance is an issue if people are treated for longer, as has been seen in the Western Cape. There has also been a growth in the number of people with mental impacts from the treatment. Treatment needs to be managed.

The Chairperson said that the point is magnitude more than capacity. Some evidence suggests that a CD 4 count of 200 is already too high and late. Capacity is a problem; the Department must “only take on what it can chew”. At some point they should discuss the SANAC restructuring.

Mr A F Madella (ANC) said that they now had a better sense of the NSP. Availability of medicines is a worry. It may not be an issue throughout the country, but there is a problem with the mobile units as people must queue and undress in the open. This is undignified and people are then reluctant to use the facility. How will competent communities be built especially with regards to the Komanani volunteers? He was happy with the SANAC developments. What is the relationship with Provincial AIDS Councils (PAC)?

Ms N C Nkabinde (UDM) said that it is not helpful to poor people for grants only to be issued once the CD 4 count is below 200. Can the Department reassure the Committee that funds will be spent? What is being done about the stigma surrounding HIV & AIDS?

Dr Xundu said that competent communities are built on a ward-based approach keeping in mind what is prevalent and how to deal with it. There is a specific approach for this.

Mr Mseleku said that people do not get grants based on the CD 4 count but on the basis of temporary disability. This can promote not taking medication. They need assistance for chronic illness. This is being looked at. SANAC and the PACs need a model at a national level that can be replicated at a provincial level. With regards to the availability of medication and facilities, more clinics are needed in some areas. It is an interesting challenge; 90% of the medication is available but some need to be moved and there may be a problem with the other 10%. They need good systems and management for efficacy; it is not always an availability issue.

Mr Morgan said that the NSP is a broad target. Testing is the first line of defence. They need to maximise the number of people tested. Compulsory counselling before testing can dissuade people from being tested. What is the position of Komanani in the tender process, are they close to appointing a new service provider? With regards to future lines of AIDS drugs, the Western Cape had a longer roll out and now has greater resistance. Does the next line need to be fast tracked?

Ms M N S Manana (ANC) commented that Dr Xundu had said that the relationship between SANAC and PAC is ward-based and the Director General had said that they want to restructure it. Ward members are the main stakeholders. Will it not be destructive to restructure those that are functional?

Mr Mseleku replied that there was no contradiction. They do not want to create a new structure. Some of the next line of drugs has already been registered with the Medicines Control Council (MCC). The expense is more of an issue than registration time. The new drugs cost in the order of 10 times that of the first line. They are trying to create generics but they are not as effective. It is a challenge to open access to the drug contents. He cannot give details of the tender process as they are trying to finalise this. There is an ongoing debate about policy gaps and appropriate counselling before testing. It is part of the policy discussion. The VCT testing is for high-risk groups. They must routinely offer testing. Infrastructure remains a limiting factor. They must address the failures of the first line drugs before introducing the second. Complications and side affects are more of an issue but the dose can be reduced to counter this. Competent communities are essential for efficacy. They are tying to make it better organised.

Ms Mashigo said that in her constituency there are many NGOs that do a lot of work but receive no funding and no monitoring. If funding is not available it is demotivating. What criteria are used to assign funding?

Ms M M Madumise (ANC) asked if asymptomatic people are treated for other diseases or are they referred elsewhere. Homosexuality used to be thought to be associated with HIV. Is it now more common in heterosexuals or homosexuals?

Ms Matsemela asked about monitoring; they now want to include traditional medicines in the plan, how far is this at the moment? Research has also been included in the plan. Male circumcision could make men careless, is it included as part of the plan?

Mr Madella said that HIV studies mainly target women. The spread has been mainly in homosexual communities but there is no proof of this. There is no comprehensive picture of the prevalence. Compulsory testing would give a real indication, especially in the penal system. How much does the new plan cater for prisoners and their access to treatment?

The Chairperson commented that sometimes the questions straddle the operational side and they understand that Dr Xundu can only really comment fully on the planning.

Dr Xundu replied that she would share what information she has. It would be better to discuss the NGO funding at another time. There are different levels of NGOs and funding is given to those especially at a National level. She is not sure of the specific case details and as such cannot really comment. Pregnant women are prioritised because they often have other communicable diseases. The homosexual case is interesting. HIV was originally found in gay men in the USA. This changed in South Africa where the most important risk factor is heterosexual sex. This is due to gender imbalance, poverty, underdevelopment and multiple partners. Male on male sex is not forgotten but these groups are diffuse. Traditional medicines will be researched, because not enough is known.

The Chairperson thanked Dr Xundu for her presentation. They need to engage further, especially how the plan will translate on the ground as this is the function of the Committee. There are also other issues like insurance problems where dead bodies are tested and insurance claims changed accordingly.

The meeting was adjourned.