Tracking Progress on the HIV and AIDS and STI Strategic Plan for South Africa

June 2000 – March 2003

Introduction

In June 2000 the Department of Health launched the HIV and AIDS and STI Strategic Plan for South Africa, 2000-2005. This followed an extensive consultation process that started in June of 1999. The aim of the Plan was to provide a framework for a multisectoral response to HIV and AIDS, at all levels of society.

Since the launch of the Plan, significant progress has been made in the implementation of the goals and activities contained in the Plan. This brief document aims to provide an overview of what has been achieved in the Strategic Plan since 2000. This will also feed into a process of a mid-term review of the Strategic Plan to be conducted in 2003, and does thus not aim to cover the response in every sector, but rather focus on the government response to HIV and AIDS and STIs.

  1. OVERALL GOALS

The overall goals of the Strategic Plan are to:

Some of the general strategies to achieve these goals included the use of appropriate information, education and communication (IEC), increased access to voluntary HIV counselling and testing (VCT), improved STI management, and improving care and treatment for HIV infected and affected.

The Strategic Plan is structured according to the following four areas, namely:

These 4 focus areas contain 15 objectives in total, and the following section will provide information on progress made against each of the 15 objectives.

However, there are some crosscutting issues, such as resource allocation and capacity building, and these will be dealt with in the following sections, rather than under the different goals.

  1. RESOURCE ALLOCATION

In the current MTEF period of 2003/4 to 2005/6, the National Treasury has set aside an additional R3.3 billion in the fight against HIV and AIDS. This R3.3 billion is over an above the HIV funds already in the MTEF (e.g. provincial own HIV and AIDS allocations). These funds are to be channelled to Health , Education and Social Development.

These increases build upon the large injection of additional funding for HIV and AIDS that was secured in 2001 through the “Enhanced Response to HIV and AIDS and TB in the Health Sector”. Working from a baseline estimate that the health sector was already spending approximately R4.4 billion in 2001/02, the “Enhanced Response” allowed the mobilisation of significant additional funds over the following three-year MTEF period. A revision of the “Enhanced Response” in 2002 resulted in further substantial increases to earmarked HIV and AIDS funding. The table below shows the additional funds allocated to the Health sector for use in HIV and AIDS programmes:

Millions of Rands  2001/02 2002/03 2003/04 2004/05 2005/06
Baseline HIV and AIDS Spend 4,191 4,191 4,191 4,191 4,191
2001 ER Equitable Share   400 627 988 1,032
2002 ER Equitable Share     500 1,000 1,500
Conditional Grant 34 210 334 482 535
National Dept of Health 220 330 330 330 330
Total Earmarked Funds 4,445 5,131 5,982 6,990 7,588

The equitable share is the major source of health funding to the provinces, and in the next MTEF period this amount is increased to cater for specific HIV and AIDS and TB spending. It will be a provincial prerogative as to what this funding will be used for.

The 2003/4 allocation for HIV and AIDS and TB in the Health Department amounts to R668 688 000. Of this amount, R333 556 000 is to be provided as a conditional grant to the 9 provinces. These conditional grants cover 8 thematic areas: HBC, VCT, PMTCT, Step-down care, Strengthening provincial management, Commercial sex worker interventions, Centres of excellence, and Non-occupational post-exposure prophylaxis.

The remaining R335 112 000 has certain “dedicated” amounts, for the following activities: loveLife transfer, SANAC, SAAVI, condoms, personnel, NGO transfers, communication campaigns, and the Global Fund contribution. The remaining R53 million is divided amongst the 12 operational activities within the HIV and AIDS and TB Programme (e.g. TB, NGO funding, VCT, and STI prevention).

  1. CAPACITY BUILDING

Capacity building, through training, is one of the key components of the various goals in the Strategic Plan. This training was primarily structured around the various HIV and AIDS and STI guidelines published by the Department of Health since 2000. These include:

Training has taken place in the last 2 years in a variety of areas, such as the 11 000 health workers trained on the management of opportunistic infections. However, one of the problems with the training is that it has been fragmented. This is being addressed specifically in 2003. Social partners could add considerable value to this.

Capacity building and training were key strategies for sector support of the National HIV and AIDS programme. The following sectors benefited from a range of workshops mainly centred around advocacy and HIV and AIDS planning: National and provincial government departments, NGOs/CBOs, local government, trade unions, traditional healers, faith-based organisations, traditional leaders, traditional healers, disability sector, women sector and men sector.

Part of the funding to be provided in 2003/4 as part of the conditional grant system is to be used for training (the Integrated Training grant). This grant is to ensure collaboration between the province and academic institutions to standardise both undergraduate and in-service training. The in-service training could also be provided using other existing institutions with training capacity such as the Southern African HIV Clinicians Society.

Part of the activities conceived for the Centre of Excellence in each province, funded by the conditional grant, is to ensure the effective distribution of the treatment guidelines for opportunistic infections, TB and STIs.

Through a partnership with the Foundation for Professional Development, health workers will be trained in issues relating to HIV and AIDS, STIs and TB. This includes a component on managing patients on ARVs. This training will target 100 health workers per province annually for 3 years. If the provinces provide additional funding, this can be further expanded to train more health workers.

  1. OVERVIEW OF PROGRESS NATIONALLY

The response to HIV and AIDS, STIs and TB was fairly limited before 1994, and focused predominantly on the provision of condoms (in small numbers) and a limited information, education and communication (IEC) initiative. In 1994 the Government placed a clear emphasis on the effort to address HIV and AIDS in the country, and the first evidence of that was the NACOSA strategy to address HIV and AIDS and STIs, released in 1995.

This commitment was also matched since 1994 by a steady increase in financial allocation to the HIV and AIDS programme within the Department of Health, the lead department in addressing the epidemic. In 1994 an amount of R30 million was allocated for the fight against HIV and AIDS. In 2002 this had grown to R409 million to the Department of Health, R148 million to Education, and R48 million to Social Development.

Other major achievements in the last 8 years have been:

The launch of the Strategic Plan and the South African National AIDS Council (SANAC) in 2000 was especially significant. The Strategic Plan provided a clear framework for addressing key issues of care and support, while maintaining a strong emphasis on prevention. The establishment of SANAC was also instrumental in ensuring that sectors outside of government have a clear understanding of the Strategic Plan and their specific roles and responsibilities in implementation.

Subsequently all provinces established Provincial AIDS Councils, and there are also District AIDS Councils in the majority of districts. However, the challenge is to ensure that there is sound collaboration between the councils at the different levels.

SANAC has been thoroughly reviewed in 2002, and some of the decisions taken to strengthen SANAC include the appointment of a small, dedicated Secretariat with technical as well as administrative skills, and advertising for nominations of members to SANAC. SANAC also endorsed the relocation of the Secretariat to the office of the Deputy President. The current term of office for SANAC civil society representatives expires on 31 March 2003. Sector representatives were requested to establish a fair and open nomination process within their sector to ensure continuation in sector representation as from 1 April 2003.

Sectoral participation is crucial to the implementation of the Strategic Plan, and it is clear that key sectors have made good progress in this regard. Some examples of these improved partnerships are:

This progress, especially the efforts of government and other organisations to focus on young people, are starting to show results. A loveLife study shows increasing awareness, and the 2001 annual survey of pregnant women receiving care in the public health sector indicated HIV prevalence amongst those less than 20 years old declining for the third year.

There is also increased participation in the fight against HIV and AIDS by other government departments. All national government departments and the majority of provincial departments provide basic HIV and AIDS related services to their staff. A growing number of departments integrate HIV and AIDS programmes into their line functions. The Life Skills programme led by the Department of Education and the DPSA Impact and Action Project have already been mentioned. Other examples are the Department of Transport (Trucking Against AIDS), Labour (Code of Good Practice on HIV and AIDS), Land Affairs (programme for land reform) and a partnership between SAPS, Defence, Correctional Services, and Health (the Civil Military Alliance). It is believed that through effective partnerships within government spheres, and with civil society, the achievements of the last few years can be built upon even more.

The following sections will address some achievements against the Strategic Plan by government, and primarily the Departments of Health, Social Development and Education, over the last 2 years since the Strategic Plan was launched.

  1. PREVENTION

5.1 Goal 1: Promote Safe and Health Sexual Behaviour

The focus in this goal is on IEC (including life skills), promotion of the consistent use of barrier methods; ensuring programmes in trade unions, implementing high transmission area programmes (e.g. trucking sector), programmes for migrant workers and cross-border initiatives.

Government has managed to make significant progress in this regard. Some of the highlights include:

5.2 Goal 2: Improve the Management and Control of STIs

This goal focuses on improving the management and control of STIs in both the public and the private sector. This involves strengthening the skills of health workers in STI management, working with traditional healers in the management of STIs, and improving services to youth-friendly health services.

Progress in this regard include:

5.3 Goal 3: Reduce Mother-to-Child HIV Transmission (PMTCT)

This goal focuses on integrating VCT into maternal and child health care services, improving family planning services to known HIV positive women, identify HIV positive women in order to improve their health seeking behaviour, and implement clinical guidelines to reduce the transmission of HIV from parent to child. (Some of the VCT issues will be addressed under goal 6).

In early 2001 the Department launched a limited programme on PMTCT to serve as research sites that would inform a broader implementation strategy. This schedule was challenged in the judicial system, resulting in a Constitutional Court judgement that saw a much more rapid rollout of the PMTCT programme.

To date approximately 600 facilities are offering VCT and the PMTCT programme that includes the provision of Nevirapine to mother and infant, and formula feed to women who choose to exclusively formula feed.

As indicated above, the Constitutional Court ruling dictated that the rollout process proceeds at a rapid rate. Presently all provinces have embarked on rollout, and it is expected that full national rollout will be achieved by the end of March 2003. To facilitate this process, significant additional resources have been made available for this programme.

5.4 Goal 4: Blood safety and HIV

South African maintains very high standards as it relates to blood safety. Blood donated to blood banks are routinely testing (using antibodies and P24 antigen testing), and this screening adheres to international standards.

5.5 Goal 5: Provide post-exposure services

The guidelines for needlestick injuries and occupational exposure have been available since 2000. The relevant protocols and drugs are available in the public sector for this intervention. Universal precautions are also in place in health facilities to reduce the risk of occupational exposure.

In terms of non-occupational post-exposure prophylaxis, the Department released guidelines and the protocol in May 2002 to ensure that survivors of sexual assault have access to an appropriate intervention. Implementation started in 2002, and additional funds have been made available in the 2003/4 budget through the conditional grant system.

5.6 Improve access to voluntary HIV counselling and testing

Ensuring access to confidential and voluntary HIV counselling and testing is one of the essential elements of the Strategic Plan, as it provides an important entry into other health interventions, e.g. TB and STI treatment. This goal focuses on expanding access to VCT in both the private and public sector.

By the end of 2002 VCT is available in 982 sites throughout the country. This includes the sites where PMTCT is available. Through the expansion plans for both VCT and PMTCT, it is aimed to have VCT services available in 80% of public health facilities by the end of the 2003/4 financial year. To this end the conditional grant for HIV and AIDS to the provinces, including expanding VCT and PMTCT, has increased significantly (from R210 million in 2002/3 to R334 million in 2003/4).

The new tender for rapid test kits has been awarded for a 2-year period. This will ensure that new retraining on the test kits is only required in 2004. Through the expansion programme new counsellors will be recruited in 2003.

A tender has been awarded to the University of Natal to assist provinces to roll out the mentorship programme for the VCT programme. The tender ends in December 2003.

Through collaboration with the Development Bank of South Africa (DBSA) and a German donor, the Department aims to address the infrastructure issues relating to the provision of VCT. As many facilities do not have sufficient space to provide VCT, the R90 million grant (routed through the DBSA) will allow for construction of additional rooms to existing facilities.

Encouraging people to go for voluntary HIV counselling and testing will be an important advocacy focus in 2003. With approximately 1000 facilities now able to provide this service, it is the opportune time to create greater awareness around the benefits of knowing one’s HIV status.

Some government departments are already investigating the establishment of VCT services. These departments include the Office of the Public Service Commission, Public Service and Administration, and the SA Management Development Institute.

  1. TREATMENT, CARE AND SUPPORT

6.1 Goal 7: Provide treatment, care and support in health facilities

This goal has a few priority strategies, namely the provision of guidelines for the treatment of opportunistic infections, consistent drug supplies, capacity building of health workers, intensified TB case finding, poverty alleviation programmes, and address issues of HIV and AIDS in the medical insurance industry.

Significant progress has been made against these strategies.

6.2 Goal 8: Provide adequate treatment, care and support services in communities

The primary focus of this goal is on the provision of community/home-based care (HBC). Progress in this regard include:

6.3 Goal 9: Develop and expand the provision of care to children and orphans

At government level the Department of Social Development takes the lead in the implementation of this goal, albeit with some assistance and collaboration with Health and Education. The focus in this goal is on services for orphans and vulnerable children. Progress include the following:

  1. RESEARCH, MONITORING AND SURVEILLANCE

7.1 Goal 10: Ensure AIDS Vaccine Development

The South African AIDS Vaccine Initiative (SAAVI) was established in 1999 to develop and test an effective, affordable and locally relevant vaccine for South Africa within ten years. This initiative has as its main funders the Department of Health, the Department of Science and Technology, and Eskom. SAAVI has received international recognition as a successful public-private partnership in vaccine development.

SAAVI continues to develop subtype C HIV vaccines and is at an advanced stage of laboratory testing of certain of these candidate vaccines. Funding for SAAVI from the Department of Health is also being increased from R5 million to R10 million per annum. The Department of Science and Technology has also effected similar increases. Eskom recently announced that its annual funding (for the next 5 years) will amount to R15 million per annum.

One of the important arms of SAAVI focuses on ensuring that the trials are conducted in line with the guidelines of Government on ethical research (released in October 2000). This is aimed at ensuring that the trial work adheres to the highest ethical standards. This has been confirmed in recent meetings between the Ministry of Health and the programme coordinators.

7.2 Goal 11: Investigate treatment and care options

This goal includes the following strategies: reviewing the use of antiretroviral therapy (ART) in PMTCT, reviewing the options for ART in the public sector, and supporting research into the effectiveness of traditional medicines. Progress in this regard include:

7.3 Goal 12: Conduct Policy Research

This goal focuses on policy research in the government sector, as well as HIV incidence research.

Research that informs policy has been prioritised in a number of departments. One example is the impact study and a policy/legislative review commissioned by the Department of Public Service and Administration. By June 2002 this has resulted in far-reaching changes to the Public Service Regulations prescribing minimum standards for departmental HIV and AIDS workplace programmes at national and provincial level. Other departments conducting impact studies for their planning include Agriculture, Defence, Education, and National Intelligence.

South Africa began HIV incidence testing in 1999, where two laboratory methods were used. The OTV assay was used to test the samples from the Western Cape, while Abbott 3A11 HIV-1 EIA was used to test samples from all eight provinces. Modified versions of these tests were used to differentiate the old infections from the recent infections.

STARHS is a name given to a simple technique that allows researchers to distinguish long-standing HIV-infections (Prevalence rate) from those acquired recently (Incidence rate). The name stands for the Serologic Testing Algorithm for Recent HIV Sero-conversions. In this technique, a standard ELISA blood test that detects HIV-fighting antibodies six to eight weeks after infection is modified by means of changing the test sample processing factors like sample dilution, incubation time and conjugate incubation time. This will form a less sensitive version that picks up antibodies within four to six months.

If the sample tests positive on the sensitive test and negative on the less sensitive test, it is likely to be a recent infection while a positive result on both tests indicate that an infection is more than four to six months old.

The Abbott 3A11-EIA can pick infections that are 129 days old (95% CI of 109 – 149 days) while OTV assay can pick infections which are170 days old (95% CI of 162 – 183 days).

The Department has sought the expertise to appropriately interpret this data from the 1999, 2000, and 2001 HIV seroprevalence antenatal surveys. The data would only be released later in 2003.

7.4 Goal 13: Conduct regular surveillance

The focus in this goal is on improving the surveillance capacity within the country, including conducting sentinel surveillance, STI surveillance, surveillance of AIDS mortality and morbidity, and routine HIV seroprevalence surveillance.

The Department of Health has placed significant emphasis on improving the surveillance efforts that inform planning. Some of these efforts have consisted of implementing second-generation surveillance tools to better track the determinants, trends and patterns of distribution of the HIV and AIDS epidemics. These have come to strengthen the antenatal HIV and syphilis seroprevalence surveys conducted annually by the Department of Health.

Significant steps currently include the following:

Using these findings in conjunction with research studies outside the government sphere, the national and provincial governments will be in a better position to plan and implement programme interventions.

  1. HUMAN AND LEGAL RIGHTS

8.1 Goal 14: Create an appropriate social environment

This goal focuses on the promotion of openness around HIV and AIDS, addressing stigma and discrimination, encouraging disclosure, promoting VCT, increasing awareness of rights, ensuring the management of mentally challenged HIV positive persons, and monitoring human rights abuses.

Addressing stigma and discrimination is a complex issue, and is not the sole responsibility of government, but rather a societal response is required. Some specific activities in this regard include:

8.2 Goal 15: Develop an appropriate legal and policy environment

This last goal in the Strategic Plan focuses mainly on HIV and AIDS and the workplace, and legislation relating to commercial sex workers. Issues in this goal that relate to the provision of post-exposure prophylaxis to survivors of sexual assault have already been addressed in the prevention section.

In 2000/01 most national government departments developed HIV and AIDS workplace policies. Some provinces opted for the development of a single provincial policy, binding all provincial departments. The amendment of the Public Service regulations in June 2002 constitutes a binding policy framework for all departments (national and provincial). The policy framework for departments is rooted in human rights principles and prescribes programmes in line with the Strategic Plan priority areas on prevention, care and support.

Other significant issues include:

  1. GAPS IN IMPLEMENTATION

Much has been achieved in the last 2 years, especially since the formulation of the National Integrated Plan (NIP). This provided the impetus for major interventions such as home-based care, voluntary HIV counselling and testing, and life skills education in schools. The NIP also allowed government to address key strategies within the Strategic Plan, and closer collaboration in the implementation of these activities (especially the NGO sector).

However, there are still some areas within the Strategic Plan that have not yet been addressed adequately. These include the following goals and strategies:

Clearly not all of these objectives are within the ambit of the Health Department, but certainly warrants further discussion within government broadly.

When comparing the Strategic Plan and the activities of Health and Government as it relates to HIV and AIDS to the international arena, it is clear that the strategies and policies of the country are on track. However, the only response intervention that is missing currently, and which is also receiving major local and international attention, is the provision of antiretroviral therapy (ART) – aside from those provided to pregnant women and survivors of rape.

Another relatively weak area is a clear and coordinated process for monitoring and evaluation. Most efforts currently are vertical and ad hoc, and do not feed into the national health information system that can provide critical information for planning and monitoring of interventions at district, provincial and national level. The Department of Health aims to develop a monitoring and evaluation framework in 2003 that is based on the Strategic Plan, rather than on vertical programmes.

  1. CONCLUSION

The brief overview of progress in three government departments - Health, Education and Social Development – shows that significant implementation of the goals and strategies of the Strategic Plan has been achieved. When this document is added to by other government departments, especially those in the Social Cluster, this picture of a concerted government effort will emerge even more clearly.

There is general agreement that the Strategic Plan is sound, and should be supported. The challenge remains that of implementation, hampered by constraints such as human resources and technical skills. Driving the multisectoral response across government and civil society has to be a key priority in ensuring the achievement of our goals.