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End of Term Review of the NSP 2007-2011  Final Report 4 November, 2011

End of Term Review of the NSP 2007-2011  Final Report 4 November, 2011. Summary.

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End of Term Review of the NSP 2007-2011  Final Report 4 November, 2011

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  1. End of Term Review of the NSP 2007-2011 Final Report 4 November, 2011

  2. Summary The purpose of this review of the National Strategic Plan (NSP) and the Provincial Strategic Plans (PSPs) 2007-2011 is to contribute to the evidence base to inform the development of the next round of strategic plans. It consists of an assessment of the achievements, challenges, missed opportunities and emerging issues to prioritise in addition to documenting lessons learnt and good practices. We are reviewing the 4 different pillars and the priority areas under each pillar. Pillar 1: Prevention Pillar 2: Treatment, Care an Mitigation Pillar 3: Monitoring, Research and Surveillance Pillar 4: Human Rights and Access to Justice

  3. Review Pillar 1: Prevention Introduction: A primary aim of the NSP was to ensure that the large majority of South Africans who were HIV negative remained HIV negative. The goal was to reduce the number of new HIV infections by 50%, with a particular emphasis on reducing new infections in the 15-24 year old age group. Although new adult infections (total annual new cases of HIV infection dropped from 640 000 in 2000 to 390 000 in 2009), the NSP target has likely not been reached.

  4. Estimated number of new infections among adults 15-49 in South Africa: 1990-2009 While HIV incidence has been declining, there are still large differences across provinces with three-fourths of South Africa’s new infections clustering in KwaZulu-Natal, Gauteng, and the Eastern Cape. In contrast, the Northern Cape has an estimated annual HIV incidence of only 0.7% resulting in an estimated 3 177 new infections per annum This incidence rate is the lowest in the country and accounts for 0.9% of South Africa’s total new infections

  5. Estimated annual HIV incidence and number of new infections in adults • 15-49 years old in South Africa’s provinces (2009)

  6. Percentage of young women and men aged 15-24 who are HIV infected

  7. It can be concluded that overall, the implementation of HIV prevention initiatives has reduced infection rates over the last decade. However, the number of new HIV infections still remains high exceeding death rates from AIDS (partly because of the effectiveness of treatment programmes) leading to an increasing number of HIV positive individuals.

  8. Prevention priority area 1: Reduce vulnerability to HIV infection and the impact of AIDS The MTR stated that the objectives under this component were “generalized national intervention strategies related to poverty reduction. It is not practical or realistic to make the multi-sectoral HIV and AIDS programme accountable for achieving poverty reduction in the way defined in the NSP”.

  9. Prevention priority area 2: Reduce sexual transmission of HIV In South Africa it is estimated that the bulk of HIV transmission (86%) is through sexual transmission. At present, the only purely biomedical interventions that are proven to be effective in preventing the sexual transmission of HIV are male circumcision, providing HAART (Highly Active Anti-Retroviral treatment/therapy) to HIV positive people and post-exposure prophylaxis. For this reason, the bulk of prevention interventions rely on people making changes to their behaviours.

  10. 1. Mass media, Information, Education, Communication and Behaviour Change Programmes. Exposure to South Africa’s HIV prevention communication through media campaigns is high, with 80% of those surveyed knowing at least one of the initiatives, in particular among the 15-24 year olds age group. In spite of these initiatives, correct knowledge on the prevention of sexual transmission of HIV was lower in 2008 than in 2005.

  11. 2. Multiple and Concurrent Partnership There is considerable interest and debate on the importance of MCP. The (NCS 2009) National Communication Survey reported that, overall, the rate of partner acquisition was three times higher in men than in women, and highest in men aged 20-24 years . The rate was highest among those who have no partner, and those who are in their early twenties. African men and women seemed more likely to acquire a new partner than non-Africans. Men and women living in tribal areas were the least likely to acquire a new partner. Comparing multiple partner data across the five national surveys, there is some indication of an increase over time in the proportion of 16-55 year old men who reported MSPs in the past 12 months. HIV prevalence was higher in respondents reporting more sexual partners. There is little data available on concurrency in South Africa although there is a growing interest in research in this area. For this reason, we present below data from the provinces on multiple partnerships only.

  12. 3. Percentage of women and men 15 - 49 who have had sexual intercourse with more than one partner in the last 12 months

  13. 4. Provincial perspectives For more information about the provincial perspectives of the Eastern Cape, Gauteng, KwaZulu Natal and North West, see p 52 and p 54 of the manual.

  14. 5. Age of sexual debut There has been a long term trend towards earlier sexual debut amongst youth. For men and women born before 1950, median age at first sex was 20 years and for those born in the 1980s; it was 18 years. Young Africans report higher levels of sexual experience than coloured, Indian and white youth. The Cape Area Panel Study (WC) found that girls in lower income households tended to have earlier sexual debut, and that community poverty rates were associated with early sexual debut and higher rates of unprotected sex. In the Africa Centre study area (KZN), the most important and highly significant factor protecting females against first sex before the 17th birthday, was school attendance.

  15. 6. Percentage of young men and women who have had sexual intercourse before age 15 (Age at first sexual debut)

  16. 7. Medical Male Circumcision Since the development of the NSP 2007-2011, new evidence has emerged that male circumcision can reduce HIV transmission in men by up to 60% and in South Africa local researchers found the risk of HIV transmission in circumcised men was reduced by 76% with no significant increase in sexual risk-taking behaviour. In 2010, South Africa instituted an aggressive roll-out of a national Medical Male Circumcision (MMC) program with the goal of reaching 80% of HIV negative men aged 15-49 (approximately 4.3 million men) by 2015. As of June 2011, almost 238 000 circumcisions had been conducted. The guidance from the UN recommends at least 5 million circumcisions would be required in South Africa as a prevention strategy to impact on new HIV infections. KZN has made the most progress of all the provinces in regards to circumcision.

  17. 8. Condom Distribution and Usage The distribution of male condoms increased from 308.5 million in 2007, to 495 million in 2010 (a 60% increase). However, this translates to an individual level of only 14.5 condoms per adult male per year (15-49) in 2010 against 12.7 per adult male in 2008. The number of female condoms distributed free has increased from 3.6 million in 2007 to 5 million in 2010 (a 39% increase). However, there are still widespread complaints that female condoms are not as readily available as they should be. Condom use in South Africa has continued to increase with the percentage reporting the use of condoms in the most recent sexual encounter increasing from 35% (2005) to 62% (2008) with the highest rates amongst younger age groups. Increased condom use among the youth may have contributed to the recent decline in HIV incidence in this age group. People above 50 and married people are least likely to report condom use. PLHIV who knew that they were HIV-positive were significantly more likely to use a condom than PLHIV who did not know their HIV status.

  18. 9. Provincial Perspectives. Table: Percent of young men and women 15-24 and 25-49 reporting the use of a condom with their last sexual partner at last sex

  19. 10. Table: Number of male and female condoms distributed annually in the provinces by the public sector

  20. 11. Key Populations Globally, men who have sex with men (MSM), transgender people (TG), sex workers (SW), injecting drug users (IDU), prisoners, and migrant populations have been shown to be at disproportionate risk for HIV infection. In South Africa an estimated 9.2% of all new HIV infections are related to MSM and 19.8% are related to commercial sex work. Because they are often marginalized by society and greatly affected by discrimination and stigma, these groups have become some of the most at-risk populations for HIV infection. These groups are collectively labelled“key populations”. HIV prevalence within these populations tends to be higher in areas where same-sex behaviours, drug use and sex work are criminalized, and where appropriate actions addressing their specific health needs are absent. High levels of prejudice and moral loading has been shown to create barriers to accessing prevention, treatment, care and support – increasing vulnerability to HIV.

  21. For:1. “Evidence that Key Populations are at higher vulnerability to HIV infection”, and2. “Key points about the NSP 2007-2011 in relation to Key Populations”, and3. “A minimum service package for all key population groups should include...” see the manual on pages 61 and 62.Question: Why are key populations at higher vulnerability to HIV infection?

  22. 12. Long Distance Truck Drivers Long distance truck drivers, particularly in the early stages of the HIV epidemic, were considered important in the spread of HIV and to have particular prevention and treatment needs. In response to this, a variety of programmes aimed at this sub-population have been developed. For info on provinces about long distance truck drivers in the Eastern Cape, Free State and Limpopo, see p 63 in the manual. Also note the section about farm workers on page 64 of the manual

  23. Prevention priority area 3: Prevention of Mother to Child Transmission (PMTCT) Prevention of mother-to-child transmission (PMTCT) programs play a significant role in averting peri-natal infections in South Africa.  Without antiretroviral treatment (ART), about 1 out of every 3 babies born to HIV-infected women will be infected.  With ART, transmission can be reduced to less than 5%, the South Africa PMTCT goal, with an effective PMTCT programme. Since 2008, South Africa has rapidly scaled-up its PMTCT and Early Infant Diagnosis (EID) programmes. By 2010, PMTCT was offered at 98% of health facilities. As a result of the scale up of PMTCT in South Africa, by 2010, transmission from mother to child at 6 weeks was reduced to 3.5 percent

  24. Table: Number of infants born to HIV infected mothers who are HIV-infected

  25. Prevention priority area 4: Minimize the risk of HIV transmission through blood to blood products South Africacontinues to achieve 100% targets for blood being screened in a quality assured manner. Across the almost 19,000 blood banks operated by NBTS that screened over 775,000 blood units in 2010, HIV transmission through blood has been virtually eliminated and the safety of blood products in South Africa is on par with international standards (UNGASS report, 2010).

  26. Review Pillar 2: Treatment, care and mitigation Introduction: The second aim of NSP 2007-2011 was to reduce the impact of HIV and AIDS on individuals, families, communities and society by expanding access to appropriate treatment, care and support to 80% of all HIV-positive people and their families by 2011.

  27. Priority area 1: Increase coverage to voluntary testing and promote regular HIV testing HIV Counselling and Testing Coverage of HIV counselling and testing (HCT) increased substantially from 2005 to 2010. In 2008/09, 96% of public health facilities in the country offered voluntary HIV counselling and testing (HCT) with a target of 100%, and 24.7% of adults had been tested and received their results in the past 12 months with a target of 11%. In April 2010, South Africa launched a national HCT campaign with the goal of promoting HIV counselling and testing and urging all South Africans to know their HIV status and be screened for TB. As of June 2011, almost 11 million people had been tested for HIV as part of the HCT Campaign. In addition, South Africa is currently scaling-up its Provider Initiated Counselling and Testing (PICT) model to extend access to HCT at health facilities.

  28. Provincial Table: Number of people tested for HIV (excluding antenatal) including provision of results

  29. Priority area 2: Enable people living with HIV to lead healthy and productive lives Roll-out of antiretroviral therapy continues to be successful, with 1.4 million persons started on antiretroviral therapy and approximately 1.1 million currently on treatment. Treatment initiation rates have reached 30,000 per month.  A revision of the treatment guidelines in 2009 has increased the threshold for ART treatment in pregnant women and patients co-infected with TB and HIV to CD4+ count 350, and the provision of safer and effective antiretroviral therapy regimens for adults and children. The number of people living with HIV receiving nutritional support (734,900) surpassed the NSP targets for 2008/09 (500,000) Overall mortality rates have demonstrated a gradual reduction, reflecting the increase in treatment access.

  30. Table: South Africa projected AIDS related deaths National ANC Sentinel HIV and Syphilis Prevalence Report. National Department of Health, 2010,

  31. Provincial Table: Percentage of adults and children with HIV known to be on treatment 12 months after initiation of antiretroviral therapy.

  32. Priority area 4: Mitigate the impacts of HIV and AIDS and create an enabling social environment for care treatment and support The Department of Health provides nutritional support to people living with HIV and AIDS mainly through the provinces. By 2008/9 a total of 734 409 people living with HIV, AIDS and TB were provided with nutritional supplements which exceeded the target of 500 000. Difficulties accessing grants is one of the main reasons why some OVCs go without financial assistance. Problems include legislative barriers requiring a guardian to receive and manage monetary assistance from government, and elaborate documentation which children are often unable to provide.

  33. Review Pillar 3: Monitoring, research and surveillance Introduction: The MTR listed the following main conclusions on the monitoring, research and surveillance component of the NSP 2007- 2011 and little has changed since then: 1. There is not one multisectoral, M&E system to collate, aggregate, analyse and report on the national response. 2. The NSP has too many, non-prioritised and in some cases, un-measurable, indicators. 3. Without a national NSP implementation plan in place, there has been a missed opportunity to break targets down by priority area and province. 4. Regular, public reports on the NSP progress do not exist. 5. Monitoring, evaluation and research tends to be an under-capacitated and underappreciated area.

  34. Note the following priority areas: (page 82-84 in the manual) 1. Priority area 1: Implement the monitoring and evaluation framework of the NSP 2. Priority area 2: Support the development of prevention technologies 3. Priority area 4: Conduct policy research 4. Priority area 5: Conduct regular surveillance

  35. Review Pillar 4: Human Rights and Access to Justice Introduction: South Africa has a very progressive constitution, as well as laws and other regulations that provide for the security of human rights and protects individuals against discrimination. These specifically include provisions for vulnerable populations such as women, young people, MSM, prison inmates and migrant populations. However, implementation of some of these policies has been poor, and policies do remain that promote stigmatization and discrimination, such as the continued criminalisation of sex work which creates barriers for HIV prevention and treatment.

  36. (continue) a. Stigma Reduction – Provincial A Stigma Mitigation Framework was developed as a collaborative effort between the National Department of Health and the USAID funded Health Policy Initiative. This framework constitutes a guideline for the design and implementation of stigma reduction interventions for chronic infectious diseases including HIV, AIDS and TB. A gender based violence assessment report for South Africa was also produced by the United States Government. This document amongst other things makes an assessment of gender based violence programmes and priorities in the country.

  37. Review Pillar 4: (cont) b. Reducing vulnerability to sexual and gender based violence A review of women, girls, and gender equality in Southern and Eastern Africa, South Africa scored high in relation to the inclusion of gender-based rights in National Strategic Plans for HIV and AIDS. However, the report also indicates several areas for improvement.

  38. Overview of the NSP 2007-2011 a. Policy Environment The KYR and other reviews have pointed out that simply having policies in place does not constitute an effective programme; it is implementation that is the key issue. The KYR report concurred with the MTR in identifying the main gap as being the lack of a national, unified prevention strategy that is adequately resourced and that flows down operationally and programmatically to provinces and districts.

  39. (Continue) Other gaps in the policy environment identified by the KYR report included: 1. The lack of male engagement in prevention of mother-to-child transmission (PMTCT). 2. The need for better communication of the post-exposure prophylaxis (PEP) guidelines. 3. The need to ensure cultural sensitivity in the development of a National Male Circumcision Policy. 4. The need to better target special populations including out-of- school youth, people with disabilities, mobile and migrant populations, commercial sex workers, and men who have sex with men (MSM). 5. The need for policies on female condom distribution, sero- discordant couples, and on regulating the provision of health services across international and regional borders.

  40. (Continue) For more information on: Management, Coordination and Institutional Arrangements – National to local, The South African National Aids Council The Provincial Aids Councils * The Provincial Aids Councils District and Local Aids Councils Ward Based Community Competency Programmes Outcomes of Community dialogues Government Response Department of Public Service and Administration’s Systems monitoring Tool Report Department of Social Development * Department of Basic Education Department of Correctional Services See pages 25 - 48 of the manual * We would like to underline the following

  41. Strategies for Orphans and Vulnerable Children The number of children who require alternative care in the form of foster care and residential care has grown tremendously due to the increase in the number of orphans in the country, as a result of HIV and AIDS. The number of children in foster care rose from 378 748 to 445 306 during the reporting period. Lets look at the Prevalence of Orphan hood in South Africa (Surveillance System Report on Maternal Orphans, 2010)

  42. Table: Number of mothers dying and children ever born to them by year *2010 figures only include information up to end of September 2010 • Of the 1,059,254 maternal orphans created in South Africa between 2003 and end of Sept 2010, a quarter (25%, 269,150) is from the province of KwaZulu-Natal. • The Eastern Cape and Gauteng are showing the second and the third largest distributions with 168,957 and 168,542 respectively. • The two Provinces with the lowest number of maternal orphans created between 2003 and end of September 2010 are Northern Cape and Western Cape Province at 29,342 (3%) and 44,565 (4%) respectively

  43. Table: Number of orphans receiving grants by grants province

  44. A list of provinces which have Provincial Strategic Plans 2007-2011, Operational Plans and M&E Frameworks in place.

  45. Scale up of the HIV and AIDS Life Skills Education Programme 2000-2004: Implementation in the General Education and Training Band: Grades 4-6 2005: Extension to Foundation Phase (Grades R-3) & Further Education and Training Band (Grades 10-12) 2010: Implementation in 25 850 schools, involving 12 260 099 learners and 418 109 educators 2010: Alignment with latest trends and NSP reporting Focus on learners & on prevention 2008-2009: Focus on learners & educators

  46. Achievement Highlights of the NSP 2007 - 2011 1. HIV incidence continues to decline, particularly in younger age groups. 2. There was renewed engagement and high-level political leadership for the HIV response as well as growing cooperation between the Presidency, the Department of Health, NGOs and all sectors of civil society in SANAC structures. 3. Provincial, District and Ward AIDS Councils have been established across the country. 4. There is some progress in restructuring SANAC. 5. Strong policies were developed to support the HIV and AIDS response 6. Research has shown that MTCT nationally has been reduced to 3.5% by 6 weeks of age. 7. The national HCT policy was approved by the NHC and the HCT Campaign was launched in April 2010 and by August 2011, 14 million HIV tests had been conducted.

  47. Achievement Highlights of the NSP 2007 – 2011 (cont) 8. A national Medical Male Circumcision program was launched and as of June 2011, 237 812 circumcisions had been conducted. 9. The revision of the ART treatment guidelines and the implementation of NIMART increased the access to treatment and there are now more than 1.1 million people on ART with new policies likely to extend access even further in coming years. 10. There was a significant reduction in ARV tender prices. 11. The number of people living with HIV receiving nutritional support (734,900) surpassed the NSP targets for 2008/09 (500,000). 12. There has been a big growth in the CBO sector and in CBOs that provide home-based care in particular. 13. South African researchers extended the evidence base with a number of high profile studies

  48. Statistical Highlights

  49. Key Challenges of the NSP 2007 - 2011 1. Little progress has been made in restructuring SANAC. 2. The SANAC Secretariat has been critically understaffed with most posts vacant and this has compromised the ability of SANAC to deliver on its mandate. 3. Most SANAC civil society sectors have no funding, no coordinator or staff and are run by professionals over and above their day to day job responsibilities. 4. Coordination of the public sector, private sector and non-government sectors remains underdeveloped. 5. Synergy between the national strategy and implementation at province, district, and ward and facility level was not consistently applied between 2007 and 2011. 6. Although the NSP was intended to be multisectoral, in practice it was very “health” orientated. 7. TB and STI integration were not well defined in the 2007-2011 NSP and little progress has been made in STI integration.

  50. 8. Most reporting against the NSP targets was dominated by the health sector, and this masked the amount of activity by other government departments and non-state organisations. 9. The absence of an overarching, prevention communication strategy to accompany the NSP. 10. There was no costing or budgeting of human rights and access to social justice component in the 2007-2011 NSP. 11. There was no clearly defined M&E framework or costing of the research, monitoring and evaluation component in the 2007-2011 NSP. 12. No shared repository of research outputs exists. 13. The extent of input, coverage, effectiveness and impact of HIV, AIDS, STI and TB programmes financed by development partners could not be established. 14. Although the implementation of the NSP is based largely on nurses, the NSP did not articulate the engagement of the HPC and in particular the Nursing Council in terms of pre-service training and nursing regulations that would allow such programmes as NIMART and the changing scope of the professional nurse within the primary health care system.

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