NATIONAL ASSEMBLY
QUESTIONS FOR WRITTEN REPLY
FRIDAY, 12 SEPTEMBER 2014
1340. Mr A F Mahlalela (ANC) to ask the Deputy President:
(1) What are the Governmentâs achievements in relation to the five broad
goals of the National Strategic Plan (NSP) 2012-2016 under the
leadership and guidance of the SA National Aids Council (SANAC)
which was launched by the President of the Republic, Mr J G
Zuma, on 1 December 2011;
(2) whether significant progress has been made in relation to the four
strategic objectives of the plan; if not, what are the
challenges in this regard; if so, what progress has been made in
each case;
(3) whether the legal status and funding of SANAC has finally been
resolved; if not, why not; if so, (a) what is its legal status
and (b) how is it funded;
(4) whether there is a framework for monitoring and evaluating the plan
by SANAC; if not, how does SANAC monitor and evaluate the plan;
if so, what is the framework? NW1621E
REPLY
1) The rate of new HIV infections amongst adults has declined from 1.79%
in 2008 to 1.47% in 2012. The number of patients on antiretroviral
treatment is 2.5 million. This has led to an increase in life expectancy
from 53 years in 2006 to 61 years in 2012. We are not on track to achieve
the target of reducing TB incidence and mortality by 50% but there may be
signs of some decline in tuberculosis that is most likely due to the
antiretroviral treatment programme. South Africa has a good human rights
culture and programmes for vulnerable populations such as sex workers, men
who have sex with men and prisoners are being expanded though sex work and
drug use are illegal. The SANAC Secretariat has commissioned to do the
first ever national survey of the levels and types of stigma that continues
to exist in our communities.
2) Progress is being made with respect to all four strategic objectives
of the NSP though there are insufficient programmes to address social and
structural drivers of HIV and social and behaviour change programmes. There
is a need to significantly improve the TB treatment success rates in all
provinces and the care of orphans needs to increase its coverage. A
national lifeskills programme is in place in the schools and DHET has
established HIV programmes in FET colleges and universities. The prevention
of HIV transmission in pregnancy has been a singular success with an almost
90% reduction. More needs to be done to reduce stigma and discrimination.
Please see below the progress has been made in relation to the four
strategic objectives of the plan; as well as some of the challenges in this
regard:
â
Strategic Objective 1: Addressing social and structural drivers of HIV, STI
and TB prevention, care and impact
Known behavioural factors that drive HIV such as age-disparate
relationships, multiple sexual partnerships, early sexual debut and low
levels of condom use are also inadequately addressed in the current
response. Although the National Communication Survey of 2012 showed good
progress with condom use at first sex and increasing condom use among young
people over the last decade the HSRC household survey 2012 showed declining
condom use in all age groups compared to 2008. This may be reflective of
the absence of any public sector condom promotion and marketing campaign
and erratic supplies to distribution outlets. The HSRC survey also showed
an increase in age disparate relationships, an increase in multiple sexual
partnerships and revealed that more young people were starting sex earlier.
In other words, risky sexual behaviour is on the increase in South Africa.
The latest available data shows that age at sexual debut is decreasing in
South Africa, whereas later age at debut is protective for HIV and
pregnancy.
The use of condoms is widespread and addresses the prevention of HIV and
other sexually transmitted infections (STIs), as well as unintended
pregnancies, among sexually active people. With a 2016 target of 1 billion
condoms for male condom distribution, male condom distribution has dropped
from the 2010 baseline of 492 million to 230,011,696 in 2011 (53% reduction
from baseline), 251,419,268 in 2012 (49% reduction from baseline) and
352,065,256 in 2013 (29% reduction from baseline).
To address HIV prevention among youth, the Department of Higher Education
and Training (DHET) established the Higher Education and Training HIV/AIDS
Programme (HEAIDS) as a national facility to develop and support the HIV
mitigation programmes at South Africaâs public Higher Education
Institutions (HEIs) and Further Education and Training colleges.
In partnership with NDOH, the Department of Basic Education (DBE) is
implementing the Integrated School Health Programme (ISHP) within schools.
Going forward a major investment is needed in social and behaviour change
programmes and programmes to protect young women from high risk exposures.
The Programming to address SO1 needs serious review as do the financial
investments and monitoring and evaluation systems.
Strategic Objective 2: Preventing new HIV, STI and TB Infections
Prevention is the cornerstone of the NSP. This is captured in the main goal
of the NSP being the reduction of incidence by 50% over the five years of
the NSP. The section on incidence provides a detailed description of
incidence due to adult sexual transmission. Although there has been a
decline in incidence since the peak of the epidemic in 2003 and 2004, HIV
incidence remains higher than expected and reductions in incidence over the
last five years have been disappointingly slow. This points to the need for
greater investments in prevention. Both the Global Fund and PEPFAR have
increased their investments in prevention though the SA Government has not
done the same.
Though important targets have been underachieved in SO2 there is definitely
a greater effort being made in the current NSP compared to the previous
NSP. According to the NCS 17 million South Africans have ever tested for
HIV. Ten million South Africans tested in the 12 months before the survey.
However the targets for HCT set in the NSP have not been met.
The PMTCT programme has been a singular success. Transmission rates have
reduced to less than 3% at 6 weeks. Targets for other key prevention
interventions have been underachieved. These include HCT and MMC.
HIV prevention programmes for key populations are increasing especially
through donor funded initiatives for key populations such as sex workers,
MSM and prisoners though it is too early to measure their impact at the end
of the first year of the NSP. Pilot programmes for IDUs have commenced
through funding from PEPFAR.
Greater investments in Social and Behaviour Change Communication programmes
are needed. Programmes such by NGOs such as loveLIFE, Soul City and JHESSA
reach millions of South Africans. There is a growing call for government to
increase its investments in SBCC following the HSRC findings that condom
use has declined over the last five years and risky sexual behaviour has
increased. It also found that HIV knowledge in the general population has
also declined.
The new strategy of the Department of Basic Education and the scaling up of
university and FET college programmes is encouraging. Plans are afoot in
the Departments of Health and Social Development to increase their
investments in prevention.
The 2012 NCS found that there has been a huge increase in the number of
South Africans ever tested for HIV, with 2.6 million more people reporting
having ever tested than three years ago.
The National Health Laboratory Services (NHLS) early infant diagnosis (EID)
data clearly shows the rapid scale-up of EID over the first decade of the
PMTCT programme from the 100-fold upsurge in PCR tests to 350,000 by 2012.
There is strong evidence that male circumcision reduces the risk of HIV
acquisition in men during heterosexual intercourse by up to 60%. Increasing
uptake of MMC is a key HIV prevention strategy for reducing HIV incidence
among men. The NDOH Annual Performance Plan (APP) target for 2012/13 was
600,000 medical circumcisions with a total of 514,991 circumcisions being
conducted during this period. Against an overall target of reaching
approximately 4.3-million HIV negative men aged 15-49, 12% of the target
had been achieved by 2012/13.
Recent data on STI prevalence levels in South Africa are limited. However,
the national antenatal survey of 2012 measured an HSV-2 prevalence of 55.8%
in pregnant women in four provinces (KwaZulu-Natal, Gauteng, Western Cape
and Northern Cape).
The October 2013 national HIV and TB Review found that the South African TB
programme was not meeting targets, although TB diagnosis and treatment is
much improved. TB treatment is widely available and almost 80 percent of
patients with new smear positive pulmonary TB are cured. TB patient follow-
up is, however, poor and there is no effective tracing of patients who drop
out of treatment programmes. TB Infection control (TBIC) has been noted to
be poorly implemented.
The number of HIV-positive people screened for TB rose almost twofold (to
1.26-million), and the number of PLHIV receiving isoniazid preventive
therapy (IPT) increased nearly threefold (from 146,000 to 373,000) between
2010 and 2011. With some 373,000 PLHIV receiving IPT in 2012, South Africa
is now the largest provider of this prophylactic regimen in the world.
Strategic Objective 3: Sustaining Health and Wellness
The Department of Health continues to increase the number of patients on
antiretroviral treatment. By March 2013 there were 2.3 million patients on
treatment in the public sector. A further 200 000 patients are on treatment
in the private sector. This has led to an increase in life expectancy.
South Africa has the largest ART programme in the world. Domestic funding
has increased to the extent that more than 75% of the HIV response has been
financed from domestic revenues since 2010. South Africa is one of the four
countries in the region to have coverage of ART among children infected
with HIV and in need of treatment that exceeded 50% in 2011.
According to the 2013 UNAIDS Regional Report, decreases in AIDS-related
deaths have occurred most prominently in countries like South Africa, where
large HIV epidemics have been addressed through steep increases in ART
provision. South Africa's HIV antiretroviral treatment (ART) programme is
estimated to have saved 780,000 lives between 2003 and 2012, increasing to
an estimated 2.2-million lives saved by 2016. Placing children and
adolescents on treatment, and ensuring retention in care remain areas where
intensified focus is needed.
Strategic Objective 4: Ensuring protection of human rights and improving
access to justice
The 2013 National HIV and TB Review found that HCT is being conducted with
proper informed consent, and that those eligible for ART are being referred
to appropriate facilities. Patients with drug-resistant TB are also being
managed as required by the national guidelines. Women living with HIV are
not denied their sexual and reproductive health rights, including the
desire to have children â although some instances of discrimination have
been documented.
Rape survivors are provided PEP services, and provision is granted whether
or not a charge is laid at a police station.
In general, the human rights and access to health services are respected.
Unfair discrimination on the basis of HIV and/or TB status is illegal in
South Africa. Significant progress has been made with regard to the
development and implementation of HIV workplace policies and programmes.
In conclusion
⢠Considerable progress has been made in reducing HIV transmission
during pregnancy and child birth, and perinatal transmission is estimated
to be 2.7%. The country is on track to reach the NSP target of less than 2%
perinatal transmission by 2016.
⢠In 2013 ART reached 2.5 million South Africans including more than
200,000 patients being treated in the private sector. The provincial health
departments will, however, need to enroll approximately 500,000 people onto
treatment over the next four years to reach the NSP targets for ART
coverage.
⢠It is likely that there is a decline in TB incidence and mortality
due to the scale up of antiretroviral treatment though the WHO reports an
increase incidence and high mortality for TB. The country is not on track
to achieve the ambitious targets of reducing both incidence and mortality
by 50%.
⢠In relation to rights, some vulnerable key populations such as sex
workers, MSM and prison inmates are being addressed. Work is also under way
to create access to legal services for persons discriminated against
because of their HIV status, while there is also unfolding work towards
addressing gender-based violence (GBV).
⢠While surveys show low levels of stigmatising attitudes, the extent
of stigma and discrimination from the point of view of PLHIV is yet to be
determined. The implementation of the SANAC commissioned national stigma
index survey, will provide necessary insight and also contribute to the
development of appropriate indicators to track progress.
3) All activities of the SANAC Secretariat fall under the SANAC Trust
which is a legal entity registered with the Master of the North Gauteng
High Court. The Trustees are appointed by the Deputy President of the
Republic of South Africa. Former Constitutional Court Judge, Justice Zak
Yacoob, is the chairperson of the SANAC Trust. The SANAC Trust receives
funds from the Tresaury via Vote 16 (Health) but discussions are under way
with Treasury, the Department of Health and the Presidency about the future
funding of the SANAC Trust. The SANAC Trust now also receives donor
funding. The question of whether the SANAC Trust should be converted into a
public entity is still under discussion.
4) A monitoring and evaluation framework is in place. The first NSP
progress report has been prepared by the Secretariat and will be tabled at
the next SANAC Plenary Meeting. A mid-term evaluation has commenced. The
SANAC Secretariat is in the process of contracting an evaluator and a
report is expected at the end of the financial year.