South African National AIDS Council Strategic Plan on HIV and Aids

Meeting report

Chairperson's opening remarks
Co-Chairperson Dr Goqwana reminded Members that this Committee would now be meeting regularly on a Friday. Since the Committee was formed, there had been difficulty in finding suitable times for all Members, and finally, authority had been obtained for the Committee to continue meeting, even if only some Members could attend. The Committee would not necessarily need a quorum but would continue to do its work. Committee programmes would now be drawn.

Dr Goqwana noted that the most important presentations would be from the Department of Health (DOH) and the South African National Aids Council (SANAC), and the Committee would then move on to deal with other matters.

He reminded Members that Parliament believed that there was a need for a Standing, Joint Committee because HIV and AIDS affected everyone, and could not be limited to one particular Committee. It was necessary to engage fully with civil society. The position differed in various provinces, with particular problems also with opportunistic infections from TB in Western Cape, although the HIV and AIDS figures were lower. For that reason, the two diseases needed to be considered together.

Co-Chairperson Ms Rasmeni read out the apologies.

South African National Aids Council Strategic Plan on HIV and AIDS
Dr Yogan Pillay, Deputy Director General: HIV and TB and Child Health, Department of Health, apologised for the absence of the Director General, but said that she welcomed the opportunity to engage with this Committee.

Historically, the Department of Health (DOH or the Department) had been the custodian of the South African National Aids Council (SANAC), as it had formerly been a unit of the Department, funded fully from National Treasury. There had been a re-think, and, in order to ensure its independence and to make it an organisation representative of labour, civil society and government, SANAC was then changed to become an independent body, although it was still housed within the DOH building. The DOH was a significant player in the HIV and TB stakes and the intention of SANAC was to make the efforts national, and to represent a number of sectors, not only health. DOH obviously remained a vitally important stakeholder, as it was its responsibility to ensure that HIV-positive patients would get the necessary healthcare.

Dr Fareed Abdullah, Chief Executive Officer, SANAC, noted that although SANAC was being repositioned, under the Chairmanship of the Deputy President, so that it would represent all sectors and work with all departments, the majority of its funding at the moment still came from the DOH. He had been in the job for one year, and had been trying to put the basic institutional arrangements in place, and had managed to make some significant progress.

SANAC was a council and a voluntary association, chaired by the Deputy President. It brought together parties, but was not a juristic or legal person. In 2002, the SANAC Trust had been created, and SANAC should have operated under this as the legal framework, although it had not done so until now, being “carried” by DOH. Now, however, a new set of trustees had been appointed and the Trust was functional and carrying out the objectives of the Council.

The National Strategic Plan (NSP) on HIV, Sexually Transmitted Infections (STIs) and Tuberculosis (TB) covered the period 2012 to 2016. TB had not featured prominently in the previous plan, but Dr Abdullah emphasised that there was a high co-infection rate of HIV and TB.

The new NSP was made up of four strategic objectives. The first related to structural drivers. There was a lot of progress on treatment and mother-to-child transmission. There was a need to deal with the causes. The newest infections tended to be in the 15 to 24 female age groups, and were drive by intergenerational and transactional sex. The Msazi Campaign would be running, for six months, to try to campaign against that. Gender-based violence and sexual assault was another driver of new infections. There were currently 52 Thuthuzela Centres, which were run by the National Prosecuting Authority (NPA) and Health Services, and SANAC was working with them to try to strengthen the centres. The conviction rate at Khayelitsha Centre was 100% for rapes, which showed how powerful these centres were in collecting evidence and driving cases to conviction. Another project was looking at poverty, since DSD found that this was a large driver of HIV, and many young women were not taking up the Child Support Grant (CSG), which tended to protect them. There was a large lifeskills programme in the schools, and the Department of Basic Education (DBE) was busy with a new curriculum. There was also a US project educating parents how to teach their children about these issues. He emphasised that the NSP ranged across the work of many departments.

Strategic Objective 2 focused on prevention. It was not possible for the country to "treat its way out of the epidemic". 350 000 new infections happened every year, and there was a need to prevent new infections. The prevention programmes included the National Sex Worker Programme, with studies being done on how many sex workers there were. Truck drivers were also being targeted, as they were prime clients of sex workers. A hitherto-neglected area was male to male sex. Male medical circumcision resulted in 60% lower rates of HIV infections, and the DOH was making a huge investment in this, with a target of having over 4 million males circumcised by 2014. South Africa was doing well on Prevention of Mother to Child Transmission (PMTCT). Pregnant women now qualified for one pill, once a day, treatment, which covered the breast-feeding period also. SANAC was looking again at the condom programme. He presented some statistics on testing, from a survey done by John Hopkins University. It was estimated that 63.4% of South Africans had undergone an HIV test.

Strategic Objective 3 focused on treatment. There were 1.9 patients on antiretroviral treatments (FDCs or ARVs) and 80% of those on treatment in April 2014 would be on the "one pill a day" treatment. In the treatment programme and scientific trials on microbicides, it had been found that people did not adhere to treatment, and that had to be improved. New possibilities included earlier treatment, and preventative treatment for those who were HIV-negative, but people still had to be urged to continue properly with treatment. Government alone could not do this work and civil society and community input was needed. In relation to vulnerable children, better psycho-social support was needed for orphaned vulnerable children (OVCs).

He outlined the statistics for elimination of MTCT. Coverage for HIV positive pregnant women was now at 99%. 99% of infants born to HIV-infected women were also provided with ARV prophylaxis to reduce the risk of early MTCT. Only Botswana and South Africa had reached this level of coverage for PMTCT. There were currently 1.9 million people on treatment, but that was probably only 75% of those needing treatment, and it was still below the 80% target.

The NSP placed much focus on the legal framework and human rights. SANAC was working with the Deputy Minister of Justice, looking at the Sexual Offences Act. The South African Law Reform Commission (SALRC) had attended the recent meetings, and legislative changes were likely to be tabled. It was concerned about the overcrowding in prisons, which was a huge driver of new TB infections in prisons. Professor Robin Woods, from UCT, recently published a paper showing a 90% probability that awaiting trial detainees would contract TB if they were detained for six months. SANAC also wanted to address the stigma around HIV. Workplace discrimination continued to be a problem and a legal clinic would be set up to deal with these matters.

The goals of the NSP were quite ambitious- to reduce HIV incidence by 50%, to have 80% on ARV, with 70% alive after five years, and to reduce stigma. Dr Abdullah tabled a slide showing the statistics for new infections each year, from 1990 to 2011. There had been a peak in 1997/8, with almost 700 000 new infections each year. Although that had dropped by about 40%, and continued to fall, the NSP called on the SANAC to focus still more on reducing new infections. He noted that the DOH wanted to increase those on treatment by half a million people, each year. There were new systems being rolled out to allow for tracking survivors on treatment, by monitoring patients.

Dr Abdullah outlined the TB incidence from 2009 to 2012, and reiterated that this was a huge problem and it would take significant efforts to push infections down by 50%. He also tabled a chart showing numbers of TB deaths, by province, but noted that the statistics may not be entirely correct since there was still a reluctance by many doctors, when recording the cause of death, to note “HIV”, and tended to name it as TB, although there was often a combination of the two. 15.7% of all deaths in KwaZulu Natal were named as due to TB.

Dr Abdullah moved on to give an summary of expenditure tackling HIV and AIDS. It was estimated that in the financial year 2013/14, R24 billion would be spent on HIV and TB in South Africa. This included donor funding of R5.7 million, and estimates of costs for in-patient care. Health economists thought that in fact the spending on HIV was probably closer to R13 billion. The conditional grant made up the largest share. He set out a summary of the Global Fund grants in South Africa, noting that SANAC had to raise funds for the Global Fund (the Fund). There were five grants, totalling R213 million, which would end in October, and SANAC had been asked to apply for a renewal. The DOH received about half those funds. This slide showed the funding actually disbursed. In 2011, only US $20 million was disbursed, but this had since increased to just over US $100 million, and there was more money flowing in. All grants were unrelated to each other, and to the NSP, although they would now be lined up with the country priorities.

SANAC had recently submitted a proposal, for a total of US $250 million over the next 30 months, to the Fund, covering prevention, treatment, and supportive environment. Significant amounts would continue to be paid to the DOH, but there would also be payments to NGOs.

He outlined the spending on prevention since 2011. The US Government had warned that it would be decreasing its funding to South Africa, over the next five years. In the case of PEPFAR funding, almost all the money had gone to NGOs, but National Treasury was trying to come up with funding that should cushion the NGOs and continue to provide funding for the essential work that they did. The decrease in PEPFAR would mainly relate to treatment, because the thinking was that more should be spent on prevention, whilst government had a responsibility to fund the treatment.

Dr Abdullah set out the new governance structures in SANAC. He confirmed that the mandate of SANAC was to bring together government, civil society, and the private sector, to create a collective response. There was a new trust deed, signed off by the Deputy President and Minister of Finance, and it was being registered with the Master of the High Court. SANAC was to foster dialogue between the various stakeholders, and advise government, although the legal authority to make policy lay with government departments. It aimed to strengthen governance, leadership and management of HIV issues at national, provincial, district and local level, and strengthen the multi-sectoral responses. It aimed to mobilise resources, domestically and internationally. A costing task team of experts had been brought it. Finally, it must monitor progress and to create and strengthen partnerships, locally and internationally.

Dr Abdullah tabled diagrams to show the new structure of SANAC. There were plenary committees of the Council, which would meet four times a year, and one extended plenary, to which the Premiers would be invited. There was an NSP financing committee, chaired by the Minister of Health, and a programme review committee, consisting of technical experts and with representation from stakeholders, to debate policy. The Secretariat reported to the Trust Board. The new Trust Board was chaired by former Constitutional Court Judge Zak Jacoob, and included other very senior members on the board. SANAC and its Secretariat were small, because despite the huge scope of work, SANAC acted as a facilitator and co-ordinator. During its first year of existence it had been doing preparatory work around the institutional arrangements, all basic systems were now in place, and the Auditor-General was busy with an interim audit. There was also a civil society forum, with 19 sectors represented. In future, SANAC wanted to support the provincial and local councils.

In conclusion, Dr Abdullah noted that SANAC looked forward to making a more comprehensive response on HIV, Aids and TB, with an increased focus on prevention. The multi sectoral response needed to be strengthened. National Treasury would be asked to make increased allocations. The new SANAC structures were working, but he noted that to date, only five of the nine provinces had functional AIDS Councils.

Discussion
Ms M Segale-Diswai (ANC) said she was happy that the Committee was now meeting, and had met with SANAC, and she was pleased to hear that SANAC was striving to do more, as she had long been concerned that its work was not visible enough.

Ms Segale-Diswai requested more information on the impact of the Provincial, District and Local Councils for  Aids (PCAs, DCAs and LACs). She wondered if there were enough resources at provincial, district and local level to allow the committees to make an impact. She also wanted to know how well the offices were resourced.

Dr Abdullah responded that a "mixed bag" of resources was found. In some provinces, mostly in KwaZulu Natal, but also in some municipalities in Gauteng, mayors were providing resources. Most municipalities had Social Services directorates or Aids departments, but SANAC was doing a survey on how many had actual dedicated offices. A report would be published soon. However, it was accepted that in general, municipalities needed to be provide more resources. Dr Abdullah pointed out that most of the discussions took place at national and provincial level, but the most impact was actually seen at local level, with issues such as supply of treatment drugs and assistance to teenagers.

Ms Segale-Diswai also wanted to know what the challenges of the office were at provincial level. The public representatives needed to assist these offices.

Ms P Tshwete (ANC) asked why some provinces did not have provincial councils.

Mr D Joseph (DA, Western Cape), attending as alternative to Mr M de Villiers, agreed that all the provincial committees should be in place.

Co-Chairperson Rasmeni asked what plans there were by SANAC to ensure that other provincial committees were responding. She also wanted to know more about the allocation of funding by provinces.

Dr Yogan Pillay said that there used to be a project with provincial government, and it was necessary to get local government going as well, and the South African Local Government Association (SALGA) had been given a project to run, but this was not formerly supported with resources.

Dr Abdullah pointed out that SANAC did not have any authority over the provincial councils, but agreed that this issue must be addressed and the position must change. There was a team from SANAC working with the councils. All nine provincial councils actually did exist in name, but only the KwaZulu Natal (KZN), Gauteng, Eastern Cape and Western Cape councils were functioning properly, with structures in place. Northern Cape was now starting to function, having met yesterday, and having established a new head office, so he was cautiously including this in the five functioning councils. In North West, although there were 40 or 50 staff, there appeared to be lack of leadership and functionality, and there was considerable concern about this. The Board of Trustees, which was meeting on the following Thursday, had asked SANAC to provide a plan to support the remaining provinces. Although there was no legal authority, SANAC hoped to offer technical support. It would be commencing with Mpumalanga, on 19 April, because the Premier there was committed to making the provincial council work, which augured well for its future. Dr Abdullah thought that it would be an excellent idea for this Committee to invite the provincial councils to meet with it. He noted that TB and HIV were a problem in all the provinces.

Dr PIllay added that the Deputy President was trying to get the Premiers involved because most of the provincial councils were in the Premiers’ offices. DOH was also trying to mobilise communities and stakeholders, although the line authority would come from the Deputy President. He was confident that there would be progress.

Dr Abdullah noted that money was available in North West, but it was not being used properly. The Western Cape had very little funding but because the departments worked well, the PCA also worked well. He suggested that this Committee may wish to pay a visit to KZN, where the Provincial Council was running with impressive results, under the guidance of the Premier, and all mayors were represented. On the previous day, in Gauteng, the Premier had launched a campaign for orphaned and vulnerable children and had visited 700 000 homes with HIV messages. Those were the kinds of results and efforts that SANAC would like to see replicated throughout all provinces. 

Ms Segale-Diswai noted that slide 29 set out the goals of SANAC, but she thought that they should have been emphasised up front, and more fully explained. She had wanted to know what exactly SANAC had achieved, and how it was performing. This information was necessary to enable Members to do their oversight.

Dr Abdullah agreed that it was necessary to set out the goals and report on them. He indicated that SAAC was doing well on fostering dialogue, as it was bringing civil society together to talk, at provincial as well as national level. There were many more scientists, doctors and nurses also attending the meetings.


Ms Tshwete noted that some of the pages were not numbered, and asked that this be corrected in the future, for ease of reference.

Ms Tshwete referred to the "Key programmes and budget allocations" slide, and asked how the money was allocated to correctional centre inmates, and whether there was a list of those centres where it was being given.

Ms Tshwete also wanted more details on the "Global Fund Disbursements" slide, and asked why there was a zero noted under 2011 for the National Religious Association.

Ms P Kopane (DA) noted that US funding was decreasing, and asked how SANAC was intending to deal with this and how it would impact on its targets.

Ms Segale-Diswai asked about the Global Fund Grant, noting that Western Cape Department of Health was given money, but questioned the criteria, as nothing appeared for other provinces.

Dr Abdullah stressed that it was important for Members to understand that the Global Fund in fact contributed a relatively small amount to the HIV and TB campaigns, and that the bulk of the funding came from government. In the past, there was not good alignment of programmes with funding and with needs. The present funding application, which had been submitted but not yet approved, was based on a much more comprehensive analysis of the funding gaps.

He explained that the funding for correctional centre inmates did seem small, but at the moment the DOH and DCS were funding the core functions so what was set out under this slide represented additional “gap” funding. He reminded Members that it was also only temporary, as the allocations would be reconsidered.

In relation to the National Religious Association, Dr Abdullah explained that the Global Fund had made agreements with all principals, but there was a dispute between the Fund and the Religious Association in 2011, with the result that the Global Fund did not give any funding for that particular programme in the 2011 year. SANAC had worked with both to resolve the matter, and the programmes were back on track.

Dr Abdullah then explained the Western Cape allocations. When the Western Cape started to receive the Global Fund grant in 2003, it was because it was, at that stage, the only province providing ARV treatment. Because of its good performance the grants had been renewed in later years. However, under the new system, it would no longer be a principle recipient, but would only receive funding via the DOH. The Western Cape was aware of that change, had accepted that it was not fair that it be the only provincial recipient, and the Global Fund funding would be phased out over the next two years. Dr Abdullah reiterated that in future, the Global Fund would be disbursing on a national basis and working with the national DOH. There were now excellent HIV policies at the national level, thanks to the Minister’s prime work in drawing policies that spoke directly to needs.

Ms Tshwete quipped that SANAC only needed to meet four times a year, yet this Committee would be meeting weekly.

Co-Chairperson Goqwana explained that this Committee, in addition to meeting with DOH and SANAC, would also be needing to meet all the organs falling under SANAC, and would be calling in associations, such as sex workers, and provincial committees. He said that there would be a significant amount of work for this Committee.

Ms Kopane (DA) asked why there were no statistics for TB for 2012.

Dr Abdullah said that this was a reporting issue as it took one year for the TB records to come through, because they was based on statistics at the end of each six months' courses of treatment, which were collated later.

Dr Pillay confirmed that he was compiling the 2012 statistics at the moment.

Ms Kopane noted that there was a note of expenditure on programmes, but the budget for administration, salaries and employees was not mentioned, and she asked where this would be reflected.

Ms R Motsepe (ANC) said that nothing was mentioned in the budget for truck drivers programmes, or male to male programmes.

Dr Abdullah said that there were not really programmes for sex workers, and the Global Fund was interested in funding programmes for the most vulnerable sectors, women and children, which was why nothing was covered in that slide. He emphasised that the figures represented start-up funding. However, he noted that if the Global Fund approved the latest proposal from SANAC, SANAC hoped to reach out to about 30 000 sex workers. However, the HIV High Transmission Area budget and programmes of DOH would provide funding for peer education, training to sex workers to deal with alcohol and violence, training to police not to harass sex workers, and training and education to the public on use of male condoms. All of these programmes had hitherto been neglected. SANAC was working with all stakeholders on a national sex workers programme, which it hoped to launch in December, and was hoping that the funding would be approved.

Mr Joseph  asked if South Africa and other African countries were contributing to the Global Fund..

Dr Abdullah noted that 90% of the funding for the Global Fund came from richer countries, from the EU and other areas, and there were contributions from other parties, such as Bill Gates Foundation. Although South Africa was  not a “rich” country it did contribute about $1 million a year to the Fund. In return, however, it managed to source about $100 million.

Mr Joseph wanted more details about the Msazi Campaign, and when it would be launched.

Dr Abdullah confirmed that it would be launched in the Gert Sibande District in Mpumalanga, and said that this had been chosen because of a sudden spike in prevalence of HIV and Aids there. Traditionally, the highest figures had been found in KZN, and DOH was currently trying to analyse the statistics and find reasons for the increase in Mpumalanga.

Mr Joseph was not sure if the priorities set out on page 5 were in order, but questioned if the funding requests followed that list.

Co-Chairperson Rasmeni asked about the key NSP Programme Objective 4, asking if students at a tertiary level were offered any targeted programmes, because theirs was the most vulnerable age-group.

Dr Abdullah noted that the Further Education and Training (FET) Colleges had been funded in the past by the US government, but that funding was being withdrawn over the next few years. SANAC and the DOH were trying to find more funding to allow the FET colleges to continue what had been good programmes, as although National Treasury had been approached, it had not approved the allocations requested. There were about 600 000 students in FET Colleges, and 900 000 in universities, who were indeed at high risk. Dr Abdullah had met with the principals at universities, and they were taking this seriously, but were not committing enough funds. A worrying fact that had emerged was that about 10% of young women at universities relied on a "sugar daddy" to put them through their programmes, and although they would end up with a degree, they also often ended up with HIV as well. The DOH was also working with the Higher Education Aids Programme on solutions.

Co-Chairperson Goqwana said that the Minister had recently expressed his extreme concern that this age group was also not using condoms and campaigning would be needed.

Dr Pillay added that the Minister had recently launched a campaign at Wits University and all the universities were starting orientation programmes. There were also mobile clinics, but there was a need for the universities to sustain the programmes and efforts throughout the year.

Dr Abdullah noted that SANAC faced many challenges still at the moment. The first was the absence of a strong legislative framework within which SANAC would operate. The second problem related to the fact that there were not so many high-profile messages being sent out. The message about HIV and AIDS needed to be reinforced continuously, but that required substantial resources, which SANAC did not have at the moment. Its budget only really allowed it at the moment to run the committees and attend to basic functioning. A third challenge was linked to its status as effectively a new institution; whilst SANAC had, in name, been in existence for a while, there had, for instance, been no bank account opened by the time that Dr Abdullah took up his post. It had spent the last year – as he had expected that it would, and as stated in the first strategic plan to the trustees – in sorting out its teething problems, and getting staff. Over the last two days, he had made the final appointments of two financial staff members. SANAC now needed to shift focus and achieve more. In addition, he reiterated that SANAC worked substantially with civil society and many sectors should be more effective in drawing sector plans and implementing programmes, but there was still quite a way to go. Plans were one matter, but there was a need now to focus on implementation.

Co-Chairperson Rasmeni asked for an elaboration on the reduction of PEPFAR funding.

Dr Pillay noted that over the last two years the US Government had indicated that it would be reducing the funding to South Africa, and there had been consultation sessions held by DOH with the bodies formerly funded so that they understood the motivation behind the reductions, and to decide what should be done to lessen the impact. It was recognised – albeit reluctantly – that the effect of the global economic crisis on the USA had caused it to re-think its priorities. It was thought that now that South Africa had joined BRICS, there were possibly other countries in Africa who were more in need of funding. There was also a suggestion that because South Africa was doing well on its programmes, it could now continue to run them with less assistance. He emphasised that the funding was not being withdrawn immediately, or entirely, but there would be a reduction, by about R500 million, over the next five years. USA would no longer be funding drugs or laboratories. National Treasury would have to find a way for the costs of these to be absorbed through DOH allocations. The DOH would also have to budget for paying for treatment within the country. There was a need to work with provincial and civil society partners to smooth the transition.

Co-Chairperson Goqwana understood that, but noted that in fact the funding that South Africa had received was not only treating its own nationals, but also other itinerant workers and refugees. Although there was not clarity on how many non-South Africans were benefiting from treatment at South African hospitals, it was clear that there were a number of Lesotho and Swazi nationals who did come through to South Africa. Although this was not an issue that could be debated today, there was a need sometime to consider whether South Africa could continue to fund them.

Dr Pillay noted that the diseases crossed borders, and had to be dealt with. The Ministers of Health in Swaziland and South Africa had met to discuss TB in the region. There was a lot of movement of people across borders. In Tshwane, many pregnant mothers had their babies at South African hospitals, and would afterwards return to their own countries. He agreed that this was a major challenge.

Mr Joseph noted, with interest, the reference to the links between poverty and HIV. Poor people were provided with RDP houses, and he emphasised that the social conditions, such as several people staying in one-roomed shacks, increased the risk of rapid spread of TB, in particular. He wondered if the Department of Human Settlements was also included in the debates, for lack of housing was exacerbating health risks.

Ms Tshwete asked about collaboration also with the Department of Agriculture.

Dr Pillay noted that lack of infection control in informal settlements was being dealt with, including through the DOH co-chairing the Social Cluster. There were monthly meetings to deal with cross-cutting issues, although DOH had no direct control over them. As part of the TB programme, the DOH was focusing on case findings and trying to isolate TB cases as early as possible, as well as running education campaigns on “cough hygiene”, the need to wash hands often, re-engineering primary health care and trying to change human behaviour. TB infection control should also be dealt with by community health workers and screening at schools. Structural and behavioural approaches were needed.

Ms Tshwete referred to slide 17, setting out the TB mortality in rates in 2010. She questioned the situation now. It was not easy to isolate whether the provinces were reducing in both death and infection rates, and said that in future she would like to see the infection rates also.

Dr Pillay reiterated that TB data was always behind because the collation of data from treatment involved substantial work, and he also reiterated that the TB mortality statistics were drawn from what doctors noted on the death certificates. However, DOH had seen fewer new cases of TB being reported, with a drop from around 400 000 to 380 000 over the last two years. DOH was not yet sure whether new cases of TB were also dropping, and this was one of the reasons why DOH was going out to seek out cases and do more proactive testing and identification.

Co-Chairperson Goqwana noted that it would be useful for this Committee to speak to community health workers.

The meeting was adjourned.