End of Term Review of the NSP 2007-2011 (Final Report - 4 November, 2011)
INDEX
Summary page Manual page
· Summary 5 9
· Review of the NSP 2007-2011 5 9
A. Review Pillar 1: Prevention 5 9, 49
a. Introduction 5 49
b. Table 10: Estimated number of
new infections among adults
15-49 in South Africa: 1990-2009 5 50
c. Table 11: Estimated annual HIV
incidence and number of new infections
in adults 15-49 years old in
South Africa’s provinces (2009) 6 50
d. Table 12: Percentage of young women
and men aged 15-24
who are HIV infected 6 50
e. Prevention priority area 1:
Reduce vulnerability to HIV infection
and the impact of AIDS 6 9, 51
f. Prevention priority area 2:
Reduce sexual transmission of HIV 6 10, 51
1. Mass media, Information, Education,
Communication and Behaviour
Change Programmes 7 10, 51
2. Multiple and Concurrent Partnerships 7 10, 54
3. Table 14: Percentage of women
and men 15-49 who have had sexual
intercourse with more than one partner
in the last 12 months 7 54
4. Provincial Perspectives 8 54
5. Age of Sexual Debut 8 10, 55
6. Table 15: Percentage of young men
and women who have had sexual
intercourse before age 15
(Age at first sexual debut) 8 56
7. Medical Male Circumcision 9 10, 57
8. Condom Distribution and Usage 9 10, 58
9. Provincial Perspectives.
Table 16: Percent of young men
and woman 15-24 and 25-49
reporting the use of a condom
with their last sexual partner
at last sex 10 59
10. Table 17: Number of male and
female condoms distributed annually
in the provinces by the public sector 10 59
11. Key Populations 10 11, 61
11.1 Evidence that Key Populations
are at higher vulnerability
to HIV infection 10 61
11.2 Key points about the NSP
2007-2011 in relation to
Key Populations 11 61
11.3 A minimum service package
for all key population groups
should include: 11 62
11.4 Long Distance Truck Drivers 12 63
g. Prevention priority area 3:
Prevention of Mother to Child Transmission
(PMTCT) 12 11, 64
1. Introduction 12 64
2. Table 20: Number of infants born
to HIV infected mothers who are
HIV-infected 12 66
h. Prevention priority area 4:
Minimize the risk of HIV transmission through
blood and blood products 12 11, 68
B. Review Pillar 2: Treatment, care and mitigation 13 12, 69
1. Introduction 13 69
2. Priority area 1: Increase coverage to
voluntary testing and promote regular
HIV testing 13 12, 69
· HIV Counselling and Testing 13 69
· Provincial Perspectives 70
Table 22: Number of people tested
for HIV (excluding antenatal) including
provision of results 13 70
3. Priority area 2: Treatment, care and
mitigation. Enable people living with
HIV to lead healthy and productive lives 14 12, 72
· Table 23: South Africa projected
AIDS related deaths 14 72
· Provincial Perspectives 15 73
Table 24: Percentage of adults
and children with HIV known to be
on treatment 12 months after
initiation of antiretroviral therapy 15 73
· Table 26: Number of people
with HIV receiving Cotrimoxazole
prophylaxis 15 74
4. Priority area 4: Mitigate the impacts
of HIV and AIDS and create an
enabling social environment for
care treatment and support 15 13, 77
C. Review Pillar 3: Monitoring, research and surveillance 16 13, 79
a. Introduction 16 79
b. Priority area 1. Monitoring, research and
surveillance. Implement the monitoring
and evaluation framework of the NSP 16 13, 82
c. Priority area 2. Monitoring, research and
surveillance. Support the development
of prevention technologies 16 14, 83
d. Priority area 4. Monitoring, research and
surveillance. Conduct policy research 17 83
e. Priority area 5. Monitoring, research and
surveillance. Conduct regular surveillance 17 84
D. Review Pillar 4: Human Rights and Access to Justice 17 14, 85
a. Introduction 17 85
b. Stigma Reduction - Provincial Perspectives 18 87
c. Reducing vulnerability to sexual and gender
based violence 18 14, 88
E. Overview of the NSP 2007-2011 18 23
a. The Policy Environment 19 24
b. Management, Coordination and Institutional
Arrangements – National to Local 19 25
· Integrated support team 19 25
· Finances 19 25
· Leadership, governance and
service delivery 20 25
· Monitoring and Evaluation 20 25
· Conclusion 20 26
c. The South African National AIDS Council 20 26
d. The Provincial AIDS Councils 20 28
· Provincial Perspectives 20 28
· Table 1: A list of provinces which
have Provincial Strategic Plans 21 28
· “Problems are?????” 21 29
e. District and Local AIDS Councils 21 30
f. Ward Based Community Competency
Programmes 23 32
g. Outcomes of Community Dialogues 23 32
· Background 23 32
· Findings 23 33
· “Problems are?????” 23 33
h. Government Response 24 34
· Coordination of Government
HIV/AIDS Response 24 34
· The Status of the NSP
Implementation in the
Public Service 25 35
i. The Department of Public Service and
Administration’s Systems Monitoring
Tool Report 25 35
· Findings 25 36
j. Department of Social Development 26 37
· Policy Activities 26 37
· Partnership with LoveLife 26 37
· Strategies for Orphans and
Vulnerable Children 26 38
· Prevalence of Orphan hood
in South Africa
(Surveillance System Report) 27 38
· Table 2: Number of mothers
dying and children ever born
to them by year 27 38
· Table 3: Number of orphans
receiving grants by grants
province 27 38
· Home and community
based care 28 39
· HCBC Monitoring and
Evaluation System 28 40
· Child Care Forums 28 40
· Grants 28 41
· Table 4 28 41
· Table 5 28 41
· Indicators - Table 6 29 42
k. The Department of Basic Education 29 42
· The HIV and AIDS Life Skills
Education Programme 30 42
· Figure 1: Scale up of the
HIV and AIDS Life Skills
Education Programme 30 43
· The National School Nutrition
Programme 30 43
· Teenage Pregnancy 30 44
· Care and Support for Teaching
and Learning (CSTL) 30 45
· Conclusion 31 45
l. Department of Correctional Services (DCS) 31 46
· Table 8: A comparison of
various HIV-related prevention
and treatment indicators
between 2006/7 to 2009/2010 31 47
· Table 9: A comparison of
various HIV-related prevention
and treatment indicators
between mid 2008 to 2010/2011
for DCS officials 32 47
m. Conclusion: Summary of highlights and
challenges with resulting recommendations 33 15
· Achievement Highlights of
the NSP 2007-2011 33 15
· Key Challenges of the
NSP 2007-2011 33 16
n. Statistical Highlights 34 17
· Table A. Summary of changes
to key HIV-related indicators 34 17
· Recommendations 34 18
End of Term Review of the NSP 2007-2011
Final Report - 4 November, 2011
· 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.
· Review of the NSP 2007-2011
A. Review Pillar 1: Prevention
a. 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 640000 in 2000 to 390000 in 2009), the NSP target has likely not been reached.
b. Table 10: Estimated number of new infections among adults 15-49 in South Africa: 1990-2009
Indicator / 1990 / 1995 / 2000 / 2005 / 2009New HIV infections (15-49) / 60,000 / 490,000 / 640,000 / 460,000 / 390,000
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 (Gouws 92010) 2009 EPP Estimates).
c. Table 11: Estimated annual HIV incidence and number of new infections in adults 15-49 years old in South Africa’s provinces (2009)
d. Table 12: Percentage of young women and men aged 15-24 who are HIV infected
Province / Baseline 2005 / Mid-term 2008 / Actual 2010/2011Eastern Cape / 12.3% / 12.0% / 11.7%
Free State / 10.4% / 9.6% / 8.5%
Gauteng / 8.9% / 7.7% / 6.6%
KwaZulu-Natal / 13.3% / 12.1% / 10.6%
Limpopo / 6.2% / 5.8% / 4.9%
Mpumalanga / 10.8% / 9.9% / 8.5%
Northern Cape / 3.7% / 4.2% / 3.8%
North West / 10.6% / 9.5% / 8.3%
Western Cape / 3.2% / 2.7% / 2.3%
Source: HSRC
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.
e. 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”.
f. 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 (MTR, 2010). 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 to HIV positive people and post-exposure prophylaxis. For this reason, the bulk of prevention interventions rely on people making changes to their behaviours.
1. Mass media, Information, Education, Communication and Behaviour Change Programmes.
There were a number of large-scale, national mass media campaigns including Khomanani (the official government communications campaign), LoveLife, Soul City and the Department of Basic Education’s life skills programme. Other media initiatives include local productions such as Siyanqoba Beat it!, 46664 (Nelson Mandela Foundation), TshaTsha and Scrutinize (Johns Hopkins University Health and Education South Africa). 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.
While exposure to mass media campaigns is high, the 2010 UNGASS report noted that there is a need to translate mass media programmes into peer-to-peer initiatives that would have a much wider impact on behaviour change. In 2009, 100% of schools provided life-skills based HIV education within the last academic year, however there has not been a rigorous evaluation of the efficacy of these programs.
In spite of these initiatives, correct knowledge on the prevention of sexual transmission of HIV was lower in 2008 than in 2005.
2. Multiple and Concurrent Partnerships
There is considerable interest and debate on the importance of MCP in spreading HIV and the relative importance of concurrency versus multiple partnerships is not resolved.
The 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 (NCS 2009). 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 (KYE, 2011).
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.
3. Table 14: Percentage of women and men 15 - 49 who have had sexual intercourse with more than one partner in the last 12 months
Province / 2005 / 2008Eastern Cape / 8.1% / 13.1%
Free State / 5.4% / 14.6%
Gauteng / 11.3% / 8.6%
KwaZulu Natal / 10.6% / 10.2%
Limpopo / 9.5% / 10.8%
Mpumalanga / 7.2% / 9.4%
North West / 11.4% / 12.9%
Northern Cape / 7.5% / 8.8%
Western Cape / 11.3% / 9.9%
National / 9.8% / 10.6%
4. Provincial perspectives
Of particular concern are HIV positive people having multiple partnerships. In the rural Eastern Cape, Jewkes et al. (2006) found that HIV positive young women reported significantly more sexual partners in the last 12 months than HIV negative women. Among the HIV positive women, 22.2% reported 3 or more sexual partners in past 12 months, while among HIV negative women, 8.7% reported 3 or more sexual partners in past 12 months.
Gauteng had the lowest average number of sexual partners per year in the last HSRC survey.
In KZN, the number those who reported multiple sexual partnership reduced from 10.6% in 2005 to 5.3% in 2009.
The North West recognises that they have a particular problem. The National HIV Communication Survey 2009 (Johnson et al., 2010a p.4), which measured multiple partners (not MCP) found that “Men aged 16-19 years from the North West Province were more likely to have MSPs [multiple sexual partners] than men of the same age from South Africa as a whole…Between 14% and 16% of sexually active young men aged 16-29 years reported having two or more partners in the past month.” According to the national HSRC study, the rate of multiple sexual partners among people in the NW actually increased between 2005 and 2008 from 11.4% to 12.9%.