Will SA’s new Aids plan be good enough?

The health department should work with others, release data, employ more staff and educate pupils

Scepticism about South Africa’s new HIV and tuberculosis (TB) national strategic plan is understandable. Those in charge of developing the new plan at the South African National Aids Council (Sanac) do not have an easy job. They must consult widely to keep everyone happy. But a plan that pleases everyone, including government, will lack the teeth required to make a difference in South Africa’s response to HIV and TB. Partly because of the difficulty of this balancing act, the finalisation of the plan has been delayed until March 2017.

The substantial challenge they face in coming months is to formulate a progressive, highly targeted plan and then to convince people to accept it.

When formulating such a strategy, it is worth keeping in mind that government will make some decisions with or without the document.

Minister of Health Aaron Motsoaledi has made good policy decisions in recent years. But there is little indication that he was guided in these decisions by the previous strategic plan on HIV, TB and sexually transmitted infections or by Sanac.

With the limited capital it has, the new plan must be focused and avoid placing too much emphasis on things that will happen with or without it. It should instead identify a few points where change is needed, but not guaranteed. These include proposals that government may be resisting or where the department of health’s hand needs to be strengthened when approaching treasury or donors for funding.

A strong plan could help to shift the dial in our HIV and TB response if it focuses on four areas: data transparency, partnerships, comprehensive sex education and human resources.

First, the new plan must bring about a radical change in the health department’s mind-set about how it shares its data with the public. At present, the health department doesn’t share much of its information for fear of bad publicity.

The trouble with this is that it makes it harder for the public to take ownership of the healthcare system and create accountability at a local level. We may know through reports from media and organisations such as the Treatment Action Campaign that certain healthcare facilities are dysfunctional, but we rarely get upto-date statistics to back up such complaints. When figures are published by the health department, they are rarely made available to the public.

Yet the department has useful statistics on the performance of healthcare facilities.

One example is data on HIV viral load testing, which measures the amount of HIV in a person’s blood and is the best way for health workers to identify whether patients are responding well to treatment. According to treatment guidelines, people living with HIV should get at least one viral load test a year.

Government should regularly publish data on whether everyone at a clinic has been given their tests. It should also report what percentage of those people who have received the tests have so-called undetectable or very low viral loads — a marker that people are able to adhere to and get their antiretroviral medication daily.

These two pieces of information tell us an enormous amount about the quality of care at a healthcare facility. Such up-to-date viral load statistics must be made easily accessible to patients, clinic committees, hospital boards, local and district Aids councils and, in short, to anyone with a stake in ensuring a public health facility functions as it should.

Second, rather than trying to manage HIV and TB efforts on their own, national and provincial health departments must do much more to bring other government departments, labour and business on board. The new plan must provide practical guidance on how to do this. For example, if we are to launch a new mass HIV counselling and testing campaign, then employers and unions must play a part in providing testing services to their members and employees.

Third, the new plan must break the ongoing impasse between the departments of health and basic education, as well as school governing bodies, to make comprehensive sex education and condoms available at schools. We have a moral duty to provide our young people with the tools they need to prevent unwanted pregnancies and HIV infection. We can’t keep tip-toeing around people’s moral qualms while young people continue to be infected with HIV at alarming rates. The initial draft of the new plan was disappointingly weak on the question of providing condoms at schools.

Last, the plan must set out a realistic road map of how to reach its HIV and TB targets. If reaching those goals means employing many more people — and it does — then we should put together a strong case in the plan for treasury to provide the funding for this.

We need to know whether we have enough health workers to support a rapidly growing antiretroviral treatment programme. If we don’t, then we need a plan to train them.

Similarly, to step up our TB response we need healthcare workers to go out and find people with TB rather than waiting for them to come to the clinic.

We also need to know whether provinces are budgeting for employing more healthcare workers and not simply burying their heads in the sand.

Although the initial draft of the plan did contain encouraging language about active TB case-finding, it should go further and make the case for why it is a worthwhile investment that must be made urgently. In this, as in other key areas, we need not only a set of targets but also a clear road map for how to reach those targets.

With the United Nations reporting more than 250 000 new HIV infections in South Africa every year, about seven million people living with HIV, and tens of thousands of people dying of TB every year, the country continues to face a medical emergency. We have no choice. We have to get this strategic plan right.