Managing

the HIV/TB/STI Response in

South Africa
Bhekisisa Centre for Health Journalism at
the Mail&Guardian
NSP Dialogue

Sandile Buthelezi
CEO: SANAC Trust Secretariat
13 November 2018

 5 PRESENTATION OUTLINE

1. The Summary of the NSP

2. Subnational Plans

3. Latest updates on the HIV Epidemic

4. Latest Updates on the TB Epidemic

5. Closing Thoughts
2
 The NSP: A roadmap for a critical stage of our
journey
•  The NSP is a roadmap that enables thousands of organisations and
individuals pull together to overcome the HIV, TB and STI epidemics by
working towards one set of national goals and objectives

•  SA has made great progress in the last 10 years but huge challenges lie
ahead, especially for prevention:
–  The number of new HIV infections remains extremely high
–  There is still a gap in terms of realising the full benefits of ‘treatment as
prevention’ due to the treatment gap among men
–  Progressive policies are not fully implemented
–  Effective programmes are not adequately scaled up
–  Ineffective and/or fragmented programmes continue to be implemented

One of the key reasons for a lack of progress in prevention is the

ongoing high rates of HIV in young women in Africa and inadequate
programming for Key Populations
 HIGHLIGHTS OF THE NSP 2017-2022

•  Key Principle of the NSP: “One country. One plan, one

response”
•  4th genera7on NSP
•  Aligned to the NDP Vision 2030 and SDGs.
•  Launched in March 2017
Key differences with previous NSPs
•  Numeric targets
•  Expanded goals (8)
•  Vociferous on KP Programming, Resource mobiliza7on
and Leadership
•  Focus for Impact
•  Subna7onal Plans (PIPs and MDIPs)

 The eight goals of the NSP

Goal 1
Accelerate prevention in order to reduce new HIV and TB
infections and new STIs

Goal 2
Reduce illness and death by providing treatment, care and
adherence support for all

Goal 3
Reach all key and vulnerable populations with services that
are tailored to their specific needs

Goal 4
Address social, economic and cultural factors that add fuel to
the HIV, TB and STI epidemics
 The eight goals of the NSP

Goal 5
Ground the HIV, TB and STI programme in human rights
principles

Goal 6
Promote leadership at all levels and shared accountability for
delivering this plan

Goal 7
Mobilise resources to support achievement of the NSP and
ensure a sustainable HIV, TB and STI programme

Goal 8
Strengthen the gathering and use of information to make the
NSP successful
 From the NSP, to the PIP, to the MDIP

•  To aWain the ambi7ous of the NSP, each province is responsible to align its provincial ac7vi7es through
its respec7ve Provincial ImplementaKon Plans (PIPs) and MulK-sectoral District ImplementaKon
Plans (MDIPs)
•  Each PIP and MDIP iden7fies priori7es and ac7vi7es - This is based on its epidemiological and
epidemic profile and input from government departments’ annual performance plans and strategies,
civil society sectors and the private sector
•  The PIPs and MDIPs aim to inform provincial, district and local-level stakeholders on strategic and
opera7onal direc7ons to be taken when developing their implementa7on plans
•  They are also used by Office of the Premier and Office of the Mayor, who are mandated with the role
to co-ordinate and monitor implementaKon by government departments, civil society sectors,
developmental partners, districts and local municipali7es
•  Developmental partners use the PIPs and MDIPs to support their provincial and local efforts to turn
the 7de with respect to the twin HIV and TB epidemics
•  The Kming and targets of the PIPs and MDIPs align with and contribute to the 7meframes and targets
in the NSP

9 PIPs and 46 MDIPs have been completed to support implementaKon of the NSP
 Framework for the PIPs
Framework for the PIPs

•  IntroducKon to the plan: including purpose and general strategic overview of the provincial
response

•  Background: including an overview of the process of development of the plan

•  SituaKon analysis: provincial epidemiological profile with analysis of key risk factors for HIV, TB and
STIs in the province

•  Focus for impact: iden7fica7on of priority districts and sub-districts, priority popula7ons and
contextual preven7on packages which are priori7sed for scale up

•  The role of the PCA and provincial sphere of government: describing the role of each
stakeholder and the coordina7on structure and func7on at the provincial level

•  Provincial implementaKon: consolida7on of baselines, targets and ac7vi7es at the district level

•  Monitoring and reporKng: including the frequency and use of collected data

•  CriKcal enablers: to facilitate effec7ve programme implementa7on and delivery of services

8
•  Financing: including the cos7ng and resource mobilisa7on for the implementa7on of the PIPs
 SubnaKonal Plans

DP Na7onal Planning
SANAC

PREMIER Provincial Implementa7on Planning PCA

EXECUTIVE District Mul7-sectoral Implementa7on

MAYOR Planning DAC/MAC

Local Implementa7on
 TOTAL NEW INFECTIONS: Thembisa estimate 4.1
(2018)
Total new HIV infecKons

340389
328766
317521
303180
288800
274967
247040

2012 2013 2014 2015 2016 2017 2018

Total new HIV infec7ons 340389 328766 317521 303180 288800 274967 247040
Total new HIV infec7ons
TOTAL NEW INFECTIONS cont.: (Thembisa estimate 4.1 -
2018)

TOTAL NEW HIV INFECTIONS BY AGE AND SEX

120000

100000

80000

60000

40000

20000

0
2012 2013 2014 2015 2016 2017 2018
New HIV infec7ons in children <15 23604 21694 19192 17312 15408 14287 13131
New HIV infec7ons in 15-24 males 39371 37237 35278 32306 29120 26164 22912
New HIV infec7ons in 15-24 females 105188 101621 98240 92973 87078 81301 73569
 HSRC PREVALENCE, INCIDENCE, BEHAVIOUR AND
5
COMMUNICATION SURVEY 2017 (SUCCESSES)

•  HIV incidence decrease by 44% between 2012 and 2017-

biggest decline of 56% in females
•  New infec7ons amongst AGYW decrease from 2000 per
week in 2016 to 1300 per week in 2017
•  67% of men 15-24 reported to be medically circumcised
•  Progress towards 90-90-90 UNAIDS target at 85-71-86
•  Compared to 2012, mul7ple sexual partnerships have
decreased though s7ll high
•  Tes7ng increased, with increased knowledge of HIV Status

12
 HSRC PREVALENCE, INCIDENCE, BEHAVIOUR AND
5
COMMUNICATION SURVEY 2017 (CONCERNS)
•  Though declining, HIV incidence remain high
amongst females esp. amongst AGYW(1.51%) and
women 15-49 years (0.93%)
•  Substan7al increase in Eastern Cape and Western
Cape
•  Consistent condom use s7ll very low
•  Early sexual debut and increase in HIV acquisi7on
in young males is major point of concern
•  Age disparate rela7onships amongst adolescent
girls s7ll very high
13
DS-TB NoKficaKons 2009-2017 (NDOH-ETR.Net)
450,000

406,082 401,048
400,000 389,974

349,582
350,000 328,896
318,193

300,000 283,085
Total TB cases

254,258
250,000
216,502

200,000

150,000

100,000

50,000

0
2009 2010 2011 2012 2013 2014 2015 2016 2017
DS-TB Treatment Success Rates (NDOH-ETR.Net)
100%

90% 86% 86%

82% 83% 82%
80% 81% 81%
80% 78% 78%
76%
74%
% Ttreatment success

70%

60%

50%

40%

30%

20%

10%

0%
2011 2012 2013 2014 2015 2016
Calendar years (cohort)

All TB New Sm+ve Linear (All TB)

 Deaths among DS-TB patients (2011 – 2016)
10.0%

9.0%
8.4% 8.4%

8.0%
7.4%

7.0% 6.7% 6.7% 6.6%

6.2%
6.0% 5.8%
% Died

5.2%
5.0% 4.5%
4.4%
3.9%
4.0%

3.0%

2.0%

1.0%

0.0%
2011 2012 2013 2014 2015 2016
Calendar years (cohorts)

All TB New Sm+ve Linear (All TB)

DR-TB NoKficaKons 2011-2017 (NDOH-EDR.Net)
14,000

744
12,000 638
655
610
465
10,000
Total cases

8,000

701
6,000 661 11,708 11,949
11,417
10,719 10,257

4,000
6,494
5,706
2,000

0
2011 2012 2013 2014 2015 2016 2017

MDR XDR
 DR-TB NoKficaKons 2010-2015 Cohort (NDOH-EDR.Net)
70%

60%
54% 53%
% Ttreatment success

50% 48% 48% 48%

40%

30% 27%
25% 25%
24%
19%
20%

11% 11%
10%

0%
2010 2011 2012 2013 2014 2015
Calendar years (cohort)

MDR XDR Linear (MDR)

 Deaths among DR-TB patients (2010 – 2015)
50.0%
47.0%
MDR XDR
44.4%
45.0% 42.40%
40.2% 41.0%
40.0%

35.0%
28.20%
30.0%
% Died

25.0% 22.5% 22.5%

22.0%

20.0% 18.9% 19.0%

15.0% 14.0%

10.0%

5.0%

0.0%
2010 2011 2012 2013 2014 2015
Calendar years (cohorts)
 WHO Global TB Report 2018

•  Annual new TB pa7ents reduced from 420 000 to 322

000 (ART impact, etc)
•  Globally in 2017, 67 countries reported ini7a7ng TB
preven7ve treatment for a total of 958 559 people
living with HIV; this included 640 201 people who were
newly enrolled in HIV care, in 60 countries. South
Africa accounted for 39% of the total.
•  Of the 30 high TB/HIV burden countries, 15 reported
providing TB preven7ve treatment to people newly
enrolled in HIV care in 2017, up from 11 in 2016.
Coverage ranged from 1% in Eswa7ni (formerly
Swaziland) to 53% in South Africa. Overall, in the 59
countries for which it could be calculated, coverage
was 36%.
hdp://apps.who.int/iris/bitstream/handle/10665/274453/9789241565646-eng.pdf?ua=1 20
 Finding the Missing TB Patients Strategy
600,000
No. of individuals at each

500,000
step of cascade

438,000

400,000 389,724

342,584

162 155
300,000
275,845 ~160 000
80 000 1
year
40 000 6 221,057
months

200,000
(TB
Cascade
2016)

100,000

0
TB burden Accessed TB Test Diagnosed with TB NotiRied & Treated Treatment success
 Strategic Interventions plugging leakages in Cascade

Interventions 1,2,3 4 5 1.  Optimised TB

screening
2.  EfRicient contact
tracing of index cases
600,000
3.  Enhanced case
detection in key
500,000
populations
438,000 4.  Improving diagnostic
yield through new
389,724 diagnostic tools and
No. of individuals at each

400,000
342,584 revised algorithms
step of cascade

5.  Improve quality

300,000 275,845 standards in
recording and
221,057
reporting and
200,000 tracking patient
transfer between
facilities.
100,000

0
TB burden Accessed TB Diagnosed NotiRied & Treatment
Test with TB Treated success
Success requires deeper, stronger foundations
A better-functioning health system is critical to success

•  Integration of HIV, TB and STI services to

–  Improve efficiency
–  Meet patient needs better and more conveniently
–  Get better results in terms of prevention and treatment

•  Stronger systems for procurement and supply of medicines and other health
supplies, such as test kits and condoms
–  Better stock monitoring to avoid stock-outs
–  Expanded direct delivery to patients at community outlets
–  Rapid response mechanism to manage shortages

•  Increased human resources for health

–  Prevention, treatment and care for HIV, TB and STIs are drive by people-
power
–  NSP demands more human resources, from medical specialists, to
nurses and pharmacists, mental healthcare workers, social workers,
community workers and peer educators
 Some closing thoughts

The NSP 2017-2022 accelerates the pace of delivery and sets steep targets

•  Its goals will only be achieved with high commitment from all role-players:
–  In the public and private sectors and in civil society
–  At every level, from national structures to local organisations

•  Coordination, unity, resource-sharing and efficiency are critical to achieving

our goals. We need to stretch our assets to the maximum

•  Well-informed selection of interventions and wise targeting of our efforts to

reach those most in need are the key to achieving greatest
LET OUR ACTIONS COUNT

ZERO
new HIV and TB infec7ons
ZERO
new infec7ons due to ver7cal transmission
ZERO
preventable HIV and TB deaths
ZERO
HIV and TB discrimina7on