Next HIV plan needs to be based on latest evidence
At the end of this year South Africa’s big plan to fight HIV and tuberculosis (TB) comes to an end. The National Strategic Plan (NSP) for HIV, TB and STIs 2012 – 2016 will be replaced by the 2017 – 2021 NSP. It is vital that the new NSP avoids the mistakes of the past and fully incorporates new scientific evidence. It is also critical that it sets an ambitious and realistic course that all of South Africa can get behind, not just people working in healthcare.
What went wrong with the previous NSP?
While there was a lot that was good in the previous NSP, we need to be honest about the problems with the NSP and how we use it. A great plan on paper is of little use if we do not have the systems or political will to use it. Two problems stand out over the last five years.
Firstly, there was so little effective tracking of our progress against NSP targets, that we only now and again got an idea of how we were performing against the targets. The NSP would have been of much more value if every single district or provincial AIDS council meeting had up-to-date data on a series of key indicators for their area. In the absence of such data, much of the work relating to the current NSP was done in a vacuum. This contributed to a lack of focus and direction.
Secondly, the lack of coordination between government and AIDS councils meant that the NSP often ended up feeling irrelevant when it came to the actual implementation of TB and HIV programmes. Few people seem to understand that at all levels, the NSP and the work of AIDS councils are supposed to set the course for our collective AIDS response. Instead, government, from local level all the way up to national, appear to do what it wishes irrespective of the work done in AIDS councils – Kwazulu-Natal at times being a notable exception. This tendency of government to forge ahead with little regard to AIDS councils undermined the vision of a wider societal AIDS response drawn together by the NSP and AIDS councils.
Top six priorities in the next NSP
In order to deal with these problems and to provide for a more focused and effective NSP the following should be considered for the NSP 2017 – 2021:
1. We need real-time monitoring of the healthcare system
Rather than setting long lists of targets, the NSP must set fewer targets that we know we can track. It is essential that these indicators must regularly be shared with AIDS councils at all levels. When a district AIDS council meets, it must have fresh stats for the entire district as well as for each facility in the district. This will help focus our response in the areas where it is most needed. Often this data is already available to the Department of Health or the National Health Laboratory System, but not being shared timeously with AIDS councils or the wider public. If the new NSP is to revitalise society’s response to TB and HIV, the Department of Health will have to start sharing more data with society.
2. We need a roadmap to treatment for all
The landmark START trial showed us that all people living with HIV should be offered antiretroviral treatment. In line with those findings and with World Health Organisation guidelines all people living with HIV in South Africa will be eligible for treatment from September this year. But merely making more people eligible is not enough. As shown by the recent Treatment as Prevention trial ( TasP trial), much of the challenge will be to test people and then to get people who test positive to start treatment. Making a success of such a campaign will require a very ambitious new test and treat campaign – as well as the thousands upon thousands of community health workers and lay counsellors required to make such a campaign work. All this must be carefully planned, budgeted and coordinated through SANAC. The document that must bring all that planning together in one place is the new NSP.
3. We need an ambitious plan for TB
While the new NSP will no doubt have good and aspirational targets for TB, it should also give clear guidance as to how those targets could be reached. For example, it should set South Africa on a course for dramatically scaled up contact tracing and active case-finding. Since these are human resource intensive activities, government has shied away from it. The NSP has to break this impasse. Similarly, the NSP should show the way toward addressing infection control both in the public and private sector – so that we can reduce TB transmission in schools, correctional facilities, taxis, hostels, shops, the mines, and all other places where TB is transmitted. As with HIV testing and linking to care, the TB response will not succeed if we can’t grow it outside of the healthcare system.
4. We need an ambitious and evidence-based HIV prevention plan
All indications are that the rate of new HIV infections in South Africa is still very high (over 300 000 per year). Rightly, much of the talk at the recent International AIDS Conference in Durban focused on prevention, especially prevention in women and girls aged 15 to 24. It is clear that we urgently need to ensure that all young people in this age group have easy access to condoms and comprehensive sex education. Yet, between the Department of Health and the Department of Basic Education government seems incapable of getting its act together in any meaningful way. The new NSP must help break this deadlock. It must launch a serious, focused, sustained, presidentially driven and endorsed HIV prevention campaign targeting schools and children of school-going age.
The NSP must also ensure that proven HIV prevention interventions like condom provision and voluntary medical male circumcision are scaled up aggressively. Promising initiatives such as the provision of pre-exposure prophylaxis to sex workers must be continued and expanded to other groups of people who are at high risk of HIV infection.
5. We need concrete plans to bring in business and labour
Ensuring more people test and are then started on treatment will require taking our AIDS response beyond the healthcare system. Many people, especially men, simply never go near a clinic and we have to find other ways of reaching them. The solution is however not to have business and labour talk shops in Sandton every six months. Instead, the NSP must outline concrete ways in which business and labour can play a part in the HIV and TB response through for example facilitating HIV testing in the workplace. It must be a key part of the work of district AIDS councils to invite and involve local business and labour in our TB and HIV response in concrete ways. There are already good examples out there. We must learn from them and replicate them.
6. We need to fundamentally reform SANAC
One of the elephants in the room is the severe dysfunction in many SA National AIDS Council ( SANAC ) sectors. Unfortunately, these sectors are often little more than talk shops. Where it matters, for example in relation to medicines stockouts and the ongoing crisis in the Free State public healthcare system, SANAC leadership is often nowhere to be found. Rather than keeping government on its toes and pushing a progressive agenda, some leaders have become the lapdogs of government. This must change if SANAC is to have any relevance going forward and if SANAC is to help mobilise wider civil society in our collective TB and HIV response.
Part of the change will have to be in leadership, but a large part of it will have to be in the way SANAC is structured. Unpopular as such a move might be, all SANAC sectors should be disbanded. It is deeply disappointing, but for various reasons they simply haven’t delivered as many of us hoped they would. Instead, a single SANAC task force of no more than 15 people, including the Minister of Health and the Deputy President, should be established and should meet at least once a quarter. Business, labour, healthcare worker groups and membership-based civil society organisations must all be represented in this task force. Critically, no individuals who are not accountable to substantial constituencies should be on this task force. In addition to the task force SANAC should also convene a technical task team made up of appropriately qualified experts to consider technical scientific issues and to provide advice to the SANAC task force and the Minister and the Presidency.
Top eight indicators for the new NSP
It is critical that we monitor our TB and HIV response in as close to real-time as we can. It is also critical that we get data sliced up by district and facility so that we can see where the trouble spots are and respond to them effectively. Ideally all of the below indicators will be available to every ward, district, and provincial AIDS council in the country. This data should also be available to all members of the public. (Note that these suggested indicators include monitoring against the UNAIDS 90-90-90 targets – By 2020, 90% of all people living with HIV will know their HIV status, 90% of all people with diagnosed HIV will receive sustained antiretroviral therapy, 90% of all people receiving antiretroviral therapy will have viral suppression.)
- Number of people tested for HIV in the last three months by facility, district, province, and nationally. In as far as possible, this statistic should also be expressed as the percentage of HIV positive people who know their status (the first 90).
- Number of people on antiretroviral treatment by facility, district, province, and nationally. In as far as possible, this statistic should also be expressed as the percentage of people who know their status that are on treatment (the second 90).
- Viral load coverage by facility, district, province, and nationally. Viral load coverage must be expressed as the percentage of people on treatment who have received at least one viral load test in the last 12 months.
- Viral load suppression rate by facility, district, province, and nationally. This should be expressed as the percentage of people on antiretroviral treatment who are virally suppressed (the third 90).
- Number of people with a confirmed diagnosis of Drug-Sensitive-TB and Drug-resistant TB by facility, district, province, and nationally.
- Percentage of people with DS-TB or DR-TB who have started TB treatment by facility, district, province, and nationally.
- DS-TB and DR-TB cure rate by facility, district, province, and nationally.
- HIV vertical (Mother-To-Child) transmission rate at six weeks and 18 months by facility, district, province, and nationally.
Note: This article was first published in Spotlight (www.spotlightnsp.co.za). It was written in Low’s personal capacity and does not necessarily reflect the views of the Treatment Action Campaign or SECTION27. Low is the co-editor of Spotlight. He is a former head of policy at the Treatment Action Campaign.
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Congratulations to Marcus Low on an excellent piece. Some months ago I was asked to consider what will be needed with regard to monitoring and evaluation for the next NSP. Here are my thoughts. I stress that they are mine alone and intended to stimulate discussion and clear thinking.
Patient monitoring
Patient monitoring in the public sector in South Africa is weak at best and not done at worst. However, the sine qua non of any good health-care system is the need to know what is happening to the patients. This is especially important for chronic conditions, of which HIV is now one, as well as for infections such as TB for which the course of treatment is of the order of months. Our first responsibility is to individual patients and they deserve to be encouraged to seek care and to be supported during the course of their treatment, however long.
The second, but equally important, responsibility is to improve health at the population level. In this regard the most important and urgent problem is the control of HIV/AIDS and HIV-associated TB. But if South Africa is to reach the 90-90-90 targets for HIV and the corresponding targets for TB we will neither be able to do this, nor even know if we have done it, unless we have good, individual level, data on our patients. The country that does this best in the world is Malawi. Every clinic in the country reports, each quarter, on the number of people that start ART, the number that are still on ART, their viral loads, the number that have died, been lost to follow up, transferred out or defaulted. Their patient monitoring for HIV was based on their TB model for which the equivalent set of indicators are measured and reported. Every quarter, staff from the Department of Health (DOH) visits every clinic in the country and goes through their data with them; not to judge but to provide support, help and advice. The feedback and support from the DOH gives the clinic staff a sense of purpose and commitment. The cost of their patient monitoring system is of the order of US$1 million p.a.; the cost of their HIV-control programme is of the order of US$100 million p.a.
Malawi has something close to a gold standard in this regard and South Africa is not going to get there over-night. I would suggest, however, that South Africa needs to set a target to reach an equivalent standard of care by 2020. While patient monitoring is not my specialty I would suggest that South Africa needs something along these lines and I am willing to defer to those who are much better versed in this matter than I am.
First, we need a way to uniquely identify individual patients. For legal residents ID numbers would suffice but this leaves out the very many non-legal residents, legal temporary residents and those under the age of 16 years. There is talk of a nation wide ‘Medical card’ system which could be considered. Others have successfully used date-of-birth followed by the first three letters of the surname. Since most people have cell-phones they could be used both to identify people and to communicate with patients. If clinic staff took a photograph on first visit and linked it to a cell-phone number this could be quite effective. In any event a way of identifying patients has to be found.
For HIV we need to decide on a standard set of data to be recorded. This starts with an HIV-test. If negative and a person is at high risk they should be given advice on available and appropriate methods of prevention; if positive they should be given a viral load test. If people test negative they should be asked if they are on ART and if so given a viral load test. HIV-negative people could be advised to come back after six-months for another HIV test, perhaps focusing on those aged say 15 to 50 years who are at greatest risk. Those on ART could then be called back after one month, six months and then annually for a viral load test. If the viral load is above 400/L, say, one might want to measure the drug levels in their blood and test for resistance. If patients do not return efforts must be made to find them.
For all TB suspects, we would follow the usual protocol for those that are HIV-negative but examine all those that are HIV positive, with a sputum smear followed by culture if smear negative, or Gene Xpert where it is available. I understand that first line treatment is still six months while second line treatment may now be cut to nine-months. We need to confirm the current protocol for following up TB patients but monthly visits to the clinic or monthly visits from an outreach worker and confirmed cure at the end of treatment should be done.
For both HIV and TB it is essential to have real-time data on how many patients have started treatment, are alive, dead, lost to follow up, defaulted, cured in the case of TB, virally suppressed in the case of HIV, on first or second line regimens for TB, drug susceptible or resistant in the case of HIV.
One of the objections to doing this has been that the health system is overwhelmed and that such ambitious plans cannot be met by overworked health staff. An important reason why the health system is under such pressure is illustrated by data from the Chris Hani-Baragwanath Hospital where, between 2006 and 2009, inclusive, 14,431 people died in the hospital’s medical wards, an average of 11 deaths each day. But of all those that died 64% of men and 82% of women were HIV positive and of those between the ages of 30 and 40 that died 94% of men and 96% of women were HIV-positive (see Black et al. 2015). Controlling HIV and HIV-related TB will massively reduce the burden on the health system but until that time the burden on the health staff could be greatly reduced by training and employing community outreach workers to encourage people to be tested, to provide them with support if positive, to recognize symptoms associated with treatment failure so that they can be brought back to the clinics, and to find them if they do not come for follow up appointments. This would have the dual benefit of dealing with HIV and TB while creating jobs in communities.
A comprehensive system of patient monitoring will take time to develop and implement and one would probably want to start with a small number of clinics representing inner city, urban, peri-urban and rural communities to find out what works and how to make it work and then expand the programme over a period of several years to reach full coverage.
Such a system will entail substantial costs. However, the cost of the HIV-programme in South Africa is currently running at about US$2Bn p.a. so if we allocated 1% of the current expenditure to developing a good patient monitoring system that would provide us with US$20M p.a. which would be more than enough to develop and fund a first-class patient monitoring system. Furthermore, success in regard to HIV and TB could then be extended to provide good patient monitoring for all other chronic conditions.
Surveillance
One area in which South Africa leads the world is in routine surveillance based on the annual surveys of HIV in women attending ante-natal clinics and these have provided excellent data on the state of the HIV epidemic for the past 27 years. As South Africa rolls-out ART and other methods of preventions there is an urgent need to know what the impact of this has been. We therefore need to extend and expand the annual surveys.
Currently the annual ANC surveys focus on HIV-status and, historically, on syphilis. In order to track progress in real time these surveys should be extend so that the health services:
• Ask the women if they know their status and if they are on treatment
• Test for HIV in all cases
• If HIV-positive measure viral load and test for anti-retroviral drugs
• If on anti-retroviral drugs with high viral load test for drug-resistance
• This would give good data on the three 90s for HIV as well as a measure of the extent of drug-resistance.
• Test all women for syphilis, gonorrhea, chlamydia, HSV-2 and other important sexually transmitted infections.
• Test all women for TB, if possible using Gene Xpert.
The cost of such a surveillance programme will not be negligible but will still be only a small fraction of the US$2Bn currently devoted to managing the epidemic of HIV. Furthermore, the major cost of such a programme is setting up the sampling frame, finding the women, getting their consent, taking the blood and sending it to the laboratory. Once the blood samples are in the laboratory the marginal cost of the additional tests will be small.
Linking to other data
There are many other sources of data in South Africa and they should be cross-linked to the key surveillance data derived from the ante-natal clinic surveys. These include:
• Vital registration data from Stats South Africa;
• NHLS data on all of their blood tests;
• PMTCT coverage
• Demographic and Behavioural Surveys carried out by the Human Sciences Research Council;
• Particular data sets such as that collected at Baragwanath and referred to above;
• Data from research studies and trials including CAPRISA, WRHI, Desmond Tutu HIV and TB Centres, as well as many others, but in particular from the Africa Centre in Hlabisa.
Summary
In order to understand, manage and eventually control the epidemics of HIV and TB it will be necessary to greatly strengthen the patient monitoring. This will ensure that individual patients get the best possible treatment and can be used to monitor performance of services in the health system. At the same routine surveillance should be expanded to provide the key set of data on epidemic trends against which other sets of data can be linked, compared and interpreted.
Reference
Black A., Kriel J,Mitchley M, Williams, B.G, Available at http://arXiv.org/abs/1512.04781