PROGRESS ON KEY INDICATORS PROGRESS ON KEY INDICATORS LIMPOPO PROVINCIAL STRATEGIC PLAN FOR HIV, TB AND STIS ( )

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1 PROGRESS ON KEY INDICATORS PROGRESS ON KEY INDICATORS LIMPOPO PROVINCIAL STRATEGIC PLAN FOR HIV, TB AND STIS ( )

2 Introduction The Limpopo Provincial AIDS Council (LPAC) which is tasked to coordinate all HIV and TB interventions in the Province took the guidance from South African National AIDS Council (SANAC) to develop a Provincial HIV, STIs and TB Provincial Strategic Plan aligned to the NSP. The plan is meant to direct the provincial HIV and TB response, assist in fulfilling the mandate of the LPAC in reporting to SANAC as well as assist in costing the response. The LPAC developed this Provincial Strategic Plan (PSP) in consultation with all relevant stakeholders and this plan has been endorsed after all the necessary crucial steps. The vision of the plan as well as the strategic objectives has all been adopted from the global and national vision The development of the PSP was heavily influenced and imbedded within the broader national and international development instruments like the South African National AIDS Council (SANAC) emphasis on a multi-sectoral approach, the Joint United Nations Programme on AIDS (UNAIDS) which advocates for Zero new infections, Zero deaths associated with HIV and TB and Zero Stigma Discrimination and the United Nations General Assembly Special Session on HIV and AIDS has responded to HIV and AIDS by involving all stakeholders. The developmental approach recognised that HIV, TB and STIs is not just a health problem but a crosscutting challenge for all sectors including the socio-structural, economic and politicolegal determinants of health as causes of the causes of disease vulnerability. From the outset the PSP acknowledges the health challenges that the country and the province is faced with. It also acknowledges the various efforts by the South African Government (SAG) at national and provincial level to address those challenges. Some of the challenges include the quadruple burden of diseases (Communicable, Non-Communicable, Violence and Injury and HIV/AIDS and TB). Some of the efforts to address these challenges include the HIV counselling and Testing (HCT) Campaign launched by government in 2010, the introduction of the Nurse Initiated Management of ART (NIMART), the National Service Delivery Agreement (NSDA) and the changes in the eligibility criteria for ART initiation (CD4 below 350), among others. Such an acknowledgment sets the tone and direction towards which efforts should be directed in order to arrest the epidemic. Page 1 of 19

3 The purpose of the strategic plan is: To guide the development of an implementation plan for the response in the Province with clear timeframes and indicators to measure progress To provide strategic direction in identifying practical interventions and the roles of the stakeholders that forms part of the multi-sectoral response To guide costing and budgeting for HIV and AIDS, STI and TB interventions to ensure availability of resources and efforts for resource mobilization To mainstream HIV and AIDS, STI s and TB services in all sectors in the Province. To strengthen multi-sectoral collaboration with greater emphasis on implementation. To solicit support and commitment of all stakeholders involved in HIV and AIDS programmes. The following is an outline of the strategic priorities for Limpopo as identified during the consultative process culminating in the PSP: Strategic Objective 1: Address Social and Structural drivers of HIV and TB Prevention, Care and Impact Strategic Objective 3: Sustain Health and Wellness Strategic Objective 2: Prevention of new HIV and TB Infections Strategic Objective 4: Protection of Human Rights and Promotion of Access to Justice Under each of these strategic objectives are sub-objectives that focus on specific areas of interest and prioritised in the PSP development process based on the epidemiological profiling of the province. Additionally, each strategic objective has a summary of indicators against which the province is obliged to report routinely. Such an arrangement makes the collection, collation, analysis, reporting and usage of data much easier. It also makes it easy to track progress on specific soft issues that do not easily lend themselves to quantitative deductions and conclusion. Page 2 of 19

4 IMPACT INDICATORS IN LIMPOMPO Province NSP Goals Reducing new infections by at least 50% using combination prevention approaches Indicator MTCT rate (six weeks and 18 months) 2.6% (6 weeks) 1 3.4% (18 months) 2 HIV prevalence among women and men aged HIV Antenatal Prevalence among women aged % (2012) % (2012) 4 HIV Incidence 1.3% 5 Total number of New HIV Infections Initiating at least 80% of eligible patients on ART with 70% alive and on treatment 5 years after initiation Total number of patients initiated on (2012/13) () treatment =96,888 7 Patients alive and on treatment 2012/13= Reducing the number of new infections and deaths from TB by 50% = HIV mortality 5.1% (2013) 9 TB Incidence 2012/13= 137/100, = 140/100,000 TB mortality 8.8% (2013) 11 1 DHIS, program progress report and District Health Barometer 2012/ Ibid 3 Shisana O, Rehle T, Simbayi LC, et al. South African National HIV Prevalence, Incidence and Behaviour Survey, Cape Town: HSRC Press; The 2012 National Antenatal Sentinel HIV and Herpes Simplex type-2 prevalence Survey, South Africa, National Department of Health: Pretoria 5 Spectrum, Ibid 7 Limpopo Provincial AIDS Council Annual Report. 2012/ / Ibid 9 Statistics South Africa. Mid-year population estimates Pretoria: Statistics South Africa; 2013a 10 Limpopo Provincial AIDS Council Annual Report. 2012/ / Statistics South Africa. Mid-year population estimates Pretoria: Statistics South Africa; 2013a Page 3 of 19

5 Goal 1: Reducing new infections by at least 50% using combination prevention approaches National HIV prevalence is estimated at 12.2% (95% CI: ) in In 2008 prevalence was estimated at 10.6% indicating an increase of 1.6%. Limpopo recorded HIV prevalence estimate (9.4%) of below the national estimate of 12.2% 12. The province is the third with a low HIV prevalence after Northern Cape and Western Cape. The graph below presents the trends of HIV prevalence in Limpopo from 2002 to Figure 1: HIV prevalence in Limpopo (2 years and older) 2002, 2005, 2008 and 2012 Source: Shisane et al., 2014 Figure 1 above shows that the HIV prevalence for people 2 years and older in Limpopo decreased from 2002 to 2005 before it started to increase in 2008 and An increase in prevalence can either be caused by increased number of newly positives or an improved retention in care meaning that most people are living longer with the virus. Another explanation to the increase in prevalence from 2008 onwards could be a result of increased efforts by government and Non-Governmental Organisations of educating people about HIV resulting in most people testing and receiving their HIV results. The province needs to identify the causes of an increase in prevalence and develop programmes to halt it in the case of increased number of newly positives. 12 Shisana, O, Rehle, T, Simbayi LC, et al. South African National HIV Prevalence, Incidence and Behaviour Survey, Cape Town: HSRC Press; Page 4 of 19

6 Percentage distribution of HIV prevalence by district in the Limpopo Province The district level variations in the HIV prevalence over the past three years are depicted in Table 1 and Figure 2 below. Most of the districts in Limpopo recorded an HIV prevalence rate above 20% as well as above the provincial average of 22.3% except for Vhembe district 13. For all the districts, prevalence rates have been fluctuating from year to year without a consistent pattern. Table 1: HIV prevalence among antenatal women by district, Limpopo, 2010 to Provincial 21.9% 22.1% 22.3% Capricon 23.7% 25.3% 22.4% Mopani 24.9% 25.2% 25.0% Sekhukhune 20.2% 18.9% 23.0% Vhembe 17.0% 14.6% 17.7% Waterberg 26.1% 30.3% 27.3% Figure 2: HIV prevalence among antenatal women by district, Limpopo, 2010 to Source: South African National HIV Survey, Department of Health The 2011 National Antenatal Sentinel HIV and Syphilis Prevalence Survey in South Africa. Pretoria. 14 Shisana, O, Rehle, T, Simbayi LC, et al. South African National HIV Prevalence, Incidence and Behaviour Survey, Cape Town: HSRC Press; Ibid Page 5 of 19

7 The 2012 HIV prevalence among year old pregnant women decreased over from 14.2% in 2010 to 13.6% in 2011 and 12.3% in The age group recorded the highest HIV prevalence throughout the period under review (Table 2). Data in the table below also shows that HIV prevalence for the age group dropped in 2011 from 25.0% to 15.8% before taking a spike in 2011 to 42.9% 16. Table 2: HIV prevalence among antenatal women by age group, Limpopo, 2010 to Age Group (Years) < > ** ** Source: South African National HIV Survey, 2012 HIV Incidence The 2012 HSRC survey estimates at national level that over the period mid-2011 to mid-2012 there were approximately new infections (95% CI: ) in the population aged 2 years and older. This translates to 1.1% estimated incidence for that period. A number of earlier models have produced estimates of HIV incidence by province, and these estimates are summarised in Table 3 below. Differences in HIV incidence trends by province are important in identifying variations in changes in the epidemic, including potential influence of HIV prevention programmes. The earlier Spectrum and ASSA 2008 estimates of adult HIV incidence for Limpopo both suggested that incidence was among the lowest compared with other provinces. The 2013 spectrum estimates is at 1.3% reflecting new infections. 16 Shisana, O, Rehle, T, Simbayi LC, et al. South African National HIV Prevalence, Incidence and Behaviour Survey, Cape Town: HSRC Press; Page 6 of 19

8 Table 3: Estimates of HIV Incidence by Province 17 Province Spectrum ASSA male ASSA female SAPMTCTE 6-week peri-natally acquired i Eastern Cape 1.30% 1.20% 2.20% 1.3% ( ) Free State 1.65% 1.23% 1.89% 1.2% ( ) Gauteng 1.30% 0.97% 1.39% 0.8% ( ) KwaZulu-Natal 2.22% 1.60% 2.47% 0.9% ( ) Limpopo 1.00% 0.62% 1.59% 0.8% ( ) Mpumalanga 2.15% 1.23% 2.45% 1.2% ( ) Northern Cape 0.69% 0.59% 1.19% 1.0% ( ) North West 1.58% 1.21% 1.90% 0.8% ( ) Western Cape 0.34% 0.41% 0.77% 0.4% ( ) Total 1.43% 1.11% 1.81% 0.9% ( ) HIV incidence in children Mother to child HIV transmission is characterised by transmission occurring at or before the time of birth or after birth through breastfeeding. Reports have shown best performance and significant strides for PMTCT programme for the two years under review as more babies were born free from HIV infection. Dramatic decline was shown in the prevention of Mother to child transmission between 2012 /13 and where the response towards HIV born free infants at 6-8weeks was found to be 3.0 and 2.3% respectively. This is attributable to the introduction of Dual Therapy when AZT was commenced from 28 weeks of gestation and single-dose Nevirapine was given in labour whilst HAART was being provided for women with CD4 counts of less than South African National AIDS Council. Progress Report on the National Strategic Plan for HIV, TB AND STIs ( ). Pretoria: South African National AIDS Council; November Page 7 of 19

9 Goal 2: Initiating at least 80% of eligible patients on antiretroviral treatment (ART), with 70% alive and on treatment five years after initiation This indicator is concerned about coverage, effectiveness and impact of the ART programme. Flowing from the country s national strategic plan for HIV, STIs and TB , the Department s strategic objectives were to scale up combination prevention interventions to reduce the rate of new infections, and to improve the quality of life of people living with HIV, by providing a comprehensive package of care, treatment and support services to at least 80% of people living with HIV and AIDS. According to the LPAC/DOH province annual report for 2012/13, the total number of patients initiated on ART was 49,276 against a target of 46,000. This represents 107% achievement for that year. In terms of the number of people on ART, the province reached 197,719 against a target of 188,410 adults and children for the same year. This represents 105% achievement on that indicator for the same year. Page 8 of 19

10 Goal 3: Reducing the number of new TB infections and deaths from TB by 50% The table below indicates that Limpopo s TB cure rate is estimated to be 75.3%, an achievement slightly above the national average of 74.2%. Those who died as a result of TB were at 8.5% which puts Limpopo at second highest position across the country. Expanded programmes of monitoring TB patients and initiating them early on treatment to improve patient outcomes are required in Limpopo. The lost to follow-up rate is the lowest across the country which buttresses the point on ensuring early diagnosis, timely initiation on treatment, adherence to treatment and course completion. Table 4: TB cases per province indicating proportion of cases in children <15 years in Table # :Treatment Outcomes: New Smear Positive TB cases (Source: ETR.Net 2013) Prov. SS + Cured Success Failed Died Lost to follow Transferred Not Cases up Evaluated No. % No. % No. % No. % No. % No. % No. % EC 21,541 14, % 16, % % 1, % 1, % 1, % % FS 8,966 6, % 6, % % % % % % GP 22,495 18, % 18, % % 1, % 1, % % % KZN 34,078 25, % 27, % % 1, % 1, % 1, % % LP 8,648 6, % 6, % % % % % % MP 9,453 6, % 7, % % % % % % NW 9,668 6, % 7, % % % % % % NC 3,610 2, % 2, % % % % % % WC 14,790 12, % 12, % % % 1, % % % SA 133,249 98, % 106, % 2, % 8, % 8, % 6, % 1, % 18 Department of Health. The 2012 Annual Tuberculosis Report for South Africa (Unpublished). Research, Information, Monitoring, Evaluation & Surveillance, National TB Control and Management Cluster, Pretoria, South Africa. Page 9 of 19

11 Goal 4: Ensuring an enabling and accessible legal framework that protects and promotes human rights in order to support implementation of the NSP. Chapter 2 of the South African Constitution makes provision for the protection and promotion of human rights and obliges the state to ensure the realisation of such rights particularly for specific vulnerable groups. These rights include amongst others, the rights to equality, dignity, life, freedom, privacy and security of the person, irrespective of sexual orientation. In line with this provision, the Limpopo province emphasised the need for programming that is sensitive and targeted at such groups of people as truck drivers, farm workers, and commercial sex workers, among others. Goal 5: Reducing self-reported stigma related to HIV and TB by at least 50%. The stigma index is the indicator for measuring this goal; the index is currently not measured in the DHIS. SANAC is driving efforts to implement the stigma index to monitor efforts to reduce stigma and discrimination and meet this fifth goal of the NSP. Local government departments continue to deliver stigma and discriminating reduction programmes in line with the NSP goals and objectives. Page 10 of 19

12 Strategic objective 1: Addressing social and structural drivers of HIV, STI and TB prevention, care and impact Social and structural approaches address the social, economic, political, cultural and environmental factors that lead to increased vulnerability. As pointed out in the NSP, every government department at national, provincial and municipal levels has a critical role to play in addressing the structural factors driving HIV and TB. With a cumulative total of 22 independent development plans (IDPs) developed by different sectors mainstreaming HIV, TB and STIs, Limpopo province is on track to meet its target by In line with the human rights provision of the Constitution of South Africa as well as strategic objective 4 of the PSP, the Limpopo province also reached out to under-privileged communities of people staying in informal settlements providing HIV and TB services. By the end of year, the province had reached its target of 100%. In terms of orphans and vulnerable children (OVC) school attendance, the province was at 55% by 2012/13 year. While it is acknowledged in the UNGASS report that data for this indicator has been consistently missing over the years, the province as a source of the data needs to be aggressive in collecting data on this indicator. Spending on HIV/TB was also on track for the province. As shown by the data in the table below, the province achieved 90% and 94% spending for the two year period under review. Against a target of 2,700, the province has already overachieved by reaching 247% by the end of year on the number of women and children reporting gender-based violence (GBV) to the police in the last year. This achievement for Limpopo could be a sign of the comprehensive programmes rolled out to reach the target population as well as the multi-sectoral approach used effectively to address social issues related to HIV. Page 11 of 19

13 Indicator % government departments and sectors with operational plans with HIV, TB and related gender- and rights-based dimensions integrated % municipalities with at least one informal settlement where targeted comprehensive HIV, STI and TB services are implemented Current school attendance among orphans and among non-orphans aged (UNGASS and MDG indicator) Baseline Values To be determined in 2012 To be determined in % (2008 SABSSM survey) Provincial Target Values (100%) 30 IDPs and Data Source LPAC annual report 20 APPs 100% LPAC annual report 100% Social Dev annual report LPAC annual report Achieved Achieved IDPs 22 IDPs 9 APPs 5 APPs 96.6% 100% 55% Delivery rates under 18 NIDS To be determined in % LPAC & LDoH annual report 7.8% 7.9% HIV and TB spend NASA 2010 Not set Financial annual report 2013/4 Number of women and children reporting genderbased violence (GBV) to the police in the last year Proportion of women who have experienced physical or sexual violence in the last year To be determined To be determined 2700 LPAC annual report Not set LPAC annual report 2013/4 90% (DoH only) 94% (DoH only) (Limpopo SAPS Crime statistics) (Limpopo SAPS Crime statistics) Page 12 of 19

14 Strategic Objective 2: Preventing new HIV, STI and TB infections "Targeted, evidence-based combination prevention is needed to achieve the longterm goal of zero new HIV, STI and TB infections. Focusing prevention efforts in high transmission areas and on key populations is likely to have the greatest impact, whilst simultaneously sustaining efforts in the general population 19." A Combination Prevention approach acknowledges that no prevention intervention on its own can adequately address the HIV and TB epidemics at the population and individual levels. Combination prevention uses a mix of structural, social, behavioural and biomedical interventions that, when implemented simultaneously, will have the greatest power to reduce transmission, as well as mitigate individuals susceptibility and vulnerability to infection 20. Reach of HCT Programme and TB Screening in the province As indicated in the introductory section of this report above, a combination of factors including the HCT campaign launched in 2010 and outreach programmes targeted at specific vulnerable populations contributed to the achievements under this indicator. With a target of reaching with HCT services by the end of 2016, the province had reached people who are counselled and tested. This represents above the target achievement by the end of year. While the table below shows that there were no set targets for the number of people screened for TB, an achievement of people reached which is five more times of those counselled and tested for HIV for the same period could be an indication of consistency in the integration of health services in the province. According to HIV treatment guidelines of, all HIV positive but TB negative people should be initiated on IPT to prevent them from developing active TB disease. Against a cumulative target of 60,000 on this indicator for the period under review, the province has already overachieved reaching 68,490 people. Condom use among age group remained low in the province. An achievement of 39.3% is below 19 SANAC. National strategic plan on HIV, STIs and TB Pretoria: SANAC; SANAC. National strategic plan on HIV, STIs and TB Pretoria: SANAC; Page 13 of 19

15 the baseline value of 40%. This is an area the province needs to improve on. This trend in performance is observed again for indicators on young women and men having sexual intercourse before the age of 15 and having multiple sexual partners. Performance on these indicators has remained below the baseline values 21. Reach of male condom distribution In terms of male condom distribution, the province appears to be on target to reach 105,000,000 condoms distributed having already reached a cumulative number of over 90,000,000 by year. However, the situation was better for female condom distribution as the province has already more than doubled the target of female condoms distributed. This is a positive sign and an indication that maybe the province should extend its focus to cover correct and consistent use of condoms by target populations. Reach of Male medical circumcision In accordance with Voluntary Male Medical Circumcision (VMMC) Policy of South Africa there is a need to upscale this programme and reach more men as this is regarded as one of the effective strategies to reduce HIV transmission amongst men. With a target of 50,000 men medically circumcised, the Limpopo province has a cumulative achievement of 105,949 which is already more than double the set target by the end of year. With an achievement of over 70,000 people reached with prevention communication at least twice a year against a target of 20,000, the province has been effective in increasing its reach to the target population which may explain its over achievement in most of its indicators. 21 LPAC & LDoH Annual report. Page 14 of 19

16 Indicator Baseline Values Provincial Target Value Number (and percentage) of men and women counselled and tested for HIV Number and percentage of people screened for TB 13 million (HCT Review Report); 62% ever tested, 37% tested in the past 12 months (2008 NCS) Eight million(2011 HCT Review) Data Source DHIS & LPAC annual report DHIS & LPAC annual report Achieved 2012/ (not separated) Achieved Counselled= Tested= Number of newly diagnosed HIV positive people started on IPT for latent TB infection 53%(2011 HCT Review) DHIS & LPAC annual report % men and women aged reporting the use of a condom with their sexual partner at last sex 40% (NCS 2008) Not set Human Sciences Research Council (HSRC) National HIV Prevalence, Incidence and Behaviour Survey % Not available % young women and men aged who had sexual intercourse before age 15 (age at sexual debut) % women and men aged15 49 years who have had sexual intercourse with more than one partner in the last 12 months 10% (UNGASS Report 2010) 7% (UNGASS Report 2010) Not set Not set Human Sciences Research Council (HSRC) National HIV Prevalence, Incidence and Behaviour Survey 2012 Human Sciences Research Council (HSRC) National HIV Prevalence, Incidence and Behaviour Survey 2012 Male condom distribution 492 million(2010/11) LPAC annual report & DHIS Female condom distribution 5,1 million(2010/11) LPAC annual report &DHIS ( ) 11.8% Not available 13.1% Not available Number of men medically circumcised Number of people reached by prevention communication at least twice a year (2010/11) LPAC annual report &DHIS To be determined in LPAC annual report Page 15 of 19

17 Strategic objective 3: Sustaining health and well being Morbidity and Mortality As part of their contribution to the work of Health Data Advisory and Co-ordination Committee (HDACC), the Medical Research Council (MRC) of South Africa and the School of Actuarial Sciences at the University of Cape Town (UCT), released data from the Rapid Mortality Surveillance (RMS) System on four key outcome indicators for South Africa in August The data reflected that the life expectancy of South Africans has increased from 56.5 years in 2009 to 60 years in The Infant Mortality Rate (IMR) decreased from 40 deaths per 1000 live births in 2009 to 30 deaths per 1000 live births in 2011; and the Under-5 Mortality Rate decreased from 56 deaths per 1000 live births in 2009 to 42 deaths per 1000 live births in These achievements far exceeded the targets set for 2014 in the NSDA of the Health Sector for 2010 to Undoubtedly, more work still needs to be done to fight maternal and infant mortality, however, the NDoH report points to the fact that South Africa should recognise and leverage these profound achievements as a celebration of the unity of purpose and the high value our nation places on the wellbeing and productivity of its children, mothers, workers and society at large. Control and management of Tuberculosis in the province Based on data obtained from the ETR.Net system, the Mpumalanga TB programme has been largely successful. Inter-sectoral collaboration is very crucial towards winning the battle against the scourge of HIV and AIDS, TB and STI. At subnational level this need to be elevated for the purpose of monitoring and evaluation of HIV and TB programmatic activities as well as reducing infection rates and the related burden of diseases affecting our communities. For the percentage of people per year becoming eligible who receive ART, the province attained 51% towards the 2016 target of 188,410. The rates of TB case registration is reduced from the baseline values and also lower than provincial target as reflected by a 137/100,000 in 2012/13 and 140/100,000 in year. The province is on track to reach a target of 22,000 TB case detection by 2016 as they have already reached over 90% of the target. Page 16 of 19

18 The table also shows that the smear positive successfully treated cases have been consistent at around 78%, an achievement above the baseline values. However, the case fatality has been increasing from a baseline of 7.1% to the highest of 8.6%. The causes of deaths related to TB need to be investigated so that appropriate and targeted interventions can be developed and implemented for improved patient outcomes. Data in this table also supports an earlier observation made that the province has successfully integrated HIV with TB in its programming. From the TB entry point, the percentage of TB patients testing for HIV is 92.3% which is above the target of 90%. Indicator % people per year becoming eligible who receive ART Baseline Values 58% Provincial Data Source Target Values LPAC report & DHIS (96 409) TB case registration rate 708/ / LPAC report & DHIS Achieved 2012/13 Achieved / / TB case detection rate 72% (2010,WHO) % smear positive TB cases that are successfully treated 73% smear positive LPAC Annual report & DHIS 8.2 % DHIS & LPAC annual report TB case fatality rate (CFR) 7,1% 8.5% DHIS & LPAC annual report CFR HIV-positive = CFR HIV-negative 54% (2010 WHO) Number and percentage of registered 54% ( % DHIS & LPAC annual report TB patients who tested for HIV WHO) (is not in rate) 78.6% 78.4% 8.6% 8.4% 90.1% 92.3% (is not in rate) (83%) Page 17 of 19

19 Data Elements Missing and to be collected by Limpopo AIDS Council Strategic Objective 3 Number of all newly TB patients who are expressed as a propotion of all newly registered TB patients. CFR HIV-positive = CFR HIV-negative Page 18 of 19