PROGRESS ON KEY INDICATORS PROGRESS ON KEY INDICATORS MARCH 2015 GAUTENG PROVINCIAL STRATEGIC PLAN FOR HIV, TB AND STIS ( )

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1 PROGRESS ON KEY INDICATORS MARCH 2015 GAUTENG PROVINCIAL STRATEGIC PLAN FOR HIV, TB AND STIS ( ) 1

2 Introduction The NSP is a multisectoral, overarching guide that informs national, provincial, municipal and community-level stakeholders on the strategic direction to be considered when developing implementation plans for a co-ordinated response to HIV in South Africa. These implementation plans should reflect stakeholder-specific contributions to the achievement of the NSP goals and objectives. A national framework provides guidance to all sectors and provinces to develop and cost implementation plans. The NSP is also aligned and consistent with national, regional and international obligations, commitments and targets. The plan has four strategic objectives, which form the basis of the HIV, STI and TB response which have been adopted but slightly changed by the Gauteng AIDS Council These are: 1. Addressing social and structural barriers to HIV, STI and TB prevention, care and impact 2. Preventing new HIV, STI and TB infections 3. Sustaining health and wellness 4. Increasing the protection of human rights and improving access to justice. The Gauteng AIDS Council (GAC) has the mandate to coordinate the multisectoral response to HIV, TB and STIs in the Gauteng Province. The GAC is an advisory council to the Premier, with its administrative secretariat located in the same office and technical secretariat in the Provincial Department of Health. The Gauteng Strategic Plan for 2009 to 2014 was developed by a multisectoral planning team based on the National strategic Plan on HIV and AIDS, the ANC elections manifesto for 2009, the Gauteng Reprioritisation, and analysis of results to date informed by research findings. The plan includes business plans submitted by government developments and is a product of extensive consultations with various stakeholders. The Gauteng AIDS Council unlike the other provinces which adopted the NSP Strategic Objectives as listed above, has split Strategic Objective 1 into 2 parts, namely: Strategic Objective 1.A. Vulnerability to HIV and TB infections in youth and adults will be reduced through social, structural, and behavioural changes and 2

3 Strategic Objective 1.B. Reduce social impacts of HIV and TB on people living with HIV (PLHIV) and TB and their households prioritizing children. However, despite the split, put together, these strategic objectives all fall under the NSP Strategic Objective 1. 3

4 IMPACT INDICATORS IN GAUTENG Province NSP GOALS Reducing new infections by at least 50% using combination prevention approaches Indicator MTCT rate (six weeks and 18 months) 2% 1 (6 weeks) HIV prevalence among women and men aged ,8% 2 HIV Antenatal Prevalence among women aged % 3 HIV Incidence 1.0% 4 Total Number of New HIV Infections Patients alive and on treatment HIV Mortality 3.1% 7 Reducing the number of new infections and deaths from TB by 50% TB incidence TB Mortality 7.3% 9 4.9% 10 1 DHIS 2013/ 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 4 Spectrum Ibid 6 Gauteng Provincial Government Health Annual report, 2012/13 7 Statistics South Africa. Mid-year population estimates Pretoria: Statistics South Africa; 2013a 8 ETR.Net, Statistics South Africa. Mid-year population estimates Pretoria: Statistics South Africa; 2013a 10 ETR.Net,

5 Goal 1: Reducing new HIV infections by at least 50% using combination prevention approaches In determining HIV prevalence, a number of methods and approaches have been used in South Africa including HIV Counselling and Testing (HCT). South Africa took a bold step in 2008 to introduce HCT and by 2012, HIV prevalence was estimated at 12, 2% from an estimated 10.6% in 2008 respectively. The Gauteng Province is estimated at 12, 4% as at 2012 ranking fifth in the country with Kwa-Zulu Natal at 16,9% ranking highest. Prevalence in the Gauteng Province as highlighted in the HSRC Survey has been steadily declining from 14,7% in 2002 to 10,8% in 2005 as well as 10,3% in Figure 1: HIV prevalence in Gauteng Province (2 years and older) 2002, 2005, 2008 and The annual National Antenatal Sentinel HIV & Herpes Simplex Type-2 Prevalence Survey in South Africa estimates HIV prevalence in the Gauteng Province to be high and ranking third in the Country after Kwa-Zulu Natal and Mpumalanga respectively 12. The HIV prevalence has not changed drastically from 30, 4% in 2010; 28, 7% in 2011 and 29, 9% in 2012 respectively 13. Table 2 below gives the general distribution of HIV prevalence by district in the Gauteng Province from 2010 to There HIV prevalence is generally stable within all districts except for the West Rand with 35,6% HIV prevalence in Ibid. 12 The 2012 National Antenatal Sentinel HIV and Herpes Simplex type-2 prevalence Survey, South Africa, National Department of Health. 13 Ibid. 5

6 Table 1: Percentage distribution of HIV prevalence by district in the Gauteng Province Gauteng 2010 (%) 2011 (%) 2012 (%) City of JHB 29,6% 28,9% 29,6% Ekurhuleni 33,8% 30,1% 32,3% Metsweding 31,2% Now part of Tshwane since 2011 Sedibeng 30,9% 31,7% 29,9% Tshwane 26,1% 24,4% 25,5% West Rand 33,2% 32,3% 35,6% The data from the HIV Sero-prevalence survey shows that HIV prevalence by age is highest in the years and years categories above the 40% mark since Table 2: Percentage distribution of HIV prevalence by age in Gauteng Province Age group (years) 2010 (%) 2011 (%) 2012 (%) <15 8, , ** 33.3 ** 14 The 2012 National Antenatal Sentinel HIV and Herpes Simplex type-2 prevalence Survey, South Africa, National Department of Health. 15 The 2012 National Antenatal Sentinel HIV and Herpes Simplex type-2 prevalence Survey, South Africa, National Department of Health. 6

7 HIV Incidence HIV incidence data is achieved through estimations including using mathematical models, DBS testing and PCR tests in infants. The NSP aims to achieve a 50% reduction in adult HIV incidence over the period from 2012 to 2016 but the challenge is in measuring progress towards achieving this goal. The HSRC study 0f 2012 estimated HIV incidence at 1,1% for people aged two years and older and the actual numbers in estimations are new infections in 2012 and for children is set at new infections respectively 16. Spectrum 2013 HIV incidence for Gauteng, for age group years was at 0.85% while for age group years was at 0.99% and using THEMBISA (ASSA) it was 1% for males and 1,8% for females 17, 18. Prevention of Mother to Child Transmission South Africa took a bold step towards the elimination of mother to child transmission and as such, added another ZERO to the UNAIDS vision which states the need to achieve ZERO mother to child transmission of HIV. Whilst challenges remain with regards to system to track outcomes of HIV infected infants at 18 months, PCR results from the National Health Laboratory services coupled with scientific studies have proven the effectiveness of the PMTCT program in South Africa especially between the infants exposed to HIV at the ages 6 8 weeks respectively. Successes of the PMTCT program include the introduction of Dual Therapy (AZT at 28 weeks gestation and single dose Nevirapine during labour), changes in ART initiation criteria (all children under 1 year who test HIV positive are eligible for ART and pregnant women with CD4 count below 350 fast traced through HAART) and a focused management of ART in children. The Gauteng Province has seen a drastic reduction of new HIV infections amongst babies at 6 weeks reducing to less than 2% and this is attributed to improvements in health care and availability of ART for pregnant women. HIV prevalence in children 2 to 14 years and also youths aged 15 to 24 years old has reduced drastically. The HIV prevalence for the ages years has reduced from 10.1% in 2008 to 5, 8% in This is attributed to safe sexual behaviours through departmental and sectoral efforts. 16 Shisana O, Rehle T, Simbayi LC, et al. South African National HIV Prevalence, Incidence and Behaviour Survey, Cape Town: HSRC Press; Ibid 18 UNAIDS

8 The Combination HIV Prevention Policy by EXCO 19 In seeking to reach the intended goal to reduce new HIV infections, the Gauteng Executive Council adopted a Combination HIV prevention policy meant to intensify effort to reach more people with prevention interventions. This policy includes the following HIV preventions efforts: AIDS campaigns by government and donor funded projects led by AIDS Councils Community leaders address social norms and behaviours Extensive life skills training in the school curriculum, Ward door to door education with referrals for unemployed youth, Peer education with referrals for high risk groups including workplaces OVC services and poverty alleviation Health care for prevention: supply condoms, PMTCT introduction of male medical circumcision, test and treat HIV and STIs. Goal 2: Initiating at least 80% of eligible patients on antiretroviral treatment (ART), with 70% alive and on treatment five years after initiation The initiation of ART has evolved over time in South Africa due to a lot of factors including policy changes with regards to ART initiation criteria and eligibility, the practice of ART initiation within and amongst health workforce cadres, accreditation criteria of ART initiation sites and drug treatment regimens. Furthermore, the introduction of Tier.net, a patient management system for the ART program improved the tracking of patient on ART, treatment outcomes and follow ups to ensure optimal adherence to treatment. HIV care and adherence to treatment have largely been the pitfalls of the ART program but measures in place are being refined to counter such challenges. The Gauteng Province since 2004 has managed to initiate patients on ART and by March 2015 and had remaining in care by end of March 2015 with initiations estimated at patients at end year There are patients who die on treatment, 19 Adopted from the Draft Gauteng Multi Sector HIV Report

9 transfer out of the District or Province or even stop ART for any other reasons which all affect retention in ART care. The tier.net is used to identify people who fail to collect their treatment so they can be traced and encouraged to continue treatment. It also tracks CD4 count and viral loads to measure treatment outcomes. Goal 3: Reducing the number of new TB infections and deaths from TB by 50% TB appears to be a challenge of the public health system. TB management includes case detection, conversion, successful completion or cure. It also tracks treatment failure, TB related deaths, patients lost to follow up clients transferred as well as TB cases not evaluated. Intensified case finding has been reinforced through the HCT campaign through symptomatic screening. TB testing technologies have improved with the introduction of the GeneXpert which reduces the turn-around time for TB testing. Gauteng province has the highest TB cure rate in SA at 84.7%, with Ekurhuleni having the highest cure rate amongst all districts at 88.6%. Sedibeng district has the highest defaulter rate at 6.8% and death rate at 7.3%. About 67% of patients who had TB also had HIV in 2013 which was a reduction from 71% in On the other hand, ART coverage in TB/HIV co-infected patients increased from 58% in 2012 to 72% in There has been a marked reduction in MDR TB cases from 749 in 2012 to 459 in

10 Figure 2: TB Program outcomes for Gauteng in Table 3: TB cases per province indicating proportion of cases in children <15 years in Table 3 :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, % 20 Adopted from the Draft Gauteng Multi Sector HIV Report ETR.Net,

11 Table 3 above gives a summary of TB outcomes and it is evident that whilst the cure rate for Gauteng is high, the cases not evaluated are also high above national average. Goal 4: Ensuring an enabling and accessible legal framework that protects and promotes human rights in order to support implementation of the NSP. Policy Mandates The Gauteng Province has successfully mainstreamed HIV and AIDS programmes in the workplace and these interventions are coordinated to reduce any chances of human rights violations. Interventions implemented in the province are in line with the Constitutions of South Africa and do not violate human rights of people. The Gauteng AIDS Council is a multisectoral body which includes all parties with interests in HIV, AIDS and TB including organisations for people living with HIV who are afforded equal opportunities to voice their concerns. One of the key elements of this Goal 4 is to provide access to legal platforms for victims of human rights abuse on the basis of their HIV status. There is access to legal services in Gauteng through social workers and legal NGOs for reporting any acts of human rights violations. Service provision is provided regardless of one s status including the provision of comprehensive services to key populations such as sex workers, MSM, migrant labourers and truck drivers. Goal 5: Reducing self-reported stigma related to HIV and TB by at least 50%. People infected and affected by HIV and TB experience varying levels of stigma and discrimination which affect their capacity for behaviour change for HIV prevention and treatment including safe sex behaviours, testing, disclosure, social support, treatment and adherence. The Gauteng Province has also been participating in the National Stigma Index Survey that was initiated in 2014 and will provide more details to inform further work. The Gauteng Province has a high social inclusion for people that living with HIV including OVCs. PLHIV, AIDS Councils and community leaders provide leadership on interventions to reduce 11

12 the stigma and discrimination although the challenge is with regards to their capacity and resources for advocacy and social mobilisation. 12

13 Strategic objective 1: Addressing social and structural drivers of HIV, STI and TB prevention, care and impact Government departments and civil society are supposed to develop sector specific or departmental specific operational plans that integrated HIV, TB and STI programing. These plans should be in line with the Provincial Strategic Plan (PSP) and implementation of these plans translates to contribution towards the goals of the PSP and the NSP respectively. The Gauteng Province achieved 80% towards the integration of HIV and TB including gender and rights based programming in broader planning amongst government and civil society in 2012 respectively. All the municipalities in Gauteng have at least one informal settlement where targeted comprehensive HIV, STI and TB services are provided. Informal settlements have been targeted as high risk areas conducive for HIV infection and as such, all municipalities through the District/Municipal AIDS Council which is chaired by the Mayor are urged to provide comprehensive HIV services. 13

14 Table 4: Strategic Objective 1 Indicator Baseline Provincial Data Source Achieved Achieved 2013/14 Values Target 2012/13 Values % government departments and sectors with operational plans with HIV, TB and related gender- and rights-based dimensions integrated 80% 100% GPG Audit 80% No Data % municipalities with at least one informal settlement where targeted comprehensive HIV, STI and TB services are implemented 100% 100% Local AIDS Council Secretariats 100% 100% Delivery rates under 18 NIDS To be Not set DoH Annual 4.8% 5.7% determined reports HIV and TB spend To be Not set NASA 2011 R 2,2 No data determined billion SA NASA (2011), UNAIDS, SANAC, CEGAA 14

15 Strategic Objective 2: Preventing new HIV, STI and TB infections Male and female condom distribution is a key prevention intervention for HIV. South African government and other development partners provide both male and female condoms free in public health and other facilities. In Gauteng Province, condom distribution for both male and female condoms decreased in 2012 and 2013 from to in male condoms; and to females condoms respectively. This was mainly due to condom shortages as the new service provider could not keep up with demand. Interestingly, surveys have indicated that the youth and other key populations groups such as men having sex with men prefer fancier condoms and as such, there have been changes in the CHOICE condom with a lot of new colours being used. TB screening is an important prevention strategy that has been improved largely through the HCT program within which TB symptomatic screening is a package of comprehensive HCT provision. Gauteng as mentioned earlier is one of the provinces with a high TB cure rate measured at 84.7%. There has been an increase in TB screening coverage from people screened for TB in 2012 to in 2013 respectively. Intensified TB case finding is being implemented in the province through door-to-door TB screening including the tracing of TB contacts in households with a TB client. Gauteng Province has also targeted populations at high risk for TB in mines, hostels as well as old age homes. The IPT uptake for latent TB among newly diagnosed HIV positive people has decreased from in 2012 to in This decrease should be interpreted in line with the HIV positive people for the specific year but it is worth mentioning that with the high TB/HIV co-infection rate in Gauteng, IP uptake should be improved. Medical Male Circumcision is rated as one of the most cost effective HIV prevention strategy with long term public health benefits. In Gauteng Province, medical male circumcisions have increased from in 2012 to in 2013 marking an upward trend in the programme The HCT campaign in Gauteng Province is targeted at reaching people that have never tested for HIV i.e. those that are testing for HIV for the first time. The target is to reach 90% coverage in the HCT programme. Data available shows that the province had 15

16 reached 68% out of their 90% target by 2016 which is relatively good although it needs strengthening. HCT is also provided at workplaces and has reached 85% of GP officials in the workplace that had ever tested for HIV. Table 5: Strategic Objective 2 Indicator Baseline Values Provincial Target Value Number (and percentage) of 13 Million (HCT men and women Review Report); 62% counselled and tested for Ever Tested, 37% HIV tested in the past 12 90% (Ever Tested) Number and percentage of people screened for TB Number of newly diagnosed HIV positive people started on IPT for latent TB infection % men and women aged reporting the use of a condom with their sexual partner at last sex % 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 months (2008 NCS) Eight Million (2011 HCT Review) 30% 53% (2011 HCT Review) % Data Source DHIS SABSSM (HSRC), NCS Achieved 2012/13 68% Achieved 2013/14 DHIS ETR % (ETR) 40% NCS 2008) HSRC, % N/A 10% (UNGASS Report 2010) 7% (UNGASS Report 2010) HSRC, % N/A HSRC, % Male condom distribution 492 million (2010/11) DHIS Female condom distribution 5.1 million (2010/11) DHIS Number of men medically (2010/11) DHIS circumcised Number of people reached by prevention communication at least twice a year To be determined in Programme Reports: Media Stats

17 Strategic objective 3: Sustaining health and well being ART coverage is optimal for sustaining the health and well-being of HIV infected individuals. The Gauteng Provincial Government has set a target of 90% which goes to show their commitment to prolong life. A marked increase was achieved in 2012 from a baseline of 58% to 81.68%. However, this marked increase in 2012 decreased in 2013 to 68.53% and the measure was done using an eligible criteria of CD4 <350. As the country introduces new ART guidelines and changes in eligibility criteria, this indicator should improve and this will be enhanced by data collected through Tier.net. TB has become a burden for the public health care system and its impact is high amongst HIV infected individuals. The Gauteng Province has surpassed the 85% target for smear positive TB cases that are successfully treated to 85.2% in The TB cure rate has improved from 82% at baseline for all smear positive TB cases, to 82.5% in 2012 and 84.7% in 2013 and this is very close to the target of 85% respectively. The TB/HIV collaboration program is yielding positive results for the Gauteng Province as it is noted that 67% of people that had TB also had HIV in 2013, a reduction from 71% in This could be attributed to the uptake of HIV testing among TB patients in the province as data in table below shows that the HIV testing uptake among TB patients has surpassed the 90% target and is currently at 93% in Data from the Gauteng Province also shows an improvement in ART coverage in people with both HIV and TB from 58% in 2013 to 72% in 2013 respectively. 17

18 Table 6: Strategic Objective 3 Indicator Baseline Values Provincial Target Values Data Source % people per year becoming 58% 80% Spectrum eligible who receive ART (UNAIDS) Achieved Achieved 2012/ / % 68.53% 708/ TB case detection rate 72% (2010 ; WHO) % smear positive TB cases that 82% smear are successfully treated Positive SABSSM (HSRC) 85% ETR.net 82.4% 85,2% (Treatment Success Rate) Number and percentage of registered TB patients who tested for HIV 54% (2010;WHO) 90% DoH GP, 2014 Not available 84.7% (TB Cure Rate) 93% 18

19 Data Elements Missing and to be collected by Gauteng PCA Strategic Objective 1 Number of women and children reporting gender-based violence (GBV) to the police in the last year Proportion of women who have experienced physical or sexual violence in the last year Current school attendance among orphans and among non-orphans aged (UNGASS and MDG indicator) Strategic Objective 3 TB case registration rate TB case detection rate CFR HIV-positive = CFR HIV-negative Number and percentage of registered TB patients who tested for HIV Number of all newly registered TB patients who are, expressed as a proportion of all newly registered TB patients 19