JOHANNESBURG, 25 June 2010 (PlusNews) - The world's largest
antiretroviral (ARV) programme may be operating in the dark most
of the time, according to a long-awaited review of the HIV/AIDS
national strategic plan (NSP) released by the South African
National AIDS Council (SANAC).
Some of the news is good. SANAC's preliminary draft shows that
since the NSP's inception in 2007, reported condom use has almost
doubled, treatment coverage among adults living with HIV has
almost tripled, and prevention of mother-to-child HIV
transmission (PMTCT) services among HIV-positive pregnant women
has reached 76 percent.
Some of it is not so good. The uptake of dual ARV therapy PMTCT
has been problematic, and there are major shortcomings in
monitoring and evaluation (M&E) that could leave decision-makers
operating in a vacuum, the report warned.
Mark Heywood, SANAC's deputy chairperson, was not surprised by
the findings. "For me, the big take-away message is that the
policies are good but the implementation is still poor, and that
we have to focus on implementation and effectiveness."
Work on drafting a new NSP has not yet started and Heywood said
the current one could run until mid-2011, to give the country a
full year to formulate a new plan and concentrate on efforts like
the recently launched national voluntary counselling and testing
(VCT) programme, which was stuttering.
South Africa runs what is probably the world's largest ARV
programme - over 700,000 people are receiving ARVs at public
Dual therapy foiled by funding shortages
VCT may not be the only thing stuttering. Dual therapy PMTCT, in
which HIV-positive mothers and their infants receive two ARV
drugs - Nevirapine and Zidovudine - was adopted in South Africa
in 2008. Dual therapy is more effective than the previous regimen
of a single dose of Nevirapine, and can reduce the risk of
mother-to-child HIV transmission to as little as five percent.
The report noted that while provinces had adopted the dual
therapy regimen and were training health workers to administer
it, some districts were still using the outdated single dose of
Nevirapine because funding to buy the ARVs for dual therapy was
The 452-page review also highlighted a dearth of data on babies
born HIV-positive, but quoted department of health estimates
showing that almost 40 percent of infants exposed to HIV were put
at risk of contracting the virus by incomplete provision of PMTCT
Monitoring and evaluation mess
The inadequate data on mothers, babies and HIV-positive patients
awaiting treatment was just the tip of the M&E iceberg, the
report said. The current NSP had 17 goals, 65 objectives and
almost 300 jumbled, unprioritised interventions; 35 "primary
indicators" fell outside the ambit of national HIV plans,
including those related to poverty reduction and safe drinking
Measuring South Africa's success against this bevy of goals and
objectives has been hard. A wealth of information on HIV/AIDS is
collected to fulfil government reporting requirements, but the
uneven quality, scope and availability presented considerable
challenges to those trying to implement evidence-based HIV
Similar M&E weaknesses were also noted in the government's
Integrated Support Team (IST) Consolidated Report, commissioned
by former Health Minister Barbara Hogan in response to the ARV
shortage in Free State province in 2009. The IST said a plethora
of reporting formats and parallel information requests led to
"information collection fatigue" and reduced quality.
Ronel Visser, director of Health Link, the M&E and information
management arm of Health Systems Trust, a research organization,
said South Africa had made considerable strides, including in
streamlining reporting requirements.
However, unfilled information management posts, an inability to
roll out necessary software and information technology systems to
many facilities, and adding data-gathering to overburdened health
professionals had resulted in a lack of M&E capacity.
Visser said remedying this would take time, but she was
encouraged by government's recognition of the problem and a call
by SANAC for an information management system that would allow
daily data capturing at primary healthcare level.
"HIV is a complex disease and needs a dedicated information
management system able to track disease management for each
individual patient," she told IRIN/PlusNews.
The review called for greater M&E capacity in SANAC and
provincial AIDS councils, and the creation of a single,
SANAC-managed multi-sectoral reporting system to improve the
quality of information available for planning and management to
combat the disease.