NACOSA (Western Cape) Comments
Chapter 9: HIV/AIDS and Sexually Transmitted Diseases
White Paper for the Transformation of the Health System in South Africa

Page 108
HIV/AIDS Statistics
We understand that at the time of writing this White Paper the results of the 1995 antenatal study were available. The statistics can thus be updated to include the seventh national antenatal survey. We would like to propose that a note be made in relation to these statistics that acknowledges that they are a conservative estimate of the number of people in South Africa that are in fact HIV positive.

An intersectoral approach
The fact that "AIDS extends beyond the health sector, requiring the commitment of and intervention by all sectors.. ." is noted. This is developed further on p. 110 [Point 9.1.1(a)] where it is noted that "an interdepartmental task team will be convened to develop a multi-sectoral approach to the problem." We would like to propose that the Minister, or the Department, or Programme responsible for initiating and driving such a commendable initiative be named so as to assist that particular body in their future planning and budgeting.

Page 110
Co-ordination with other NGOs and CBOs and other role-players
The initiatives and efforts of a number of NGO and CBO role-players and the private sector are acknowledged in Point 9.1.1(a). We would like to propose that a sentence be included to support the Government's interaction with NGOs and CBOs that includes the establishment of a collaborative and equal partnership between the parties.

Page 111
National HIV/AIDS and STD Advisory Group
There is some concern amongst AIDS service organisations that the National HIV/AIDS and STD Advisory Group is not operating at a level that it should be given the original motivation for (and concept behind) the Advisory Board's establishment. It is assumed that given it's terms of reference (that are listed on this page), the National HIV/AIDS and STD Advisory Group (and the complimentary sub-groups like those listed in (iii) and (vi)), would have been consulted on issues such as the funding of the Virodene research, or on the allocation of a significant national media budget to support the Sarafina musical.

We would thus like to recommend that before the terms of reference for the National HIV/AIDS and STD Advisory Group are incorporated into any further national health policy documents, the Department of Health and the National Directorate: HIV/AIDS and STDs review the existing terms of reference and reconsider whether they are in fact acceptable to the Department. We would like to propose that the terms of reference (as stated on this page) also be reviewed by the present members of the National HIV/AIDS and STD Advisory Group.

Page 112
Committee on NGO Funding
No acknowledgement is given in Point 9.1.1. (b) (iii) to the current process of the devolution of power to the Provincial Health Departments. It has been our understanding that the principle of devolution - particularly in relation to NGO funding - was to have been implemented in the current financial year, as the Provincial Health Departments are in a better position to assess proposals, work in conjunction with projects, and evaluate the outputs of provincial programmes that are receiving funding from the Department of Health. We would like to propose that the principle of devolution in relation to NGO funding be incorporated into this section.

Working relationships with international agencies
Working relationships with the international "community" are emphasised in Point 9.1.1. (b) (v). We would propose that the section also makes reference to, and includes the establishment of a "working relationship" with international drug companies. At present real hope exists in the Northern Hemisphere countries with regard to HIV/AIDS treatments and the possibility of viewing HIV/AIDS as a "chronically managed disease". People living with HIV and AIDS in South Africa are currently not able to share this vision.

In relation to the promotion of appropriate care and support it is noted that "(t)he procurement of drugs for treatable opportunistic infections" will be undertaken [Point 9.1.1. (c) (v)]. We would like to propose that in order to effectively implement such a strategy the establishment of a working relationship with international drug companies will enable those living with HIV/AIDS in South Africa to gain access to these treatments. In addition, it is proposed that the State assume a very pro-active role in their dialogue with these companies.

It has been our experience in the past that these companies are not bound by rigorous ethical practices that protect HIV + patients participating in drug trials. The State should take the initiative and assume responsibility for ensuring that best practice and strict ethical guidelines be adhered to in relation to any HIV related (and other) drug trial being conducted within the country.

Page 113
Life-skills programme targeted at youth
We would like to propose that three additional points be included into Point 9.1.1
(c)(i):
Firstly, that this strategy should be run collaboratively between the Departments of Health and Education, with emphasis being place on the Department of Education to assume more of a responsibility for educating students about HIV/AIDS, sexuality and lifeskills;

Secondly, that this programme should be initiated at primary school level; and,

Thirdly, that reference should be made to the implementation of a national HIV/AIDS policy for schools that protects HIV+ learners from any form of discrimination. This policy is currently in draft form and has been developed by the South African Law Commission (Discussion Paper 73, Project 85).

Page 114
Use of mass communication media
In Point 9.1.1. (c) (ii) the list of communication techniques to popularise key prevention concepts in AIDS has been omitted from the text in this section. This needs to be included in the final text.

Page 115
Inclusion of Welfare needs
We would like to propose that the various welfare needs in relation to people living with HIV/AIDS be included in the list in Point 9.1.1. (c) (v). The National Department of Welfare has recently circulated for comment a draft document on their "Welfare Plan on HIV/AIDS" (Draft 1, July 1997), and the Department of Social Services, Provincial Administration of the Western Cape has recently developed a policy and discussion document in relation to their HIVIAIDS related services. It would be important to ensure that the main points in these two welfare policy documents are incorporated into this particular section.

Page 218
Setting objectives and indicators for the National AIDS Control Programme
We note that objectives have only been set for the five key strategy areas (detailed on pages 113 - 115). We would strongly recommend that objectives and indicators be established for the other initiatives, policy directives and strategies that are elaborated upon within the Chapter, and that they be included in Table 21.15 on Page 218:

For example, a key principle of the national AIDS control plan is that of promoting inter-sectoral collaboration and establishing a partnership with other Government departments and civil society. It would thus be important to define this principle in terms of an objective and identify indicators that would allow for an element of evaluation. Likewise, no objectives and indicators have been developed for the principle and implementation strategies relating to the involvement of PLWNHIV and their protection against discrimination. It would be important to develop these as well.

We would also like to propose that objectives and indicators be established to monitor the development and implementation of strategies which relate to the critical link between HIV/AIDS and TB infection. We would like to propose, in line with comments on Chapter 10, that the objectives and indicators relating specifically to HIV/AIDS and TB be incorporated into Table 21.16 on Page 219.

Finally, we would like to make some more general comments in relation to Chapter 9. These are as follows:

The use of the names of specific organisations
On a number of occasions in the Chapter, reference is made to specific organisations, for example on Page 114 The National Youth Development Forum and the South African National Student's Congress are noted, and on Page 110 the organisations of NACOSA and NAPWA are noted.

It might be an idea to consider making reference to these organisations as examples, as opposed to making rather exclusive reference to these organisations. For example, The reference on Page 114 could be re-phrased to:
"National and provincial organisations that address issues related to youth development, such as The National Youth Development Forum and the South African National Student's Congress, will be supported in their efforts to provide life-skills training to their constituents."

The reference on Page 110 could be re-phrased to:
"In this regard, the initiatives and efforts of NGOs and CBOs, such as NACOSA and the National Association of People living with HIV/AIDS (NAPWA), and the private sector are recognised and affirmed."

Recommendations from the National AIDS Review (July 1997)
We would like to recommend that Department of Health ensure that the key findings and recommendations emanating from the National AIDS Review (which was conducted in July/August 1997 by the National Directorate: HIV/AIDS and STDs) be checked, so as to see whether they have been incorporated into the present proposals and strategies contained in this Chapter, and in Chapter 10. In this way, we can ensure that we have learnt from the lessons of the past few years in relation to our AIDS control programme.

NACOSA (Western Cape) Comments
Chapter 10: Infectious and Communicable Disease Control
White Paper for the Transformation of the Health System in South Africa

Background
The significance of the dual epidemics of TB & HIV has been recognised for some time by the National Health Department: TB has been declared a top national health priority & the HIV/AIDS Control Programme was accorded the status of a Presidential Lead Project in the RDP.

HIV infection increases the risk of TB illness, and TB accelerates the progression of HIV. An estimated 1,4 million South Africans are dually infected with TB and HIV and half of these will get sick with TB before they die.

Some of the findings in relation to the interaction between HIV/AIDS and TB from the National STD/HIV/AIDS Review, conducted in July 1997 by the National Directorate: HIV/AIDS and STDs noted that:

· In some cases up to 50% of patients in TB hospitals are dually infected with TB & HIV, but staff in these hospitals have had limited training in relation to HJV, and are over-burdened and cannot cope with the psychological and social needs of PLWA.
· Collaboration in training, evaluation and policy formulation between the two programmes has begun at the national level but is limited.
· Collaboration at provincial and district level is minimal.

The manner in which the HIV/AIDS and TB link is noted in Chapter 10
Chapter 10: Infectious and Communicable Disease Control of the White Paper for the Transformation of the Health System in South Africa makes two references to the HIV/AIDS and TB link:

Firstly,
· "TB is the most common opportunistic infection in people infected with HIV and kills more people than any other infectious disease." (p.121);

and secondly,
· "Early identification and treatment of opportunistic infections for TBIHIV will contribute to effective management of both TB and HIV/AIDS." (p123).

The recommendation
We would like to propose that -given the significance of the two epidemics- a specific paragraph be developed within this Chapter which addresses the dual epidemics of TB and HIV/AIDS, and clarifies how the Department of Health proposes to address the issue. We would like to alert readers of this Chapter to the fact that an epidemic that is predicted to infect 25% of the population in 7 years, will require significant intervention and resource allocation between programmes. We believe that two sentences on the link between the two epidemics in insufficient to allow for this.

Our recommendation in relation to what a paragraph like this should contain is as follows;

The collaboration and link between TB & HIV/AIDS and STD Control Programmes should be increased: In particular, links should be made in relation to training; education; advocacy; policy formulation; referral mechanisms; home-based care and provision of Directly Observed Treatment Short-course (DOTS); research into vaccine developments and cheaper treatments of opportunistic infections as well as the production and obtaining of anti-retrovirals which are affordable and effective.

In addition,
· There should be co-ordinated training on STD & TB clinical management, so as to ensure that health care workers are knowledgeable about the link between HIV, TB and STDs.
· Media needs to be developed to inform the public about the link between HIV & TB, and what measures should be taken to reduce the infectious pool.
· The two control programmes should develop a more integrated approach to community education; counselling and treatment in relation to HIV and TB, and the possibility of developing special strategies to address TB in high prevalence HIV areas should be explored.
· Post-test counselling sessions need to inform patients about the link between HIV and TB (including providing information on symptoms; treatment).
· Mechanisms should be developed whereby the dual infection of HIV and TB can be monitored as part of the provincial surveillance system.
· HIV+ health care workers should be made aware of the dangers of excessive exposure to TB and that mechanisms be put in place to protect HIV+ health care workers as well as patients from TB.

It will be important in developing collaborative strategies - that the issues commonly associated with TB and HIV - such as fear, stigma and discrimination
- are addressed in a sensitive manner.