South Africa's National Strategic Plan for HIV, TB and STIs (2023 - 2028) was launched on Friday at Tlhabane Stadium in Rustenburg, North West as the world commemorated World TB Day. Present in the fully stacked marquee tent was Deputy President Paul Mashatile, government ministers, including Dr Joe Phaahla, the CEO of the South African National AIDS Council, Thembisile Xulu, activists, residents, and representatives of various civil society organisations.
The Presidency in a statement prior to the launch said the new NSP, also called the People's NSP, is "by far the most critical since it will be the last one ahead of Agenda 2030, where the global community committed to ending AIDS by the year 2030". It is South Africa's fifth NSP.
The document is described as a blueprint and roadmap for a multi-sectoral, people-centred approach to eliminate HIV, TB and STIs as public health threats by 2030. The plan has four strategic goals: breaking down barriers to achieving HIV, TB and STIs solutions; maximising equitable and equal access to HIV, TB and STIs services and solutions; building resilient systems for HIV, TB and STIs that are integrated into systems for health, social protection, and pandemic response; and to fully resource and sustain an efficient NSP led by revitalised, inclusive, and accountable institutions.
Tackling stigma
Delivering the keynote address, Mashatile, who is also the chairperson of the South African National AIDS Council (SANAC), said the NSP is about our lives and how to prolong them. "This should be the last NSP in our lifetime," he said.
Mashatile said as South Africans we should collectively fight against social isolation associated with TB at a community level. We must also continuously maintain well-coordinated, multi-sectoral interventions against stigma and discrimination in our communities. It is unacceptable that in the year 2023, people are still talking about stigma, he said.
Focus on mental health
The new NSP places much greater focus than previous NSPs on access to mental health support and services for people living with HIV/AIDS and those who are taking TB treatment. One of the plan's key objectives is to "integrate and standardise delivery and access to mental health services".
Vuyo Masebotsana, a peer educator from Access Chapter 2, a LGBTQI+ advocacy organisation, says he is happy that mental health services are included in the NSP. "There are a lot of human rights violations when people are trying to access treatment. Transgender people are faced with a lot of discrimination when trying to access healthcare services. I am happy that for the first time, the NSP encompasses these needs of key populations such as the LGBTQI+ community," he says.
"The prevalence of mental health conditions, including depression and anxiety disorders, among people with TB is estimated to be between 40% and 70%," the NSP states. "The addition of mental health services integration responds to the clear two-way link between HIV, TB, GBV, human rights violations, inequalities, and mental health." The aim is thus to provide "intensified" screening and support for mental health conditions and access to psycho-social support. This will be achieved through the "rolling out of guidelines that integrate mental health into HIV and TB programming, ensuring that healthcare workers in the HIV and TB programmes can recognise, manage and/or refer people with mental health conditions".
"Mental health and physical health are closely interlinked - improving mental health leads to improved physical health outcomes," says Michel'le Donnelly, Project Leader for Advocacy and Awareness at the South African Federation for Mental Health (SAFMH). "Estimates show that if mental health is integrated into HIV and TB programmes global HIV and TB infections can be reduced by up to 17% and 20%, respectively."
She says mental health services and interventions must be delivered to all people at all levels of healthcare by well-trained, well-equipped, culturally- and gender-sensitive health workers, who are paid fairly and can recognise the comorbidities between physical and mental health. "There must be an adequate budget to support this integration," she says.
While the new NSP places much focus on mental health, another policy document called the National Policy Framework for Mental Health is the Department of Health's key policy document when it comes to mental health. According to Donnelly, that document is still being drafted and the SAFMH is waiting for progress updates. As previously reported on Spotlight, the country's previous National Policy Framework for Mental Health expired in 2020. A key criticism of the previous National Policy Framework for Mental Health was that it was not resourced with sufficient budget to be effectively implemented.
There are over 150 references to mental health in the 228-page NSP, but we could not find any references to the Department of Health's new or old mental health policy framework. It is thus unclear if and how these two critical policy documents will complement each other.
TB: Implementing the interventions we have
Among the objectives of the new NSP to ensure improved and equitable access to TB solutions is "to strengthen TB diagnosis and support for people with TB". This is important since the National TB Prevalence Survey released in 2021, showed that annually tens of thousands of people sick with TB are not diagnosed and many who are sick are asymptomatic. The aim is also "to accelerate the scale-up of innovative processes, diagnostic tools, and regimens for the diagnosis, treatment, and care for people with TB" - the importance of which experts like Professor Willem Hanekom, Director of the Africa Health Research Institute (AHRI) stresses.
Hanekom tells Spotlight that in South Africa, there are about 300 000 people who develop tuberculosis every year and about 56 000 people die. "That is about the number of people that can fill the stadium in Durban - the people who die from tuberculosis in South Africa every year. So this is a huge public health problem and we have to intervene."
He says the country has done a great job on many fronts - including on TB incidence that has been coming down dramatically over the last ten to 15 years.
"The NSP," he says, "really focuses on the implementation side - on how to get people diagnosed, how to put people on treatment, and how to get people to complete treatment successfully. And it's an extremely good document for that purpose. However, if one wants to intervene in tuberculosis, there are two things that you can do," he says.
"The one is to use current tools - so the current diagnostic and treatment approaches - to try and intervene and use them most optimally. So, the NSP is really focused on using those tools that we currently have most optimally. But there's also a very important other part to this," Hanekom says. "And that is to develop new tools - new diagnostics to diagnose TB, new treatments for TB, and most importantly, probably, new vaccines to prevent TB, altogether. It's important to develop these new tools because the mathematical modelling that scientists have done has shown that we cannot control the TB epidemic globally and in South Africa without ultimately introducing new tools. So both implementation of the current tools is important and the development of new tools," he says.
Commenting on what can be improved in the TB response, Hanekom says, "I think it's all the way along the cascade of identifying TB patients, to making sure they get on treatment, to making sure they stay on treatment and making sure that they are cured from tuberculosis - every step of the way. We can improve and that is really what the NSP addresses."
However, he says it is sad that in 2023, TB treatment still last six months, which is an incredibly long time for patients and for care providers to intervene. Hanekom says there are already new regimens in the fold that are only four months - so two months shorter, and that would actually make an incredible difference to both patients and to providers. "However, in South Africa, we have not been able to introduce these new regimens yet, although I'm sure that there are plans underway to do so."
Among the objectives of the new NSP, Ingrid Schoeman from TB Proof (a South African advocacy group) points out, is to focus on strengthening TB diagnosis and support for people with TB. "TB diagnosis through targeted universal TB testing in high-risk groups will save lives," Schoeman says. "We know from the TB Prevalence survey that the majority of people with TB had no symptoms, so we cannot afford to wait for people who feel sick to seek healthcare. Instead, we should be offering TB tests such as digital chest X-rays and urine LAM to high-risk groups (people living with HIV, household contacts of people with TB, and those with previous TB) over weekends and in the evenings when people are not at work to increase access as a matter of urgency. Each person diagnosed with TB should receive quality family-centred TB counselling by trained health workers so that people can be supported throughout their TB journey to overcome difficulties such as TB stigma or depression."
Referring to the NSP's objective to focus on strengthening TB prevention efforts, she notes the exciting developments around short-course treatment that prevents TB, and the health department's release of the long-awaited updated TB infection guidelines this month. "These guidelines indicate that people living with HIV, TB contacts, people with silicosis, and high-risk groups (including people who previously had TB, prisoners in correctional facilities, and health workers), should get tested for TB and if the test is negative, can access short course TB preventive therapy to help prevent them from getting sick with TB."
Schoeman says TB Proof is now calling for an immediate scale-up of short-course TB preventive therapy across South Africa.
HIV: Closing the gaps
As was widely expected, the new NSP includes the 95-95-95 targets for HIV. These aim that 95% of people living with HIV, especially those in "key and other priority populations", should know their status, that 95% of those diagnosed should be on treatment, and that 95% of those on treatment should be virally suppressed. The plan also places much focus on key and other priority populations and, as noted above, access to mental health services. Proven forms of HIV prevention such as condoms, voluntary medical male circumcision, and pre-exposure prophylaxis (PrEP) are all endorsed in the new NSP. (PrEP refers to antiretrovirals taken to prevent HIV infection.)
"Achieving the very ambitious goals of 2030 means that we really do need to refocus on TB and HIV as a dual epidemic in this country," says Professor Linda-Gail Bekker, Director of the Desmond Tutu Health Foundation. "We must make sure that we don't lose focus from the fact that this needs our attention. We still have breakthrough vertical transmission and in a country like ours that really is almost inexcusable," she says.
Bekker, like other experts, believes a lot of work still lies ahead for HIV and TB and the new NSP can be an important lever in this process.
"Closing all the gaps in each of these populations - young women and girls, young key populations, and young women who become pregnant and breastfeed are all individuals who need both active prevention with PrEP. They need to have easy access to treatment that is differentiated to ensure that they can keep their treatment going and then to make sure that we continue to reduce stigma and discrimination wherever possible."
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According to her, there are still roughly 2 million people to find and place on antiretroviral treatment. "And then amongst our treatment population, it's very important that we not only start them on therapy but keep them on therapy and make sure they are virally suppressed. If we do that, we will get the secondary benefit of U equals U, which means we will reduce onward transmission of HIV," she says. "So, these are the key areas that we really need to focus and work on." (U=U stands for undetectable = untransmissible, which refers to the fact that people living with HIV who have suppressed viral loads cannot transmit HIV to their sexual partners.)
Ensuring accountability
According to Schoeman, the new NSP can bring the change that the TB community has been waiting for. "But, she says, we can end TB only if political leaders prioritise closing implementation gaps through a close partnership with local leaders who represent communities."
She welcomes the health department and policymakers' efforts to make consultations as wide and inclusive as possible with all key stakeholders, including TB survivors and civil society organisations who could have a say in the development and alignment of the TB Recovery Plan and the new NSP. "This process," Schoeman says, "secured buy-in from local leaders, district-level facility managers, and provincial TB managers to support policy implementation over the next five years that will benefit communities that need TB care most."
Sihle Mahonga-Ndawonde, a project officer at the TB Accountability Consortium (TBAC) who attended the launch of the NSP, tells Spotlight that they are looking into establishing an accountability forum to help ensure the National TB Recovery Plan that was launched in 2021, is implemented.
The State of TB in South Africa report released by TBAC last week shows how important it is to ensure that there is capacity, skills, and expertise at the provincial, district, and clinic levels to implement the TB programme effectively. According to the report, there seems to be a lack of available information on provincial implementation of the TB Recovery Plan, which may suggest that either this plan has not been implemented effectively at provincial level or that there is no readily available record of this implementation, she says.
Mahonga-Ndawonde says TBAC will also be looking at how they can hold accountability meetings with the provinces to continually monitor implementation of TB plans, including the new NSP.
