1. Review of the Free State Performance in relation to the NSP: 2007-2011 Mr. SC Polelo General Manager: HIV&AIDS, STI, TB and Partnerships Free State Department of Health

2. Outline of presentation 1.Introduction 2.Objectives of the review 3.Review Methods 4.Key achievements 4.1Prevention 4.2Treatment, care and support 5.Recommendations 6.Conclusion

3. 1. Introduction The Province developed a Provincial Strategic Plan (PSP) for HIV & AIDS, STIs and TB, a Monitoring and Evaluation Plan to accompany the PSP and indicate the interventions in the PSP for the period 2008-2011. Leading to the development of the new, 2012 - 2016 PSP, the Province reviewed the progress towards implementation of the current HIV and AIDS response. The National Plan on HIV/AIDS has delivered mixed results,hopefully,the next one will be more strategic.

4. 2. Objectives of the review Review implementation in the current 2008-2011 PSP against targets set in the Plan; Indentify and document achievements and gaps in the provincial response that are critical to the development of the new 2012- 2016 National Strategic Plan (NSP); Identify and document good practice, emerging issues, themes, and policies relevant to the development of the new 2012-2016 NSP and PSP; Identify and build consensus on strategic priorities for the implementation of the new 2012-2016 PSP; Facilitate the drafting of the provincial HIV & AIDS, STI and TB implementation plan of the new 2012-2016 NSP.

5. 3. Review Methods The data for the study came from several sources. – Program managers in government department ; – District Health Information System (DHIS) database; – Departmental annual reports; – Mid-term review document of the NSP (2010) – SANAC Review reports e.g. National Health System review (2009) and National TB Review (2010); – Other research reports e.g. Prevalence and Behavioural Surveys from HSRC (2005; 2008); Know-your-epidemic (KYE)Know your response (KYR), reports Two stakeholder consultative workshops were held on 14-15 June 2011 and 23-25 June 2011 to review input and obtain additional information A third stakeholder consultation is planned for the week of 22 August 2011 to finalize the input and endorse the Provincial Review Report. All stakeholders are invited to this consultation.

6. 4.1. Key achievements in Prevention The province supports combination prevention and offers a comprehensive prevention package to the people of the Free State. There have been many achievements but for the purpose of this presentation, we will among others only focus on the five key achievements: – Condom provision; – HIV Counselling and Testing (HCT); – Prevention of Mother to Child Transmission of HIV (PMTCT); – Blood products and services; and – Medical Male Circumcision (MMC).

7. 4.1.1. Condom Provision Condom use is the most effective method to reduce risk of HIV infection during sexual activity. The actual provision of condoms has far exceeded the target for the provincial plan. – Approximately 10 million male and approximately 170 000 female condoms were distributed through social marketing. – At High Transmission Area (HTA) sites approximately 6 million male and 100 000 female condoms had been distributed during the past financial year. Access to female condoms remains inadequate though.

8. Condom provision through social marketing and at HTA sites: 2010/11 CONDOM DISTRIBUTION

9. Condom provision through social marketing and at HTA sites: 2010/11 CONDOM DISTRIBUTION ON HTA SITES

10. 4.1.2. HIV Counselling and Testing Campaign HCT enabled individuals to become aware of their health status and take appropriate precautions to preserve their health and take steps to reduce the likelihood of transmitting HIV to others. By end of the HCT campaign, (June 2011), the province had tested more than 976 000 people, exceeding the provincial target of 957 889 people tested. – To date, more than 1.01 million people had been tested in the province since the start of the HCT campaign. It is however of concern that fewer men have presented themselves for testing as shown by the HCT data.

11. 4.1.3. Vertical transmission (PMTCT) There has been significant reduction in vertical transmission of HIV from approximately 5.7% in 2009 to approximately 4.5% by March 2011; All pregnant women are offered Provider Initiated Counselling and Testing (PICT) services also known as (“opt out” because client can refuse the test) at the first ANC visit; More than 90% are tested for HIV; Approximately 10 800 (89%) HIV positive pregnant women had been initiated on Highly Active Antiretroviral Therapy(HAART) during 2010/11; Approximately 11 700 (98%) of exposed infants were tested with PCR at 6 weeks; PMTCT is almost exclusively supported by government; and; The role and contribution of Private Sector is still to be realisable.

12. Source of funding for PMTCT in Free State

13. 4.1.4. Blood services and products Government research and effective blood screening procedures have lead to HIV transmission through blood transfusion as being very rare; All blood used for transfusion in the Free State is screened using high technology; All facilities implement Infection Control (IC); All health care workers have been trained in IC; Despite this, some health care providers often delay or do not report possible cases of exposure to contaminated blood products. – This, may be due to fear and stigma

14. 4.1.5. Medical Male Circumcision (MMC) MMC is known to reduce men’s risk of becoming infected with HIV by 60% - randomized clinical trials done in SA, Uganda and Kenya The MMC prevention program has been launched on 14 July 2011 in Lejweleputswa. It was preceded by an intensive advocacy, education and information campaign lead by the men’s sector The launch was well supported by both men and women from all the districts. To date 4560 men have been medically circumcised – For 2011/12, the Province has set an ambitious target of 33 000 men medically circumcised. The Province has recently appointed a specialist in urology to drive the expansion of the MMC programme.

15. 4.2 Key achievements in treatment, care and support for PLHIV HCT and ART Expansion of ART programme; Pre - ART care and prophylaxis; and TB/HIV integration.

16. 4.2.1. HCT and ART All districts and facilities are providing HCT The HCT campaign contributed to a dramatic uptake in treatment and care services for People Living with HIV (PLHIV); By March 2011, there were an estimated 72 000 adults on first line therapy; For 2010/11 about 16 600 new adults and 2 046 children under 15 were targeted to be initiated on ART: - For adults, the 2010/11 achievement was 34 003 and for children the achievement was 3 258 (total of 37 261 against target of 18 664). Total number of adults on ART is approximately 74 000 against a target of 44 900 for 2010/11: - There are more than 48 000 women on ART.

17. 4.2.2. Expansion of ART program The ART Expansion programme was driven by: - Task-shifting from the doctor driven ART to Nurse initiated ART program (NIMART); - Mentoring nurses at Primary Health Care Facilities to initiate patients on ART; and - Site assessment rather than accreditation. As with PMTCT, the rapid expansion of ART programme has been largely by Government with little contribution from private sector as shown in the next slide: - There is very little private sector expenditure for ART; and - Private sector is handing back ART patents to the Public sector especially when their Medical Aid is exhausted before year end.

18. ART Sources of Funding in Free State

19. 4.2.3. Pre-ART care and prophylaxis For 2010/11 approximately 25 200 eligible adults and 12 700 children were newly started on cotrimoxizole prophylaxis ; Approximately 12 400 HIV+ new patients were started on INH prevention therapy during 2010/11 The province has also through collaboration with Non-Profit Organizations established Wellness Support Groups for clients not yet eligible for ART

20. 4.2.4. TB/HIV integration SANAC endorsed TB/HIV integrated services in 2009; TB Directorate with five district Coordinators is in the process of implementing the new TB guidelines; The new guidelines include amongst other management of co-infection TB/HIV; All programmes such as HIV and AIDS, PMTCT and TB should integrate and provide a single service provider; The new approach has beard fruits and HIV testing in TB screening and testing has increased more than 10 fold in past 3 years; To improve service delivery, the Province has forged good relations with private services such as Mines, other sectors department e g. Correctional Services, Military and some NGOs; The efforts of the above Organisations has improved indicators;

21. 4.2.4. TB/HIV integration continued The TB Cure rate has increased from 64% in 2003 to 77% in 2010; and The Province aims to reach a cure rate target of 85% by 2015; In order to manage increasing MDR infections the second MDR Centre has been opened in Welkom catering for 45 patients; Plans are underway to establish additional MDR TB beds at Pelonomi Hospital; The Province has a TB FREE project providing training for Community Health Workers, FREE SABTA providing treatment, care and support to TB patients. and a defaulter tracing projects;

22. SOME CONCERNS RAISED Among others,the NSP is silent on the issues of infant mortality. This gap will be addressed in the drafting of the NSP 2012 -2016. The Provincial Council on HIV/AIDS still to establish M&E Unit.

23. 5. Recommendations Prevention: – Improve prevention programs for Key populations (Men Sleeping with other Men (MSM), Sex workers, and Injecting Drug Users (IDU) - Expand the MMC program; and – Expand the workplace HIV program to include TB. Treatment and Care for PLHIV – Educate the provincial population about the eligibility criteria for ART initiation so that all those who qualify are initiated early on ART to reduce the risk of HIV transmission; – At service delivery level, integration of TB and HIV should be accelerated; – Provide all people living with HIV with cotrimoxizole until their CD4 count improves; – Embark on a mass IPT campaign to get the TB burden down. This will be especially important in the mines. – This is where private sector can contribute significantly; and – Provide l IPT for PLHIV.

24. 6. Conclusion The next NSP should be more strategic, simpler and easier for people to mobilise around; It should a national strategic framework within which the province, government departments, private sector and civil society organisations should develop operational plans; Operational plans to be led by the Premier; and Drawing other departments into the HIV/AIDS/TB fight.

25. THANK YOU