1. A better Gauteng is in the making PURPOSE To recommend strategies to intensify reduction of new HIV infections for 2009 to 2014 for approval of EXCO. [Department of Health and Social Development] REVISED GAUTENG STRATEGIC PLAN ON HIV AND AIDS FOR 2009 TO 2011 AND 2014 REDUCE NEW HIV INFECTIONS BY 50% BY 2011 Socio Economic and Infrastructure Development Sub-committee 14 th October 2009 1

2. A better Gauteng is in the making Background Mandate: a revised Gauteng Strategic Plan on HIV and AIDS to reduce new HIV infections to reach the target of a 50% reduction in new HIV infections by 2011. Joint planning with all departments, members of the Gauteng AIDS Council and civil society partners. Mandates: 1.Premier and MEC speeches in 2009. 2.ANC election manifesto 2009. 3.National Strategic Plan on HIV and AIDS for 2007 to 2011. 4.Millenium Development Goals for infants, mothers and youth. 2

3. A better Gauteng is in the making GOALS for Gauteng 2009 to 2014 1.Reduce new HIV infections by 50% by 2011. 2.Reduce deaths from TB and AIDS by extending treatment care and support to 80% of people with HIV. 3.Normal development of children affected by AIDS with sustainable households. 4.Extend partnerships through AIDS Councils with monitoring and evaluation. 3

4. A better Gauteng is in the making Measuring HIV prevention 1.Measure new HIV infections (incidence) = National goal. 2.Measure overall HIV infections (prevalence) in adults = many surveys. Why HIV prevalence no longer measures prevention: a.People infected with HIV live longer on ART. b.AIDS deaths reduce HIV prevalence. We therefore focus on measuring new HIV infections in youth. (some technical challenges). 4

5. A better Gauteng is in the making 1.The HSRC household survey measured all adults and children. HIV prevalence is CHECK for all in 2008 HIV prevalence is 15.2% for 15 to 49 years in 2008 2.The antenatal survey measured pregnant women. 1.HIV prevalence is 29.9% in 2008. Measuring HIV prevention 2004 – 2009 HSRC measured all adults ANC measured pregnant women 5

6. A better Gauteng is in the making Measuring HIV prevention 2004 – 2009 HIV prevalence epidemic curve among antenatal women, Gauteng, 1990 to 2008. Overall HIV infections (prevalence) in pregnant women have “stabilised” from 2004 = no increase in HIV prevalence. 6

7. A better Gauteng is in the making Analysis: Reduce new HIV 2004 to 2009 HIV prevalence trends among antenatal women by age group, SA, 2006 to 2008. women by age group, SA, 2006 to 2008. 14 Gauteng is fifth of nine provinces. The HIV infection rate in Gauteng is just above the national average.

8. A better Gauteng is in the making Analysis: Reduce new HIV 2004 to 2009 HIV prevalence trends among antenatal women by age group, SA, 2006 to 2008. women by age group, SA, 2006 to 2008. 15 Increases above 30 years. Insufficient decrease under 20 years.Slight decrease 20 to 30 years.

9. A better Gauteng is in the making Results 2004 to 2009 Gauteng GOAL 1: Reduce new HIV infections (incidence). Halved in children: maternity services (PMTCT). Halved in teenagers: lifeskills in schools and media. High in the age group 20 to 30 years, especially females. Overall infections in adults (prevalence) have “stabilised”.  No increase in prevalence for pregnant women and adults. Increased safe sex behaviours.  Condom use doubled from 32% in 2002, to 58% in 2008  The key problem is multiple partners (specific groups) Note: A reduction of new HIV infections in the youth is the first stage of “turning the tide” of new HIV infections. 7

10. A better Gauteng is in the making Results 2004 to 2009 Gauteng GOAL 2: Longer productive life for people living with HIV (PLHIV). Some reduction in deaths: e.g. TB ±8%. Life expectancy dropped by 15 years. About 50% of deaths are due to AIDS:  Increased infant and maternal deaths undermine our ability to reach Millenium Development Goals.  Overloaded health services. Very high access to health care. 51% know HIV status. High uptake of ART: a total of 210 000 people have been started on ART. TB cure rate at 76%. ART adherence is good in research sites. 8

11. A better Gauteng is in the making Results 2004 to 2009 Gauteng GOAL 3: Normal development of children affected by AIDS with sustainable households. High inclusion and support by family, friends and schools. High uptake of social grants (over 75%). Children’s services are provided for 40 000 children. Increase in youth headed households : less than 150 child headed households in 2008 = families and community include OVC. More research in progress. AIDS affected households which utilize NGO, free and subsidized services can cope. 9

12. A better Gauteng is in the making Results 2004 to 2009 Gauteng GOAL 4: Organise an effective multisectoral AIDS response in Gauteng. Met 70% of national targets of the National strategic Plan on HIV and AIDS for 2007 and 2008. All departments and sectors of civil society are involved. 6 of 7 AIDS Councils are in place. We can measure service outputs (80%) and outcomes (60%). Jointly reached 40% of population face to face in 2008. Evaluation of the multisectoral strategy: started (3 research projects). Limited results for workplace AIDS programmes: low outputs/coverage for HIV prevention services (education) Note: Refer to item 3.2.1 in the strategic plan enclosed for details including sources of information on outcomes and impacts. 10

13. A better Gauteng is in the making Analysis: Reduce new HIV 2004 to 2009 1.New HIV infections halved in children. Reduced in babies in research sites from 7% to 3.5% due to PMTCT (of all babies after “dual ARVs”). 2.New HIV infections halved in teenagers (15 to 19 years) : Due to very high safe sex behaviours. Linked to lifeskills in schools, family and media. 3.New HIV infections increase rapidly after 20 years of age, especially females. Reduced in males under 25 years in 2005 (waiting for 2008 from HSRC). Increased sexual activity after leaving school. Multiple partners, delayed marriage, alcohol Young females infected due to inequality (gender and economic). 30% of male students are circumcised (Gauteng) Note: High risks for unemployed youth. 11

14. A better Gauteng is in the making Analysis: Reduce new HIV 2004 to 2009 4.Adults over 25 years (25 to 49 years) Risks due to multiple sex partners. Condom use doubled from 2002 to 2008. Gauteng reported the lowest number of sex partners in 2008 with a small reduction from 2005. 5.Key social risks are recognised: inequality, sex for gifts and mobility. Multiple partners is “normal” for some groups. 6.STIs (syphilis) reduced in pregnant women (from 3.8% in 2007, to 2.7% in 2008). Notes: 1.More details are available on sources of information e.g. Meta-analysis by CIET. 12

15. A better Gauteng is in the making Effective methodologies 1.Key interventions which show changes in sexual behaviour on research: Peer education on best practise model:  Sex workers in Hillbrow and Berea, and several projects in the region. Lifeskills in schools:  High association in local surveys. Internationally. Probably “educational” drama: reports from Soul City. 2.PMTCT has reduced HIV in babies 3.The health service or “medical model” has had limited impact on sexual behaviour and HIV : Limited impact of VCT on sexual behaviour. STI treatment does not automatically reduce HIV. 4.Media on its own increases knowledge and attitudes but not behaviour: multiple sources. 5.Social factors also drive sexual behaviour: Social norms, poverty, power etc. 13

16. A better Gauteng is in the making 1.Babies and children: further reduce HIV through PMTCT. Increased coverage of ARVs for mothers and babies in 100% of maternity services. 2.Teenagers: further reduce HIV. Sustain lifeskills in schools. Peer education for high risk schools. Continue youth media. Add male circumcision for male youth 15 to 24 years: traditional, public health from 2010 and private sector. Plan: Reduce new HIV by 50% 2009 to 2014 16

17. A better Gauteng is in the making 3.20 to 30 years: top priority Focus on education for students and unemployed youth.  Peer education for students.  Ward based education in 60% of wards for the unemployed. Prioritize reduction in sex partners. Reduce social risks of young women (inequality and poverty). 4.Adults: Involve men. A joint campaign for the World Cup in 2010. Reduce transactional sex (sex for gifts) A big increase in coverage of workplace education from 8% to 25% per year: public and private sectors. Plan: Reduce new HIV by 50% 2009 to 2014 17

18. A better Gauteng is in the making 5.All groups: Improve the condom supply: reliability. A bigger media campaign to increase knowledge and attitudes. CBOs focus on social values to reduce the number of sex partners and transactional sex (sex for gifts). Extend coverage of workplace education by government, business and unions through the peer education model. Sustain effective health services: VCT for couples, treat STIs, PEP, infection control, and safe blood supplies. 6.Extend partnerships to reach 40% of the population each year. Key departments: Education, SACR, Municipalities, Health and Social Development. Key sectors: business, sports, youth, media, faith based, traditional, unions. Plan: Reduce new HIV by 50% 2009 to 2014 18

19. A better Gauteng is in the making 7.Reduce social vulnerability of young women: all programmes of government (vulnerability is increasing due to poverty). 8.Measure outcomes of education and health services regularly (every 3 years) and change where necesssary. Notes: 1.Media campaigns = knowledge and values with limited impact on sexual behaviours. 2.Education (face to face in small groups) and lifeskills increase safe sex behaviour. References available. 3.Social drivers of HIV will continue to limit the effectiveness of education. For the revised strategies for health care, children and multisectoral coordination: refer to Gauteng Strategic Plan on HIV and AIDS for 2009 to 2014. Plan: Reduce new HIV by 50% 2009 to 2014 19

20. A better Gauteng is in the making Summary of Plan 2009 to 2014 SUB-PROGRAMMEDEPARTMENTTARGETS 1. Increased safe sex behaviours for key population groups 1.Lifeskills in schools for grades 1 to 12. 2.Ward based door to door education by volunteers. 3.CBOs educate members. 4.Peer education by NGOs for high risk groups. on best practise model. 5.Education in all workplaces. a big increase in coverage 6.A joint media campaign Education Municipalities CBOs (MSAU) NGOs 4 departments All departments Business Health & Social Development with partners (MSAU) 100% schools 60% of wards 30% population 5 million reached (cumulative) 700 000 reached (cumulative) 25% of employees 75% of population 2.Reduce social vulnerability and gender and economic inequality 1.Government programmes on gender and poverty 2.Involve men in education and awareness AllSee above 20

21. A better Gauteng is in the making Summary of Plan 2009 to 2014 SUB-PROGRAMMEDEPARTMENTTARGETS 3. Further reduction of HIV infection in babies 1.Full implementation of the revised PMTCT policyHealth100% of clinics 90% of mothers and babies get ARVs. 4. Reduce new HIV infections through health services 1.Add male circumcision for youth. 2.Test for HIV (VCT). 3. Treat STIs 4.Supply of free male and female condoms (access, numbers and quality) 5.Safe blood supply 6. Reduce exposure to carers. 7.Reduce HIV after sexual assault (PEP). Health, Traditional sector Health Health (HAST) Blood transfusion services Health & NGOs Health From 2010. 80% of traditional surgeons trained, 80% of initiates educated. From 300 000 to 500 000 people pa (tbc) 100% clinics. Increase supply of male condoms to 15 million per month. 100% screened. 33% of carers trained per year (tbc). 13 000 treated per year. 5.Measure results 1.Measure resultsAll (MSAU)Joint reports per year: four quarters (outputs) & annual (outcomes) 21

22. A better Gauteng is in the making Budget implications 2009 to 2014 1.1 The following increases are needed : A multisectoral strategy requires a multisectoral budget to achieve coverage and outcome targets. Continue the provincial conditional grant for AIDS. Ward based door to door education by Municipal volunteers. Peer education for students and high risk groups by NGOs. An expanded media campaign. Community organizations reach members Add male circumcision (public, private and traditional sector.) Province procures extra condoms to ensure a reliable supply. More research to measure service results every 3 years 22

23. A better Gauteng is in the making 1.2 Costs Actions to contain costs: refer to item 4.1.2 in the enclosed plan. Costed to 2014 (activity based costing) involving departments and civil society. 1.3 Increased Costs for 2009 to 2014 Protect HIV prevention budget (modest increases) from high costs of health care and social support. Shift workplace costs to prevention: implement the peer education “best practice” model to increase safe sex behaviour. National Conditional Grant for Health for AIDS covers baby milk and ARVs for PMTCT and the VCT service. NDoH supplies 10 million free male condoms per month. Tender more research projects to measure programme results (outcomes and impacts): high quality service providers for credibility. Add value to national surveys (ANC and HSRC). 23 Budget implications 2009 to 2014

24. A better Gauteng is in the making Human Resources Continue to dominate the costs due to the scale of education. Over 35 000 educators have been trained in lifeskills since 1998. Scale up education on safe sex for employees and involve unions. Relies on community workers and unemployed volunteers paid with stipends through NGOs:  Sustain volunteerism (CBOs).  More skilled NGO project managers to ensure quality services for communities.  Monitor and evaluate community services (quality and sustainability)  An efficient government NGO funding system. Shortages of skilled professionals in government are being addressed:  Train, employ and retain professionals and add mid-level workers.  Increase programme management and expertise including M&E. 24

25. A better Gauteng is in the making Consultation 1.Planning process Joint planning team of departments and sectors. Costed business plans by departments. MTEF tables: outputs and costs: see Annexure to memo. 2.Consultation process Departments: all programme managers, key SMS. Civil society: 10 sectors done with 2 to follow. Members of the Gauteng AIDS Council. 25

26. A better Gauteng is in the making Consultation 3.Civil society input Inclusion: PLHIV, children and vulnerable groups. Address social values, focus on men and reduce inequality. Improve the condom supply: reliable quality and supply. A joint safe sex campaign for the 2010 World Cup focussing on men. Sustain volunteerism. 26

27. A better Gauteng is in the making Communication 1.Internal communication through planning and consultations. 2.A media strategy: see Annexure for the communication strategy. Publicity led by the AIDS Council Advertising (radio, print and outdoor murals) to reach 75% of the population. Mass supplies for education programmes. A joint annual campaign starting with safe sex for the 2010 World Cup Proposal : a joint Gauteng AIDS Summit on strategy for 2009 to 2014 Key themes: 1.“Safe sex saves lives”: ABC options for different groups. Prioritise reduction of sex partners. 2.“Making a difference”: social and personal responsibility for safe sex and inclusion of PLHIV and children. 3.“Get treatment for TB and AIDS to live longer” (tbc). 27

28. A better Gauteng is in the making Organizational Arrangements Refer to the memorandum: Review of the Gauteng AIDS Council Monitoring and Evaluation 1.Indicators drawn from national and international guidelines and targets; refer to table. Minimum standards for education consulted and confirmed. Departmental policies apply to services: health, education, children etc. 2.A monitoring and evaluation system has been set up: Measures changes in knowledge, values/attitudes and sexual behaviours. National surveys track HIV infection rates over time. Measure the results of sub-programmes (outcomes and impacts). 28

29. A better Gauteng is in the making Indicators for HIV prevention 2009 - 2014 OUTCOME INDICATORSTARGETS 1.Increased knowledge on safe sex. 2.Increased safe sex behaviours (varies per group). Use BSS indicators. 3.Reduction in STIs (syphilis in ANC). 4.% of women and babies receiving ARV in PMTCT. > 90% 80% – 90% <2% 90% IMPACT INDICATORSTARGETS 1.Reduction of new HIV infections (incidence) Babies 0 – 1 years (MDG) Children 2 – 14 years Youth 15 – 24 years (UNGASS) 2.No increase in HIV prevalence for adults 25 to 49 years or reduce incidence in adults 50% 0% 25 to 50% (tbc) Notes: 1.Departments will set targets to reach outcomes: input, process and outputs. 29

30. A better Gauteng is in the making Recommendations 1.The report and analysis of results of HIV prevention for 2004 to 2009 are noted. 2.The revised goal, strategic objectives and targets to reduce new HIV infections for 2009 to 2014 are adopted. 3.Senior managers across departments participate in increasing outputs according to the agreed strategic plan including the workplace. 4.The budget for HIV prevention (provincial conditional grant for AIDS) is increased and protected. 5.A joint communication strategy is agreed. 5.All departments participate in the joint system for measuring results (outcomes and impacts). Note: The full Gauteng Strategic Plan on HIV and AIDS for 2009 to 2014 is enclosed – this memo addresses GOAL 1 on HIV prevention. 30