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 sector facilities.
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adopted the dual therapy regimen and were training health workers to administer it, some districts were still using the outdated single dose of Nevirapine because funding to buy the ARVs for dual therapy was problematic.
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 services.
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 water.
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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 interventions.
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.