South African National AIDS Council Research Articles

Monitoring and evaluation lessons from the design and implementation evaluation of the ‘You Only Live Once’ social behaviour change programme for adolescents: A partnership between the United States Agency for International Development, Department of Social Development, South African National AIDS Council, Pact SA and Mott MacDonald

Background: Conducting evaluations in South Africa has become a common government practice because of the rise in demand for evidence-based policymaking. However, evaluation is often seen as an exercise to be undertaken at the end of a programme – summative – instead of playing a distinct role at all stages of the programme cycle – formative and process evaluation. Subsequently, programmes are often designed without the help of monitoring and evaluation (M&E) specialists to ensure robust and testable theories of change (TOCs) and implementation modalities, or monitoring systems that assess performance to enable adaptive management. Objectives: This article presents findings from a case study regarding what the public sector can learn from formative evaluation to improve public sector programmes. Method: The case study focuses on implementing and utilising the results of a formative evaluation of the ‘You Only Live Once’ (YOLO) programme to highlight frequently experienced limitations and potential solutions to utilise M&E as a form of effective programme management in the public service. It is aimed at the public sector to provide evidence that other forms of evaluation and monitoring systems are critical to enable effective public programming. Results: Key lessons learnt include the significance of developing a clear and comprehensive M&E system at the programme planning and design stage, embedding the culture of M&E in programme implementation, evaluating potential modalities of implementation, rather than simply assuming modality robustness, and capacitation of implementation agencies to internalise and implement M&E requirements. Conclusion: These lessons present the critical role of formative evaluation in ensuring that big-budget public sector programmes are designed and implemented effectively.

Will the current National Strategic Plan enable South Africa to end AIDS, Tuberculosis and Sexually Transmitted Infections by 2022?

BackgroundIn May 2017, the South African National AIDS Council released the fourth National Strategic Plan (NSP) for HIV, tuberculosis and sexually transmitted infections. This five-year plan (2017–2022), which aims to track the progress towards transitioning these epidemics to no longer being public health threats by the year 2030, is built on the successes and barriers of the previous NSP (2012–2016). However, the NSP does not address some critical components, which may contribute to a future failure in achieving its hefty goals.ObjectivesThis article outlines the gaps within the new NSP, as well as highlighting aspects requiring careful focus, which are critical to address in order for South Africa to make progress towards the set targets.MethodThis commentary included an in depth review of the NSP, other South African National Strategic Plans and documents, and scientific literature.ResultsThe NSP does not address gaps in funding, oversights in prevention and treatment strategies, human resource shortages and lacking health system requirements.ConclusionTo realistically achieve the NSP targets and goals, a robust, client-centred strategy addressing the NSP gaps needs to be implemented. The strategy must be cost-effective; provide active linkage to care; and address health system weaknesses that inhibit its successful implementation, including human resources, service delivery and supply chain management, accountability and monitoring and evaluation (M&E).

Progress and prospects for the control of HIV and tuberculosis in South Africa: a dynamical modelling study

In September, 2016, South Africa adopted a policy of providing antiretroviral treatment to everyone infected with HIV irrespective of their CD4 cell count. Studies of universal treatment and expanded prevention of HIV differ widely in their projections of effects and the associated costs, so we did this analysis to attempt to find a consensus. We used data on HIV from the Joint UN Programme on HIV and AIDS (UNAIDS) from 1988 to 2013 and from data from WHO on tuberculosis from 1980 to to 2013 to fit a dynamical model to time trends in HIV prevalence, antiretroviral therapy (ART) coverage, and tuberculosis notification rates in South Africa. We then used the model to estimate current trends and project future patterns in HIV prevalence and incidence, AIDS-related mortality, and tuberculosis notification rates, and we used data from the South African National AIDS Council to assess current and future costs under different combinations of treatment and prevention approaches. We considered two treatment strategies: the Constant Effort strategy, in which people infected with HIV continue to start treatment at the rate in 2016, and the Expanded Treatment and Prevention (ETP) strategy, in which testing rates are increased, treatment is started immediately after HIV is detected, and prevention programmes are expanded. Our estimates show that HIV incidence among adults aged 15 years or older fell from 2·3% per year in 1996 to 0·65% per year in 2016, AIDS-related mortality decreased from 1·4% per year in 2006 to 0·37% per year in 2016, and both continue to fall at a relative rate of 17% per year. Our model shows that maintenance of Constant Effort will have a substantial effect on HIV but will not end AIDS, whereas ETP could end AIDS by 2030, with incidence of HIV and AIDs-related mortality rates both at less than one event per 1000 adults per year. Under ETP the annual cost of health care and prevention will increase from US$2·3 billion in 2016 to $2·9 billion in 2018, then decrease to $1·7 billion in 2030 and $0·9 billion in 2050. Over the next 35 years, the expansion of treatment will avert an additional 3·8 million new infections, save 1·1 million lives, and save $3·2 billion compared with continuing Constant Effort up to 2050. Expansion of prevention, including provision of pre-exposure prophylaxis, condom distribution, and male circumcision, could avert a further 150 000 new infections, save 5000 lives, and cost an additional $5·7 billion compared with Constant Effort. Our results suggest that South Africa is on track to reduce HIV incidence and AIDS-related mortality substantially by 2030, saving both lives and money. Success will depend on high rates of HIV testing, ART delivery and adherence, good patient monitoring and support, and data to monitor progress. None.

Implementing a multi-sectoral response to HIV: a case study of AIDS councils in the Mpumalanga Province, South Africa

ABSTRACT Background: A multi-sectoral response is advocated by international organisations as a good strategy to address the multiple drivers and impact of human immunodeficiency virus/acquired immune deficiency syndrome (HIV/AIDS), and was historically mandated as a condition of funding. In March 2017, the South African National AIDS Council (SANAC) launched the latest 5 year National Strategic Plan (NSP) to address HIV, sexually transmitted infections and tuberculosis. As with previous iterations, the NSP calls for multi-sectoral action (MSA) and mandates AIDS councils (ACs) at different levels to coordinate its implementation. Efforts have been made to advocate for the adoption of MSA in South Africa, yet evaluation of these efforts is currently limited. Objective: This paper assesses the implementation of a multi-sectoral response to HIV in South Africa, through a case study of the Mpumalanga Province. Methods: We identified and reviewed key policy documents, conducted 12 interviews and held six focus group discussions. We also drew on our involvement, through participant observation, in the development of NSPs and in AC meetings. Results: SANAC is struggling to provide much-needed support to provincial, district and local ACs. Therefore, most ACs are generally weak and failing to implement MSA. Membership is voluntary, there is a lack of sustained commitment and they do not include representatives from all sectors. There is little capacity to undertake the activities necessary for coordinating the implementation of MSA, and unclear roles and responsibilities within ACs result in divisions and tension between sectors. There is inadequate senior political leadership and funding to facilitate effective implementation of MSA. Conclusion: We identified three interventions that we argue are required to support the effective implementation of MSA: strengthening and stabilising the SANAC structure; building capacity of ACs; and creating an enabling environment for effective implementation of MSA through political leadership, support and resourcing of the HIV response.

Two years later: preservice teachers' experiences of learning to use participatory visual methods to address the South African AIDS epidemic

IntroductionSouth Africa continues to struggle with high rates of HIV and AIDS. The general population has an HIV prevalence rate of 19% and the annual death rate due to AIDS-related causes is 200,000 (UNAIDS, 2013). Amongst the highest rates globally, 7% of South African youth between the ages of 15 and 24 years are HIV positive. They also have the lowest rates (14.3%) of national ARV treatment exposure (Human Sciences Research Council [HSRC], 2014). In the integrated national and provincial strategies laid out by the Department of Basic Education (DBE), the Department of Higher Education and Training (DHET), and the South African National AIDS Council (SANAC), teachers are thought to be well positioned to respond to the physical, emotional, and pedagogical impact of HIV and AIDS on learners' lives (DBE, 2012; DBE & DHET, 2011; SANAC, 2011). Specific curricular and professional requirements further outline teachers' responsibilities to address the intersecting influences of gender inequity, HIV stigma, and health behaviour (e.g., condom use, alcohol and drug use) on HIV transmission and prevention (DBE, 2000; 2011a; 2011b). While there are many possible approaches to addressing these issues, this article reports on the findings of a follow-up study with South African preservice teachers who were introduced to participatory visual approaches to HIV and AIDS education. Framing the study theoretically in Mitchell's (2014) concept of the afterlife of research interventions, this study asks: What can we learn about HIV and AIDS education through a follow-up study with individuals previously trained in participatory visual methods? Taking up the question, this article begins by describing Youth as Knowledge Producers (YAKP) as the research context and my connection to the project. This is followed by an outline of my data collection methods. The findings report on preservice teachers' reflections on learning participatory visual methods for HIV and AIDS education, how they have or plan to integrate these methods into their teaching, as well as on challenges they have experienced in applying a participatory visual approach. The findings are discussed in relation to what they might contribute to the development of HIV and AIDS teacher education.Teacher Education and HIV and AIDSThe DBE response to the epidemic is reliant on teachers. This is, however, far from straightforward for teachers themselves. Teaching about sex and the body in its sexualised form can pose fundamental challenges to teachers' identities, and threaten their authority in their classrooms (Baxen, 2010; Baxen & Breidlid, 2004). In the process of life orientation (LO) teaching, teachers may come into conflict with the nationally prescribed curriculum-which is rights-based and comprehensive-and their personal values about sexuality and gender (Ahmed, Flisher, Mathews, Mukoma, & Jansen, 2009; Helleve, Flisher, Onya, Mukoma, & Klepp, 2009). They may also have difficulties responding to the specific needs of learners who, for example, are not able-bodied or heterosexual (Chirawu, Hanass-Hancock, Aderemi, de Reus, & Henken, 2014; Francis, 2012). The emotional component of talking about relationships, love, illness, and death is often avoided by teachers (Naidoo, 2014). The use of didactic, teacher-centred methods can undermine the learner-centred approach advocated in the LO curriculum (Gibbs, Willan, Jama-Shai, Washington, & Jewkes, 2015). The dearth of in-service teacher education itself remains an issue. Francis and DePalma (2015), for example, found that many teachers responsible for sexual health education indicated that they have had no training or very minimal training in HIV and AIDS education content and pedagogy.Preservice teachers should be acquiring teaching knowledge and skills during a 4-year undergraduate, or 1-year postgraduate, programme at a higher education institution (HEI). However, numerous studies on teacher education conclude that HEIs are failing to prepare preservice teachers for the evolving South African school system impacted by HIV and AIDS (Clark, 2008; James-Traore, Finger, Daileader Ruland & Stephanie, 2004; Wilmot & Wood, 2012). …

Institutions and social change: a case study of the South African National AIDS Council

Institutions play an important role in the success or failure of social models, as they promote or limit particular political and economic activities. Central to this point is the understanding that institutions and traditions are in a constant state of flux. Taken in this light, state and non-state institutions are continually being ‘re-invented’ to reflect a particular society's changing economic, political and cultural division of power. Immanent in this constant process of change is the possibility of transforming formal political institutions to more closely reflect the needs of human beings. The South African National AIDS Council provides a useful case study to illuminate how non-state social alliances can transform state institutions to reflect the needs of society. Through the mobilisation of non-state and community-based organisations, the South African HIV/AIDS movement successfully influenced the South African government to expand the public health response to the HIV/AIDS epidemic.

Institutions and social change: a case study of the South African National AIDS Council

Institutions play an important role in the success or failure of social models, as they promote or limit particular political and economic activities. Central to this point is the understanding that institutions and traditions are in a constant state of flux. Taken in this light, state and non-state institutions are continually being ‘re-invented’ to reflect a particular society's changing economic, political and cultural division of power. Immanent in this constant process of change is the possibility of transforming formal political institutions to more closely reflect the needs of human beings. The South African National AIDS Council provides a useful case study to illuminate how non-state social alliances can transform state institutions to reflect the needs of society. Through the mobilisation of non-state and community-based organisations, the South African HIV/AIDS movement successfully influenced the South African government to expand the public health response to the HIV/AIDS epidemic.

Being pimped out - How South Africa's AIDS response fails sex workers

abstract Sex work is highly stigmatised in South Africa. All aspects of sex work are currently a criminal offence. Sex workers’ stigmatised position in society, and the nature of their work-multiple, concurrent sexual partnerships, working within dangerous and violent spaces, and lack of services and legal protection-render them particularly vulnerable to HIV and other Sexually Transmitted Infections (STIs). No recent data on sex worker HIV prevalence in South Africa exists, but it ranged from 45%–69% in 1998. Sex work often occupies a much maligned – and often sensationalised or lurid – space in contemporary thinking and social change activism on feminism, health matters, policy-formation and human rights in Africa. Few individuals or institutions treat sex work or sex workers with seriousness or respect. Indeed, in areas of policy-formation, programme design or law reform, sex workers are often either overlooked, paid lip-service to, or they are let down during power-broking. South Africa's AIDS response has been no exception. This Briefing explores South Africa's 2007 and 2012 AIDS Plans and the South African National AIDS Council (SANAC) processes during 2007–2011 as a case study of sex work marginalisation at a critical time where their interests and demands should have been heeded: not only as it would recognise sex worker health, human rights and dignity, but as it would have significant public health effects.

HIV infection and cardiovascular risk in black South Africans

HIV infection and cardiovascular risk in black South Africans

Taming the HIV/AIDS monster in our lifetime?

She could have said that sufficient counselling rooms and trained staff exist, that the health system is ‘patient friendly’ enough to ensure most of the 1.65 million people who’ll test HIV positive in the massive new campaign will be treated and retained. But Dr Nono Simelela, CEO of the South African National AIDS Council (SANAC), has lived through an era of political make-believe and HIV denialism as the country’s reluctant former AIDS chief. She knows the harsh reality of public health care delivery and some of the political arrogance that contributed to today’s shameful outcomes. In the new era of HIV pragmatism Simelela is forthright about the challenges inherent in what is the most ambitious health care testing and counselling campaign involving HIV the world has seen. Testing 15 million of South Africa’s 48 million people by June next year – and then treating those found positive -- is no small task of an overburdened public health care system that easily tips into dysfunction, prolonging suffering and costing lives. The success of the campaign hinges on the long overdue integration of HIV/AIDS care into mainstream primary health care, major financial and logistical private and NGO health care sector involvement, massive government financial backing and creative human resources recruitment.

Changes to the ART guidelines – an overview

In 2009 the South African National AIDS Council (SANAC) Treatment Technical Task Team (TTT) finalised recommendations for changes to the national standard treatment guidelines for adult and paediatric management and treatment, as well as changes in the prevention of mother-to-child transmission of HIV (PMTCT) guidelines, moving away from monotherapy to dual therapy. President Zuma announced changes in the national antiretroviral therapy (ART) programme on World AIDS Day 2009. Subsequently additional changes were made to the treatment guidelines to be in line with these new Presidential mandates, which came into effect on 1 April 2010.

Male circumcision roll-out certain – now for ‘the how’

The deputy chairperson of the South African National AIDS Council (SANAC), Mark Heywood, believes oft-cited legal barriers to universal, voluntary neonatal circumcision are over-rated and can be overcome to bolster HIV prevention. The HIV treatment activist lawyer was responding to Izindaba questions at the 5 th Social Aspects of HIV/AIDS Research Alliance (SAHARA) conference at Midrand early last December about barriers to the proven and potent infection control efficacy of large-scale male circumcision (MC). After 2 years of consultation and scientific briefings of stakeholders SANAC has prepared MC guidelines, while the health department is busy with a feasibility study and cost analysis. MC will be part of a comprehensive new HIV prevention package due out later this year, officials have confirmed. Head of the National Health Insurance (NHI) task team, Dr Olive Shisana, has additionally said that MC will almost certainly be part of the benefit package her 28-member expert team is preparing for legislation this June.

Did South Africa's soccer bonanza bring relief to sex workers in South Africa? The 2010 FIFA World Cup and the impact on sex work

abstract Sex workers are an exceptionally vulnerable group in South Africa. Ongoing criminalisation of the sex work industry fuels the AIDS epidemic by precluding effective prevention and education strategies, and infringes human rights. The 19th FIFA World Cup was held in South Africa in June–July 2010 and was expected to attract 450 000 or more visitors. Intense attention was focused on HIV transmission and public health in a country that has the highest number of people with HIV/AIDS in the world. The soccer bonanza offered a rich opportunity for advocacy and education. Members of civil society and the South African National AIDS Council (SANAC) engaged government, FIFA organisers and the media on strategies to ensure the safety and rights of sex workers and international tourists. A number of practical strategies were drafted in a broad-based forum and submitted to these governing bodies. Yet very few—if any—of these strategies were implemented by the South African government or the FIFA Local Organising Committee. This Reportback will describe the advocacy initiatives undertaken by SANAC and sex worker organisations in the run-up and duration of the World Cup and the lessons learnt about the impact of an international event on already-marginalised groups.

The downside of participatory-deliberative public administration

This article provides an empirically grounded critique of ‘Participatory-Deliberative Public Administration’, based on an in-depth study of three participatory fora in South Africa: the National Economic Development and Labour Council, the Child Labour Intersectoral Group and the South African National AIDS Council. Drawing freely on Habermas’ Between Facts and Norms, the article argues that coordination through deliberation is unlikely to occur in formal settings, where discourses are mostly about the accommodation of existing interests, and is more likely to be found in the informal public sphere, where the preferences of citizens are still malleable and where it is possible for civil society groups to build communicative power by articulating moral arguments that motivate and mobilize the public. This form of power can then be used by civil society groups to counterbalance other forms of (non-communicative) power that impinge on the formal decision-making sphere.