Johannesburg, South Africa

South African government has chosen World AIDS Day 2011 to launch its new national strategic plan that, for the first time, will guide not only the national fight against HIV but also tuberculosis (TB) until 2016. The document contains several major policy changes, including the immediate provision of lifelong antiretroviral (ARV) drugs to all HIV-positive mothers and TB patients, as well as a focus on positive prevention.

The new National Strategic Plan (NSP) for HIV and AIDS, sexually transmitted infections (STIs) and TB 2012-2016, presented in the seaside town of Port Elizabeth, is the product of months of national consultations after a first draft was released in October 2011. [ NSP summary:http://www.scribd.com/doc/74353109 Summary ]

The plan marks several firsts for South Africa: It specifically includes TB, the leading cause of natural death, and is the only HIV plan to have been at least partially costed prior to being introduced. An estimated US$16 billion will be needed to implement the plan in the next five years, to be sourced publicly and privately.

South Africa's largest HIV lobby group, the Treatment Action Campaign, has welcomed the new plan, but raises concerns that it has not yet been fully costed, particularly in areas with difficult-to-discern price tags, such as human rights.

In a statement the group also calls for the plan to include the decriminalization of sex work - a promise made by government in the previous national strategic plan, which expired in 2011.

Under the new plan, 400,000 HIV patients per year will begin treatment. However, this goal may be in jeopardy in 2014 if current budgetary projections hold true, according to the treasury. A possible tax on financial transactions to help generate funds is being considered.

Each of South Africa's nine provinces will now create operational plans in line with the document. By mid-November, when the national strategic plan was approved at a South African National AIDS Council plenary meeting, at least three provinces - Eastern Cape, KwaZulu-Natal and Northwest - had already started developing their plans. Provincial plans, which will be launched on 24 March 2012 to coincide with World TB day, will also be costed before being implemented.

TAC says the new guiding document is symbolic of the shift in South Africa's political will to tackle HIV. "Since the last five-year plan, we have seen a revolution in the response to AIDS," TAC said in a statement.

"South Africa started the last plan with Manto Tshabalala-Msimang as Minister of Health and Thabo Mbeki as president. Although the plan was adopted... some of the key interventions it proposed... were delayed. For several years the roll-out of ARVs was kept as slow as possible [and] preventable infections and deaths continued. Five years later, all that has changed."

Then and now

An emphasis on TB/HIV integration, costing, and the introduction of provincial operational plans are not the only changes in the new national strategic plan. The creation of the document has also been marked by an unprecedented level of civil society and government consultation, resulting in two previous drafts.

Informed by the new investment framework released by UNAIDS, Know Your Epidemic, as well as the country's previous strategic plan, the new document includes a reduced number of key activities and indicators. It is hoped that these will improve monitoring and evaluation.

New goals include reducing TB-related deaths and halving HIV stigma, which may be measured against a stigma index being developed by South Africa.

The government estimates that about 70 percent of all TB patients are co-infected with HIV. Given the high rates of co-infection, the need to integrate HIV and TB services has long been a goal for South Africa, but integration remains poor.

TB screening will now be included in prevention of mother-to-child HIV transmission (PMTCT) services as one way of reaching this goal. PMTCT services will also be integrated into sexual and reproductive health services, alongside neonatal circumcision of boys. Medical circumcision has been shown to reduce a man's chances of contracting HIV by 60 percent.

The plan also includes mental health services, and palliative care for HIV patients, who sometimes suffer chronic pain.

Finally, on the heels of a ground-breaking year in HIV prevention research, the documents also stipulates that the government and its partners should prepare to implement new, biomedical prevention strategies once they have passed regulatory approval.

These measures include microbicides and the use of treatment as prevention, in which HIV-positive partners are started on ARVs early to reduce the risk of transmitting the virus to HIV-negative partners, or high-risk HIV-negative people are put on ARVs to prevent infection.

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