South Africa has crossed a Rubicon in the past few months in relation to HIV and the ball is now in civil society’s court to achieve progress, Mark Heywood of the AIDS Law Project told the closing session of the Third South African AIDS Conference in Durban on June 8th.
Unlike previous conferences in South Africa, this year's meeting featured a minimum of political conflict between government and civil society. Instead delegates gathered to celebrate the successful agreement of a new national plan on AIDS that has broad support across all sectors of society.
The new South African National Strategic Plan on AIDS, published in March, has been allocated 45 billion rand for implementation. The plan aims to bring treatment to 80% of those who need it by 2011, and to reduce the rate of new HIV infections by 50%.
But implementation will depend on a broad social mobilisation to ensure that all levels of government, civil society and the business community carry out their tasks.
“We now have to go to the communities, to the districts, to ensure that community AIDS councils are set up in the next year, and that the declaration is translated into simple, local plans that are owned by local communities,” said Mark Heywood, who is vice president elect of the South African National AIDS Council (SANAC).
Last week’s conference adopted a consensus declaration confirming its support for the plan, and highlighting a number of urgent issues that need to be addressed.
The consensus declaration, developed during a two day meeting among stakeholders in May, represents a decisive break with the oppositional politics of the past. It was endorsed by over 4000 delegates attending the conference.
Key points from the declaration are summarised below.
HIV testing
The National Strategic Plan requires dramatic expansion in HIV testing services. The consensus statement endorses WHO guidelines for provider-initiated testing, but emphasises that voluntary counselling and testing services will continue to be essential. These should be integrated into community, outreach and other non-medical settings. More people should be enabled to provide counselling and testing services through training.
Behavioural interventions
The conference repeatedly highlighted the contributions of poverty and gender-based violence to the spread of HIV in South Africa. Gender-based violence – the alarming level of rape and the routine brutality facing women – needs to be addressed as part of a national strategy, says the consensus statement. New indicators are needed in HIV programmes to measure the prevalence of violence against women and the success of measures against it. Efforts to empower women need to be intensified.
A greater emphasis on avoiding concurrent partnerships and intergenerational sex is needed in prevention messages, together with promotion of HIV prevention activities with HIV-positive people. Expansion of antiretroviral treatment could reduce viral load, thus reducing transmission opportunities.
HIV prevention interventions need to be incorporated into routine clinical care of HIV-positive people.
Breastfeeding
Poor infant feeding practices are wiping out the gains from prevention of mother to child transmission programmes. Exclusive breastfeeding is recommended for the first six months unless replacement feeding is acceptable, feasible, affordable, sustainable and safe. Breastfeeding should stop when a nutritionally adequate and safe diet can be provided without breastfeeding. Mixed feeding should be avoided.
Counselling and support for nursing mothers needs to be strengthened, especially at the key points when feeding decisions are made – after birth, after the infant is tested for HIV, and at six months of age.
Continuity of care for HIV-exposed infants is essential, and health systems need to be strengthened in order to provide this continuity, and in order to reach the hundreds of thousands of HIV-positive women who will become pregnant each year.
Male circumcision
South Africa is not ready for the implementation of a national circumcision policy, but government needs to look at how it can implement circumcision more widely in consultation with traditional leaders. Medical circumcision should be included in the prescribed medical benefits package.
Long-term side effects
More antiretroviral agents should be made available in order to reduce toxicity. If tenofovir and other drugs are affordable, they should replace drugs currently causing problems, such as d4T. National monitoring to establish the incidence of drug-related toxicities is needed in South Africa, and guidelines need to take the findings into account.
New prevention technologies
Promote the use of female condoms and develop a national distribution plan, and make any new prevention technology that is at least 50% effective.