South Africa's new five-year AIDS battle plan entered the final stage of a lengthy drafting and consultative process last week.
Government officials and representatives from various sectors met in Johannesburg to debate a draft version of the National Strategic HIV and AIDS Plan for 2007 to 2011, with the goal of hammering out a final version by the end of March.
South Africa's HIV/AIDS epidemic is one of the worst in the world and continues to grow by an estimated 1,500 new infections a day, according to a report published this week by the Human Sciences Research Council. Government's past efforts to address the problem have been criticised for lacking the necessary urgency.
Deputy President and Chairwoman of the South African National AIDS Council (SANAC), Phumzile Mlambo-Ngcuka, pledged the government's commitment to intensifying its HIV/AIDS response by building on the successes of the first AIDS plan, which expired in 2005, and learning from its failures.
She acknowledged that the failures included poor coordination by SANAC, and the lack of a monitoring and evaluation framework or measurable targets.
The new plan seeks to avoid those mistakes by setting ambitious targets for the next five years: halve new HIV infections; provide treatment, care and support to 80% of people known to be HIV-positive; increase the number of people who have been tested for HIV to 70% of the population; and reduce mother-to-child transmission of HIV to less than 5%.
The various sectors will use a detailed set of indicators to report to SANAC twice yearly on their progress in meeting the targets.
The goal of the 119-page document, assembled by an expert task team of clinicians, health economists, scientists and activists after several rounds of consultations with various sectors, is to provide guidelines for government departments, health authorities and civil society organisations to develop more specific operational plans.
Relations between the government and non-governmental organisations (NGOs) working in the HIV/AIDS sector have been marked by tension and conflict, but after resounding condemnation of the government's lacklustre HIV/AIDS response at an international AIDS conference in Toronto, Canada, in August 2006, Mlambo-Ngcuka and Deputy Health Minister Nozizwe Madlala-Routledge have led efforts to re-energise the fight against HIV/AIDS by building partnerships with civil society.
Health Minister Manto Tshabalala-Msimang, the focal point of past conflict between government and AIDS activists, has been absent during much of this process due to ill-health.
"I have a sense that we're really all moving in the same direction, and it's a new feeling," commented Denise Hunt, executive director of the AIDS Consortium, an umbrella organisation for AIDS NGOs.
Dr Nomunde Xundu, director of South Africa's HIV/AIDS Unit, noted that the plan went beyond the usual prevention and treatment interventions to address some of the drivers of the epidemic such as poverty, gender equities and substance abuse.
A detailed costing is yet to be finalised, but Mlambo-Ngcuka estimated that implementation would cost around R14 billion (about US$1.9 billion) over the next five years, of which about 40% would go on antiretroviral drugs.
Xundu emphasised that the country could not afford to provide free antiretrovirals to a growing number of HIV-positive people indefinitely. "We need to close the tap," she said, referring to the plan's prevention goals.
Besides encouraging more people to seek voluntary counselling and HIV testing, the plan recommends that HIV testing be routinely offered to people accessing health services. UNAIDS estimates that 5.5 million people are living with HIV in South Africa but, said Xundu, "We're not finding them."
The plan recommends that recent findings about the protective effects of male circumcision be translated into policies and programmes. Xundu emphasised that this would need further interrogation of the research and a consideration of how male circumcision could be incorporated into prevention strategies.
The scaling-up of wellness and prevention interventions aimed at people living with HIV, and a review of the guidelines for prevention of mother-to-child HIV transmission are also included. Most provinces only give a single dose of nevirapine (Viramune) to mother and infant but many experts have called for a more effective combination of drugs.
After two days of debate and fine-tuning, delegates endorsed the plan but expressed concern about how it would translate into action. "We need to approach implementation with the same vigour as we've approached the plan," said Sipho Mthathi, chairperson of the AIDS lobby group, Treatment Action Campaign (TAC).
Hunt was impressed by the amount of time and consultation that had gone into the document: "It's time well spent, because the more buy-in you have, the more ownership there is, and the more chance we have of it turning into real commitments, but what I'm hoping to hear now is the way forward."
Whether the same level of inclusiveness and consultation that has marked the development of the strategic plan would extend to the drafting of an operational plan is unclear. Dawn Cavanagh, a women's rights activist and director of the NGO, Forum for the Empowerment of Women, said she was taking no chances. "We need to get the key language right now, because we don't know if we'll be at the table for that operational plan process."