Recommendations for policy in the Western Cape Province regarding the prevention of Major Infectious Diseases including hiv/AI

Table 2: Epidemic in Children in the Western Cape - Projected AIDS Orphans

	1997	1999	2001	2003	2005	2007	2009
Total orphans	42,598	46,128	51,475	60,042	71,561	84,295	98,399
Total AIDS orphans	466	1,739	5,152	12,470	23,555	36,677	51,873
Total non-AIDS orphans	42,132	44,389	46,324	47,572	48,006	47,618	46,526

Source: ASSA2003 model

3. 
   COMPREHENSIVE HIV & AIDS STRATEGY
   

The conceptual model is as follows:

The comprehensive HIV & AIDS strategy for the Western Cape has been developed within the strategic context of the global, regional, national and provincial responses to the pandemic.

The comprehensive strategy is built on the following principles:

1. 
   Integrating prevention, treatment, care and support;
   
2. 
   Focusing on 15 –24 yr olds, realising that they are part of a “a life cycle” from a child to an adult (male and female), within a social context;
   
3. 
   Multiple sectors working together to address the common objectives and targets set.
   

4. 
   GOALS, OBJECTIVES AND TARGETS
   

The Provincial Inter-Departmental AIDS Committee (PIDAC) has recommended the following strategic objectives and targets towards attaining universal access to HIV prevention, treatment, care and support in the Western Cape by 2011:

4.1. Strategic Objectives and targets:

1. 
   Reduce HIV prevalence in young people between 15 and 24 years, by at least 25% by 2010;
   
2. 
   Reduce the transmission of HIV from mother to baby to < 5% by 2 yrs of age in all HIV +ve mothers, in the Western Cape by 2010;
   
3. 
   Provide anti-retroviral treatment to >80% of those needing treatment in the Western Cape by 2010;
   
4. 
   Protect and support and ensure that 80% of orphans and vulnerable children have access to basic services in the Western Cape, by 2010;
   
5. 
   Provide access to home community based care to >80% of those in need of care in the Western Cape by 2010.
   

4.2. Supportive Objectives for the Prevention Strategy:

1. 
   Strategic Objective 1: Reduce HIV prevalence in young people between 15 and 24 years, by at least 25% in the Western Cape by 2010
   

Supportive Objectives:

1. 
   Achieve annual VCT coverage of 15% of adults >15 yrs of age by 2010
   
2. 
   Provide access to accurate HIV & AIDS information and behaviour change programmes to 90% of youth aged 15 – 24 yrs by 2010
   
3. 
   Delay age of sexual debut by 1 yr among Western Cape youth by 2010
   
4. 
   Increase annual male condom uptake to 100 condoms per adult male >15 yrs of age by 2010
   
5. 
   Increase annual female condom uptake to 10 condoms per adult female >15 yrs of age by 2010
   
6. 
   Increase STI partner treatment rate to 50% by 2010
   
7. 
   Provide 80% of new sexual assault victims with full course of PEP by 2010
   

2. 
   Strategic Objective 2: Reduce the transmission of HIV from mother to baby to < 5% by 2 yrs of age in all HIV +ve mothers, in the Western Cape by 2010
   

Supportive Objectives:

1. 
   Provide access to pMTCT service to 100% pregnant women by 2010
   
2. 
   Provide >90% uptake of anti-retroviral regimen in HIV +ve mother/infant pairs
   
3. 
   Reduce HIV transmission from mother to infant to <3 % by 6 weeks post partum
   
4. 
   Reduce mixed feeding to <10% in HIV +ve mother/infant pairs by 2010
   

5. 
   IMPLEMENTATION PLAN
   

Countries that have been most successful in reducing HIV prevalence have pursued a “combination prevention approach”. Developing countries that have recorded major prevention successes have promoted condom use, raised general awareness of the AIDS threat, provided sexuality education in schools, targeted prevention interventions to populations at special risk, expanded access to voluntary counselling and testing, involved multiple sectors in the fight against AIDS, and enacted strong human rights protection for people living with HIV and AIDS.

International best practice experience suggests that programme effectiveness critically depends upon attaining sufficient coverage and intensity of effective interventions aimed at key behaviours that drives the epidemic (Gillespie et al. 1996). The implementation plan will therefore focus on the following key areas:

1. 
   Communication – prioritising and disseminating the key essential messages;
   

2. 
   Behaviour change programmes – focussing on prioritised behaviour changes in key at risk groups;
   

3. 
   Counselling and testing – scaling up access to counselling and testing services;
   

4. 
   Condoms – scaling up distribution of male and female condoms;
   

5. 
   STI management – maximising detection and effective management of STIs;
   

6. 
   pMTCT – maximising access to and continuity of care of mother-infant pairs;
   

7. 
   Other strategies – post-exposure prophylaxis for rape victims and high-risk workers, preparation for microbiocides, male circumcision and vaccine development.
   

1. 
   COMMUNICATION:
   

There is a need to develop a comprehensive communication strategy, focusing on the following:

1. 
   General Information:
   

This should include information about the comprehensive HIV & AIDS strategy in this province and information about availability of services across the various sectors.
The aims will be to communicate to:

1. 
   all key sectors what their role is in contributing to the fight against HIV and AIDS;
   
2. 
   the general public what services are available and how to access it.
   

2. 
   Specific prevention messages:
   

There is an increasing body of evidence concerning the key behaviours that are driving the epidemic especially in South Africa. There are four key behaviours that should be prioritized as part of the prevention strategy:
i) Reducing the number of concurrent partners:

There is increasing evidence from settings where the epidemic has risen rapidly and from settings where there have been reversals in the epidemic that the number of concurrent partners is crucial. A recent paper in the British Medical Journal presented evidence that where HIV prevalence has declined among pregnant women (Uganda, Thailand, Zambia, Ethiopia, Cambodia, and the Dominican Republic) the primary reported behaviour change has been partner reduction and monogamy by men, especially older men (Shelton et al. 2004).

ii) Reducing the exploitation of younger women by older men:

A recent community survey in Khayelitsha found that during 2003-4, 37% of women aged 14 to 49 years had partners who were more than 5 years older than themselves (MSF/UCT 2003). Studies conducted in South Africa (Jewkes et al., in press) and in other sub-Saharan African countries such as Uganda (Kelly et al., 2003) and Kenya (Luke, 2005) have demonstrated that the age differences between young women and their male partners is a significant HIV risk factor, caused by transmission from older male partners. Jewkes and colleagues found that it was in relationships marked by substantial age differences (5 years or more) that communication was poorer, and the likelihood of women being able to suggest condom use was lower. Uganda’s experience shows that achieving sexual deferral and partner reduction among men, particularly older men, may create safer environments for women, particularly young women. Community norms that proscribe older men having sexual relationships with younger women may be especially protective.

iii) Increase Age of Sexual Debut:

There is well-documented evidence from settings where there have been reversals in the epidemic that the delay of sexual debut has a significant impact. Trends on age of sexual debut among learners in peri- urban areas of this province showed a delay in the age of sexual debut for about one year (Flisher 2005). This behaviour change will have a significant impact in reducing the HIV prevalence in the 15 – 24 yr age group.

iv) Increasing the use of Condoms:

There is well documented evidence from settings where there have been reversals in the epidemic that the consistent use of condoms has a significant impact. Condom use is reported to vary by gender among adolescents in this province, with an estimated 49% of males and 33% of females reported to have used a condom at the last sexual intercourse (Reddy et al. 2002). However, it is evident that for the period 1997 to 2004, there has been a decline in condom usage among adolescents, particularly among males. In 1997, 67% of grade 8 males had used condoms at their last sexual encounter and this significantly decreased to 44% in 2004 (Flisher 2005).

3. 
   Implementation strategy:
   

The most effective communication strategy involves getting a uniform message communicated across multiple levels of communication channels. This will involve the following key steps:

1. 
   Alignment of the Western Cape communication strategy with the National Khomanani campaign;
   

2. 
   Creating central co-ordination for a comprehensive HIV and AIDS communication strategy in the province (Provincial Department of Health to co-ordinate, with multiple stake-holders);
   

3. 
   Implementing an integrated communication campaign, targeting all sectors and the general public, through multiple complimentary media and communication channels (including person to person communication).
   

4. 
   All sectors should implement this uniform communication strategy, for it to be effective. A template with “sector-specific responsibility” is attached:
   
5. 
   
   

Sector	Key intervention strategies	Specific Responsibilities
Faith-based sector	Communication, behaviour change programmes, care & support	Advocate abstinence and delay in sexual activity for young people Advocate mutual monogamy and condom protection for sexually active people Offer skills training Offer care and support for PLWHA
Business and labour sector	Communication, behaviour change programmes, condom distribution, access to testing, treatment, care & support	Advocate abstinence and delay in sexual activity for young people Advocate mutual monogamy and condom protection for sexually active people Offer skills training Offer access to testing and treatment Offer non-discriminatory workplace environment for PLWHA
NPO sector	Communication, behaviour change programmes, condom distribution, access to testing, treatment, care & support	Advocate abstinence and delay in sexual activity for young people Advocate mutual monogamy and condom protection for sexually active people Offer skills training Offer access to testing and treatment Offer care and support for PLWHA
PLWHA sector	Communication, behaviour change programmes, condom distribution, access to testing, treatment, care & support	Advocate abstinence and delay in sexual activity for young people Advocate mutual monogamy and condom protection for sexually active people Offer skills training Offer access to testing and treatment Offer care and support for PLWHA Reduce community stigma & discrimination
Government sector	Communication, behaviour change programmes, condom distribution, access to testing, treatment, care & support, pMTCT, STI management, other interventions (PEP)	Advocate abstinence and delay in sexual activity for young people Advocate mutual monogamy and condom protection for sexually active people Offer skills training Offer access to testing and treatment Offer care and support for PLWHA Reduce community stigma & discrimination

Behaviour Change Programmes

Programmes to encourage safer sexual behaviours are anchored in a wide range of recognised behavioural theories. Evidence-based prevention programmes include those that attempt to directly alter personal beliefs, attitudes and behaviours, as well as interventions that indirectly seek to influence personal behaviour by affecting social networks and community norms. Specific approaches include social marketing, small group interventions, safer sex information and skills building sessions, popular opinion leader and peer-based interventions. These approaches seek to:

1. 
   increase condom use among people who are sexually active;
   
2. 
   persuade individuals to reduce their number of sexual partners;
   
3. 
   encourage young people to remain abstinent or delay sexual activity.
   

There is a need for large-scale behaviour change among specific high-risk groups in the Western Cape, if we are to achieve the target of reducing HIV prevalence in the 15-24 yr age group. The following factors will influence these programmes:

1. 
   The evidence indicates that HIV infection in younger women is most likely due to having sex with men who are on average between 5 and 10 years older than them;
   
2. 
   The geographic variation of the epidemic across the province;
   
3. 
   The need to target specific high risk groups such as men having sex with men (MSM), commercial sex workers, injecting drug users (IDU).
   

1. 
   Behaviour change programmes focussed on protecting young women:
   

A recent paper in the British Medical Journal presented evidence that where HIV prevalence has declined among pregnant women (Uganda, Thailand, Zambia, Ethiopia, Cambodia, and the Dominican Republic) the primary reported behaviour change has been partner reduction and monogamy by men, especially older men (Shelton et al. 2004). Uganda's experience shows that achieving sexual deferral and partner reduction among men, particularly older men, may create safer environments for women, particularly young women. Community norms that proscribe older men having sexual relationships with younger women may be especially protective. A recent study from Malawi found that a fifth of the population were in mutually faithful relationships and that two thirds were linked by one single chain of exposure over the last three years. What is important is that those chains weren’t held together by sex workers or core transmitters, but rather by decentralized, robust, complex chains of sexual networks.
A systematic review of large-scale HIV reduction showed that the HIV prevention responses were rapid, endogenous, inexpensive, and simple. They preceded large-scale exogenous assistance and leadership came from within the community. They promoted changes in community norms, thus creating enabling and protective environments long before the concept gained currency. They relied on interpersonal communication channels and networks, rather than mass media (Wilson 2004).
The above suggests important reasons why men are a key group of people to target for study and for HIV prevention and intervention programmes, particularly men who have multiple partners (i.e. more than one partner in a 3-month period) where there is a 5-year or greater age differential between them and their partners. Furthermore there is evidence that these men form networks whether it is around shebeens or football clubs. Sharon Weir and colleagues (Weir et al. 2003), working in townships in the Western and Eastern Cape provinces and a business district in the Eastern Cape, successfully identified such venues: shebeens and bars/taverns. It was in these venues that extensive and diverse social networks, characterized by high rates of new sexual partner formation, concurrency and low condom use were common. Given these findings, it is recommended that a set of interventions focus on slightly older men to reduce the number of concurrent partners and to practice safe sex. Channels of communication should be focused around men who are key parts of social networks.
Implementation strategy:

1. 
   Focussed formative research should be conducted on men who have concurrent partners (especially those that are significantly younger) in different geographic settings in the province. Similar formative research should be conducted on women who are ‘girlfriends’ of such men in different settings.
   

2. 
   Appropriate interventions based upon this research and targeted at these men and women be developed, implemented and evaluated at scale. The networks identified through this research should also be used for other communication and intervention efforts.
   

3. 
   Existing NPO behaviour change programmes should be standardised and subjected to minimum norms and standards, target setting, performance management and monitoring and evaluation.
   

2. 
   Behaviour change programmes focussed on other high risk groups:
   

1. 
   Men who have sex with men (MSM):
   

Men who have sex with men (MSM) make up 5-10% of the HIV infections globally and up to 70% of infections in developed countries. Most cases of HIV transmission among MSM stem from unprotected anal intercourse, although there appears to be a real, but much smaller risk of transmission from oral sex. It is important to target behaviour change interventions aimed at MSM in the gay community and in prison populations in the Western Cape.
Implementation strategy:

1. 
   Identify high risk hot spots for MSM in the gay community and prison population in the Western Cape;
   

2. 
   Contract NPOs to offer targeted interventions that are standardised and subjected to minimum norms and standards, target setting, performance management and monitoring and evaluation;
   

3. 
   Establish gay and lesbian friendly clinics
   

2. 
   Commercial sex workers:
   

Commercial sex workers represent an especially vulnerable and epidemiologically important population for the sexual transmission of HIV, especially in “emerging epidemics”. It is therefore important to target behaviour change interventions aimed at commercial sex workers, especially in relatively low prevalence areas in the Western Cape.
Implementation strategy:

1. 
   Identify high risk hot spots for commercial sex workers in the Western Cape;
   

2. 
   Contract NPOs to offer targeted interventions that are standardised and subjected to minimum norms and standards, target setting, performance management and monitoring and evaluation;
   

3.