Monitoring and Evaluation Indicators of the HIV & AIDS programme in Grahamstown‘s public sector health care system A thesis submitted in fulfilment of the requirements for the degree of MASTER OF PHARMACY IN PHARMACY PRACTICE of RHODES UNIVERSITY by PHEHELLO ANTHONY MAHASELE January 2011 DEDICATION To the loving Memory of my Grandmother Makolone Masefora Augostina Mahasele 01 January 1919 – 22 May 2008 ii Abstract South Africa is one of the countries hardest hit with the Human Immunodeficiency Virus (HIV) and Acquired Immuno Deficiency Syndrome (AIDS) epidemic. In response to the epidemic, the South African government adopted the Comprehensive HIV & AIDS Care, Management and Treatment programme strategic plan (CCMT) in 2000 (1) and developed the Operational Plan for CCMT for antiretroviral therapy roll- out in 2003 (2). In order to monitor the progress of the implementation of CCMT, the National Department of Health (NDOH) adopted the Monitoring and Evaluation (M & E) framework in 2004 (3). The aim of this study was to assess the HIV & AIDS programme in Grahamstown‘s public sector health care system by using the national M & E indicators of the HIV & AIDS programme. The national M & E framework was used as the data collection tool and available information was collected from various sources such as the District Health Office (DHO), Primary Health Care (PHC) office, accredited antiretroviral sites and the provincial pharmaceutical depot. Group interviews were conducted with key stakeholder health care professionals at the District Health Office, Primary Health Care office, Settlers Hospital and the provincial Department of Health personnel. A one-on- one interview was conducted with the Deputy Director of HIV & AIDS Directorate, monitoring and evaluation in the National Department of Health. Available indicators such as budget and expenditure including antiretroviral procurement; human resources; nutrition-related indicators; prevention care and treatment indicators were collected. A group interview was conducted to document current practices, or where there was a lack of documentation, for indicators such as traditional medicines and pharmacovigilance. Most of the national M & E indicators are not required to be collected or collated by the district because the reporting format designed by the provincial Department of Health is different. Facilities, districts and provinces in South Africa are at different levels of implementation of the antiretroviral programme and hence a common format of the M & E indicators is not used by all provinces. Uniform data collection is not achieved due to human resources‘ constraints iii and other challenges such as continued use of manual reporting systems by the clinics. Districts are expected to report according to the formats drawn up by the provincial Department of Health (DOH) and there is a lack of awareness regarding the national M & E document amongst the Grahamstown Health Care Professionals. There is a need for training on the use of the M & E national framework so that the HCPs at the primary and secondary levels of the health care system are proficient with the process of M & E, and can provide inputs as well as take ownership of the process. The establishment of an M & E unit in Grahamstown is essential so that data collection and submission of the HIV & AIDS programme in the public sector according to the National M & E framework is addressed. However, despite all constraints and challenges in the public sector health care system in Grahamstown, available human and financial resources are being used effectively to maintain the HIV & AIDS programme. iv Acknowledgements I would like to thank the All Mighty God for opening the door for me to do this project. I am very grateful to many people who kindly contributed to the successful completion of this project. I am indebted to so many people for their support and guidance: the list would be an endless one to write. I am very grateful to Ms Babalwa Sishuta for introducing me to the Ford Foundation and for her assistance in helping me to secure a Ford Foundation Scholarship; to Mr Maesela Sebothoma for prompting Radio 702 to consider my need for a computer geared to my particular requirements, and to the BOSASA group of companies for providing the computer. I am also thankful to Dr Kevin Kelly for referring me to my supervisor, Prof. Sunitha Srinivas. I am very grateful for her guidance, understanding and her patience that helped me to reach this stage, and for her invaluable and constructive criticism. Thank you to the faculty and staff of the Faculty of Pharmacy, Rhodes University, for their warmth, support and opportunity to conduct this project. I am very grateful to Ms Janet Whelan and Ms Sheila Hicks for proofreading and editing the entire thesis and making useful comments and suggestions and to Ms Debbie Gunter, for her comments and advice. I thank Mr Anton Meyer of the District Health Office in Grahamstown for providing information for most indicators, and I thank other programme managers for their help. Thank you, too, to Ms Antoinette Cannon from the Settlers District Hospital. I would like to thank the health professionals from the Eastern Cape Department of Health and the National Department of Health for giving me the opportunity to conduct interviews with them. I would like to express my deep gratitude towards my benefactors, the Ford Foundation International, for their generous financial support. And finally, to the Fellowship Director, Ms Louise Africa, and administrators: thank you so much for your kind support. This work is dedicated to the memory of my late grandmother Masefora Mahasele. I thank her for her guidance, care and prayers. I would also like to thank my mother, v Thuntso Maria Raleting and other family members for their encouragement. I also would like my mentor and ―father‖ Mr EAS Lesoro for his support and encouragement. To all my friends who helped me, your support is highly appreciated. vi Table of Contents DEDICATION ..............................................................................................................ii Abstract ....................................................................................................................... iii Acknowledgements ....................................................................................................... v List of Tables ............................................................................................................. .xii List of Figures ............................................................................................................ xiv Acronyms and abbreviations ....................................................................................... xv 1. Introduction .......................................................................................................... - 1 - 1. 1 About HIV and the discovery of AIDS ............................................................. - 1 - 1.2 HIV transmission modes ..................................................................................... - 2 - 1.2.1 Horizontal transmission of HIV ....................................................................... - 2 - 1.2.2 Vertical transmission of HIV ........................................................................... - 2 - 1.2.3 Nosocomial transmission of HIV ..................................................................... - 3 - 1.2.4 Occupational transmission of HIV ................................................................... - 3 - 1.3 Impact of HIV & AIDS ...................................................................................... - 3 - 1.3.1. HIV & AIDS in developed countries ............................................................... - 3 - 1.3.2 HIV & AIDS in developing countries .............................................................. - 4 - 1.3.3 HIV & AIDS in Africa ..................................................................................... - 4 - 1.4 Five critical and uncertain forces driving AIDS in Africa.................................... - 5 - 1.5 HIV & AIDS epidemic in South Africa .............................................................. - 6 - 1.5.1 Women and HIV & AIDS in South Africa ....................................................... - 7 - 1.6 HIV & AIDS influencing factors and determinants ............................................. - 8 - 1.7 Response to HIV & AIDS epidemic ................................................................... - 9 - 1.7.1 Chronology of global response......................................................................... - 9 - 1.8 Nutrition and HIV & AIDS epidemic................................................................ - 12 - 1.9 Drug Procurement and Distribution .................................................................. - 13 - 1.9.1 Drug Access Initiative (DAI) and Accelerated Access Initiative (AAI) .......... - 14 - 1.9.2 TRIPS and the Doha Declaration ................................................................... - 14 - 1.10 Voluntary Counselling and Testing (VCT) for HIV ........................................ - 15 - 1.11 HIV & AIDS and TB control .......................................................................... - 15 - 1.11.1 ProTEST Initiative ....................................................................................... - 16 - 1.12 Highly Active Antiretroviral Therapy ............................................................. - 16 - 1.12.1