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6.3 Compliance with Focus of Proposal Requirement

At a high level, all three of the WC GF Objectives relate to two of the three UNAIDs Strategic Directions for a renewed global HIV response: HIV prevention and Treatment, Care and Support (UNAIDS 2011-2015 Strategy). The WC GF Objectives align to the National Strategic Plan (NSP) and thereby also the WC Provincial Strategic Plan (PSP). With regard to the NSP the WC GF Objectives align to three of the four strategic objectives:

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  Address social and structural factors that influence the three diseases.
  
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  Prevent new HIV, TB and STI infections.
  
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  Sustain health and wellness. Such that the primary objective is to ensure: access to quality treatment, care and support services for those with HIV/AIDS (National Strategic Plan 2012-2016)
  

Key Populations for the HIV / AIDS response in the Western Cape, South Africa

Even though the Western Cape HIV prevalence is well below the national figure, it is impacted by the national generalised HIV epidemic. In the Western Cape there are still higher levels of infection and transmission within certain geographic areas, as well as among some key populations. In line with the National Strategic Plan (NSP) the Provincial Strategic Plan (PSP) promotes a broad framework for addressing HIV, STIs and TB at a general population level, it also identifies certain sub-populations that should be targeted for specific prevention, care, treatment and support interventions based on risk and need. The identification of key populations for targeted interventions should be included in all implementation plans.

In line with the identification of key populations, the Western Cape GF Grant works within the provincial identified areas where the HIV epidemic is concentrated and where those who are most at risk live.

The Western Cape GF Grant is a bridge funding mechanism between what services the WC can afford to pay for within its current budget envelope and what services are needed. As such the WC GF Grant ensures services are able to be delivered to those who are most marginalized and most likely to be stigmatized due to the resource constraint on the province which had meant that the WC was not able to entirely address all HIV prevention, treatment and care needs within its jurisdiction. The incremental decrease of GF investment in the Western Cape over a planned number of years ensures that the accelerated extension of services, possible through the initial grant periods, is sustainable into the future.

Key populations identified in the NSP which are specifically relevant to the Western Cape GF Grant include the following:

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  Young women between the ages of 15 and 24 years are four times more likely to have HIV than males of the same age. (This risk is especially high among pregnant women between 15 and 24). On average young females become HIV-positive about five years earlier than males;
  
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  People living in informal settlements
  
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  People with the lowest socio-economic status are associated with HIV infection. Those who work in the informal sector have the highest HIV prevalence with almost a third of African informal workers being HIV positive. Among women, those with less disposable income have a higher risk of being HIV positive;
  
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  Persons with disabilities have higher rates of HIV. Attention should be paid to the different types of disabilities, as the vulnerabilities of different groups and the associated interventions required will be different.
  
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  Orphans and other vulnerable children and youth are another key population for whom specific interventions will be implemented as primary prevention for HIV, as well as to mitigate impact and break down the cycle of on-going vulnerability and infection.
  
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  Children and adults living with HIV
  

Overall it needs to be noted that the ART programme has done pretty well for women but less well for men. An analysis carried out by Morna Cornell et al last year, which included data from three WC public sectors ART cohorts (Khayelitsha, Gugulethu/ Hannan Crusaid and Tygerberg) and 5 other cohorts from round the country showed the following:

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  In all cohorts, enrolment was far higher among women (on average 65% female) than men. Even when it was taken into account that there is a slightly higher prevalence among women than men, this level of reported enrolment is disproportionately high.
  
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  Men were older and sicker than women at ART initiation (lower CD4 cells, more likely WHO Stage III/IV).  Numerous other African ART programmes have reported a higher mortality risk among men than women and have suggested that this may be due to men's 'health-seeking behaviour' (i.e., men do not typically seek care regularly, and when they do they seek care later and are less likely to be adherent to treatment and remain in care.
  

However, it needs to be noted that these factors only partly explained the persistently higher risk of death for men versus women. Additional research was carried out so as to ascertain if there is a link between gender differences in death among HIV-positive patients and a hypothetical cohort of HIV-negative South African men and women (via a clever actuary). It was found that the gender difference in mortality among HIV-negative individuals was far greater: twice the risk compared with a 31% higher risk among patients on ART. This suggests that there is generalized higher male versus female mortality rate in South Africa such that the HIV epidemic adds an additional complication to this dynamic.

For further information and details as referred to above please review the below:

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  WCDOH Annex 17, Gender and survival on ART PLoS Medicine published paper
  
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  WCDOH Annex 18, Does the success of HIV treatment depend on Gender Future Microbiology editorial Jan 2013
  
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  WCDOH Annex 19, Men and mortality published letter and response Feb 2012
  

HIV care and support is required to happen within a multi-pronged approach. To enable that this happens the three objectives within the WCDOH focus on ensuring that services are extended to those most at risk at an accelerated rate. While the department runs gender awareness campaigns throughout the year to create awareness within specific risk groups and age groups, the GF grant is used to extend all services as much as possible to all those at risk male, female, old, young, able and disabled, regardless of race.