A Strategy for the Management of Hiv/ Aids in the Health Sector of the City of Johannesburg

The HIV/AIDS pandemic is posing major challenges to all sectors in South Africa, including the health sector of the city of Johannesburg. The health sector of the city of Johannesburg, as a result of the pandemic, is faced with increasing demands on its scarce resources at a time of major reform at local government level including transformation of the health sector. The overall objec­ tive of the study is to explore and describe a strategy for the management of HIV/AIDS by the health sector of the city of Johannesburg. An exploratory, descriptive and quantitative research design was utilized and the UNAIDS " Guide to the strategic planning process for a national response to HIV/AIDS " (1998), was employed to formulate the strategy. The content validity of the strategy was determined according to the process origi­ nally described by Lynn (1986) and adopted by Muller (in Booyens, 1998:607-609). The research was conducted in two phases. The first phase, the developmental phase, involved the exploration and description of the theoreti­ cal framework and the response to the pandemic, and formulation of a draft strategy. The second phase, the quantification phase, involved the assertion of the con­ tent of the strategy by a group of experts and determi­ nation of the content validity index (CV1). The final strat­ egy focused on the following: to lead and facilitate intersectoral collaboration; to strengthen primary health care services to provide comprehensive community-based care; prevention of new infections; community mobilization towards prevention, non discrimination and non stigmatization and empowerment of the health sec­ tor to deal with the AIDS .pandemic. The CVI results showed that the average content validity index deter­ mined during this study was adequate: full score (1.0) for acceptability and technical soundness, and 0.89 for feasibility and perceived affordability. The strategy for­ mulated for the management of HI V/A1DS by the health sector of the city of Johannesburg is therefore accept­ able, technically sound and feasible and perceived as affordable. It was finally recommended that the strat­ egy be adopted for implementation within the health sector of the city of Johannesburg.


Introduction
South Africa is currently faced with the fastest growing HIV/AIDS pandemic in the world.It is estimated that at the end of the year 2000,4.7 million out of an estimated popula tion of 43 million South Africans were infected with the Human Immuno Deficiency Syndrome (HIV) which inevita bly causes Acquired Immune Deficiency Syndrome (AIDS) (Department of Health, 2001a: 19).Since the introduction of the annual national HIV/AIDS survey of women attending public sector antenatal clinics in South Africa, the HIV/ AIDS prevalence rates have increased from 1.49% in 1991 to 24.8% in 2001.The survey also revealed that in the cen tral Witwatersrand region, constituting the city of Johan nesburg, the prevalence rate was 29.8% among women at tending public sector antenatal clinics (Department of Health, 2001 a:8).An impact analysis conducted for the city of Johannesburg estimated that 168 921 HIV infected per sons were living in the city of Johannesburg in the year 20CK) (City of Johannesburg, 2001:21).Among the higherrisk groups such as persons availing themselves for the treatment of sexually transmitted infections (STIs), the re corded HIV/AIDS sero prevalence rates were recorded even higher, at 53% for female and 35.8% for male persons (South African Institute for Medical Research, 2(XX): I).
The inhabitants of the city of Johannesburg are particu larly vulnerable to HIV/AIDS infection because of the of job prospects that tend to lure migrant labourers from the whole of Africa to the city, the transport infrastructure of the area, the high levels of mobility of the community, the existence of single sex hostels, marginalized communities living in informal settlements, income inequality and pov erty.Other aspects increasing vulnerability applicable to the circumstances in the city of Johannesburg include the disruption of family and communal life resulting from apart heid and the migrant labour system, very high levels of other STls, the low status of women in society and in rela tionships, social norms that accept or encourage high num bers of sexual partners and resistance to condom use (Smart, 2(X)1:6).
The high HIV/AIDS prevalence rates and social circum stances peculiar to the city of Johannesburg strongly stress the threat of HIV/AIDS to the inhabitants of the city of Johannesburg.Since the local government elections in December 2000 the management of the city of Johannes burg has introduced a process of mayor restructuring.The new council of the city of Johannesburg has identified HI V/ AIDS as a threat and has prioritized HIV/AIDS as one of the six strategic priorities (City of Johannesburg, 2001: 2; 34).A strategic plan, in coherence with the plans at national and provincial governments, that would guide the manage ment of the health sector of the city of Johannesburg, will enable the sector to anticipate the impact of the pandemic, to be situation-specific in getting to the root of the prob lem, and would result in moving towards a situation where HIV spreads less rapidly and has fewer negative conse quences for those infected, and for their families and soci ety.
The following research question is relevant: What strategy should be adopted by the health sector of the city of Jo hannesburg to manage the HIV/AIDS pandemic in the fu-tureV The purpose of the study is to explore and describe a strategy for the management of HIV/AIDS by the health sector of the city of Johannesburg.

Terminology HIV/AIDS
AIDS is a severe, life-threatening clinical condition that represents the late clinical stage of infection with the hu man immunodeficiency virus (HIV), which most often re sults in progressive damage to the immune and organ sys tems, including the central nervous system (Benenson, 1995:1).

Pandemic
A pandemic is an epidemic that spreads over a widespread geographical area.

A strategy
A strategy is a series of steps designed to move from one situation to another.The steps in strategic planning will be defined in terms of the programmes or initiatives that will carry the country or district from the current situation to wards realising the objective.A strategy is thus made up of a series of steps, each of which creates a new situation in a gradual march towards the objective (UNAIDS, 1998: 12).
Primary Health Care as delivered by the health sector of the city of Johannesburg The core business of the city of Johannesburg is the deliv ery of Primary Health Care (PHC) services.Buch (2000:4) refers to Primary Health care as non-hospital care provided through health centres and clinics and in the community.It is commonly divided into personal and environmental health, both of which engage in prevention of health problems and promotion of health, care and rehabilitation.

Research design
An exploratory, descriptive and contextual research design was utilized (Bums & Grove, 2(X) 1: 43-52;249;Brink, 1996:11), consisting of a developmental and a quantification phase.The development of the strategy was based on the process applied to strategic planning for a regional/national re sponse to HIV and AIDS as described by the United Na tions (UNAIDS, 1998), consisting of the following steps: situation analysis, response analysis, strategic plan formu lation and resource mobilization.The situation analysis is based on the exploration and description of the following: factors that may be relevant to HIV and AIDs; factors that favour or impede its spread; factors that favour or impede achieving the best quality of life for the affected and in fected; international, national and provincial strategies; the legal framework, issues oflocal importance, the stakeholders and the underlying dynamics (UNAIDS, 1998:1 -4).The re sponse analysis seeks to determ ine the best practice through a literature review of best practice.It also consid ers programmes and initiatives that are succeeding or fail ing, the potential opportunities and obstacles by conduct ing strategic sessions w ith internal and external stakeholders.A gap analysis is then conducted to identify the gaps in the response to the pandemic and in considera tion of the outcome of the situational analysis (UNAIDS, 1998:6).
The following data collection methods were utilized during this phase of the study: The contributions of the group members are made in an organized and non-threatening manner • Group members give their critical judgment inputs in a round-robin fashion, followed by critical and focused debate of all the group members, with final consensus as to what CV1 rating (yes/no) should finally be allocated to the particular dimension of the draft strategy.
The principle of sufficient consensus reached by the appraisors/validators during the critical debate and judge ment of content validity during this phase, was applied (Muller, 1998:608-609).The draft strategy was reflected in a structured questionnaire format, consisting of the follow ing: information on the appraiser/validator with reference to representation and domain expertise, the dimensions of the draft strategy reflected in the form of a check list (yes/ no) with reference to acceptability, technical soundness and feasibility, as well as the perceived affordability (UN AIDS, 1998:16).
A descriptive frequency distribution was analysed and the mean "yes" rating by the validators for each dimension of the draft strategy was determined which was reflected as the CVI.The maximum group size of the validators was ten, as recommended by Lynn ( 1986:384) and Muller (in 1998:608).
The CVI is based on a sliding scale: 1,0 equals ten members allocating a "yes"; 0.90 equals nine members confirming the validity with a "yes", etc.According to this propor tional sliding scale, at least seven members should confirm the validity of the specific dimension to be accepted as sufficient consensus.

Population and sampling
The research population consisted of both internal and external stakeholders within the city of Johannesburg with reference to primary health care service delivery.They were the members of staff within the health sector of the city of Johannesburg who account for the implementation of the strategic plan.The positions included the director health services, deputy director(s) programmes, sub-district health directors, managers and operational managers, staff directly involved with HIV/AIDS services, as well as the HIV/AIDS co-ordinators.Provincial internal stakeholders were also included in the population: directors, deputy directors and assistant directors at the Gauteng Provincial Regional Of fice Region A and regional HIV/AIDS co-ordinators.
The external stakeholders were 24 funded organizations: the non-governmental organizations (NGOs), communitybased organizations (CBOs) and faith-based organizations (FBOs).The Johannesburg AIDS Council represents these organizations.Other groups included in the population are the persons living with HIV/AIDS (PWAs ) and those af fected by the disease.
A purposive non-probability sampling method was utilized (Burns & Grove, 2001:374-375).Roleplayers/stakeholders and domain experts were identified by the researcher, in consultation with members of management, based on the following inclusion criteria within the context of the health sector of the city of Johannesburg: • The researcher defines "experts" as those persons who will be responsible for the implementation of the strategy, adherence to the key performance in dicators and time frames; • Members that have a formal full time and permanent appointment in the positions described in the popu lation • Members that would be available to participate in the scheduled consultative workshops • Representation from all stakeholder groups was ensured, utilizing the principle of quota sampling (Bums & Grove, 2001:375).

Reliability and validity
The following control measures were applied to ensure validity and reliability of the strategy (Thomson, 1997:185-193): • Appropriate selection of the stakeholders/ roleplayers in both the developmental phase (draft ing of the strategy during consultative workshops) and the validation of the strategy to ensure adequate expertise, ownership and representation of all stakeholders/roleplayers • Participants were given equal opportunity to par ticipate in the consultative workshops and the vali dation phase when the nominal group technique was applied • Theoretical validity is based on the application of a comprehensive process, as described by the UNA1DS(1998).• A formalized process was followed to draft the strat egy and to determine the content validity of the strategy.

Ethical considerations
The ethical standards for research, as set out by the Demo cratic Nursing Organization of South Africa (DENOSA, 1998) were adhered to in this research.The researcher ob tained written, informed consent from the relevant author ity to conduct the research and participants were informed of the status and objectives of the research, type and method of data collection, and possible benefits to the authority and the participant.Due to the sensitive nature of HIV/ AIDS participants were informed that they may withdraw from the study at any time they wish (especially partici pants living with or affected by HIV/AIDS).

Results
The Empowerment of the health sector to deal with the HI V/A1DS pandemic.
A total of two consultative workshops were held and thir teen participants attended the workshops.Individual inter views were conducted with two internal stakeholders rep resenting managerial positions (refer to population).Two sessions, utilizing the nominal group technique (Muller, 2002:173) were held to determine the content validity of the draft strategy.Ten and nine participants (domain experts) appraisors/validators rated the draft strategy respectively.
The draft strategy was confirmed as valid.The average Content Validity Index (CVI) determined, was 1,0 for ac ceptability and technical soundness (all ten participants in both workshops confirmed the content validity) and 0.89 for feasibility and 0.89 for perceived affordability.There fore, a high Content Validity Index (CVI) with reference to acceptability and technical soundness was obtained.

Theoretical framework
The theoretical framework was developed, based on local, provincial, national, as well as international principles and criteria for the management of HIV/AIDS, in relation to the context, objectives, stakeholders, the process/strategy and underlying dynamics.This process entailed a situational analysis, followed by a response analysis, in accordance with the process of strategic planning for the management of HIV/AIDS (UN AIDS, 1998  1999a,b,c;2002;Gauteng Provincial Government. 2001;Greater Johannesburg Met ropolitan Council, 1999;Harley, 2000; Intersectoral AIDS Unit, 2(X)1; Johannesburg HIV Management Services, 1998;Karim et al" 1997;SAIMR, 2000;Smart, 2001;UNAIDS, 1999;Wilson, 2(XX);World Bank. 1999).

Situational analysis
The strategy is developed for the city of Johannesburg in Gauteng.A situational analysis was conducted with refer ence to the factors relevant to HIV, factors that favour or impede the spread of HI V and factors that impede of favour achieving the best quality of life for those living with HIV and the affected.International, national and provincial strat egies, within the professional, ethical and legal framework, were analysed and described.Issues of local importance, such as the demographic profile of the city of Johannes burg, economic profile, human resource development, safety and security were assessed.Both the internal and external stakeholders involved in a strategy for the man agement of HIV/AIDS, were identified.The internal and external dynamics that could possibly impact the strategy, were also deleniated.The concluding statements, based on this analysis, are as follows: • High levels of HI V/AIDS prevalence were noted within communities of the City of Johannesburg, particularly among the highly vulnerable popula tion groups.HIV/AIDS is a definite threat to the capacity of health services and the socio-economic development of the city.The reasons for the high levels of prevalence are factors characteristic to the City of Johannesburg driving the pandemic.

•
The factors favouring the spread of HIV include high levels of sexually transmitted infections (STIs) and mother-to-child-transmissions (MTCT), high rates of prostitution, gender discrimination, women and child abuse and occupational exposure to HIV.The spread of the disease is being impeded by (vol untary counseling and testing (VCT), health educa tion and condom distribution.Factors favouring achievement of the best quality of life to those af fected and infected include the delivery of PHC serv ices, counseling and home based care.

•
The international, national and provincial strategies indicate that political commitment is the key to ad dressing the problem of AIDS.Political commitment to tight the pandemic/epidemic has been observed and has become evident in the recently appointed AIDS Council and the prioritizing of the disease on the Council's agenda.

•
Common trends in both national and provincial strat egies are the prevention of new infections in order to reduce the incidence, the provision of care to those infected and affected to promote their quality of life and reduce the socio-economic impact and the development of monitoring and evaluation sys tems.These issues also became part of the major strategic thrusts employed by the strategy for the city of Johannesburg.The goals of the strategy com piled for the city are to lead and facilitate intersectoral collaboration; to strengthen primary health care services and provide comprehensive community based-care, prevention/reduction of new infections and community mobilization towards prevention, non discrimination and non stigmatization and ca pacitate the health sector to deal with the AIDS epi demic/pandemic.

•
Intersectoral collaboration and development of pro grammes at local-government level are key focus areas of the provincial strategy pointing to the need for a strategic focus on HI V/AIDS by the local gov ernment.The role of various stakeholders is acknowl edged, whilst the key role of co-ordinating these stakeholders to maximise the joint response to the epdemic/pandemic is identified.It should be noted, as has been mentioned, that one of the goals formu lated for the strategy is to lead and facilitate intersectoral collaboration.

•
The health sector is leading the response to the pandemic according to the stipulations of the Health Act (South Africa, 1977, as amended).This act re quires local government to prevent the spread of diseases, promote health and deliver curative and rehabilitative services.The White Paper for the Transformation of the Health System in South Af rica, 1997, affirms the principles for HIV/AIDS pre vention, treatment and care (Department of Health, 2000b: 17-18).These principles were taken into con sideration during the drafting of the strategy.

Response analysis
A response analysis was conducted (UNAIDS, 1998), fo cusing on local, provincial/regional and national studies in relation to the principles of best practice, performance au dit and gap analysis.The best practice analysis focused on the following: the management of sexually transmitted infections (STI's), condom promotion and distribution, be haviour change and communication, voluntary counseling and testing (VCT), challenges in home care, comparative costs, adolescents and breast feeding and mother-to-childtransmission (MTCT).The performance audit (UNAIDS, 1998) was based on the outcome of various workshops held with internal and external stakeholders.The gap analy sis was performed, also based on the principles described by UNAIDS (1998).The following dimensions were ana lysed: the role of the AIDS Council in relation to the sub district HIV/AIDS intersectoral committees, nutrition sup port and a supplementary feeding scheme, advocacy for healthy living and mother-to-child-transmission (MTCT).
The following concluding statements, with reference to the response analysis, are relevant:

Conclusion
The objective of this study was to explore and describe a strategy for the management of HIV/AIDS by the health sector of the city of Johannesburg.The research was based on the UN AIDS (1998) Guide to the strategic planning proc ess for a national response to HIV/AIDS.A strategy for the management of HIV/AIDS by the health sector of the city of Johannesburg was formulated and was confirmed as valid with reference to technically soundness, feasibility and perceived affordability.

Lim itations
The limitations of the study are: • Limited time frames and work pressure were experi enced impacting on participants' response to attend the consultative workshops • The Gauteng Provincial Health Department did not respond to any of the invitations • The study did not include the process of resource mobilization recommended by UNAIDS (1998).

•
The UN AIDS (1998) guide recommends field visits to be paid to external stakeholders during the re sponse analysis.The performance audit was con ducted by means of workshops with internal and external stakeholders.Thus the audit of the response was limited to stakeholders who participated in the workshops.

Recommendations
The following recommendations are made: • Implementation and evaluation of the strategy, with appropriate resource mobilization to achieve the ob jectives within given resources allocated • Empowerment of staff responsible for the implemen tation of the strategy • The establishment of a monitoring committee to monitor and evaluate the implementation of the strat egy and the health sector's progress towards the key performance indicators stipulated in the strat egy and time frames indicated • An impact analysis be conducted to determine the impact of the strategy on the key performance indi cators, on resources such as human, financial, goods and services, and on the community.