Sunday Times (Johannesburg) - August 10, 2003

The vibrant Mabele made a potent case for treatment to be placed high on the conference agenda, revealing that sponsored antiretrovirals had allowed her to narrowly avoid death.

"You nearly lost me," she said, raging about the "political card games" being played with the lives of half a million South Africans needing these drugs.

But if promises made at the four-day conference in Durban are kept, the games will be over.

And a Cabinet instruction on Friday for the Health Department to urgently develop a detailed operational plan for a national treatment programme seems to build on the momentum.

The 2003 conference will be remembered as a turning point for Aids treatment in S A . It moved the country closer to the launch of a national treatment programme.

Forces combined inside and outside the halls to contribute to the shift, with protest demonstrations by the Treatment Action Campaign (TAC), specialist presentations on treatment, and the opportunity for key players to engage with each other . At the closing ceremony, KwaZulu-Natal Health MEC Dr Zweli Mkhize declared that South Africa had moved beyond the issue of whether to provide life-saving drugs - to the issue of when.

Top health officials, including director-general Dr Ayanda Ntsaluba, also publicly supported the scaling up of public antiretroviral treatment.

Even before the conference began on Sunday, it was clear that the demand for treatment had reached a flash point, with TAC protestors vowing to resume their civil disobedience campaign . Wearing yellow T-shirts with slogans like "Two pills a day saves lives", they maintained a high profile throughout the conference.

On the opening night, they held up posters with the names of fallen comrades, and chanted "Aids treatment now" during the health minister's keynote speech .

The next day hundreds of TAC demonstrators converged on the conference to appeal to the 2 500 delegates, from 52 countries, to support their call for treatment. Conference scientific chairman Professor Jerry Coovadia accepted their memorandum, saying if they wanted his backing, his response was: "Yes, a hundred times. Yes, a thousand times. Yes.

"We are sitting in the white heat of the epidemic and we must strain every sinew in our body to overcome it," he said during the conference.

Treatment dominated discussions, with the conference confirming that it was possible to provide treatment in a public health system. Treatment efficacy, safety, models for impoverished communities, the costs, and the stalling by government were all on the agenda.

The head of the Western Cape's HIV/Aids programme, Dr Fareed Abdullah, put it most clearly: "It has become abundantly clear that no Aids programme can be effective without the widespread use of antiretroviral therapy . . . for long-term treatment of adults and children."

The Western Cape is leading the way by treating some 1 000 people with antiretrovirals, in partnership with humanitarian organisations.

Its pioneering projects have had noteworthy results in improving the survival rates of patients . The province has also achieved universal coverage for its preventative mother-to-child-transmission programmes.

Other provinces, including rural KwaZulu-Natal, have also succeeded in rolling out treatment programmes to prevent such transmission.

Since the 2000 conference, 80 000 women in South Africa have benefited from such programmes, roughly halving the rate of HIV infection among their newborn babies.

The explosive possible withdrawal of mother-to-child-transmission drug nevirapine was also high on the agenda. The Medicines Control Council (MCC) has threatened to withdraw the drug's registration, after a pivotal nevirapine study was found to have had technical faults.

But leading paediatricians, like Professor Catherine Wilfert of Duke University Medical Centre, presented evidence that nevirapine - used in mother-to-child programmes worldwide - had proved to be an effective and safe drug.

MCC registrar Precious Matsotso pledged to meet researchers and doctors to review evidence, in order to avert a crisis before the deadline for nevirapine's registration expired.

The conference also heard that the council had made progress in registering at least five generic antiretrovirals, a move which would make Aids treatment more affordable.

Globally, the cost of antiretrovirals has fallen sharply, from about 12 000 for an annual course to as low as $300 .

Another positive development this week was the finalisation of an agreement between South Africa and the Global Fund to Fight Aids, TB and Malaria, after a protracted delay.

Donor funds and cheaper drugs will make a significant difference to the government, which raised the financing of the treatment, along with a weak health infrastructure, as obstacles to treatment programmes.

The executive director of UNAIDS, Dr Peter Piot, acknowledged "numerous real constraints" in a broadcast to delegates. But he urged: "Let us not wait to act until we have the perfect solution . . . access to HIV treatments should be urgently expanded."

This urgency was reinforced during the conference, which narrowed the gap between players in the HIV/Aids field, who pledged to work together after they left Durban.

"We have a sense of forward movement and better cohesion," said the head of South Africa's HIV/Aids programme, Nono Simelela.

Ntsaluba confirmed this: "We need to encourage platforms where there is open dialogue and I believe the conference has taken us forward ."

Clearly there is no time to lose. The country is entering a new phase in its HIV/Aids epidemic - the worst in the world - where mortality is starting to exceed the incidence of infection, according to epidemiologist Quarraisha Abdool Karim.

A woman between 25 and 29 is now three-and-a-half times more likely to die than in 1985.

At the closing ceremony Dr Kgosi Letlape, head of the SA Medical Association, begged President Thabo Mbeki - markedly absent from the conference - to lead the way.

The next step lies in the hands of Mbeki and his Cabinet, who will have to approve the department's operational plan, expected to be completed by the end of September. The plan could save 1.7 million lives by 2010 if all South Africans needing Aids treatment have access to it.

For more on the Aids issue, go here.
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