Sunday Times (Johannesburg) - August 17, 2003
Ranjeni Munusamy

If the hype following last week's Cabinet announcement that antiretroviral drugs are to be rolled out is anything to go by, four million HIV-positive people in this country should begin queueing at their local clinics to receive treatment.

The reality is that antiretrovirals are administered only to people who have developed full-blown Aids - currently estimated at between 400 000 and 500 000 people in South Africa - and have a CD4 (white blood cell) count below 200, an indication of increased risk of serious infection.

Even then, it will take two to three years to get the process of dispensing treatment to all these people up and running.

The publicity around the government's perceived U-turn - the spindoctors argue the turning point was actually April 17 last year when the government said a countrywide antiretroviral programme was being worked on - has detracted from the monumental task this country faces in undertaking a universal roll-out of the drugs.

According to the Clinton Foundation, which is providing technical assistance to the government on the treatment plan, South Africa is the first country with a large infected population to roll out such a comprehensive HIV/Aids programme.

The only two other developing countries to have done so are Brazil, where the incidence is low, and Botswana, a small country.

The plan's implementation is a logistical minefield.

The report by the joint Health and Treasury task team, on which the Cabinet based its decision, recommends that provision runs concurrently in rural and urban areas, in all nine provinces. Implementation would therefore occur in two or three "waves", with groups of well-equipped hospitals and poorly resourced rural hospitals selected for each phase.

The roll-out will have to be managed by a dedicated unit with sufficient personnel and skills to dispense the drugs properly and equitably. There also has to be constant monitoring, evaluation and research, as well as surveillance of drug resistance.

Achieving a 100% coverage target by 2008 will require all public hospitals and community health centres across the country to join the programme by the end of next year, the report says. The cost of training medical personnel will be R12.1-million in the next year.

The Clinton Foundation has advised that a communications plan to health providers and HIV-positive South Africans needs to be undertaken as a matter of urgency.

The campaign to pressure government into providing treatment has, to some extent, built false expectation about the drugs and what they are capable of doing.

Not many people know that it is the international norm to dispense antiretrovirals only to people diagnosed with Aids, not to everyone who tests HIV-positive. People with HIV are treated for opportunistic infections and have to rely on good nutrition, as the Health Minister Manto Tshabalala-Msimang keeps telling us.

Some people may stop taking the drugs when they start to feel better, or when they experience side-effects. Others may revert to irresponsible behaviour, including unsafe sex, which could see them develop new strains of the disease, the Clinton Foundation says in arguing for an intensive communication campaign.

The task team recommends "rationing" the drugs on the basis of behaviour to discourage irresponsibility.

The task team advocates a doctor-driven programme - which would mean the drugs could not be prescribed willy-nilly by nurses or pharmacists - but the public health system is chronically short of doctors.

The country's patent laws will make it difficult simply to purchase the drugs. The current cost of medicines in South Africa is substantially higher than internationally. The best price for a regimen for an adult with Aids overseas in the first year is R8 139, compared with R12 232 a year in South Africa.

All this will have to be covered while maintaining targeted spending of between R550- and R570-million a year on the programme.

The question remains as to whether there has been a change of mind set in the upper echelons of government regarding Aids treatment.

What about all the concerns President Thabo Mbeki has raised about the drugs and their side-effects?

The task team report spells out the fact that antiretroviral therapy is "not without its hazards". It says the drugs do have serious side-effects and there are instances where heart disease, cancer and abnormal cholesterol concentrations have manifested. "There have also been cases of death as a direct result of antiretroviral usage."

But the report also state s that the best scientific knowledge available has shown that proper use and careful management of the drugs help restore patients with Aids to an "appreciable level of human functionality and they do defer death".

Last week's decision was taken after weighing the risks and benefits. The implications of the decision, in all its manifestations, are now our collective responsibility, not the Cabinet's.

This is, after all, what we wanted. Right?

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