Sunday Times (Johannesburg) - September 28, 2003 - Health-e News Service
Kerry Cullinan, Health-e News Service

For the past six weeks, health officials and specialist advisers have been burning the midnight oil to meet Tuesday's deadline, set by the Cabinet, for a detailed operational plan for an antiretroviral treatment programme.

"It is as if we have finally woken up to the fact that we are in an emergency. People are working as if we are a country at war," says a source close to the process.

While cynics say the urgency is being fuelled by next year's general election, few in the HIV/Aids field doubt that South Africa has reached the point of no return on the provision of antiretroviral drugs.

The Cabinet-driven programme has the potential to commute the death sentences of about 1.2 million South Africans who are expected to develop Aids over the next seven years, and prevent 860 000 children from becoming orphans.

But there is a potentially devastating downside: not properly implementing the programme the first time will result in drug-resistant HIV, which will effectively render antiretrovirals useless, and they are the only weapons the world has to fight the virus.

It has been a difficult time for the Health Department. Its director-general, Dr Ayanda Ntsaluba, left at the end of August and HIV/Aids head Dr Nono Simelela has been seriously ill twice.

But, says the Medical Research Council's Dr Tony Mbewu, who heads the government-appointed task team, "everything is on track" for Tuesday's deadline.

Treatment Action Campaign secretary Mark Heywood says there is a "seriousness within the task team, which is being thorough in its approach".

Aside from helping provinces with their roll-out plans, the task team has been looking at staff training, laboratory services and drug procurement. It has met drug companies, including Cipla, the Indian manufacturer reputed to make the world's cheapest generic antiretrovirals.

Finance for the roll-out is to come from a conditional grant from the Treasury. The beauty of conditional grants is that they allow national government to inspect provincial operations to make sure the money is being spent where it is supposed to be.

Thus, the task team has been able to send a team to Mpumalanga to help with preparations for the roll-out. This is something the national government has been unable to do in the past, even though the province's HIV/Aids programme was virtually destroyed under former health MEC Sibongile Manana.

While provinces have been able to select their own facilities, they have to ensure that these offer citizens in rural and urban areas "equitable access". As a result, most provinces have centred their roll-out plans on district hospitals.

Realistically, the programme may only start properly in the new year when facilities have been prepared and staff trained. However, Heywood says, sites that are ready should begin operations in November as "any delays will kill people".

For the government's Simelela, the biggest challenges of the roll-out are "staff training, proper infrastructure and ensuring community understanding of how to take antiretrovirals".

There are plans to set up provincial HIV/Aids centres to train health workers and link doctors who have little HIV/Aids experience by phone and e-mail to HIV experts.

According to a report by the Treasury and the Health Department, by 2010 it will cost between R16.9-billion and R21.4-billion, depending on drug prices, to treat all Aids patients.

Generic medicine can reduce costs massively. The government's best estimate for the drugs 3TC, d4T and nevirapine is R7 611 a patient a year, but the Generic Antiretroviral Procurement Project says it can treat people for R2 460 a year using generics.

University of Cape Town economist Professor Nicoli Nattrass says the money could be raised by increasing VAT by between 3% and 7%.

If South Africa's programme is to succeed, money will have to go into improving infrastructure to ensure stable drug supplies, adequate laboratory support and more staff. These measures will benefit all South Africans using public health. And health workers' morale will be boosted as they will no longer be helpless when faced with destitute Aids patients.

"This is a once-in-a-lifetime opportunity," says Dr Douglas Wilson, medical specialist at Greys Hospital in Pietermaritzburg. "In future, health workers should look back on this roll-out as the highlight of their professional careers."

Wilson says: "You can get addicted to watching the progress of your patients on antiretrovirals, as they put on weight and go back to leading normal lives."

In May and June, I spent six weeks with a group of women preparing to go on antiretrovirals at iThemba Clinic in Mariannhill outside Durban. Every week, at least one of the 10 women would be admitted to hospital.

The transformation in the women after a few weeks of treatment has been remarkable, in terms of their physical and psychological well-being.

As antiretrovirals boost people's immunity, more room will be made available for non-Aids patients "crowded out" of hospitals by Aids patients.

But, at the same time, there are immense dangers. If the programme is not properly implemented, it could result in a multi-drug-resistant HIV that will not respond to any known drugs.

The success of the programme relies on patients taking their drugs properly and at the same time every day, 95% of the time. Proper patient adherence relies on a number of things, including adequate support from families.

South Africa's longest running antiretroviral programme, Doctors Without Borders' Khayelitsha programme, will not give drugs to people who have not disclosed their HIV status to at least one member of their household.

"Disclosure lightens the psychic burden. Often people don't have the mental energy to tackle adherence if they are trying to deal with the knowledge of their HIV status on their own," says Wilson.

However, lawyers have told the Health Department that it will only be able to exclude people for "factors within their control, such as drug and alcohol abuse".

Drug resistance is already a problem in countries that have had antiretroviral treatment for some time. Researchers at the Paris HIV Conference in July reported that 10% of 1 600 European patients newly diagnosed with HIV, and who had never taken antiretrovirals, had strains of drug-resistant HIV. This suggests they were infected by people who had not been taking their drugs properly.

This chilling report underscores the importance of treatment needing to go hand in hand with prevention efforts.

Wilson smiles when I ask about the challenges that lie ahead: "A Chinese saying keeps going through my head," he says. "'The gods grant the wishes of those they want to punish.'"

Kerry Cullinan wrote this article for Health-e News Service

Source: www.health-e.org.za

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