Important note: Information in this article was accurate in August 2000. The state of the art may have changed since the publication date.| "The imperative for the International Association of Physicians in AIDS Care (IAPAC) to actively engage in the Southern African region is made even more relevant by the prospects and opportunities for developing and implementing programs that will achieve measurable impacts on HIV/AIDS care in the region. Given the enormity of the HIV epidemic in Southern Africa, it is most appropriate for IAPAC to establish a regional office from which to coordinate assistance that will contribute toward Southern Africa's campaign for survival." |
| -- José M. Zuniga, IAPAC President July 12, 2000, Durban, South Africa |
The opening of IAPAC's first regional office in Johannesburg, South Africa, marks the beginning of a notable chapter in the association's history. The site for IAPAC's first regional office was chosen after careful deliberation about how IAPAC can best meet its most urgent challenge: serving as a leader in responding to the global HIV pandemic, while ensuring that we achieve a relevant and effective role in the most severely HIV-affected regions of the world.
Our association is addressing this challenge by rapidly implementing concerted and sustained responses that will lead to measurable impact. There is no more urgent priority for IAPAC than establishing a presence in one of the worst affected regions--Southern Africa (which includes the countries and kingdoms of Botswana, Lesotho, Namibia, Malawi, Mozambique, South Africa, Swaziland, Tanzania, Zambia, and Zimbabwe).
The base of experienced HIV-treating physicians in Southern Africa has historically been limited to relatively few interested practitioners. There is an urgent requirement for greater numbers of physicians who are adequately prepared to manage HIV. Furthermore, these physicians must have an enabling environment that includes clinical guidelines, managed care programs, physician clinical decision support services, and patient support programs.
IAPAC's objectives for the Southern African region are to rapidly build infrastructure, develop capacity, and implement targeted programs that will produce measurable outcomes. IAPAC has the opportunity to achieve these objectives through its regional office in Johannesburg.
Headed by newly appointed Executive Director Shaun Conway (formerly the director of the Southern African HIV Clinicians Society), the office's fundamental mission is to enable HIV-treating physicians to provide appropriate care for local HIV-infected populations and to mobilize a physician-activist membership that will advocate on behalf of its patients. [Editor's Note: More details about IAPAC's programmatic objectives for Southern Africa may be found in the sidebar below.] For some of IAPAC's members, the XIII International AIDS Conference in Durban, South Africa, provided the opportunity for a brief introduction to the vast constellation of issues that define Southern Africa's AIDS crisis. I would like to describe in more detail those issues that have significantly factored into the development of IAPAC's plan of action for the region.
Westerners who hope to contribute to the fight against AIDS in Southern Africa must first come to terms with the harsh truth that antiretroviral (ARV) therapy, the imperfect but still impressive arsenal that is central to HIV treatment efforts in the developed world, is not a realistic "solution" in any of these countries. Even in the relatively wealthy private sector, an order of magnitude price reduction would be required before net healthcare savings could be expected, although these therapies are able to achieve dramatic health benefits for the few for whom access is not an issue. The delivery of basic healthcare programs needs to be the foremost priority in this setting.
To provide better healthcare to people with HIV and AIDS, both the public and private health sectors need to shift to more cost-effective models of care delivery. This shift requires a fundamental re-orientation toward lower-cost, hospice-type care instead of acute hospitalization, along with consistent and substantial support for community-based care initiatives. Neither of these interventions has received much attention from the public sector to date.
Furthermore, there is still an urgent need to implement cost-effective secondary prevention programs, such as those targeting tuberculosis and pneumonia.
An overview of the challenges facing one of the countries in the region--South Africa--gives a sense of the enormity of the problems facing all of Southern Africa. In South Africa, the medical profession at large has been slow to respond to the epidemic and remains mostly reactionary in dealing with care issues. Physicians are either government-employed in the public health service (which is relatively understaffed), or are in private practice. There are striking inequities in the geographical distribution of physicians in both public and private service and a hugely disproportionate number of physicians reside in urban areas, leaving rural and township areas severely underserved.
Although South African-trained physicians are well skilled and clinically very competent, few have had any experience managing ARV therapy. Overall, physicians who received their medical credentials more than five years ago have had little formal training in the clinical management of HIV.
In South Africa's taxpayer-funded public healthcare sector, which serves an estimated 80 percent of the population, physicians from all clinical disciplines have had to deal with exponential growth in the number of HIV-infected patients. They have not had formal opportunities to update their skills in managing HIV disease. Consequently, the knowledge and skills-base in the public sector are suboptimal. Human resource issues rooted in economic and racial inequalities exacerbate the skills shortage.
The estimated cost of care for HIV-infected individuals in South Africa is staggering, even without ARV therapy. In the public sector, the average annual cost of caring for an individual at stage one or stage two illness is US$200, and the average annual cost of caring for someone at stage four illness is US$2600. Within the context of South Africa's estimated per capita income of US $2336 (with a huge disparity between the low-wage-earners who make up the majority and the small number of high-earning professionals), this leaves most uninsured HIV-infected individuals entirely dependent on the greatly overburdened public healthcare system.
Significantly, South Africa does not entirely reflect the challenges of the AIDS epidemic in the greater region that IAPAC has committed to represent.
South Africa is better positioned than most of its neighbors to respond to HIV. Indeed, the data that yielded the figures quoted here are a precious commodity that only South Africa possesses (albeit insufficient to adequately describe the epidemic). In other Southern African countries, an important priority for the new IAPAC-Southern Africa Regional Office will be to help understand and determine the details of the epidemic, quantifying the impact and needs of specific communities.
Most of Southern Africa's numerous clinical research projects focus on new treatment developments (including ARV drugs and AIDS vaccines). Because clinical research in the region is currently undertaken at a variety of sites with differing affiliations, there is a widespread impression that the overall effort lacks coordination, regulation, and quality controls.
Many scientific questions relating to the epidemic in the region remain unanswered. Further epidemiological studies and research into more effective strategies to prevent and manage the epidemic in this context will be an important priority for the regional office.
IAPAC has committed to partnerships with the Southern African HIV Clinicians Society and other institutions whose missions resonate with IAPAC's aim of crafting and implementing strategies to improve the quality of care provided to people living with HIV/AIDS. Through these partnerships, IAPAC will implement the strategies that will have the greatest impact on Southern African people living with HIV/AIDS and the physicians who are charged with their care.
Sadly, only a small group of dedicated and informed physicians are deeply engaged in meeting the complex challenges of HIV/AIDS in the Southern African region. It could be argued that there are few equivalent places where the IAPAC credo--"Battling complacency. Advancing commitment."--is as relevant. With this credo and a plan of action, backed by resources and international support, IAPAC is particularly well suited to undertake an important role in the region.
In announcing the opening of IAPAC's first regional office in Johannesburg, South Africa, IAPAC President José M. Zuniga and IAPAC-Southern Africa Executive Director Shaun Conway explained that program areas for the Southern Africa regional office will be defined within the context of what IAPAC is currently undertaking.
Zuniga and Conway identified the following programmatic objectives as priorities for the IAPAC-Southern Africa Regional Office:
José M. Zuniga is President/CEO of the International Association of Physicians in AIDS Care.
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