ARV treatment
Where are we now?

In April 2004, after pressure from the judiciary and organisations such as the Treatment Action Campaign, the Government finally took steps to implement its Comprehensive HIV and AIDS Care, Management and Treatment Programme (“the Comprehensive Programme”) across the country. Now is a good time to ask: how far have we come in providing treatment for HIV/AIDS for those who need it?

But before we look at what progress has been made regarding the roll-out of anti-retroviral (ARV) treatment, it is important to emphasise that ARVs are only prescribed for persons who are HIV-positive, have a CD4 count of below 200, and have disclosed or are willing to disclose their status to another person so that they can be given support. Prior to starting treatment, the patient must receive training from a hospital or clinic about how to take the medication and the importance of adherence to the treatment regimen. Treatment for HIV/AIDS continues for the rest of a person’s life: once a person starts taking ARVs, they should never stop taking them.

The original goal of the Comprehensive Programme was for 53 000 HIV-positive people to be receiving ARV treatment by March 2004. That target was not reached. So the Department of Health revised the goal and committed themselves to 53 000 people on ARVs by March 2005.

Across South Africa, 50 out of the 53 health districts have at least one service point providing ARVs. But in addition to these facilities that supply the drugs, laboratories are also needed to analyse CD4 and viral load tests. Of the National Health Laboratory Service’s 250 certified laboratories in the country, 20 have thus far been selected to provide CD4 tests and seven can perform viral load tests. Although there are few of them, these laboratories have sufficient supplies and are able to operate efficiently.

Nonetheless, by September 2004, the Department said that only about 12 000 patients nationally were accessing ARVs. Most of these people, about 7500 in total, are in Gauteng and the Western Cape. In Limpopo and Mpumalanga combined, less than 300 people are on treatment. In KwaZulu-Natal, 31 service points are treating about 1556 people. From these figures it is clear that while treatment is being provided, the country is well behind the Government’s proposed timeframe, not least of all because ARVs are only available from a limited number of facilities across the country.

The reasons given by the Department of Health for the slow start-up include:

• the need to first strengthen the health system – e.g. some facilities or service points need structural renovations in order to comply with the necessary requirements of providing ARVs; also data management and information systems need to be put in place at many facilities.
  
• the need for more human resources and training – there is a dire insufficiency of health personnel such as doctors, nurses, pharmacists, dieticians and counselors in the public health system. This is partly because many health professionals have moved to the private sector, and many have migrated to developed countries overseas. The Department of Health is busy developing a plan to retain and train personnel, which should be ready by 2005. One initiative in that plan is, for example, to pay an extra allowance to health personnel working in rural areas.
  
• the tender process for supplying ARV drugs was started in February 2004 and a tender has still not been awarded, therefore the Provinces have had to source their own medications.
  

Of course, it is not just a matter of how many people are on treatment, but what the quality of that treatment is. A Monitoring and Evaluation framework has been developed by Government in order to monitor the implementation of the Programme. Indicators used in the monitoring process will look at patient progress and programme performance by considering issues such as: access to treatment, compliance, affordability, sustainability, the quality of services, and the integration and strengthening of the health system. In addition, a new computerised system to track the movement and storage of ARVs will be developed in due course, which will minimise drug losses because the drugs will be traced from the original supplier all the way to the patient who finally receives them.

One of the key issues in the Government’s five-year strategic plan for HIV and AIDS is that prevention remains a cornerstone in HIV and AIDS policy. Voluntary counseling and testing is now available at 3072 facilities in South Africa (not including private facilities that also provide VCT), and the uptake of VCT has doubled since last year. One “prevention highlight” for 2004 was the launch of the new Choice-branded condoms by the Khomanani campaign. These condoms in bright blue and yellow packaging are available countrywide. Distribution of female condoms increased from 114 to 203 service points, and the Department expects that even more female condoms will be distributed next year.

The implementation of the Comprehensive Programme is supported by a vigorous information, education and communication campaign. 10 000 booklets describing guidelines for adult ARV treatment have been distributed; 11 million copies of a booklet on prevention, care and treatment have been dispersed nationally; adverts on television, radio and in local newspapers are used to educate all South Africans about the Programme; a 24-hour HIV/AIDS telephone help line is available (0800 012 322) in all official languages for anyone needing advice or help; and social mobilisation efforts are being channeled towards ensuring that people living with HIV and AIDS have access to care, treatment and support structures in the communities in which they live.

Planning for the roll-out of ARVs took a number of years. Now that we have embarked on the journey at last it is good to keep looking back to see how far we have come. More important is that we need to look forward to how far we still have to go. There will be obstacles and challenges. South Africa desperately needs more health professionals to support those working in the public health system, and solutions need to be found for problems such as the lack of transport for patients in rural areas. We are travelling the road slowly. It will take a concerted effort from everyone involved – government institutions, civil society, community bodies, non-governmental organizations and faith groups – to reach our destination. We will have arrived at last when free ARV treatment is available and accessible to all citizens.

Figures quoted in this article are from the following sources:
Department of Health (2004). Monitoring Review - Progress Report on the Implementation of the Comprehensive HIV and AIDS Care, Management and Treatment Programme.
“Missing the Mark”, article in Mail and Guardian, 19 October 2004.

Statistics snapshot
Last year UNAIDS released their report estimating the prevalence of HIV and AIDS worldwide, as at the end of 2003. The Department of Health also released their 2003 report, showing HIV statistics for South Africa as a whole and for each province. This is a snapshot of the some of the latest HIV and AIDS estimates which are provided in these reports.

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