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Southern Africa: AIDS Plans Updates
AfricaFocus Bulletin
Feb 11, 2004 (040211)
(Reposted from sources cited below)
Editor's Note
Little more than two months after the announcement of a national
plan for providing AIDS treatment, South
African President Thabo Mbeki and Health Minister Manto Tshabalala-Msimang
have raised new doubts about the commitment of top
political leaders to rapid implementation of the plan. A
statement by the Treatment Action Campaign issued today accuses the
two government leaders of "serious factual misrepresentations"
and "causing confusion in the public and despair among people with
HIV/AIDS and health professionals."
See http://www.tac.org.za for the February 11 TAC statement, and
http://allafrica.com/stories/200402100552.html for an article in
the Cape Argus noting the health minister's backtracking on
commitments made in November to enroll 53,000 patients in therapy
by the end of February. For a report on the November announcement,
see http://www.africafocus.org/docs03/tac0311.php
At the same time the TAC acknowledged "tangible progress by
government in improving policies, budgets and plans to prevent and
treat HIV infection." And treatment access advocates acknowledge
that there are enormous practical problems as well as leadership
issues involved in providing treatment.
This issue of AfricaFocus Bulletin contains excerpts from two
articles from the HIV & AIDS Treatment in Practice (HATIP)
Newsletter, a twice-monthly publication, evaluating both political
will and practical obstacles facing AIDS treatment programs in
Botswana and South Africa.
Another AfricaFocus Bulletin today contains excerpts from the
keynote speech delivered by UN AIDS Envoy Stephen Lewis in San
Francisco at the 11th Conference on Retroviruses and Opportunistic
Infections
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Learning from Botswana
A report from Botswana's First National Research Conference on
HIV/AIDS/STI/Other Related Infectious Diseases
[Excerpts from HIV & AIDS Treatment in Practice #20, last updated
Jan 16, 2004. See http://www.nam.org.uk/main/hatip.asp for full
report. For more information on AIDS in Botswana visit
http://www.achap.org]
This article was written by Theo Smart with additional
contributions from Keith Alcorn.
Botswana Reviews its Progress
... the First National Research Conference on HIV/AIDS/STI/Other
Related Infectious Diseases held [in December] in Gaborone,
Botswana, was one of the most dynamic meetings this reporter has
ever attended. The conference demonstrated that the Government of
Botswana and its international collaborators and development
partners have put into place a model programme, the most
sophisticated response to the HIV/AIDS epidemic on the African
continent to date. As it is still ramping up, the programme is far
from perfect, however, and has encountered unanticipated and
complex problems from which other nations can learn.
But much of the meeting was dedicated to honestly assessing the
gaps between the "needs" the programme is meant to meet and its
actual performance, and then to the design and testing of
interventions or policies to tackle those obstacles or gaps in
provision. ...
Why Is Botswana So Seriously Affected?
... Participants at the conference devoted much discussion to the
reasons why Botswana has been so severely affected, and what can be
done to improve prevention efforts.
Ten or fifteen years ago in southern Africa, hardly anyone was
worried about HIV. Although, the first cases of AIDS were diagnosed
in 1982 in South Africa and in Botswana in 1985, the disease spread
very slowly in the 1980s. In fact, most people in the region
thought AIDS was a white man's disease, an effect of malnutrition,
or even worse, a fiction. To a surprising extent, these perceptions
still persist in many areas.
What is shocking is how swiftly and deeply HIV got its hooks into
the population during the last ten years - in many areas 30-40% of
the population has been infected, and the majority of people in
some age brackets. Similar data were reported at this month's
meeting by the Local Government Minister, T Shipinare, from the
most recent Botswana HIV/AIDS Surveillance report.
275,000 adult (15-49 years) Batswana are now estimated to be living
with HIV/AIDS (out of a total population of ~1.6 million). 37.4% of
adult pregnant women are HIV-positive, tens of thousands of their
children become infected and even more will become orphans. ,,,
According to the Surveillance report, "condom use in the last
sexual act with a non-marital and non-cohabiting partner was over
60%." Cultural practices which encourage intergenerational and
multiple partner sex also persist, according to the survey. "The
proportion of people with multiple partners is still high at 32%
for men and 17% for women." ...
Several presentations highlighted the woman's unequal role in
Botswana. They all added to evidence that has been highlighted for
years, but evidence nevertheless worth restating: women often have
little control over sex. If they refuse sex from their partner, he
could interpret it as a sign of unfaithfulness, and the partner
could then rape her. These patterns are not merely applied to
marriages but in affairs, dating couples and intergenerational
relationships as well.
The woman has no right to refuse sex, and therefore winds up being
put repeatedly at risk, and yet, if she tests positive she is
condemned as adulterous or a prostitute.
Fear of the male partner's reaction if he found out that she was
positive came up again and again in Botswana as a reason for women
not to get tested, to not return for test results, to not disclose
her results, to not go into PMTCT studies, and not to go onto
treatment. If they did get treatment, they might be poorly adherent
because they would try to conceal pill taking. ...When we talk
about stigma as an obstacle to treatment scale-up, we are talking
about a phenomenon that is largely structured by gender.
Sub-type C HIV-1
Dr. A B. Khan who is the head of the National AIDS Coordinating
Agency (NACA) and was also the doctor who diagnosed the country's
first AIDS case concurred that being both a woman and a doctor had
sometimes placed her in dangerous situations. But there must be
other factors besides male chauvinism that explain the severity of
the epidemic, because that isn't unique to Botswana. ...
"There's growing evidence for genotypic/phenotypic differences for
HIV-1C of southern Africa to help explain differences in
epidemics," Dr. Max Essex said during the opening plenary of the
conference. Dr. Essex is Chair of the Harvard AIDS Institute, and
the Botswana Harvard Partnership, just one of the several
international collaborations that Botswana has set up. Harvard has
built a $30,000,000 lab, partly to study these basic science
questions. Dr. Essex also happens to have discovered HIV-1C.
"AIDS deaths are at a new high, reflecting HIV infections that
happened 5-10 years ago and the lack of widespread use of HAART.
But sub-Saharan Africa, especially southern Africa, has much higher
rates than any other area. HIV-1C accounts for as many infections
as the other major subtypes (A, B, D, A/G, A/E) combined."
Dr. Essex first detected HIV1-C, in 1989 but at the time there
wasn't very much of it about. But since that time, it has spread so
rapidly that it is by far the most common subtype. No one's really
sure why this is the case, but Dr. Essex noted a number of unique
features of HIV-1C.
First, the countries with HIV-1C have the highest HIV prevalence
rates regardless of cultural differences. In general, non-subtype
B viruses are more efficiently transmitted heterosexually than
subtype-B. Meanwhile, subtype-C seems to be more readily
transmitted perinatally than subtypes A and D. ...
... Botswana isn't satisfied with [prevention and treatment]. They
want to go beyond that to become a country doing cutting edge
research. A centre of excellence, because they've realised that HIV
is a formidable enemy. And it isn't exactly the same HIV as is
common in the West - they certainly can't take it for granted that
the solution to their problem will be the same as in the rest of
the world. ...
The Masa Antiretroviral Therapy Program in Botswana
The successes and frustrations of Masa were described by its
operations manager, Dr Ernest Darkoh, at the opening plenary.
In 2001, the challenge posed by offering free antiretroviral
therapy was immense. The epidemic in Botswana was full blown and
out of control. There were approximately 300,000 HIV positive
people in the country. At least 35% of these were in the primary
income earning stage of life. 110,000 would probably be eligible
for therapy immediately, based on clinical criteria. But more than
90% of these didn't know their HIV status, and there were steep
socio-cultural barriers to getting them tested.
The country did not have the capacity to offer treatment yet. There
were few trained doctors, nurses, or lab personnel. There was no
infrastructure or equipment. They would need to create systems and
policies for the programme.
They established a dedicated implementation team (based on a
public/private model) and supporting structures. They decided to
build four strategically located centres in Gaborone, Francistown,
Maun and Serowe to serve patients who met the eligibility criteria
(a CD4 count of 200 or less and/or the presence of an AIDS defining
illness). They would establish a system to monitor early uptake
and adjust eligibility criteria as necessary. They would build more
capacity nationwide as rapidly as possible to address the full
burden of disease. At the same time, they would try to strengthen
ongoing prevention initiatives.
Progress
... As of November 2003, the combined [ten] Masa sites had tested
a total of 16,400 eligible patients, 10,264 are on treatment and a
total of 994 (9%) had passed away on treatment.
Masa has been criticised for the very large gap between the
perceived need for treatment and its ability to deliver. Dr Darkoh
pointed out however, that they could only scale up gradually and
that the number of patients over the last several months has
increased dramatically, ...
Others have worried about the high rate of death on treatment, but
Dr. Darkoh pointed out that these were very advanced patients with
an average CD4 cell count of only 50-60 cells. However, the
programme has shown that it can you can get good patient follow-up
in Africa, with fewer than 10% lost to follow-up. Also, patient
adherence, using a zero tolerance standard for missing or being
late on a dose is high, at over 85%. Less than 7% had to switch
medication due to toxicity. Complete viral load suppression was
achieved in 85% of the patients.
The plan is to continue scaling up and expanding as long as
necessary. Sites have been completed at two mining hospitals, and
three more are planned at Botswana Defense Force facilities. The
plan is to identify ten other potential sites for rollout by the
end of fiscal year 2004 ...
But the key challenges going forward? The first and foremost is
that most people in the country (including patients) still do not
know their HIV status. Socio-cultural factors and stigma remain
barriers.
Dr Darkoh says that they've learned several lessons from the
experience.
- "Capacity or capability build-up ... takes time in the
beginning."
- Each new site experiences the same "teething problems" therefore
spread the net as wide as possible after an initial "pilot."
- "The sickest come forward first: so we may need to "split" the
queue to allow some healthier patients onto treatment before they
become severely ill.
- VCT should be supplemented with routine testing to enable more
rational demand management; we need to convince people that it
would save their life AND livelihood.
- Much of the workload is follow-up of patients rather than initial
assessment.
- Set up monitoring and evaluation systems early.
...
South Africa's HIV Treatment Programme:
Is Slow Progress a Sign of Lack of Commitment?
[Extract from HIV & AIDS Treatment in Practice #23,
February 6, 2004 - full text will be available at
http://www.nam.org.uk/main/hatip.asp]
Distributed by e-3x5@healthnet.org See
http://list.healthnet.org/mailman/listinfo/e-3x5 for list archive
with full text and subscription information
This article was written by Theo Smart (Cape Town) with
contributioms from South African members of HATIP's advisory panel.
South Africa Seems to Change Direction on ART
People were guardedly optimistic last August when the South African
Cabinet issued instructions to its Department of Health to develop
an operational plan to provide ART in the public sector. Many were
surprised. For years, the current administration had delayed taking
any clear-cut positive actions and often seemed hostile to the
idea.
Activists initially may have questioned the composition of the team
appointed to develop it but when the very aggressive "operational
plan for comprehensive HIV and AIDS care, management and treatment"
- including the "roll-out" of antiretroviral therapy (ART) - was
presented and then approved by the Cabinet, people were literally
dancing in the streets.
The plan promised to distribute free ART within a year to at least
50,000 people in the nation's 77 health districts and to reach
every South African in need of treatment within five years. It also
committed government to investing substantial finances into
upgrading the national healthcare system via "recruitment of
thousands of professionals and a very large training programme to
ensure nurses, doctors, laboratory technicians, counsellors and
other health workers have the knowledge and the skills to ensure
safe, ethical and effective use of medicines."
Initial Reactions
After the plan's approval, HATIP queried South African members of
its Advisory Panel on what they thought of the new treatment
programme. Responses ranged. ...
Dr. Catherine Orrell of Somerset Hospital, a public hospital in
Cape Town had doubts. "While I'm quite happy that the plan has
finally been approved my excitement is tempered because it is going
to be very difficult to implement and is going to take years to get
treatment out to everyone who needs it, particularly in areas that
are already under-resourced. ...
To offer HIV care, the OP requires facilities to meet stringent
accreditation criteria. "It's a big list and quite a tall order. It
might be possible to achieve in some districts in Gauteng or the
Western Cape but what of the Northern Cape or Limpopo or
Mpumulanga? The program is going to have to be driven at the
national level."
Dr. Norman Nyazema who works at least half the year in Limpopo
Province said bluntly. "People are playing games. It's not going to
happen."
Most of the operational plan can be downloaded from:
http://www.gov.za/issues/hiv/careplan19nov03.htm .
Not Even Out of the Starting Gate
So far, a little more than two months after its approval, there is
little evidence that tasks are being implemented in a timely
fashion. No one has received treatment except in the Western Cape,
which has little to do with the operational plan because the
province had already allocated funds to provide ART on its own. In
fact, the drug procurement process has only just begun. This week
the government began tendering requests for proposals to drug
suppliers to shop around for the best price. Treatment probably
won't become available until April.
But aside from the drug supply, Dr. Conradie doesn't think the
situation is so bleak. "We have been gearing up our system for the
roll-outs interacting with people in the national government who
are quite actively working on the implementation of the plan."
It should be noted that Dr. Conradie works at what could be
considered a flagship site [Helen Joseph Hospital]. Still other
South African clinicians contacted concur that they are working
closely with the Department of Health on improving infrastructure
for the rollout. However, one of these, a HATIP panel member who
wishes to remain anonymous, said that parts of the Department of
Health "seem to be in complete disarray and the right hand often
doesn't know what the left is doing."
Given the grand scale of the treatment programme and the effort
needed to coordinate its implementation, a slow start is perhaps to
be expected. But is this merely a slow start, or the first of many
such delays? It is very difficult to say, because of one central
problem: a lack of communication between the government and the HIV
community.
Storm Brewing
Frustration is building amongst those who actively want to work
with government to secure the implementation of the plan.
* Communication Breakdown.
TAC complains that the operational plan commits to communication of
its details, but this hasn't happened. Perhaps the government felt
that posting most of the operational plan and other materials
online on November 19 fulfilled that commitment. However, there has
been no further communication about the operational plan since that
day. ...
* The community has already become disillusioned.
Virtually the day after the operational plan's approval, TAC had
mobilised to do its part. They began marshalling community-based
organisations and other non-governmental organisations to fight
stigma, encourage voluntary testing, scale up treatment education,
home-based care and other related activities. They believed that
the government was acting in good faith and that there would be a
new era of cooperation between TAC and the national government. TAC
offered an olive branch but has been rebuffed. Now the organisation
demands to know what is going on.
* Funds have not been allocated.
According to a recent TAC National Executive Committee report, only
R90 million of the R296 million requested by the operational plan
for the fiscal year ending March 2004 has been allocated. None of
that appears to have been disbursed to the provinces. ...
* Site accreditation problems.
TAC also feels that the accreditation process for service points in
the operational plan "is unduly onerous and the NEC was reliably
informed that sites that were accredited by the operational plan
task team are being re-evaluated for accreditation." Is the goal to
accredit or discredit sites? What is the national government doing
to help these sites become accredited? ...
* Who is training the healthcare workers?
Around the country various groups have or are developing training
programmes locally. In the strategic management chapter of the
plan, the responsibility for training seems to be delegated to the
provinces. But there have been no appropriated funds disbursed for
this purpose, which is crucial if the treatment programme is ever
going to provide care to people with HIV outside of a few flagship
sites in the nation. ...
* Accountability
All too often secrecy is simply a fear of public accountability.
Conspicuously, a crucial piece of the operational plan has still
not been released to the public: Annex A. This document details the
implementation schedule and week-to-week tasks required to
implement the treatment program. TAC is calling on the government
to make Annex A public. ...
* Who is driving the process? Where is the leadership?
The operational plan is well designed and doubtless there are many
in government working hard to make it happen. But as the task force
acknowledged, its implementation can be delayed or undermined if
even one strategic manager does not do his or her essential task in
a timely manner. Openness or strict oversight by a strong manager
or leader who is committed to the programme could prevent such
delays and help drive the process. But who is leading the charge
for the South African treatment rollout? Who in the government is
committed put and keep the plan in motion? ,,,
AfricaFocus Bulletin is an independent electronic publication
providing reposted commentary and analysis on African issues, with
a particular focus on U.S. and international policies. AfricaFocus
Bulletin is edited by William Minter.
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