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South Africa: AIDS Treatment Update
AfricaFocus Bulletin
Aug 9, 2004 (040809)
(Reposted from sources cited below)
Editor's Note
"Not more than 10,000 people are receiving anti-retroviral
treatment in South Africa at public health facilities. Of these,
many are funded by donor agencies. At this rate, the Plan will fall
far short of the target announced by President Mbeki of 53,000
people on treatment by March 31, 2005. a target that is already
more than 100,000 people less than that proposed in the Plan." -
Treatment Action Campaign
Almost nine months after the South African Cabinet adopted a long-delayed
plan for urgent rollout of anti-retroviral treatment (see
http://www.africafocus.org/docs03/tac0311.php), the Treatment
Action Campaign reports, substantial efforts are being made to
implement the plan in several provinces and many districts.
Overall, however, the effort still suffers from ambivalent national
leadership and lack of human resources for implementation.
This AfricaFocus Bulletin contains brief excerpts from two
documents. One is the report from the Treatment Action Campaign on
implementation of the government's plan for AIDS treatment, with
estimates by province comparing the targets and the number of
people now being treated. The other is a reflective analysis of the
current status of the issue, by Mandisa Mbali, a researcher at the
Centre for Civil Society in Natal who is also a TAC activist. The
full versions of both documents and much additional information are
available on the websites of TAC (http://www.tac.org.za)
and CCS (http://www.ukzn.ac.za/ccs).
For earlier AfricaFocus Bulletins on related subjects, see
http://www.africafocus.org/healthexp.php
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"Our People Are Suffering, We Need Treatment" (Health Care Worker
in the Eastern Cape)
Treatment Action Campaign (TAC) & AIDS Law Project (ALP)
Updated First Report on the Implementation of the Operational Plan
for Comprehensive HIV/AIDS Care, Management and Treatment for South
Africa (Operational Plan)
July 2004
[Excerpts: full report available at:
http://www.tac.org.za/Documents/ARVRollout/FinalFirstARVRolloutReport.pdf
]
... The purpose of this report is not to attack the commitment of
health care workers who are trying to make the ARV programme a
success; instead the report is a necessary tool to monitor the
efficacy of the programme, to share information and to make
government accountable to the people who will most benefit from the
Operational Plan. Of course, the process of information gathering
is on going. ...If you or your organisation would like to add to or
correct information in this report please contact: Ayanda Bekwa
(011 717 8600 or bekwaa@law.wits.ac.za) Fatima Hassan (083 279 9962
or fatima@tac.org.za)
Compiled by Fatima Hassan
Law & Treatment Access Unit, AIDS Law Project.
With contributions from TAC provincial offices, health-care workers
and several provincial health departments.
Executive Summary
This report shows that substantial effort is being directed at
implementing the Operational plan at district and provincial level.
However, this effort is not being matched with the degree of
prioritisation and political commitment to this service that is
necessary at a national level. This is making it more difficult for
provinces to overcome many of the difficulties that they encounter
in speedily implementing the Operational Plan.
Communication about and popularisation of the plan is also
extremely weak in most provinces. ...While lists of some accredited
sites are made available to internet users and the media, the list
and contact details of actual sites that are providing treatment
are not being made available to ordinary people who have some
access to radio, television and/or newspapers. Provinces such as
Gauteng, KZN, FS and the WC are examples of how public media should
be used, but the same level of information dissemination is also
needed in other provinces. ,,,
The failure to provide national leadership is widening the gap
between resourced and underresourced provinces . in particular
assistance and instruction is needed in provinces such as the
Eastern Cape and Limpopo. ... One particular concern is that
although hospitals and clinics are coming under pressure to start
to provide a treatment service, they are not getting the additional
capital or human resources that the plan promises. ...
Waiting lists at Johannesburg's hospitals already run into 2005 -
many patients will die waiting for an appointment. ...
Finally, there are clear problems with drug supplies. Accredited
sites that have capacity are holding back because they cannot
guarantee drugs to patients. This too is a management and
monitoring issue.
The updated report estimates reflect that not more than 10,000
people (the figure is closer to 6,000) are receiving ARV treatment
in SA at public health facilities. Of these, many are funded by
donor agencies. At this rate, the Plan will fall far short of the
target announced by President Mbeki of 53,000 people on treatment
by March 31, 2005 - a target that is already more than 100,000
people less than that proposed in the Plan.
So, despite the best efforts of health care workers, political
prevarication and weak management continue to deny many people
access to health services that would save their lives. Despite the
attack by the Minister regarding TAC's ability to report
objectively about the rollout, and despite some provinces accusing
TAC of misleading the public, we are satisfied that the updated
report confirms that not even 10 000 patients are receiving ARV
treatment in public facilities across South Africa.
Below is a table that summarises the comparison between national
targets as they appear in the Operational Plan and estimates of
patients on ARV treatment as at 20 July 2004.
B. Comparison of National Targets V Actual Number of Patients
Receiving Arv Medicines
| Province |
Operational Plan
March 2004 target
(Revised for 2005) |
Numbers on treatment (Adults and children) |
| Gauteng |
10,000 |
2,300 (Adults 1924) (Children 416) |
| North West |
1,808 |
130 (Adults 130) (Children -) |
| Northern Cape |
790 |
(capacity July-September 600) (Adults 51) (Children -)
Possibly < 100 |
| Eastern Cape |
2,750 |
298 (Adults 287) [227 MSF, 60 Province] (Children 11) [11
MSF] |
| Western Cape |
2728 |
May 2004 3059 (Adults 2256) [537 Province 1719 Donor]
(Children 803) [304 Province 499 Donor] (Inc.MSF, ARK, Tshepeng
Trust, donor funded)
20 July 2004 3750 patients
|
| KZN |
24,902 |
120 Possibly max. 250 |
| Limpopo |
6965 |
Do not know Does not appear to have started dispensing
ARVs |
| Mpumalanga |
1934 |
51 Possibly <100 |
| Free State |
Target: 2127 |
Current: Not > 50 (capacity next 2 months 90) [*SACBC 100 patients
at 3 sites per year- pending] |
| TOTAL |
Target: 54,004 (53 000) |
Current: <10 000 (close to 6000) |
"Iphi i-treatment? Where is the Treatment?": Reflections on the
Treatment Action Campaign (TAC) People's Health Summit
by Mandisa Mbali
Mandisa Mbali is a Research Fellow at the Centre for Civil Society,
University of KwaZulu-Natal. She has written this piece in her
personal capacity.
[Excerpts: full report available at:
http://www.ukzn.ac.za/ccs/default.asp?2,40,5,435]
Introduction: Where is TAC headed?
In late 2003, largely as a result of pressure exerted by TAC, the
government formally committed itself to rolling out HIV treatment.
This policy shift has posed several questions related to TAC's
interim and long term political future, given the reality of the
roll-out. Will the 'centre fail to hold' as factions emerged in the
politically 'broad umbrella' social movement that is TAC? Will it
simply become a service-delivery focused NGO working for the
Department of Health? Will the government's commitment to HIV
treatment policy reform lead to TAC's co-option? Will it render
itself obsolete through its own success lobbying for wider HIV
treatment access?
Now that the roll-out is a reality, one cannot fail to be struck by
the immensity of the challenges it poses: thousands of health
workers need to be trained in managing patients with
anti-retrovirals; communities and patients need to be informed
about and mobilised around the issue of adherence to HIV treatment;
a consistent drug supply needs to be secured; systems have to be
set in place to get blood samples to laboratories and results back
to roll-out sites on time. Even if one recognises these challenges,
it hard not to feel increasingly frustrated with the roll-out's
pace and the seeming lack of political leadership and transparency
on its progress exhibited by national and provincial governments.
The reality is that in KZN, where hundreds of thousands of patients
are in desperate need of treatment, only two hundred patients are
receiving treatment as a part of the public sector roll-out. Even
Gauteng, where five times the number of patients are receiving
treatment as a part of the roll-out, has public sector roll-out
sites where waiting lists for treatment extend into 2005. However,
measuring the success of the roll-out is not merely a numbers game,
as there appears to be a lack of political will to ensure the
success of the roll-out at the highest levels of national
government.
In the context of the roll-out's slow progress, I attended TAC's
People's Health Summit in East London from 2-4 July, as a
representative of the University of KwaZulu-Natal's TAC branch.
This paper contains my reflections on that summit and what
political future TAC may have, given the government's commitment to
roll out HIV treatment.
There are three main impressions I gained from the summit as a
researcher of TAC and a member of the organisation.
- Firstly, the summit marked a subtle, but strategic, shift in
TAC's emphasis: it positioned itself as a movement advocating for
wider HIV treatment access as a part of a broader campaign for the
strengthening of the public health system. In reality, TAC never
really was the 'single issue movement' which some critics have
claimed it was: lobbying for wider HIV treatment access has always
implied a bigger vision of claiming the right to access to health
for all, at very least this has been the case since the period of
the Consitutional Court challenge on the Prevention of Mother to
Child Transmission (PMTCT):
- Secondly, TAC has never been stronger politically: it has more
branches than before, all of whom seem to be deeply committed to
the organisation's aim of campaigning for wider HIV treatment
access. TAC encompasses activists from a variety of civil society
organisations, classes, genders and sexual orientations and
activists from across the left-wing ideological spectrum. However,
a unifying factor remains, which is the overarching aim of ensuring
the success of the roll-out by holding government to commitments it
has made.
- Thirdly as discussed above, the antiretroviral roll-out has been
woefully slow, in a large part, due to the lack of political
commitment to the roll-out from the highest levels of the
government. This has generated anger and frustration among ordinary
TAC members who find that far too little is being done to alleviate
the status quo of needless deaths of members of their support
groups, family members and communities.
TAC has a treatment project which provides treatment for hundreds
of its members and collaborative projects with MSF providing
treatment to hundreds of community members in Khayalitsha and
Lusikisiki (an area facing grinding poverty in the rural Eastern
Cape). This has clearly shown ordinary TAC members across the
country the benefits of HIV treatment. In the summit some of these
members proudly carried their pill boxes around and were happy to
discuss in plenary sessions their personal experiences of
treatment's benefits such as: dramatic weight gain, added energy
and surges in their CD 4 counts (a type of immune cell that HIV
attacks, which can be measured to show whether someone needs AIDS
treatment). Their personal experiences of the startling benefits of
HIV treatment have only heightened their frustration that the
government is not providing HIV treatment to everyone else who
needs it.
...
Before discussing each of these three key impressions I gained from
the summit on future trends in TAC it may be worth providing a
brief overview of the history of TAC.
A brief history of TAC
TAC was founded in 1998 to push for wider HIV treatment access and
in memoriam of anti-apartheid, gay rights and AIDS activist Simon
Nkoli. One of TAC's major strategies has been to urge people living
with HIV/AIDS to be open about their status in order to push for
access to HIV treatment. The movement has always battled against
two major foes: the pharmaceutical industry's abuse of patent
monopolies on anti-retroviral drugs and government AIDS denialism.
TAC has had several major successes in its brief history. In 2001
it forced multinational pharmaceutical companies to drop their case
against the government's Medicines Act which allowed for production
and importation of cheaper generic antiretroviral drugs. TAC's
pressure for generics has led to a major reduction in the price of
HIV treatment: combination anti-retroviral therapy cost over four
thousand rand a month when TAC began its campaign, whereas today
such combinations begin at three to six hundred rand per month.
In the same year, it forced the government to expand provision of
the drug Nevirapine (which can cut the risk of mother to child
transmission by half) to all antenatal sites in South Africa, by
obtaining a Constitutional court ruling. This ruling has been
international celebrated as it confirmed the right to access to
Health care enshrined in South Africa's Bill of Rights. (2)
In 2002, it tried to obtain an agreement on a comprehensive plan
for HIV treatment and prevention at the National Economic
Development and Labour Council (NEDLAC). When these negotiations
collapsed in early 2003, due to government intransigence (linked to
government denialism), TAC embarked on a civil disobedience
campaign.
Finally in August 2003, following the first South African National
AIDS Conference held in Durban, Cabinet instructed the ministry of
Health to develop a comprehensive HIV/AIDS treatment and prevention
plan. As a result of pressure from TAC, the Department of Health
produced Operational Plan for Comprehensive HIV and Aids Care,
Management and Treatment for South Africa (hereafter referred to as
the 'roll-out plan'). The South African government finally
committed itself to rolling out comprehensive HIV treatment. Since
the government committed itself to rolling out HIV treatment, it
has been interesting to reflect on what TAC's role in the roll-out
would be and what it would mean for the future of movement. It is
clear that TAC organised the summit to begin the work of figuring
out its future political directions following the roll-out.
Building a house on sand: The need for public health reform and the
roll-out
The summit was not only convened to discuss the shortcomings of the
roll-out in a narrow sense. As Olive Shisana argued in a plenary
address, the roll-out must be used to strengthen the public health
system. Similary, the health system must be strengthened in order
to ensure the long-term success of the roll-out. AIDS
simultaneously deepens and draws attention to the crisis in the
public health sector. To paraphrase the parable, you can't build
the house of a sustainable and successful roll-out on the quick
sand of a public health system in crisis.
Achmat gave an eloquent address in the opening session, which
outlined the legacy of apartheid's production of racial
inequalities in access to health care and health status. The crisis
in the health system can be largely explained in terms of the
following statistic 50% of health spending in South Africa is in
the private sector largely serving the 16% of the population
privileged to have medical aid, whereas over 80% rely on the public
health sector. This statistic was represented in the poster
advertising the summit which showed photographs of a packed waiting
room in a run down public sector facility and an almost empty,
luxurious hotel-like, private sector facility's waiting room. The
overarching call was to reduce the inequalities between the public
and private sectors and for there to be a reallocation of resources
from the private to the public sector. On the other hand, as I have
mentioned above, there was a diversity of opinions on how to
address this crisis. ...
Many other, related problems facing the public health sector were
also highlighted in an explosive report on the state of public
sector health service delivery in the Eastern Cape formulated by
the Public Service Accountability Monitor. Delegates heard research
claiming that the provincial department of health had not properly
accounted for hundreds of millions of rands of its health and AIDS
budgets. The PSAM cited government reports alleging mismanaged,
unhygienic mortuaries and ambulances which arrived hours late, some
of which had been privatised. This resonated with ordinary
activists' experiences of staff shortages in rural clinics, so
severe that in some cases only one nurse single-handedly ran a
whole clinic. This lead to lengthy queues and occasionally, at
times when the few staff went on leave, a total interruption of
clinics' services.
The Eastern Cape MEC for Health, (Monwabisi Goqwana) who was
invited to address the opening session of the Summit, eventually
only arrived on the final day. When he arrived a fascinating debate
ensued between him and Colm Allen (of the PSAM). The MEC denounced
the PSAM research as a 'pack of lies' and celebrated the
'achievements' of the Eastern Cape government in delivering health
care including purchasing two helicopters to medically evacuate
patients when required. At the end of his speech TAC activists
spontaneously burst into song and began toyi-toyi-ing asking the
Minister Iphi i-treatment (where's the treatment).
Indeed, TAC spokesperson Sipho Mthathi expressed the sentiments of
many TAC activists when she asked the MEC to devote an equal amount
to implementing the rollout as he has to implementing legislation
to ensure safe male circumcision (a practice common among
Xhosa-speaking people in the Eastern Cape). His pet project of
purchasing two helicopters was out of touch when there was
inadequate basic ambulance coverage of most of the province.
Mthathi also asked the MEC to apologise for telling people in
Lusikisiki "Not to listen to white people" who promoted 'toxic'
drugs. ...
Deadly delays and 'business as usual' in the roll-out
TAC is even stronger since the roll-out, which was not necessarily
a given in August 2003. Reform can either co-opt opposition, or, if
it is cosmetic or half-baked, it can show the power of resistance
and make people even more militant in pushing for the realisation
of all of their demands. TAC's review of the roll-out presented at
the summit argued that government was not treating the roll-out as
an emergency. ...
Indeed, in the case of the roll-out, I would argue the second
scenario of incomplete reform increasing resistance may be
materialising. As TAC's reports on the roll-out show, government is
far from on track with reaching its own target to treat fifty
thousand people by the end of March 2004, TAC estimates that it was
only treating ten thousand people by the end of June 2004
(including just over one thousand people on HIV treatment at the
TAC/MSF clinics). President Mbeki recently announced that there
will be a one year delay in meeting initial targets. This is a
deadly delay, which has resulted in the waiting list extending into
2005 at some Gauteng roll-out sites. One wonders how long
desperately ill patients will have to wait in other provinces such
as KwaZulu-Natal. TAC estimates that only two hundred people are
being treated of just under twenty five thousand stated in the
KwaZulu-Natal provincial government's targets. The deadly wait may
be even longer in provinces such as Limpopo, where TAC has received
no evidence that anyone has begun treatment.
Another delay earlier this year happened when TAC had to threaten
court action to push the government to procure drugs for the
rollout. TAC's review also argued that a Helpline set up to answer
questions about the roll-out was not giving accurate information
and government was not using mass media to its full potential to
publicise the roll-out and promote treatment literacy.
The most damning aspect of TAC's critique was that there had been
a lack of visible, unambiguous political leadership for the
roll-out from the highest levels of national government. ...
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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