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South Africa: AIDS Treatment Update
Jun 11, 2005 (050611)
(Reposted from sources cited below)
Despite good outcomes in many treatment centers, the message from
reports and demonstrators at the Second South African AIDS
Conference in Durban last week was that the government's 18-month-old
plan for AIDS treatment in the public sector is still falling
far short. Results are very uneven among provinces, few children
are receiving treatment, nutrition programs as well as
antiretroviral (ARV) drugs are failing to reach the majority of
those needing treatment, and there is still no plan to address the
critical shortage of medical personnel.
The Joint Civil Society Monitoring Forum presented its latest
report both in the official conference sessions and at a parallel
gathering hosted by the Treatment Action Campaign and Medecines
sans Frontieres. TAC called for a new commitment to bring
treatment to at least 200,000 of those in need by the end of 2006.
Currently, only about 45,000 people are receiving antiretroviral
treatment in the public sector. Among children, only about 3,000 of
the 60,000 estimated to need ARV treatment are currently receiving
This issue of AfricaFocus Bulletin contains a statement by TAC
presented to the conference and excerpts from the civil society
monitoring report. The full text of the monitoring report is
available in Word format on the TAC website at
For more reports on the conference, see the AF-AIDS listserv at
http://www.hdnet.org/e-forums3.asp and the UN's PlusNews
(http://www.plusnews.org). The official conference site is at
For earlier AfricaFocus Bulletins on health issues, see
++++++++++++++++++++++end editor's note+++++++++++++++++++++++
TAC Electronic Newsletter
9 June 2005
Treatment Action Campaign
Yesterday, over 1,500 people participated in the MSF/TAC meeting
at the 2nd South African AIDS Conference. It was followed by a
march to hand over a memorandum to the head of the AIDS
Conference, Professor Lynn Morris.
At the MSF/TAC meeting the following important documents were
released (now available on the TAC website,
Here is the memorandum that was handed over by the marchers:
Treat 200 000 Adults and children by 2006
Build a Better Public Health Care Service for All
End denial about the HIV/AIDS crisis
8 June 2005
Dear Professor Morris and delegates to the 2nd SA National AIDS
The TAC welcomes the holding of the second SA national AIDS
conference in Durban and the belated decision of the national
Ministry of Health to participate in the conference. We regret
that the high cost of conference registration makes it impossible
for most poor people and communities of people who are directly
affected by HIV to participate in its deliberations.
Nonetheless we recognise that this conference brings under one
roof many of our best researchers, health care workers and public
health officials and that it is an opportunity to reflect on what
has been done to control the HIV/AIDS epidemic and what still
needs to be done.
We salute the many doctors, nurses, government officials and
others whose efforts are beginning to improve the lives of some
people with HIV, particularly by extending access to
antiretroviral treatment to communities.
The conference also takes place at a critical time in this
epidemic: although the treatment plan has been in operation for
18 months, many more people are dying than receiving treatment;
tens of thousands of new HIV infections take place every year,
including of babies as a result of mother-to-child transmission
prevention. Basic medicine shortages continue.
We were angry and disappointed with the comments of Minister
Manto Thabalala Msimang to this conference yesterday. We found
them insulting to people with HIV.
In response to the Minister's refusal to discuss specific numbers
of people on antiretroviral therapy we say that is it specific
numbers of people who are dying of AIDS, each one a person, each
one adding to the numbers, and that is why we must count and
measure our response to this epidemic. As Statistics South Africa
has shown, by 2002 there were already 200,000 additional deaths
per annum, mainly due to HIV. These are the numbers against which
we should measure our progress - because each death is of a
person who had human rights in the new SA, a person to whom the
government had a duty. We offer our services to the department in
monitoring progress with numbers.
In response to the Minister's claim that she does not know what
is going on with the plan we attach to this Memorandum a short
report that we have compiled on the state of implementation of
the Comprehensive plan. It shows that:
- Nationally only about 45,000 people are receiving
antiretroviral treatment in the public sector.
- In some of the worst HIV affected Provinces, especially Limpopo
and Mpumalanga, barely a thousand people are receiving treatment.
- The Operational Plan's nutrition programme is not being rolled
out except at a few sites.
Scale up Antiretroviral Treatment now!
The experience of the plan so far confirms that antiretroviral
treatment saves lives. TAC is calling this conference to support
a national mobilisation to treat at least 200,000 adults and
children by 2006. This target is necessary and possible.
It can be found in the original targets provided in the Cabinet
approved Operational Plan. But achieving it needs political will,
combined with mass treatment literacy education and support to
our health care workers. Achieving it will turn the tide of this
We also draw your attention to other important matters:
- The national HIV prevention Plan (Strategic Plan) expires in
- As yet there is no plan and no evaluation of how to
massively improve HIV prevention in this country. We cannot have
"prevention, prevention, prevention" without a prevention Plan.
- Three years after the Constitutional Court order to provide
mother-to-child transmission prevention services there is little
reliable information from the department of health about the
extent of implementation. But many reports from people on the
ground show that the programme is very weak. We still have a duty
to save children's lives and it is critical that this programme
is made a priority and a success.
- Nutritional support is not being provided to most people with
HIV and others in need of it. We call for rapid steps to
implement and monitor nutritional support. The right to nutrition
is part of the right of access to health care services. In this
respect we call on the conference to insist on a rapid scientific
evaluation of some of the nutritional 'products' that claim to
have a particular benefit to people with HIV, including 'African
Solutions' that is being promoted by the Minister of Health. It
must also be stated clearly by the Minister that none of these
'solutions' are an alternative to antiretrovirals.
- Health care workers are bearing the brunt of care in this
epidemic, but South Africa still does not have a human resource
plan. We call for the urgent finalisation of the Plan and for a
programme to recruit and train new health care workers, draw back
health care workers who have resigned, improve conditions, amend
scopes of nursing practice, and restore dignity to this
In conclusion we wish to meet urgently with the Minister and
provincial officials to discuss how treating at least 200,000
people by 2006 can be achieved and how this can be used to
strengthen the health service for all people. Unfortunately
however the Minister still refuses to engage with the TAC. We ask
this conference to demand that such a meeting take place urgently
in a spirit of co-operation and common purpose.
We request that this Memorandum be made available to delegates
and read out at the start of the plenary on Friday June 10th
Linda Mafu (TAC National Organiser) and Nkosinathi Mthetwa (TAC
KZN Provincial Chairperson)
Aids Law Project (ALP)
Treatment Action Campaign (TAC)
'Let Them Eat Cake' - A Short Assessment of Provision of
Treatment and Care 18 Months after the Adoption of the
08 June 2005
Second Joint Report on the Implementation of the Operational Plan
for Comprehensive HIV and AIDS Care, Management and Treatment for
[Excerpts only. For full report see http://www.tac.org.za]
The first joint AIDS Law Project (ALP)/Treatment Action Campaign
(TAC) monitoring report on the implementation of the Operational
Plan was presented to the People's Health Summit (PHS) held in
East London in July 2004. Since then, the Joint Civil Society
Monitoring Forum (JCSMF) - consisting of more than 12 civil
society organisations, including the ALP and TAC - was formed. In
addition to its launch meeting in Polokwane, in September 2004,
the JCSMF has met on three separate occasions - in Bloemfontein,
Durban and Nelspruit. ...
This second joint ALP/TAC monitoring report considers the
implementation of the Operational Plan, some 18 months since its
adoption. It focuses on early reports of patient outcomes,
explains provincial variations in relation to patient numbers,
and addresses some of the key barriers in the way of speedier
implementation. Importantly, it is limited to the public sector.
Compiled by Fatima Hassan (email@example.com), Law &
Treatment Access Unit, ALP.
On 8 August 2003, South Africa's Cabinet made a commitment to
provide antiretroviral (ARV) treatment in the public health
sector. On 19 November 2003, little more than three months later,
government published the Operational Plan on Comprehensive HIV
and AIDS Care, Management and Treatment for South Africa (the
Operational Plan). ...
This report provides a preliminary review of whether some of the
key commitments made in the Operational Plan have been met, some
18 months after its adoption. Future reports will provide updates
about the extent to which ARV treatment is available in the
private sector. This report, which is limited to the public
health sector provision of treatment, focuses on certain key
[good outcomes in several sites; an update by province; and some
of the key barriers to implementation] ...
Good Outcomes of Treatment in the Public Sector
Several reports confirm good outcomes of ARV use in the public
health sector. They provide incontrovertible evidence that the
use of ARV medicines has saved the lives of thousands of people
living with HIV/AIDS. Below is a brief summary of key aspects of
some of the reports that were released prior to the 2nd South
African AIDS Conference.
- A study conducted in Cape Town found that people with a CD4
count of 200 or less who do not take ARV medicines have a 35%
chance of surviving three years, compared to an 80% chance of
survival for those taking ARV medicines.
- The results of a study of 262 children accessing ARV treatment
at Harriet Shezi Clinic at Chris Hani Baragwanath Hospital in
Soweto have recently been published. The vast majority of the
children are demonstrating excellent outcomes. Only two children
(0.76%) reportedly showed signs of toxicity: the treatment
regimen was altered for one and discontinued in the other.
Although 18 children (7%) died during the study, not a single
death was ARV-related. Instead, the deaths were reported to be
associated with disease progression - the children simply
accessed ARV treatment too late.
- Three clinics at the primary health care level in Khayelitsha
provide ARV treatment to nearly 2 000 adults and children. When
patients first started treatment, the average CD4 count was below
100 (i.e. advanced AIDS). After three years of ARV treatment,
four out of every five patients are still alive. Without ARVs,
half would have died within a year. Almost all deaths were due to
the advanced stage of the disease, with only four deaths being
ARV-related. In three years, only one in every ten patients has
had to change treatment regimens as a result of side effects.
- The Ndlovu HAART programme in Mpumalanga has reported a 100%
success rate with its prevention of mother-to-child transmission
of HIV (PMTCT) programme.
[more examples in full report]
National Patient Numbers and Provincial Variations
As at the end of March 2005, official government figures
indicated that at least 42 000 patients were accessing ARV
treatment in the public health sector. Of these, less than 4000
were children. The 3rd JCSMF meeting heard that most patients on
ARV treatment in the public sector are receiving care at academic
hospitals and the so-called "main sites", with very few patients
accessing ARV treatment at rural and remote sites. ...
Given the need, patient numbers in the public sector are
significantly lower than what the demand actually requires. ...In
comparison, the number of patients on ARV treatment in the
private sector (as of the end of March 2005) was between 50 000
and 60 000.
the situation varies from province to province, particularly in
relation to the pace of implementation:
- In particular, North West has in the last few months
dramatically increased its patient numbers. This has been
attributed to exemplary leadership and commitment shown by health
- But the North West is not just about patient numbers. It has
been particularly creative in the use of its available resources,
including human resources. For example, patients are prepared,
assessed and staged at wellness facilities prior to their first
visit at a designated treatment site. This has managed to
decongest the treatment sites, also ensuring that first visits
are much shorter and streamlined. In turn, this has reduced
waiting periods and waiting lists. Importantly, it has improved
the morale of health care workers and patients as the latter move
more speedily through the system.
- KZN may have (along with Gauteng) the most number of patients
on ARV treatment in the country. But the pace of the programme
and its reach is nevertheless cause for concern. Given the very
high HIV prevalence in KZN and the associated need for treatment,
it requires a dramatic injection of new patients into the ARV
programme, including children.
- Provinces such as the Northern Cape and Free State are more
cautious with implementation. As in most other provinces, very
few children are accessing ARV treatment in these two provinces.
However, both show that political leadership and the commitment
of health care workers are the crucial ingredients to successful
implementation. A positive factor is that both programmes are
administered with openness and transparency.
In provinces such as the Eastern Cape, Mpumalanga and Limpopo,
the situation is very different. Of significant concern is the
fact that they show very little improvement over the last year.
Several factors have been advanced to explain this:
- The JCSMF has repeatedly noted that the Eastern Cape health
department continues to under spend on its health budget. It has
placed a moratorium on new appointments, despite the public
health care sector being understaffed.
- Mpumalanga is struggling to meet the overwhelming demand for
treatment because it is under resourced and is in urgent need of
technical support from the national department of health.
- Limpopo is faring the worst:
- It was the last province to start treatment
- It has the lowest number of patients on ARV treatment
despite an overwhelming demand for treatment
- It only has a handful of children on treatment
- It has not accredited four essential treatment sites,
resulting in long waiting periods and lack of access to health
- It shows inexplicable contempt for civil society
- It refuses publicly to release information about its
Donors Supporting the Public Sector
Several donors partially or fully fund patients accessing ARV
treatment in the public sector and contribute towards the costs
of staff or medical equipment. For example, many provinces have
entered into partnerships with donors such as Medecins Sans
Frontieres (MSF), Absolute Return for Kids (ARK), One2One Kids,
Catholic Relief Services,10 the South African Medical Association
(SAMA) and the US President's Emergency Plan for AIDS Relief
(PEPFAR). Without this type of support, the public sector patient
figures would be even lower. Nevertheless, the long-term
sustainability of these partnerships must be monitored closely.
But the Western Cape example of a donor initially kick-starting
an ARV treatment programme that is - over time - taken over by
the province is a useful model.
Crisis in Human Resources for Health
The pace of implementation is being hampered by the lack of
trained doctors, nurses, pharmacists and other health care
providers. Attracting, retaining and training health care workers
remains a formidable challenge for the public health sector. But
without addressing the crisis in human resources for health (HRH)
- including poor working conditions, low salaries, concerns about
career pathing, the lack of incentives and the international
poaching of HRH - our health programmes will suffer. Without a
reasonable, flexible HRH Plan that addresses short, medium and
long term needs, the Operational Plan will continue to be
Government has a constitutional duty to develop such a plan. But
while the need to address the HRH crisis was identified as far
back as 1994, we are still without a plan some 11 years into our
Other Gaps with Implementation
It is widely accepted that poverty and the lack of food security
are major national challenges, and that there is a clear link
between employment, access to income and food and nutrition
In assessing the nutrition assistance programme, the 4th JCSMF
meeting noted anecdotal evidence indicating fragmentation and
unevenness, with the programme being beset by problems. At the
Harriet Shezi Clinic at Chris Hani Baragwanath Hospital, the
largest paediatric treatment site in the country, only 6% of
children who are on ARV treatment have access to nutritional
support - fortified maize meal and milk formula - through the
resident dietician. ...
Serious gaps in the nutrition programme at individual facility
level have arisen because of a shortage of social workers,
dieticians and nutritionists. The lack of proper guidelines,
inadequate supervision and poor resources has compounded the
In the first joint TAC/ALP report, we noted that the drug
procurement process had yet to be finalised, notwithstanding an
initial forecast made to Parliament by the national department in
February 2004 that the process would be completed by June 2004.
However the award of the drug tender was only announced on 2
March 2005, some 13 months after the drug procurement process
commenced and more than 16 months after the Operational Plan was
Table 4 below [in full report] looks at the following three
details in respect of each ARV medicine procured by the public
sector: tender award; registration and availability on the market
generally; and award of licences to generic companies. In light
of the public health need to ensure sustainability of supply
regarding ARV medicines, the table clearly shows that action
against various multinational companies is urgently required. ..
With this in mind, the TAC has already begun taking the necessary
legal steps to ensure that companies such as MSD and Abbott
Laboratories grant licences for the local production and/or
importation of generic versions of their patented medicines. To
this end, the TAC has also demanded that the Minister of Health
use her powers under the Patents Act to issue the compulsory
licences required. She has until 17 June 2005 to respond, failing
which the TAC will institute legal action based on her failure to
take reasonable measures to ensure access to a sustainable supply
of ARV medicines. ...
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