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South Africa: AIDS Treatment Update

AfricaFocus Bulletin
Jun 11, 2005 (050611)
(Reposted from sources cited below)

Editor's Note

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 it.

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
http://www.tac.org.za/Documents/JCSMF/JCSMF-Report-8June2005.doc

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 http://www.sa-aidsconference.com

For earlier AfricaFocus Bulletins on health issues, see http://www.africafocus.org/healthexp.php

++++++++++++++++++++++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,
http://www.tac.org.za):

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 Conference

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 epidemic.

We also draw your attention to other important matters:

  1. The national HIV prevention Plan (Strategic Plan) expires in
  2. 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.
  3. 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.
  4. 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.
  5. 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 profession.

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 2005.

Yours sincerely

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 Operational Plan

08 June 2005

Second Joint Report on the Implementation of the Operational Plan for Comprehensive HIV and AIDS Care, Management and Treatment for South Africa

[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 (hassanf@law.wits.ac.za), Law & Treatment Access Unit, ALP.

Introduction

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 issues:

[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 care workers.
  • 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 services
    • It shows inexplicable contempt for civil society organisations
    • It refuses publicly to release information about its programme.

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 undermined.

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 democracy. ...

Other Gaps with Implementation

...

Nutrition

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 security. ...

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 problem. ...

Drug Procurement

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 adopted. ...

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. ...


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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