Successes Show It's Not All Bad News

Cape Times (South Africa), October 29, 2007 | Go to article overview

Successes Show It's Not All Bad News


BYLINE: Liz McGregor

One of the ironies of the acrimony and divisiveness of the HIV/Aids debate in South Africa is that, in spite of everything, we have managed to come up with a remarkably successful treatment programme.

By the end of the year, 300 000 people with HIV will be on anti-retroviral treatment (ART) in the public sector, and more than 100 000 in the private sector. This is an extraordinary figure. South Africa has arguably more people being treated effectively for HIV/Aids than any other country in the world.

But, as was pointed out repeatedly at a conference on health systems and anti-retroviral access in Bloemfontein last week, the need for treatment remains voracious.

The meeting was convened by the Centre for Health Policy at the University of the Witwatersrand, the Infectious Disease Epidemiology Unit at the University of Cape Town, and the Centre for Health Systems Research at the University of the Free State. Researchers and health practitioners from around the country gathered to assess the state of the war against Aids.

The conclusion was that prevention strategies were in a dismal state, but treatment was much more promising. However, a radical shift in process was needed if targets were to be met.

Only about 20% of people who need ART get it. The target set by the government when it introduced its policy of universal access to ART in 2004 was 80%. Every year, about 500 000 more people need ART because their CD4 counts drop to below 200, which means their immune systems have become dangerously compromised and they are vulnerable to infection and likely to die from the next one that comes along.

The treasury and international donors have pumped billions of rands into the ART programme. There are 313 sites in the country dispensing ART, each equipped with dedicated doctors, nurses, pharmacists, counsellors and dieticians.

The feeling now is that such specialised units are no longer necessary or desirable. They leach resources from the rest of the health system and are too cumbersome to process patients swiftly and efficiently.

Nor does a developing country such as ours have enough professionals to meet the need. In some areas, three-quarters of patients are dying while languishing on waiting lists that are several months long.

There are huge differences between provinces: the Western Cape has a much better record than just about anyone else - shorter waiting times, better record-keeping and monitoring, and better patient adherence to treatment. However, there are patches of brilliance in the most unexpected places, where the 80% target has been not only met, but surpassed.

If every province is to meet this target, nurses will have to be given the power to prescribe and dispense ART. Community care workers will have to be drawn in to provide counselling and administrative support.

Treatment will have to be decentralised from hospitals to districts and primary healthcare clinics. HIV should no longer be seen as a special case, but integrated into care for other diseases such as TB. The overlap between the two is huge, with about 60% of TB patients being HIV positive. Integrating treatment seems a logical step.

Aids, like diabetes and hypertension, could also be treated alongside other chronic diseases. Nurses already play a major role here. But there are differences, and what emerged from last week's assessment of our headlong rush into treatment is that there are some areas that need closer examination.

Chief among these is a category known by the poignant phrase "lost to follow-up". These are the patients who have been put on ART and then suddenly stop coming to collect their drugs. They could have died; they could have moved away; they could have simply stopped taking the drugs. …

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