South Africa's ARV programme
The long-awaited announcement this month by the South African government that
it would introduce a publicly funded national HIV/AIDS treatment plan was
greeted with much celebration.
With an estimated five-million HIV-positive people, South Africa's treatment
programme will be the world's largest. But while activists have lobbied long and
hard for the rollout of a comprehensive HIV/AIDS initiative, health care
professionals warn that significant challenges remain over its implementation.
The total cost of providing the drugs to everybody needing them will be
between US $1 billion and $1.09 billion by 2005, according to the findings of a
joint health and treasury task team. Their report, on the costing of a national
treatment plan, led to the cabinet's decision on 8 August to go ahead with the
The task team estimated that 1.7 million lives could be saved by 2010 if
antiretroviral (ARV) drugs were given to everyone needing them. Up to 1.8
million more children would be orphaned by 2010 if ARVs were not provided. This
number would be reduced by 860,000 if there was 100 percent drug coverage, and
by 350,000 if there was 50 percent coverage, the report found.
An ARV rollout on the scale envisaged for South Africa has implications in
terms of both the expectations of HIV-positive people, and the impact on the
health care system and health professionals who will administer the programme.
The story of Mavis Mnisi is hidden away in the raw figures of HIV infection.
She had come to the Helen Josephs HIV/AIDS Clinic in Johannesburg last week to
seek treatment for the rash and sores around her mouth. A former domestic
worker, she was diagnosed as HIV-positive early last year and her employer
promised to pay for her ARV medication.
"I started taking the tablets and my boss was paying, but then she said
it was too much for her. Now I don't have a job and I don't have the tablets
because they are too expensive," she told IRIN.
Mnisi heard about the imminent rollout of the government's treatment
programme on the radio. "I went to the clinic and I asked when I could
start taking them, but they said it was still too early, the government was not
Since she was dismissed from her job, Mnisi has been unemployed and is living
with relatives, but is planning to move back to her home in a rural village in
the North West province.
With a CD4 cell (cells that orchestrate the body's immune response) count of
less than 200 - one of the criteria for ARV treatment - Mnisi has frequently
been ill and is too weak to work.
"I can't afford to live here [in Johannesburg] and I can't wait here
until they are ready," she said.
Mnisi is not alone. According to Sister Sue Roberts, head nurse at the
clinic, more than half the patients diagnosed as HIV positive should be on
treatment but are unable to buy the drugs themselves.
"We currently have about 100 patients on treatment, and this is paid for
employers or family members who club together," Roberts told IRIN.
The rest of the patients eligible for ARVs are "eagerly" waiting
for the government rollout, she said.
The government's task team had warned against "creating false
expectations" over an imminent ARV programme. But that is what the staff at
the Helen Joseph clinic have had to deal with since the cabinet announcement was
"People are so desperate, they just want to take the drugs. They don't
care about the information we try to give them. Now we have had to tell people
to be patient, and that this is not going to happen overnight," a
counsellor at the clinic said. "But it's difficult to tell this to people
who have lost hope and think this is the answer to their prayers."
Educating people about treatment was the only way to counter these
expectations, Sipho Mthati, treatment literacy coordinator for the AIDS lobby
group, Treatment Action Campaign (TAC), commented.
"There's no way around it, we have to have treatment literacy," she
said. TAC has been running a treatment literacy campaign focused on providing
information on HIV/AIDS, the treatment of opportunistic infections and an
understanding of ARVs in most of the provinces across the country, and hopes the
government will replicate their efforts when preparing to implement their own
Although Mnisi admitted that ARVs were not a cure for HIV/AIDS, she knew they
would make her "feel better" and enable her to start looking for a job
and help her relatives.
The Helen Josephs HIV/AIDS Clinic recently embarked on a wellness course for
1,000 patients, teaching them how to live positively with HIV/AIDS before
"We are definitely going to see a demand once they [ARVs] are rolled
out. People are becoming more literate about treatment, they come in and want
access to our services," Sister Roberts observed.
Impact on health-care staff
Strengthening the quality of care and training health care providers was
another recommendation in the task team report.
"All this talk about support and training for staff ... we don't have
time to get training. The [staff] shortages have to be addressed first,"
Roberts said. The clinic has three staff members and is supported by volunteer
staff. "We wouldn't be able to function without them," she added.
"The clinic already has a massive [work] load, it would be great to have
patients who don't require hospitalisation because they are on treatment. We all
feel so happy when someone manages to get on the medication. It gives us
[nursing staff] hope," she said.
Roberts acknowledged that the treatment plan would demand "a lot of
extra work" from nursing staff, but this was not an insurmountable
"We will just have to make more use of the volunteers - we have no
shortage of those. The most important implication for staff is the time spent
keeping accurate records of how people are coping on the drugs," she noted.
According to Roberts, the main challenge will be providing a
"guaranteed" supply of medicines - not just ARVs, but medication to
treat opportunistic infections as well. "We already have a problem with
supply - running out of these drugs will be senseless, if not dangerous."
The health and treasury departments also called for a "fast-track
process" of negotiation with suppliers to facilitate better access to ARVs.
Senior health department officials are currently preparing a
"detailed" operational plan for distributing the drugs.
Meanwhile, hospital ward staff are in no doubt about how the universal
provision of anti-AIDS drugs will benefit them. "When you see people dying
- people in your age group, your brothers and sisters, you will obviously have a
negative attitude. If there's nothing you can do for these people, how can you
cope? But if there's something you can do, at least you will be empowered to
work with patients," Roberts commented.
Counselling and testing
Makie Kunene, an HIV/AIDS counsellor at the Esselen Street clinic in downtown
Johannesburg, does not see the rollout of the treatment plan as "an instant
According to Kunene, an immediate challenge for counsellors will be turning
away HIV-positive patients. "There are about five million people living
with HIV/AIDS [in South Africa]. What are we going to do when everyone starts
rushing to clinics asking for the drugs?" she asked.
The "main thrust" of the drug programme should be the expansion of
voluntary testing and counselling (VCT) services. Up to 1,000 people are tested
at the clinic every month. "People are utilising VCT, a lot of people want
to know where they stand," she noted.
But counsellors would require additional training. The clinic currently
offers basic 15-day training courses for "mostly lay people and health
"We briefly touch on issues around treatment and the management of ARVs
- we will have to intensify this part of the course," Kunene added.
The programme's success would hinge on overcoming stigma and discrimination.
"People who work in town prefer to come here and not [to go] to their local
clinics. They still don't want people at home to know they're accessing these
services," she said.
Despite all these challenges, Kunene welcomed the move. "We used to
encourage people to come forward for testing, but we had nothing to offer them
when they were [HIV] positive. Informing people about a treatment option, which
is available when they reach a certain stage in the illness, will make a
Emmanuel Banda is a 22-year-old student volunteer counsellor who has been
training at the Helen Josephs clinic since May 2003. When asked how this would
change his life, he said: "It's going to be exciting ... the drugs will
help patients help themselves."
Mavis Mnisi is determined to return to Johannesburg when the drugs are
eventually administered in public hospitals and clinics - this time, hopefully,
she will continue her treatment without any interruptions.
"We've seen how well people do on treatment. We've seen them getting
back to work. They become empowered and they will now be able to get better,
with or without assistance from relatives and employers," Sister Roberts
TAC - who was involved in a bitter standoff with the government over its
delay in providing drugs - remains "cautiously optimistic".
"We need to see financial commitment from the government in the next two
months, clinics need to be identified by the end of September, so they can be
given the go-ahead to rollout in the first wave," TAC spokesman Nathan
Geffen told IRIN.
The group also faced a challenge of adapting their strategies to help develop
the treatment programme. "It's no longer about what the government can do,
but what we all can do to assist," he added.
This article courtesy of IRIN may not
necessarily reflect the views of the United Nations. Copyright (c) UN Office for
the Coordination of Humanitarian Affairs 2003.