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For the past six weeks, health officials and specialist advisors have been working late into the night to meet Tuesday's (30 Sept) deadline set by Cabinet to come up with a "detailed operational plan on an anti-retroviral treatment programme".
"It is as if we have finally woken up to the fact that we are in an emergency. People are working as if we are a country at war," says a source close to the process.
While cynics say the urgency is being fed by the 2004 general election, few in the HIV/AIDS field doubt that South Africa has reached the point of no return on the provision of ARV drugs.
The Cabinet-driven programme has the potential to commute the death sentences of approximately 1,2 million South Africans expected to develop AIDS over the next seven years, and prevent 860 000 children from becoming orphans.
It also has the potential to revitalise our health system and restore the morale of health workers.
But if it is not implemented properly first time it will result in drug-resistant HIV, which will effectively render useless the only weapon the world has to fight the virus: anti-retroviral drugs.
A government-appointed task team headed by the Medical Research Council's Dr Tony Mbewu has been driving the process, assisted by experts from the Clinton Foundation.
It has been a difficult time for the health department. Its director general, Dr Ayanda Ntsaluba, left at the end of August while its HIV/AIDS head, Dr Nono Simelela, has been hospitalised twice recently.
But, says Mbewu, "everything is on track" for Cabinet to get the final report on the operational plan on Tuesday (30 September). Cabinet is likely to take at least a week to respond to the report before it becomes public.
Treatment Action Campaign (TAC) secretary Mark Heywood says there is a "seriousness within the task team, which is being thorough in its approach". TAC has made a submission to the team and is also helping some of the provinces.
Aside from assisting provinces with their rollout plans, the task team has been looking at staff capacity and training, laboratory services and drug procurement. It has met a number of drug companies, including Cipla, the Indian generic ARV manufacturer reputed to make the cheapest ARVs in the world.
For once, there is significant financial backing for the rollout. Aside from R4-billion set aside for HIV expenditure in the provinces, Treasury has made available a conditional grant of R210-million for this financial year alone. A lot more money is expected soon.
The beauty of conditional grants is that they are earmarked for specific things and allow national government to inspect provincial operations to make sure the money is being spent where it is supposed to.
Thus, the task team has been able to parachute a team into Mpumalanga to assit with preparations for the rollout. This is something national government has been unable to do in the past, despite the fact that the province's HIV/AIDS programme was virtually destroyed under former health MEC Sibongile Manana.
While provinces have been able to select their own facilities, they have had to ensure that these offer citizens "equitable access" to ARVs - in other words, in both rural and urban areas.
As a result, most provinces have centred their rollout plans on district hospitals. The general consensus is that doctors should be responsible for prescribing the antiretroviral drugs. However, nurses will need to play a significant role in both the assessment and ongoing management of the patients on treatment.
Realistically, the ARV programme may well only start properly in the new year when facilities have been prepared, staff have been trained and patients are not likely to disappear over Christmas. However, Heywood says sites that are ready should begin in November as "any delays will kill people".
For government's Nono Simelela, the biggest challenges of the rollout are "staff training, proper infrastructure and ensuring community understanding of how to take ARVs".
There are plans to set up provincial HIV/AIDS centres to train health workers. Doctors with little practical experience of HIV/AIDS may also get support via phone and email from HIV experts, to deal with drug side-effects and the many complications that come with treating people with very weak immune systems.
According to a Treasury-Health department report, by 2010 it will cost between R16,9-billion and R21,4-billion, depending on drug prices, to treat all AIDS patients.
Generic medicine can reduce costs massively. While government's best estimate of drug costs is R7 611 per patient a year for a combination of the drugs 3TC, d4T and nevirapine, the newly formed Generic Antiretroviral Procurement Project says it can treat people for R2 460 a year using generic versions of the same drugs.
While foreign donor support is available at present, University of Cape Town economist Professor Nicoli Nattrass says the necessary finances could also be raised by increasing valued-added tax (VAT) by between three and seven percent.
However, it is unlikely that 100% of those who need treatment will seek it. In Botswana, for example, only 7 000 of the estimated 110 000 eligible patients are on ARV treatment. While AIDS stigma is one barrier, some say Botswana spent too little time raising public awareness about treatment before offering the drugs.
If South Africa's programme is to succeed, money will have to go into improving infrastructure to ensure that drug supplies are stable and that here is adequate laboratory support necessary for tests to monitor immunity in the blood (CD4 counts) and viral loads. Extra staff will be needed and current staff will need training. These measures will benefit all South Africans using public health.
Health workers' morale will be boosted as they will no longer be helpless when faced with destitute AIDS patients.
"This is a once in a lifetime opportunity," says Dr Douglas Wilson, medical specialist at Greys Hospital in Pietermaritzburg. "What is happening in South Africa has never happened anywhere else in the world. In the future, health workers should look back on this rollout as the highlight of their professional careers,"
Wilson, who has treated AIDS patients at Somerset Hospital in the Western Cape over a number of years, says "you can get addicted to watching the progress of your patients on ARVs, as they put on weight and go back to leading normal lives".
A Nigerian study of 74 patients starting ARVs found that they gained an average of 12kgs in 24 weeks.
In May and June, I spent six weeks with a group of women preparing to go on ARVs at iThemba Clinic in Mariannhill outside Durban. At the beginning of the six-week treatment training course, most were thin and constantly shivering. Every week, at least one of the 10 women had been hospitalised.
The transformation in the women after a few weeks on treatment has been remarkable, both in terms of weight gain and improved health as well as a sense of psychological well-being as they have been freed from the burden of staring death in the face.
As ARVs boost people's immunity, making them less prone to infections, health workers will have to treat less AIDS patients. This will make more room for non-AIDS patients, particularly the elderly and children who have been "crowded out" by AIDS patients, according to a recent study by the Human Sciences Research Council (HSRC).
But at the same time, there are immense dangers. If the programme is not properly implemented, it could result in multi-drug resistant HIV that will not respond to any known ARV drugs.
The success of the programme relies on enrolled patients taking their drugs properly and at the same time every day 95% of the time. Proper patient adherence relies on a number of things, including adequate support from their families.
The country's longest running ARV programme, the Medicins sans Frontieres' Khayelitsha programme, will not give drugs to people who have not disclosed their HIV status to at least one member of their household.
"Disclosure lightens the psychic burden. Often people don't have the mental energy to tackle adherence if they are trying to deal with the knowledge of their HIV status on their own," says Wilson.
However, government will not be able to impose such a condition. According to former director general of health, Dr Ayanda Ntsaluba, lawyers have told the department that people will only be allowed to be excluded for "factors within their control, such as drug and alcohol abuse".
Drug resistance is already a problem in countries that have had ARV treatment for some time. In July this year, researchers at the Paris HIV Pathogenesis Conference reported on a study of 1 600 people from 17 European countries. All were newly diagnosed with HIV and had never taken ARVs, yet 10% had strains of HIV that were already resistant to ARVs. This suggests that they were infected with drug-resistant HIV from people who had not been taking their ARVs properly, thus causing their virus to become resistant.
This chilling report underscores the importance of treatment needing to go hand-in-hand with prevention efforts. South Africa cannot afford to divert resources from prevention to pay for treatment. One effort cannot succeed without the other.
Successful ARV programmes also rely on a contract between health providers and patients, says Wilson. "Patients have to be empowered to take their medication. They have to understand what they are doing as they have to do it for the rest of their lives," he says.
At iThemba clinic, trainer Zinhle Thabete tells potential patients: "I never want to hear you talking about 'those little yellow pillies'. You need to know the names of your drugs and what their side effects can be. You also need to have a treatment plan and know exactly when you are going to take the drugs."
Wilson smiles when I ask about the challenges that lie ahead: "A Chinese saying keeps going through my head," he says. "The gods grant the wishes of those it wants to punish!"
This article is courtesy of Health-e News Service.
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