The country has made substantial progress in the fight against HIV, but there are still many holes in the system - particularly around TB treatment.
Sandile died a few weeks ago. Although he was on antiretroviral medication for HIV, he had started treatment late and his body could not rally the energy to fight the tuberculosis that preyed on his weak immune system.
It is shocking that a young, intelligent man like Sandile should die of HIV-related TB in 2012, when TB and ARV treatment is freely available and the government has ploughed massive resources into addressing these twin epidemics that feed off one another.
But Sandile slipped through one of the many holes that still exist in the health system. Like many people with HIV, his tuberculosis was not in his lungs so it did not show in the usual sputum (spit) test so it took a while to be diagnosed.
He attended a clinic in uMgungundlovu, the health district with the highest HIV rate in the country, where staff and resources are over-stretched. In addition, like many other South African men, he started his ARVs late, when his immune system was already weak and it was very hard to build it up again.
The government, under the energetic leadership of Health Minister Dr Aaron Motsoaledi, has made impressive progress in the fight against HIV/AIDS in the past few years guided by the aims of “Zero new infections, Zero deaths and Zero stigma”, the cornerstones of our National Strategic Plan for HIV, STIs and TB.
Unlike many other government programmes, progress can be directly counted in lives saved. About 100 000 fewer South Africans died of AIDS last year in comparison to 2005, according to the Joint UN Committee on AIDS (UNAIDS) 2012 World AIDS Day.
South Africa has also increased its scale up of HIV treatment by 75% in only two years, ensuring that 1.7 million people are now on ARVs, according to the UNAIDS report.
New HIV infections have also fallen by 41 percent in the past two years, meaning that some 50 000 fewer people have become infected with HIV. Health experts attribute this to massive progress in preventing mother-to-child HIV infection as well as “treatment as prevention”, namely that people on ARVs are unlikely to transmit HIV when their viral load is rendered undetectable by the medication.
The price tag for South Africa’s success has been in the region of US$ 1.6 billion, the highest expenditure of any low- and middle-income country and a fivefold increase since 2006.
While it is a relief that government is serious about moving to a point of zero new infections, trying to manage almost six million people with HIV is not easy – particularly when provincial governments are the implementing agents and many are dysfunctional and plagued by corruption.
There are many worrying reports of a number of clinics, particularly in the Eastern Cape and Gauteng, running out of medicine, including ARVs. A break in ARV treatment can cause the HI virus to mutate and become drug-resistant, meaning that patients will need other, more expensive drugs to keep HIV in check. This is entirely a health system failure that is beyond the control of patients.
However, the biggest gap in the fight against HIV is still in preventing new infections. While massive progress has been made in reducing the transmission of HIV from mothers to their babies (down from 8% to 3.5%), not enough is being done to prevent adults from infecting one another.
The reason adults do still infect one another is not usually out of malicious intent but ignorance. Unless there is mass, continuous HIV testing easily available to all, people will continue to be ignorant of their HIV status. In 2010, government launched a massive HIV testing campaign that reached an estimated 13 million people, but this has fizzled out in many provinces.
Medical male circumcision, which has the potential of reducing a man’s risk of getting HIV by 60%, is only really being pursued on a large scale in KwaZulu-Natal, and other high prevalence provinces such as the Free State and Mpumalanga should follow suit.
Adults living in informal settlements are the most vulnerable to HIV, according to a number of surveys. Priority should be given to providing free HIV testing in informal settlements and easier access to treatment.
In July, the US Food and Drug Authority approved a commercial HIV test that can be done at home using saliva. While the test costs around R250 commercially, it is something that should be considered here to maximize South African’s access to HIV tests.
Unfortunately, the money that international agencies have contributed to fighting against HIV is drying up – and one of the areas affected is prevention. Innovative media prevention campaigns, such as the television series Intersexions and the campaigns “Scrutinise” and Brothers for Life, supported by Johns Hopkins Health and Education SA (JHHESA) are to be affected when JHHSA’s grant from the US President’s Emergency Plan for AIDS Relief (Pepfar) ends next year.
Some of the most innovative and oldest HIV treatment and care programmes have closed, including HIV care for non-medical aids patients at McCord Hospital in Durban.
While there is general consensus that government can afford to cover ARV treatment for all citizens, government’s refusal to take over some of these facilities where the best-practice was forged, with highly experienced staff, seems short-sighted.
There are still many challenges ahead, and many cracks through which people like Sandile are going to fall in resource-stretched provinces. But there is a united front against HIV/AIDS with strong national government leadership, and that is a cause for celebration this AIDS Day.
Article courtesy of Health-e News Service.
The life expectancy of South Africans has increased by six years since 2009, but recent health gains could be lost if the management of services is not improved.
This is according to an expert panel’s review of the state of South Africa’s health, published today (30 November) in the prestigious The Lancet journal.
Co-author Professor Salim Abdool Karim described the 10 percent increase in life expectancy from the age of 54 to 60 in three short years as “absolutely stunning”.
The main reason for the dramatic increase in life expectancy has been the massive expansion of the country’s HIV treatment programme, now reaching around 1.8 million people.
“Three years ago, we had a doom-and-gloom situation where all our data showed we were moving in the wrong direction. This increase in life expectancy, in which each of the over fifty million people will live an extra six years on average, will be of amazing benefit to society,” said Professor Abdool Karim, vice-chancellor of the University of KwaZulu-Natal and head of the Centre for the AIDS Programme of Research in South Africa.
The same expert panel led a comprehensive examination of health care in South Africa in 2009, which was also published in The Lancet. It concluded that “leadership, accountability and investment” was needed to address “four colliding epidemics”: HIV and TB; chronic diseases, high maternal and child mortality, and violence and injury-related deaths.
Today’s review praises the “effective leadership” of Health Minister Dr Aaron Motsoaledi and his senior staff for “radical policy changes”, particularly in HIV management.
By 2010, virtually all pregnant women were tested for HIV and 85 percent of all health facilities provided prevention of mother-to-child HIV transmission programmes. This has led to a dramatic drop in babies being born with HIV, from some 30% ten years ago to a mere 2.7 percent last year.
But the review warns that the health bureaucracy has been “slow to change”. Abdool Karim said the country was at a “tipping point”, and that human resource weaknesses in the health sector could “make the country slide back from recent gains”.
“Reports of antiretroviral drug stock-outs in provinces are very concerning because they could lead to large numbers of patients stopping their medicines, resulting in drug-resistant HIV,” said Abdool Karim. “We have already walked that road with TB, where we have seen the emergence of extensively drug-resistant TB, which has a very high mortality rate.”
In 2010, the country had the third highest number of patients with multi-drug-resistant TB in the world (5 402 patients), according to the review.
While there has been little change in the death rate for chronic diseases, government had recently committed itself to new targets, including less salt and alcohol consumption, which should see a reduction in these deaths.
Homicides, traffic deaths and injury-related violence have all fallen in the past decade. But the review notes that there have been few “infrastructural responses to prioritise injury prevention issues such as inter-personal violence, violence against women and girls, male youth violence, child and youth safety and traffic safety”.
However, government is paying more attention to gun control, alcohol and drug abuse, which are significant factors in interpersonal violence and traffic accidents.
“Undeniably, much remains to be done to improve the health and living conditions of large sections of the population. However, for the first time in two decades, this progress instils a basis for hope,” said Professor Bongani Mayosi of the University of Cape Town, who headed the review group.
Other authors were Dr Joy Lawn, Dr Ashley van Niekerk, Dr Debbie Bradshaw and Professor Hoosen Coovadia.
This article is courtesy of Health-e News Service.
The annual World AIDS Day (WAD) has left me with mixed feelings for a number of years and continues to do so. My earliest memories of WAD make me think of the (somewhat clichéd) red ribbon, previously or possibly still regarded as a symbol of support, connectedness, a struggle, stigma, unity, fatigue or in some cases a tick on an annual ‘to do’ list. I can remember asking people on 2 December about the absence of their red ribbons and getting a range of evasive responses, if any at all.
I have been involved in the AIDS field for more than 15 years and WAD carries another association for me, over and above red ribbons. An annual frenzy, with an array of companies, NGOs and government departments all looking for speakers, teachers, condoms, mass testers, orphans, candles, and needless to say: masses of red ribbons. This frenzy normally ensues in the last week of November and sometimes continues until mid-morning on the 1st of December. The rest of the year none of this is required. Also for some time an associated frenzy was the number of companies phoning me to try and sell WAD ‘products’. An old favourite was the red ribbon banner that one could buy at a ‘bargain’ price to surround or wrap your organisation’s premises with, to show your ‘commitment’ and ‘care’ to your stakeholders.
While I might paint a bleak commercialised picture, it is not my intention. WAD can be a very personal experience, a day on which you may remember loved ones that one might have lost. It can also mean taking a breather for others as volunteers take some daily tasks and challenges off their hands. For organisations it could actually offer an opportunity do something meaningful as a symbol of their commitment. Support child headed households, or if you have the resources, have you considered truly investing in the young people heading those households and making bursaries available to them?
WAD is also an opportunity to celebrate our successes and I guess we should. I do want to challenge everyone however to look critically beyond the number of people tested, treated and even the amount of foreskins removed. Look beyond the goals and targets achieved and the stretched targets for the coming year and ask yourself: what does 1 December signify for a woman in an abusive relationship that continues to put her at risk of infection? What does it signify for a person of a sexual minority group not being able to access preventative or therapeutic services due to pervasive stigma and discrimination? Also ask yourself what am I (or what are we) doing on the other 364 days of the year?
World AIDS day has become more a celebration of life than a day spent grieving deceased loved ones. The reason for celebration is due to the advancement of modern medicine that allows HIV positive people to live longer, and communities have become more accepting and supportive of people living with HIV. HIV has created a platform for dialogues on societal challenges like human sexuality and poverty, among others. Even though we still have a long way to go, we are certainly in a much better place to cope with the disease and all other related medical and social ills it comes with. The day also facilitates a process of positive reflections of where we come from, where we are and where we are going. The reflection has become more positive, influencing future endeavours to deal with the disease.
When I think about world AIDS day, I realize there are things I have not thought about in a long time, including the fact that it is supposed to be a day of enlightenment; a day of commemoration as well as celebration. It is a day to celebrate the heroes that came in this new "struggle", as well as the advocates that have risen to champion the case of all South Africans.
We are meant to remember that we are all united under one cause, to eradicate HIV, but the bigger picture is that we are actually coming together to address society's deepest wounds: gender based violence, racism, inequality, unequal access to resources, poverty and maternal death rates. These things have all been highlighted greatly by the HIV epidemic.
In us coming together to find a cure, better treatments and a generally better standard of living for all, we've all had to learn difficult lessons. Life is not as beautiful as we wish it to be, human rights are not respected as they're supposed to be and treatment should not to be withheld or overlooked.
As much as there have been negatives around HIV there have also been many positives: greater openness in society in regards to sexuality; new policies to accommodate those who cannot access services; and less discrimination against those who were previously excluded from these services. Treatment standards have risen, mother to child transmission has significantly dropped, and prenatal care has been made a further priority.
World AIDS day can mean a lot of things, but it is no longer just a candle being lit to remember, but it is also a flame to push us forward.
In some ways it feels surreal to be writing this – it is over 30 years since I first started hearing about a new disease which seemed, then, to only be affecting gay men. Then there were stories about sex workers and drug users also getting ill. For Americans and Europeans it was not only a disease of the marginalised, it was also a disease of Africans from the “dark” continent. For many Africans it was a western disease imported from, or deliberately spread by, the United States or some other racist scientific clique. In short, it was a disease of someone else, not me, not us. When it became clearer that haemophiliacs who had blood transfusions were also getting HIV, and that mothers could pass the virus onto their babies, and that “faithful” wives could get infected by their “unfaithful” husbands (or vice versa), and that “ordinary” people were not immune or exempt, the picture became more complicated, and our judgements became less certain.
And in the beginning as I saw people dying and I lost friends and acquaintances, and then clients as I began to work in the field in the late 1980s, it was hard to keep hopeful and to believe that something could be done to reduce the deaths and the impact. I can remember telling friends “don’t test for HIV, there are no treatments and there is a lot of stigma – just be careful, use a condom and look after your health”. It was a time of depression, fear and suspicion – and life seemed very precarious, as it always is when you are in the middle of a “war”. And we don’t have a shortage of war and conflict in many parts of the world today, where there is still despair and life is still very uncertain, not to mention outbreaks like Ebola which frighten and unsettle a lot of people.
But in many ways, where HIV is concerned, there is so much more reason to be optimistic. I am not saying it’s good to be HIV positive today, but I am saying the picture is improving. And in South Africa we have a lot to be grateful for. Even though we have over 6 million South Africans living with HIV, over 2 million of them are on treatment. And we have reduced mother to baby transmission rates to around 4% at 6 weeks. We know that over 10 million South Africans tested for HIV in 2011, largely a result of making testing more available to us. We know that nurses are being trained to initiate people onto treatment and that the government is committed to making ARVs available for the foreseeable future, especially as prices have gone down. We are more committed to tackling TB so that people who are co-infected have better survival rates, and we know that death rates related to HIV are generally dropping. I would speculate that stigma and discrimination have lessened too, partly because we have an excellent human rights framework around HIV and partly because we have begun to see HIV as part of our personal, social and political landscape. HIV is more “normal” now than it has ever been.
These are things to celebrate.
But there are things to work on too. And we need to be vigilant and challenge complacency, because HIV and AIDS are dynamic and changing, as is our society. HIV incidence rates are still higher than we would like, and HIV prevalence rates in gay men, and other men who have sex with men, are astonishingly high here. In some studies figures of up to 50%, compared to less than 20% in some heterosexual samples. This tells me something about the homophobia and rejection these men still experience, and a health care system and HIV response which has been reluctant to deal with this “community”. Lesbian women are not safe either, as our sorry record of rape and attacks on them show. While treatments are now more accessible than ever, we have had stock and supply problems, and our monitoring and support of people on treatment is less than it should be. As our medical interventions get better and grow in number –like ARVs for positive people, ARVs for negative people to prevent transmission, ARVs after accidental exposure, making testing more accessible – we run the risk of forgetting that behind these important and necessary initiatives are people: humans with lives, loves, beliefs, stories, families, fears, struggles and dreams.
We must never forget the human element. We are all on this precarious journey of life and all of us, HIV positive and HIV negative and HIV affected, have challenges and joys. Sometimes we can forget, in our important focus on people with HIV, that everyone has “stuff” that they deal with every day, and their own share of heartaches and loss, along with joys and successes. Some of you reading this may be living with HIV, some of you may have other chronic diseases which you manage, sometimes well and sometimes not so well.
And many of us will have experienced some form of discrimination or rejection – after all as humans we seem to be quite good at judging and labelling. It is human to speculate and gossip and chat, that’s often how we deal with our fears and anxieties. But when the speculation, gossip and chat turns into rejection and devaluation and harm, then that’s a problem. This is why, even in 2014, it is useful for people living with HIV to weigh up an HIV disclosure very carefully and thoughtfully. This can also be helped if they have had a chance to process their “internalised” stigma, often a profound barrier to accessing, and asking for, help.
There are many kinds of disclosure – some people want to become activists and wear their status on a T-shirt, some want to tell their colleagues to build a more inclusive work place, some will only confide in their close family and friends, some may tell no one. I think all of these are OK – it’s not always easy being defined by your “condition” and it can be tiring to always be educating someone about a condom, or seeing in their eyes the question “I wonder how they got it”?
For me, this pressure should not only be on the person living with HIV, it’s also about us as lovers, partners, family, friends and colleagues. What have we done to create a safe and respectful space – not only for people to confide in us about health, but for our children to talk about sex and sexuality, for a friend in a difficult relationship to say she has had an affair, for a junior colleague to say they feel bullied in the workplace?
So for me, World AIDS Day is not just about people with HIV and those affected by it, it is also about how we build a society which rewards, personal, social, economic, organisational and political integrity. It starts with me and with us, today.
I always have a sense of ambivalence about World AIDS Day. I recognise that it may be helpful to have a periodic wake-up call to all of us to renew our commitment to reducing HIV infections and working with PLHIV to promote their rights to healthcare and non-discrimination. However, I worry that the difficult questions about how we do this are not centre stage on World AIDS Day. Instead, it's possible, after a rousing day of speeches, to press the snooze button on the annual catchy slogans, so that they become little more than background noise to getting back to business as usual.
A Red Ribbon in honour of World AIDS Day 2014? Red reminds me of... a fresh-cut rose, a colourful glass of wine. The colour red brings to memory different things for different people but red reminds me this time of year most of the red ribbon, the symbol for HIV/AIDS awareness. HIV affects more people than only those who are living with HIV but also those who have a loved one, or know someone who is positive. HIV means a lot to quite a lot of people, and affects more people than we realize.
Before joining the CSA, I did not really know or understand what HIV or AIDS were and so World AIDS Day was lost on me. Honestly, I didn't pay much attention to it. I feel I was not the only one who didn't care much about World AIDS Day or even know what it actually meant and I feel that still today there are people who do not understand it. It was usually a day of turning on the TV and seeing boring speeches on nearly every channel and me moaning because “I can’t watch my cartoons”.
Reflecting on World AIDS day now, I somewhat feel that it is redundant, that society doesn't take HIV as a threat any more. Yes it is no longer a death sentence, but I would think people would still not want to contract it and would want to keep themselves safe. Perhaps society is suffering from AIDS fatigue, where people think they know all there is to know and now that there are ARVs it means HIV is no longer a problem. I truly feel that World AIDS Day has lost its intended meaning.
So World AIDS Day has become a day where Government and society feels it is their obligation to reflect on the past struggles and the lives that HIV/AIDS has affected. It seems like it’s just another box ticked off, a day of boring speeches.
But for me, since joining the CSA, HIV and AIDS have become part of my everyday life and World AIDS Day is every day, not just on the 1st of December.
Sitting down and thinking deeply of this day "World AIDS Day" it really tears me apart remembering all the loved ones who have departed and thinking of the orphans left behind. In the community where I live I do campaigns and health talks and I still find people not taking advantage of ART to live longer for their children. I have lost a sister who knew about her status and struggled to accept her situation, to find hope through taking ART. Death is inevitable, but as a nation we have a choice because of ART: you can prolong your life.