HIV, tuberculosis (TB) and malaria continue to be the leading causes of mortality and morbidity in Sub-Saharan Africa. The region remains home to 62 percent of global HIV infections and 72 percent of global AIDS mortality - mainly amongst women and children. It is estimated that there are 33.4 million people living with HIV. Most of them continue to face illness and death if they are unable to access treatment.
South Africa remains the epicenter of the epidemic. The country has 28 percent of the global population of people with dual HIV/AIDS and TB infections. It has a maturing HIV epidemic, mainly driven by heterosexual sex, multiple concurrent sexual partnerships, intergenerational sex and mother-to-child (vertical) transmission. HIV prevention strategies are not succeeding in cutting the number of new HIV infections – largely because they are unfocused, lack resources, and lack full and ongoing political commitment.
In South Africa and across Sub-Saharan Africa there are visible signs that we will not meet the targets of achieving universal access to treatment by the end of 2010. Universal access targets were agreed to by G8 members and, subsequently, heads of states and governments at the 2005 United Nations (UN) World Summit. The main reason why we are not meeting the targets is due to a lack of committed national and international leadership to prevent and treat HIV.
The Treatment Action Campaign (TAC) believes that civil society must remain vigilant and monitor the implementation of HIV and AIDS plans across the region.
Global Political Commitment – But Will It Last?
In 2001 we started to see world leaders and African governments committing to fight AIDS/TB and malaria in developing countries. The UNGASS Declaration of Commitment in 2001 was a landmark in global commitment to HIV. The declaration was followed in 2002 and 2003 respectively with the establishment of the Global Fund to Fight AIDS, Tuberculosis and Malaria and the US President’s Emergency Plan for AIDS Relief (PEPFAR).
The result is that today five million people that would have died without access to treatment are receiving antiretroviral treatment (ART). 4.5 million orphans have received medical services, education and community care and 790 000 HIV-positive pregnant women have received PMTCT treatment.
These tangible gains make all the more worrying an apparent change of heart by the most powerful governments of the world, who are contemplating reduced funding for HIV, and creating artificial contrasts between funding health systems and funding AIDS. It is essential that civil society and governments in developing countries unite to challenge cuts in AIDS funding. We also call on our partner organisations in developed countries to highlight the price that we will pay with our lives for their government’s austerity measures.
Can Political Will in SA Translate Into Action?
In South Africa, we began to see a turning of the tide in the country’s HIV and AIDS response last year. AIDS denialism was buried. The new political leadership, led by Deputy President Kgalema Motlanthe, the new Minister of Health, Dr Aaron Motsoaledi, and occasionally President Jacob Zuma, has shown commitment to tackling the epidemic. This was reinforced by the appointment of Dr Nono Simelela to lead the South African National AIDS Council (SANAC) secretariat, which TAC welcomed.
At last, after years of civil society advocacy, South Africa has a strong policy for the treatment and prevention of HIV. This policy aims to treat 80 percent of people who require treatment and to reduce new infections by 50 percent by 2011. The country is currently updating its treatment and prevention guidelines to take advantage of scientific evidence showing that there are more effective methods to reduce mortality and prevent new infections.
HIV and AIDS must be tackled side by side with strategies to strengthen all aspects of the health system. The government has also developed a 10-point plan to provide strategic leadership and create cohesion amongst stakeholders for better health outcomes through: the implementation of National Health Insurance (NHI) and by overhauling the health care system to improve the management and quality of health services. Priorities include: addressing human resource shortages; improving development and management; revitalising of infrastructure; accelerating the implementation of the HIV and AIDS and Sexually Transmitted Infections National Strategic Plan (2007-2011); building focus on TB and other communicable diseases; and reviewing the drug policy to strengthen research and development.
The recent budget put money behind most of these priorities.
However, the big question is whether funds allocated for health will be sustained, and whether this government truly has the political will to root out corruption and inefficiency in the health system.
Linked to this is the question as to whether the private health sector will recognise its constitutional duty to fully and extensively support the national effort around HIV prevention and treatment - with financial resources, health personnel and infrastructure.
Challenges and Priorities for 2010
1. Scale and Up and Sustain Access to Treatment
South Africa currently has the biggest antiretroviral (ARV) programme in the world. But still less than half of the people in need are able to access treatment. We recognise that government is trying to address these challenges and we welcome the removal of the long accreditation process to ART clinics, often delaying access to treatment.
We need to address the substantial implementation challenges at provincial and district level. These challenges include: removing all waiting lists; integrating HIV/AIDS and TB services; decentralisation of care in order to increase access closer to communities; ending drug stock-outs and monitoring availability of essential drugs.
We need to implement effective strategies to improve treatment adherence – both for the health of patients and to reduce drug resistance and the need for second and third line ART. We need to provide ART regimens with better side effect profiles. We need fixed-dose combinations. We need more social support. We need better education about HIV. We need a more welcoming health system that is sensitive to issues of mental health.
On World AIDS Day 2009, President Zuma announced a number of updates to South Africa’s treatment guidelines. From 1 April 2010 pregnant women and people who are co-infected with TB and HIV must be provided with ART at a CD4 count of 350 and all infants who test positive should be treated with ART immediately.
Government must address financial and human resource shortages to ensure the timeous implementation of these changes.
2. Make HIV Prevention Work
South Africa has a maturing HIV epidemic, mainly driven by heterosexual sex and mother to child (vertical) transmission. One in three women between the ages of 25-29 is living with HIV (32.7 percent). We need to dispel the myths such as: ‘prevention is easier than treatment’, or ‘we must have treatment over prevention’ - we need both.
Preventing new infections and AIDS-related deaths amongst young women in South Africa is crucial. Some of the main drivers of our epidemic are early sexual debut, gender-based violence and gender inequality, intergenerational sex, multiple concurrent sexual partnerships and a lack of knowledge about HIV and HIV status. We need to address the lack of access to: prevention of mother-to-child (vertical) transmission programmes, voluntary medical male circumcision, sexual reproductive health services, and male and female condoms.
It must be noted that prevention messaging starts with our leadership in the South African National AIDS Council (SANAC). As our country’s leader, our President needs to protect us and his family from the scourge of HIV. His behaviour, or that of other political leaders, must not send mixed messages to the public.
We need to scale up evidence-based prevention interventions if we want to meet the NSP target to cut new infections by half by 2011.
TAC believes that prevention strategies must prioritise:
- Scaling up prevention of mother-to-child (vertical) transmission programmes by increasing access to and uptake of HIV counseling and testing, especially before 14 weeks of pregnancy, and proper implementation of the new revised PMTCT protocol and consistent monitoring and evaluation of the programme.
- Scaling up services that empower young women and girls to negotiate in their relationships. This includes economic empowerment of women so that they are not dependent on partners that put them at risk of HIV infection. Further, prevention tools that are women owned are very limited. South Africa distributes less than six million female condoms per year and there are currently no other women owned prevention measures. Part of the NSP’s aims is to support research development of new prevention tools that will help reduce women’s vulnerability to HIV.
- Scale up the implementation of voluntary male medical circumcision by implementing pilot sites in KwaZulu-Natal, Eastern Cape and Western Cape. The Global Fund and PEPFAR are committed to funding this intervention which has the potential to greatly reduce new infections both in men and women.
3. Increase Resources for Health
South Africa is aiming to scale up treatment and prevention services through its revised guidelines. Scaling up services demands: addressing the human resource capacity constraints and the introduction of task shifting, increasing financial resources and implementing needs-based budgeting, and securing affordable essential drug prices.
The 2010 ART tender must be for the drugs that are to be included in the new first line regimen. It must promote adherence by prioritising fixed dose combinations and co-packages.
Ignoring TAC’s advice in the last tender led to South Africa paying avoidably high prices for drugs - making local and international pharmaceutical companies rich. The new tender process is a very good opportunity for South Africa to fight for lower prices for ART. The UNITAID patent pool is a new opportunity that all drug companies should make use of to ensure a sustainable and sufficient supply of life saving drugs.
If it is devised and implemented properly, the proposed government plan to reform health funding and delivery through a system of National Health Insurance (NHI) could ensure equity in health care provision. The private health system must be regulated to control costs and to require it to share the costs of expanding human and financial resources to the poor. South Africa’s universal health plan should keep the promise of the Constitution that says ‘everyone’ should have access to health care services – a right that should not be based on their income. But ‘everyone’ must include all people in South Africa. TAC will fight any plan to turn our backs on the health needs of refugees and undocumented migrants. To be able to introduce NHI, South Africa will have to tackle current human resource capacity problems, management challenges and systematic problems.
4. Let SANAC Lead with Action
This year must be a year of action because we have to report on our universal access to treatment targets by the end of 2010. Secondly, we need to implement the recommendations that came out of the NSP mid-term review to ensure we are on track.
SANAC must be turned into an efficient and cost effective statutory body. Each sector and government ministry should demonstrate accountability, transparency and action.
A priority must be to strengthen the provincial, district and local AIDS Councils to implement our targets locally. Establishing functioning AIDS Councils should be made part of the performance agreements of the president, premiers and mayors, and be assessed by SANAC.
Every person in South Africa should take part in the HIV testing and counseling campaign - this has to start with the highest office in the country. This must be a multi-sectoral response that involves provincial, district and local AIDS Councils, in order to ensure that it reaches the most rural areas. We say that by the end of 2011 every South African should know their HIV status!
As a matter of urgency, treatment guidelines must be finalised and distributed to all districts to prepare them for scaling up their treatment and prevention programmes.
HIV prevalence and incidence remains unacceptably high in South Africa. We are only left with a year to meet the goals of the NSP, which includes reducing new infections by 50 percent and providing appropriate treatment, care and support to 80 percent of HIV positive people by 2011.
The role of civil society in monitoring, advocating for and promoting health system reform has not diminished – and TAC will continue to be instrumental in strengthening the voice of civil society in this regard.
- This article was first published in the Treatment Action Campaign’s Electronic Newsletter, 19 February 2010 and it is republished here with the permission from the TAC, a NGO working to ensure that every person living with HIV has access to quality comprehensive prevention and treatment services to live a healthy life.