xtermin8or
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Understanding South Africa's approach to AIDS
Can Africa follow in the footsteps of the countries of the North in addressing the challenge of HIV and AIDS in the region? What lessons can be learnt? The challenge of HIV and AIDS in Europe and North America has been portrayed as a problem facing marginalised communities - Africans in diaspora, immigrants, men who have sex with men, injecting drug users and so on. Very few cases of HIV infection are attributed to heterosexual relationships.
These countries have many more resources to support their social security system and their populations have access to much more complex health systems. With the advent of antiretroviral drugs, many of the people living with HIV and AIDS in these countries were put on antiretroviral treatment.
However, UNAIDS, the joint United Nations programme on HIV and AIDS, has reported that new cases of HIV infection and other sexually transmitted infections are increasing in these countries. UNAIDS says, the rate of new cases of HIV infection in Canada, which hosted the recent International AIDS Conference, has increased by 20% over the past five years.
In an article entitled "The real story of HIV rates in UK", published in July 2004, this is how BBC News reported on HIV infection in Britain:
"The number of people living in Britain with HIV is increasing every year because more people are joining this group than are leaving it. People join the group in two ways: people with HIV migrate to Britain from abroad (imported infections); and people living in Britain pick up HIV (domestic infections).
"Because HIV is still incurable, people only leave the group by moving away from Britain or by dying. The two communities that are bearing the brunt of HIV in Britain are the gay community and the African community."
Despite the difficulties in reducing infection rate, it is necessary to discuss whether South Africa and Africa in general would have been able to follow the path of the North in responding to HIV and AIDS. Is it feasible for Africa to meet expectations that are based on a model from the North?
In sub-Saharan Africa, HIV and AIDS is a generalised challenge not limited to a specific and small section of the population. Most of the cases are attributed to heterosexual relationships.
Our understanding of the difference in the manifestation of this challenge in Africa as opposed to the North is that Africa has high levels of poverty and underdevelopment affecting the vast majority of its population. There are serious health system challenges in our continent, including shortage of human resources and inadequate infrastructure. Access to affordable and quality medicines and limited social security support for the poor, who constitute the majority of our populations, remains a challenge.
With all these challenges, and the fact that we have significantly higher numbers of people estimated to be living with HIV and AIDS than Europe, adopting a model which focuses exclusively on antiretroviral (ARV) therapy would not solve our problem.
As we developed the most appropriate response to the epidemic on the continent, we had to acknowledge that the high prices of antiretroviral drugs as they entered the market meant that we would have had to divert resources from other social needs - education, water, housing and so on - to provide ARVs. Even if we had done so, the probability of these drugs reaching the patients and patients taking them at a required frequency was very low.
What did South Africa do under these circumstances? We said that since there is still no cure or effective vaccine for HIV and AIDS, let us focus on prevention as the first element of our response. Simply put, our first challenge was to make sure the problem did not get any worse than it was.
Secondly, we encouraged our people to find out their HIV status, and made voluntary counselling and testing services available in more than 80% of our facilities.
We then had to look at how to respond to the needs of those already infected. We asked ourselves: what can we do to prolong the period between HIV infection and development of an AIDS defining condition? What can we do to maintain optimal health for people living with HIV and AIDS?
We introduced the Healthy Lifestyle campaign that promotes regular physical activity and encourages people to avoid health risks like smoking, alcohol and substance abuse, as well as unprotected sex to deal with the challenge of both re-infection and new infections.
To deal with the broader problem of the poor nutritional status of our population, we introduced interventions that encourage intake of necessary micronutrients, like providing appropriate vitamin supplementation to pregnant women and children. Vitamins and minerals are now added to staple foods like maize meal and wheat flour and communities are encouraged to produce and eat fruits and vegetables.
These interventions are aimed at strengthening the body's ability to fight infections and maintain good health for a longer period. When infections occur, we provide appropriate treatment as most of the opportunistic infections can be treated even in the presence of HIV.
There is also another element that is peculiar to Africa and that is African traditional medicines. The World Health Organisation (WHO) estimates that 80% of our people use traditional medicine for various conditions including HIV and AIDS. So we decided to encourage research and development of these medicines and create an appropriate regulatory environment for them.
Over the past few years, we made progress in reducing the price of medicines, increasing social expenditure and, to a certain extent, improving our health system. Progress in these three areas created a possibility, by the end of 2003, of introducing antiretroviral therapy. Based on WHO recommendations, we made antiretroviral therapy an option for HIV positive people whose CD4 count had dropped to 200 and less.
We evaluated facilities that could provide this treatment with a target of having at least one service point in every district by the end of the first year of implementation and we achieved that. We took this approach because we wanted to ensure that people in both rural and urban areas have access to more or less the same level of care. We now have 231 health facilities providing ARVs free of charge and they are spread across 72% of local municipalities.
Our targets are set in terms of establishing infrastructure and making services available to our people. While we make all the efforts to market these services, we avoided setting targets based on the number of people using the services because there are a number of factors influencing uptake and some of these factors are outside the control of the state.
The WHO, for instance, launched an initiative to put three million people on antiretroviral therapy by 2005 popularly known as the '3by5' initiative. At the AIDS conference in Toronto, it was reported that about 1,6 million people were on ARVs almost 8 months after the '3by5' target was missed.
In South Africa, the experience in the mining industry has been similar.
Only a quarter of the HIV-positive workers at AngloGold Ashanti who need AIDS drugs had taken up the company's offer of free treatment, a local newspaper, Business Day, reported on 22 April 2005. About 2,700 were estimated to be requiring treatment but just 730 workers were taking antiretroviral medicines after one and half years of providing free drugs.
This represents 27% of people initially targeted by AngloGold.
Experts can discuss the AngloGold's experience in detail. But it highlights the complexities involved in implementing a programme of this nature.
We should not mislead the public and claim that there can be easy victories in our efforts to curb the spread of HIV infection and reduce the impact of AIDS. Our collective duty is to emphasise prevention and ensure understanding of all the interventions that government is making available at different stages of the progression of this condition.
From the Letter from the President ( 31 Aug 2006 )
