THE SOUTH AFRICAN GOVERNMENT'S RESPONSE TO THE HIV and AIDS EPIDEMIC

CONTROVERSIES AND PRIORITIES

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Five priority areas, as identified in the HIV and AIDS/STD Strategic Plan for South Africa, 2000 - 2005, underpin the response to the HIV and AIDS epidemic. These areas are:

1. Prevention
2. Treatment care and support
3. Human rights and legal issues
4. Research, surveillance, monitoring and evaluation
5. Information, education and social mobilisation

It is expected that the report of the President's Advisory Science Panel on AIDS will make a crucial contribution to the process of the further elaboration of a correct and focused response to HIV and AIDS.

We remain convinced that an effective, sustainable response to the challenge of acquired immune deficiency in the South African context has to confront fundamentally the pervasive scourges such as poverty and diseases like TB, Malaria, Sexually Transmitted Infections (STD) and other chronic diseases. At the same time, there is a fundamental need to be better equipped to confront the health crisis in our country, including proper management of anti-retroviral drugs prescribed for HIV and AIDS. Accordingly we refer here to a comprehensive national response to the health crisis, not based on the medicalisation of poverty and underdevelopment.

As President Mbeki stated, we continue to intensify our national response to HIV and AIDS based on the national strategy released in June 2000. A key component of this is our national commitment to the adequate treatment of opportunistic infections. Guidelines in this regard were released earlier this year.

1. PREVENTION

1.1 CONDOM PROCUREMENT AND DISTRIBUTION

a) Condom Procurement and Distribution

• The Department through the Directorate: HIV and AIDS and STDs procures and distributes male condoms to all provinces.
• Condoms are supplied freely to the public.
• All condoms supplied by government undergo quality testing by the SABS in accordance with WHO standards.
• Strategies to improve access to condoms through non-traditional outlets, for example spaza shops, clubs, and taxi ranks, are being implemented.

b) Female Condoms

• The government procures a limited supply of female condoms (± 1 million)
• Female condoms are provided at selected sites in provinces.
• A phased-in strategy to expand access is currently being developed.

1.2 TREATMENT OF STDS

There is a lot of evidence supporting the importance of adequately treating STDs as an important intervention in the prevention of HIV transmission. Studies in our own country continue to show high levels of STDs. We are consequently promoting successful interventions that would lead to early and adequate treatment of STDs. Accordingly, we are:

• Continuing the training of health care providers in the Syndromic Management of STDs
• Training of private sector practitioners on Syndromic Management of STDs
• An audit of STD services will be conducted to identify shortcomings, evaluate services and formulate policy.

1.3 STRATEGIES TO REDUCE TRANSMISSION OF HIV FROM MOTHER TO CHILD

• The Government of South Africa is committed to the use of all effective, safe and affordable interventions aimed reducing mother-to-child transmission of the HIV virus.
• Towards this the Department of Health released clinical guidelines for the obstetric management of women who are HIV positive earlier this year.
• Furthermore, we have supported local research into affordable regimens of antiretrovirals for use in developing country contexts. One such initiative has been the support given to the SAINT (South African Intrapartum Nevirapine Trails). The results of these trails were presented during the XIII International AIDS Conference in Durban.
• The national Minister of Health convened a national consultation on 12 & 13 August 2000 at which we reviewed the major recommendations emanating from the Durban conference. A specific focus was given to an analysis of available evidence on MTCT with a focus on:

• The results of the SAINT studies
• Breastfeeding
• The development of resistance which was earlier reported in the Nevirapine (HIVNET012) studies in Uganda

• The implications of the reversal of some of the benefits that attends continued breastfeeding in mothers who have been given antiretrovirals.
• South African researchers and other identified stakeholders were invited to these discussions. The above discussions will contribute to the formulation of public policy.
• Subsequent to this meeting, the Ministers and MECs took a decision to expand the research sites on Nevirapine. The aim is to better understand operational challenges as well as help lay a solid platform for the rollout of VCT services. It needs to be noted that Nevirapine is not registered for use in MTCT in South Africa. The MCC is currently evaluating the application from the company. 
  Furthermore, WHO is holding a technical meeting in October to review data related to Nevirapine in order to advise member states.

1.4 LIFE SKILLS PROGRAMME

• The Life Skills Education is now a compulsory component in secondary schools.
• This programme has been strengthened through the Integrated Strategy for Children. This programme is funded through a special three-year allocation from Cabinet (R450 million over three years) for the Departments of Health, Welfare and Education. The Life Skills element will aim to expand the programme to all primary and secondary schools over the three-year period.
• Life Skills Education has already commenced in primary schools and is now in its second year.

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2. TREATMENT, CARE AND SUPPORT

• The Department of Health affirms its commitment to treating every person with treatable conditions, regardless of their HIV status.
• To relieve the burden on the public healthcare system, one strategy pursued for the care and treatment of all chronic patients, including HIV and AIDS patients, is the development of quality home-based care.
• The models for home-based care have been developed and provinces are adapting these to suit the different communities.
• Strategies are focusing on a multi-sectoral approach including as many of the stakeholders as possible.
• Minimum standards for training community health workers on caring for the ill have been developed and will be used to improve the skills of community care workers in this regard.

2.1 TREATMENT OF OPPORTUNISTIC INFECTIONS

• Common opportunistic infections that occur in people who are HIV positive can be managed in our public health facilities. The drugs necessary for the treatment of these infections are on the Essential Drugs List and are available in the public sector.
• In addition the Department released treatment guidelines for opportunistic infections earlier in the year.
• Training of healthcare providers in the implementation of these guidelines has commenced.
• The challenge is to ensure that healthcare providers are skilled in early diagnosis of these conditions and that facilities do not run out of stocks of these essential drugs.
• All medical schemes in South Africa are also legally obliged to adequately and fully fund the treatment for opportunistic infections as part of the mandated Basic Minimum Package of Care and Treatment.

2.2 THE USE OF ANTI-RETROVIRAL DRUGS

• Presently, anti-retroviral drugs are not available in public healthcare facilities. At current prices, these drugs are beyond the reach of developing countries. Even with an 80-90% reduction in drug prices, these drugs would still be unaffordable.
• Apart from the issues of cost, the introduction of anti-retroviral drugs in the health system will require a number of things:

• Training of health providers on the appropriate use of these drugs
• Laboratory facilities to monitor regularly the effect of these drugs on the patients in order to tailor therapy
• Infrastructure to procure and safely distribute these drugs
• A supportive environment to ensure compliance to therapy

• In the absence of these it will be impossible to monitor patients and failure to adhere to treatment schedules will result in the development of resistant strain of the virus that will be impossible to contain with existing drugs. In addition, anti-retroviral drugs have serious/toxic side effects, hence the need for close monitoring. To monitor some indicators, e.g. CD4 counts, requires a certain level of medical expertise that it not always feasible, especially in rural settings.
• The focus of the government remains the improvement of access to all drugs, including anti-retrovirals.

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3. HUMAN RIGHTS AND LEGAL ISSUES

• A tender to monitor human rights abuses against HIV positive persons has been advertised.
• A major campaign to promote openness and acceptance of HIV positive people will commence in October.
• An evaluation of the legal framework to identify areas that may need to be strengthened to create a supportive environment for people living with HIV and AIDS has already commenced.
• The Employment Equity Act ensures that nobody is discriminated against in the workplace due to his or her HIV status.

4. RESEARCH, MONITORING AND SURVEILLANCE

4.1 VACCINE DEVELOPMENT

• The objective is to develop a preventive vaccine for general use in South Africa as soon as possible.
• The vaccine work links into the South African national AIDS control effort by being an integral part of the total prevention programme of government. The South African AIDS Vaccine Initiative (SAAVI) regularly reports to the President and Minister of Health.
• Focus activities include:

• Candidate vaccine development
• Vaccine evaluation and immunology
• Advocacy and education on HIV vaccines
• Develop and implement ethical guidelines
• Vaccine trials

• The Government provides 50% of the funding for SAAVI. The other funding is provided by research organisations, NGOs and business (both local and foreign). Deliberations at the Durban 2000 International AIDS Conference confirmed that this is a worthwhile investment to make in the search for an effective and sustainable solution to the HIV and AIDS pandemic.
• Management is contracted out to the MRC. Overall responsibility and monitoring resides with government and major funder-stakeholders. Scientific integrity is ensured through a panel of internationally recognised experts. Management structures have been set up and are functional.
• There are 2 tracks of vaccine development - one predominantly local with foreign collaboration, and the other predominantly foreign with local collaboration.

4.2 TB/HIV RESEARCH

• The dual epidemic of TB and HIV presents a significant challenge.
• TB infection is compounded in the presence of HIV.
• Conversely, TB infection impacts on HIV viral replication, increasing viral loads and thus posing an increased risk of HIV transmission.
• This highlights the importance of aggressive treatment of TB. The adequate treatment of TB in a person with a positive HIV antibody test improves quality of life.
• In four provinces research in the use of prophylaxis against TB in HIV positive people is currently underway.
• This will inform policy on an appropriate package of care for people who are HIV positive but do not have TB as well as those who are infected with both HIV and TB.

4.3 SURVEILLANCE

• The antenatal survey of pregnant women attending public health facilities is currently the only method available to estimate HIV prevalence in the South African population.
• There is a realisation that this does not fully address the surveillance needs of the government, and efforts to address these shortcomings have already begun through collaboration with the Centres for Disease Control in the USA.
• The use of sentinel surveillance conducted by the MRC will also be used to supplement the antenatal survey data.
• Behavioural surveillance is also used as a barometer of attitudes and perceptions. These surveys are an important tool for monitoring behaviour change among specific target populations, such as young people. Behavioural surveillance will be used to identify determinants of risky behaviour, understand health-seeking behaviour among specific target groups, as well as what issues influence this behaviour. Interventions will thus be tailored to address these specific areas.

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5. INFORMATION, EDUCATION, COMMUNICATION AND SOCIAL MOBILISATION

• The interventions described above are underpinned and supported by a communication strategy, using print media, radio, TV, leaflets, billboards, and mobile media, such as taxis.
• The AIDS toll free helpline provides an important tool for providing advice, education and support to people.
• Communication strategies to reach those who are physically challenged have also been developed and continue to be improved.

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6. OTHER MAIN AREAS OF FOCUS

Support to partners in the Partnership Against AIDS (business, PLWAs, labour, women, faith-based organisations). This is being expanded to include all 16 sectors represented in the South African National AIDS Council.

• Financial support to NGOs (R20 million in the 2000/01 financial year)
• Financial and technical support for the labour movement
• Support for the Civil Military Alliance
• Training and support for traditional healers
• Support for and collaboration with faith-based organisations.
• We have also allocated additional and dedicated resources amounting to R450 million over 3 years targeted at a programme for children infected and/or affected by the epidemic. This includes, inter alia, a comprehensive approach to caring for orphans as well as accelerating the implementation of a life skills programme as a compulsory element of the curriculum in schools. The care of orphans however, is part of a broader strategy on the care of orphans, irrespective of their circumstances.

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