Government is taking advantage of new developments to enhance our country's comprehensive response to HIV and AIDS. It will, as matter of urgency, start implementing a programme to provide anti-retroviral treatment (ART) in the public health sector. Let us build on the foundations laid in the past three years through implementation of the five-year strategic plan.
WHAT IS GOVERNMENT'S APPROACH TO HIV AND AIDS?
Ours is a comprehensive strategy based on a partnership of all sectors of society, because HIV and AIDS represent a challenge to all of us. Success depends on close collaboration and continuing strengthening of partnership. The Partnership was formalised in October 1998 in a national launch by then Deputy President Thabo Mbeki, and is now represented by the South African National Aids Council (SANAC).
WHAT ARE THE ELEMENTS OF THE COMPREHENSIVE APPROACH?
The comprehensive programme includes prevention, treatment and care, research and human rights:
WHAT ARE THE MAIN ELEMENTS OF THE TREATMENT PLAN?
The treatment plan has two goals - to provide comprehensive care and treatment for people living with HIV and AIDS, and to help strengthen the country's national health system.
The programme responds to the holistic needs of people at all stages of HIV infection and attempts to slow progression and maintain the person at the highest functional level.
Voluntary counselling and testing (VCT) is a crucial entry point. Once identified as HIV-positive, patients will be assessed for the stage of their illness and referred into appropriate medical care. The assessment will involve a CD4 count test and the patient's medical history and status.
HIV-positive patients will enter into a system of care that monitors progress of infection. Care will focus on slowing progression to full-blown AIDS and maximising health through prompt diagnosis and treatment of opportunistic infections, periodic medical examinations and CD4 and viral load tests. They will be closely monitored for TB, a common opportunistic infection associated with HIV.
AT WHAT STAGE, FOR PATIENTS, WILL ART BE CONSIDERED?
Patients who are symptomatic and/or with a CD4 count less than 200 will be counselled and offered the option of antiretroviral therapy. They will be fully informed about the benefits of restoring immune function and improving the quality of life and about serious side effects that may result from treatment with these drugs. For those choosing antiretroviral therapy, CD4 and viral load tests will be done as treatment begins.
Patients will be treated at Service Points that have been accredited to provide antiretroviral treatment and will be treated by health professionals who have been trained and certified. They will receive psychosocial and nutritional support, as needed.
Community care and support services such as transportation, home-based care, hospice services, etc., often provided by NGOs and CBOs, will help keep people in care and encourage their adherence to treatment.
Nutritional support will be provided as part of this comprehensive care and treatment programme.
WHEN IS IT TO BE INTRODUCED; WHERE; HOW IT WILL BE SCALED UP.
The goal of the programme is to establish at least one accredited service point in every health district (in each District or Metropolitan Municipality) by the end of the first year of implementation and within a period of five years to provide all South Africans who requires comprehensive care and treatment for HIV and AIDS equitable access to the programme within their local municipal area.
Some areas will be able to start sooner than others.
However we should all be aware that this is a complex programme with many elements requiring cooperation of various role-players, inside and outside government - the actual pace of change will depend on how well we all cooperate in implementing the plan.
WHY IS IT BEING INTRODUCED IN STAGES?
The plan calls for significant additional capacity in the national health system, in particular strengthening human resource capacity and providing incentives to recruit and retain thousands of health professionals in historically under-serviced areas. Over the next four and a half years, over R750 million is proposed for upgrading systems in the healthcare infrastructure in areas such as drug distribution, patient information systems and monitoring of reaction to the drugs.
We must ensure the safe and effective use of antiretrovirals and other medicines; the care we provide must be of the highest quality; and it must be accessible to all South Africans on an equitable basis.
We will need a system for procuring the necessary drugs at the best price.
We will need to establish facilities - Service Points - of a standard that can provide the whole range of required interventions: diagnosis, counselling, treatment of opportunistic infections, other preventive and supportive strategies such as nutrition and nutritional supplements and traditional and complementary medicines with immune-boosting properties as well as antiretroviral drugs for the management of AIDS. A service point will be a group or network of linked health facilities operating through a hospital or clinic in a defined catchment area.
IS THERE A ROLE FOR TRADITIONAL MEDICINE?
Many people including those living with HIV and AIDS consult traditional health practitioners and use traditional medicine to meet some of their health needs. We will work together with these health practitioners to share experiences in the care of people with AIDS and they will also serve as a critical resource in providing support and assisting patients to adhere to treatment regimen.
Government is also committed to upscale research into traditional medicines that may in future render further treatment options.
WHAT IS REQUIRED FOR A HEALTH FACILITY TO BE ACCREDITED?
The plan establishes standards for accreditation of service points. This will ensure that comprehensive HIV and AIDS care and treatment of high quality can be delivered. There will be technical assistance and financial resources to help service points meet the accreditation requirements, with special attention paid to underserved areas of the country to promote equitable implementation
The criteria defining the conditions at a service point for high quality care
and treatment include:
WHAT WILL BE NEEDED TO ENSURE THAT ALL AREAS ARE SERVICED?
The programme will need an integrated national structure to manage and coordinate implementation, incorporated within the existing national health system, and in particular integrated within the prevention and education programmes.
HOW LONG WILL IT TAKE BEFORE PEOPLE CAN ACCESS ANTIRETROVIRALS?
Within a year there will be at least one service point in every health district and within five years access to all who need it in their own municipal area.
Some areas will be able to start sooner than others, and each service point per district may begin to operate as soon as it is accredited, and as soon as the drugs are available.
HAS GOVERNMENT MADE A U-TURN?
In April 2002 after reviewing its approach to HIV and AIDS, Cabinet reaffirmed its commitment to the Strategic Plan. Noting progress in the implementation of the Strategic Plan, Cabinet decided on a number of measures to strengthen and reinforce these efforts, including:
In July 2002, Government established a joint Health/Treasury task team to investigate issues relating to the financing of an enhanced response to HIV and AIDS, including Anti-retroviral Treatment.
On 8 August 2003 Cabinet received the team's report, which provided options for introducing antiretroviral therapy. The Minister of Health was requested to present a detailed operational plan in this regard.
An Implementation Task Team was set up, made up of South African experts and advisors working with the Clinton AIDS Foundation. A summary of plan is available on SA Government On Line www.gov.za
WHY IS THIS STEP BEING TAKEN NOW -IN PARTICULAR WHY IS ART BEING INTRODUCED NOW INTO THE PUBLIC SECTOR?
The possibility of considering sustainable and effective antiretroviral therapy in the public sector is a natural progression of the implementation of the comprehensive 5-year strategic plan. A number of positive developments with regard to the constraints on such treatment made this possible:
WHAT WILL IT COST TO IMPLEMENT THE PLAN? IS IT SUSTAINABLE?
The cost of implementing the plan is R296 million for the rest of fiscal year 2003/4, growing to nearly R4.5 billion in 2007/8.
The budget is based on international tendering as the means of procuring drugs.
Total Programme Budget Estimate (Millions of Rands)
2003/04
New Healthcare Staff: 21
Laboratory Testing: 20*
Antiretroviral Drugs: 42
Nutrition: 63
Other Health System Upgrades: 70
Programme Management (National & Provincial): 16
Capital Investment: 30
Research: 34
Total: 296
Note: Includes R20 Million advance payment to NHLS through March '04.
2004/05
New Healthcare Staff: 322
Laboratory Testing: 152
Antiretroviral Drugs: 369
Nutrition: 343
Other Health System Upgrades: 171
Programme Management (National & Provincial): 103
Capital Investment: 75
Research: 55
Total: 1590
2005/06
New Healthcare Staff: 432
Laboratory Testing: 311
Antiretroviral Drugs: 725
Nutrition: 421
Other Health System Upgrades: 184
Programme Management (National & Provincial): 128
Capital Investment: 100
Research: 55
Total: 2358
2006/07
New Healthcare Staff: 662
Laboratory Testing: 520
Antiretroviral Drugs: 1118
Nutrition: 532
Other Health System Upgrades: 160
Programme Management (National & Provincial): 128
Capital Investment: 100
Research: 48
Total: 3268
2007/08
New Healthcare Staff: 1027
Laboratory Testing: 806
Antiretroviral Drugs: 1650
Nutrition: 656
Other Health System Upgrades: 160
Programme Management (National & Provincial): 128
Capital Investment: 0
Research: 48
Total: 4474
This enhancement of our response to HIV and AIDS has been designed to be cost-effective and efficient without compromising quality. To ensure sustainability most of the budget will come from government. This has been made possible by the sound economic policies government has pursued, releasing resources for social spending. But where appropriate, financing of the programme may be supplemented using donor sources.
WON'T IT TAKE RESOURCES FROM OTHER HEALTH CARE AND SOCIAL SERVICE?
The decision of Cabinet comes with new resources that have been allocated to fund it. It will not detract from other programmes, whether in the fight against HIV an AIDS or in the reconstruction and development of our society. In fact the strengthening of the health system which is required for sustainable ART will bring benefits to health care more generally.
More than half the proposed total expenditure will go toward: strengthening the national health system; emphasizing prevention; and promoting healthy lifestyles. These funds will not only allow for delivery of comprehensive care and treatment for those infected with HIV - they will improve the overall capabilities of the public health system and benefit all.
WHY IS THE PRICE OF DRUGS IMPORTANT?
Two years ago this programme for comprehensive care and treatment would have been impossible, amongst other things due to the cost of the medicines and laboratory tests required. Falling prices internationally and new opportunities to manufacture some drugs in South Africa; as well as successful negotiations with drug companies made it feasible to consider such a programme.
The plan provides for a system of drug procurement that will secure drugs at prices well below today's best international prices. In time South Africa will have its own production facilities for these drugs.
WHAT CAN ART DO, AND WHAT ARE ITS LIMITATIONS?
Many uncertainties remain and our knowledge of HIV and AIDS continues to evolve rapidly. But we are better equipped now to ensure that the benefits of ART outweigh the risks, for patients already in a desperate state of illness that has progressed beyond what can be managed by other means alone.
There are important facts we should be aware of:
Patients should be able to make an informed choice. Information will be provided to patients, to explain the benefits, limitations and possible negative effects.
ART also brings great responsibility on health practitioners with regard to ethical conduct in line with the requirements of the profession, concerning such matters as the rigour of HIV tests, counselling, management of ARV prescriptions and so on
HOW WILL THE ART IMPACT ON THE COMPREHENSIVE STRATEGY?
We must not relax our prevention efforts, but rather sustain and intensify them so that we reduce the level of new infections. The operational plan emphasises that prevention of HIV infection is the bedrock of Government's comprehensive approach and makes provision for integrating treatment and care with intensified prevention.
Most people infected with HIV have not reached the stage at which they require antiretroviral medicines. But they do need access to treatment for opportunistic infections, so provision for that treatment will be stepped up. No one should be refused treatment simply because of their HIV status.
Since HIV thrives on a weak immune system, and in turn also weakens this defence system of the body, proper nutrition for all South Africans and dealing with poverty remain critical in the fight against HIV and AIDS. These social programmes of government will continue with even greater intensity.
We will continue and intensify support to families and individuals affected by HIV and AIDS. Together we must continue to fight discrimination and stigma.
DOES THE ROLE OF PARTNERSHIP CHANGE?
Success in the implementation of ART, as with every other aspect of our comprehensive strategy will rely on partnership across society.
That includes communication of objective facts about the new elements of treatment and about the spread of HIV infection and the impact of AIDS and its management. Creating false expectations or an atmosphere in which society lowers its guard on matters of awareness or change in lifestyle, or engaging in mutually debilitating contestation about what can be achieved by when, could undermine not only the treatment programme but set back the hard-won advances made curbing the spread of HIV and reducing the impact of AIDS.
We must intensify every aspect of our comprehensive national programme. To do so we must strengthen the partnership by joining hands in the war against AIDS
Through this enhanced care and treatment programme, government is adding to the nation's armoury in the fight against AIDS.
A cooperative relationship among all sectors, particularly in the implementation of this element of the comprehensive strategy, the spirit of letsema and vuk'uzenzele, a message of hope and responsibility as well as constructive engagement in the realm of practical work would ensure that South Africa advances even more decisively in this endeavour, which is literally a matter of life and death.
Issued by: Government Communication and Information System
19 November 2003