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AIDS policies
World Report
South Africans hope for a new era in HIV/AIDS policies With the new dominance of deputy president Phumzile Mlambo-Ncguka over HIV/AIDS policy in South Africa, there is an unprecedented united front between government, civil society, and communities to fight HIV. And, as Clare Kapp reports, positive changes are already being made.
www.thelancet.com Vol 368 November 18, 2006
antiretroviral campaigns by vitamin peddler Matthias Rath. TAC president Zackie Achmat said the movement was also willing to drop its longstanding demands for the dismissal of much-maligned health minister, Manto Tshabalala-Msimang, because it was satisfied with the new political leadership. The appointment of the deputy president to shake up government AIDS policy was widely interpreted as a snub for Tshabalala-Msimang, who earned scathing headlines at the AIDS conference in Toronto for including garlic, beetroot, and lemons on the South African stand. The minister was admitted to hospital in early October for a “lung infection” and has not so far returned to her official duties. Instead, Deputy Health Minister Nozizwe Madlala-Routledge, who commands widespread respect but was reportedly gagged by her boss, has emerged from the shadows. Madlala-Routledge wowed the audience at a civil society AIDS conference last month by her frank admission of the government’s failure to slow the epidemic and provide treatment for its victims. “Our country is in pain. We are all in pain”, she declared in unprecedented comments for a senior government official. “We are losing our children and youth, our future. We are losing mothers and fathers and seeing an ever-growing number of orphans and child-headed families. We are losing teachers and health-care workers and we are losing the lifeblood of our economy, the workers.” The deputy minister subsequently shared a platform at Cape Town university with Achmat—previously unthinkable for a top health ministry representative. “We have come to a
critical stage in the national response to the HIV and AIDS epidemic. South Africans are talking to one another and are making a commitment to work together to fight the epidemic that is threatening to roll back the gains of democracy”, she said. In a country where AIDS-related deaths remain largely taboo, MadlalaRoutledge spoke of her own personal agony in losing two cousins who did not get antiretroviral therapy in time. Madlala-Routledge’s Cape Town speech was remarkable not just for its content but also for the fact that it was—for the first time—posted on the health ministry’s web site. Although the government has dismissed talk of a palace coup in the health department, many commentators hope that the change in direction is irreversible.
The printed journal includes an image merely for illustration
AP
A new era of unity and action on HIV/ AIDS appears to be dawning in South Africa after years of confusion and conflict that made the health ministry the target of international ostracism and caused untold deaths. The government plans to unveil a new strategic 5-year plan for the prevention, treatment, and care of people with HIV/AIDS on World AIDS Day, Dec 1, amid reports that it aims to initiate 650 000 people on antiretroviral therapy in the public sector by 2011, up from the current 235 000. The Treatment Action Campaign (TAC) has urged the government to set ‘’bold, unambiguous but realistic targets’’ and has hailed the political leadership shown by Deputy President Phumzile Mlambo-Ncguka, who was appointed in September to spearhead a new drive against HIV/AIDS. In just a few short weeks, MlamboNcguka moved to revitalise the defunct South African National AIDS Council, which rarely even met under her predecessor Jacob Zuma. She also held talks with TAC leaders previously shunned by the government and spoke at a conference co-hosted by TAC. “We are now witnessing the emergence of a united front of government, civil society and communities in a common effort”, TAC general secretary Sipho Mthathi told a press conference on Nov 8. “Our task is to end 1000 new HIV infections daily and to reduce the AIDS death rate of more than 900 deaths every day”, she added. Mthathi said TAC and its supporters hoped for an end to the war of words over HIV/AIDS. She said that the movement was ready to reach outof-court settlements on suits filed to force the government to provide antiretrovirals to inmates at a Durban prison and to stop the misleading anti-
Deputy president Mlambo-Ngcuka is now leading the fight against HIV/AIDS
1759
World Report
AP
The printed journal includes an image merely for illustration
Health minister Manto Tshabalala-Msimang has been widely criticisised by activists
“There is definitely a shift. We have had years of conflict and arrogant dismissal from the minister and some of her staff”, says Francois Venter, an HIV/AIDS specialist who heads the South African Clinicians Society and recently called for compulsory HIV testing to try to slow the spread of the pandemic. “Suddenly, there are requests for help, acknowledgment of prior mistakes and policy problems, calm scientific statements, and, quite frankly, the sort of humility from the public service that none of us thought was possible. It is a long time coming, and thousands of people have died unnecessarily in the process, which is difficult to forgive and forget, but the state has the constitutional responsibility to look after its people, and we need to help them to get it right”, Venter says. Madlala-Routledge and MlamboNcguka have reportedly formed a close alliance ahead of the launch of the new strategic plan. A draft of this plan accorded top priority to reducing new infections, especially among people aged 20 to 39 years, and to reduce the impact of HIV/AIDS on individuals, families, and communities, according to the news service Health E-News. It described the lack of monitoring, evaluation and clear targets as “major weaknesses” of the previous plan, and 1760
set a new series of ambitious targets, including the provision of antiretroviral therapy for 650 000 by 2011, said Health E-News. The government has not confirmed the report, but has been far more open about figures than previously. It said at the end of September 235 378 people had been initiated on antiretroviral therapy, 10% of them children, at 273 accredited facilities in the public sector. An estimated additional 80 000 people are on antiretroviral therapy in private-sector health care. In her civil society speech, MadlalaRoutledge said far more needed to be done to boost prevention efforts by encouraging pop stars and other personalities to be tested and so help shed the stigma surrounding AIDS. She added that South Africa needed to “speak honestly” about the huge challenges it faces. These included: the shortage of health professionals; lack of infrastructure; more integration of the HIV/AIDS and tuberculosis programmes; better access to antiretroviral drugs for prisoners, children, pregnant women, and people with tuberculosis; and better calculation of the antiretroviral adherence rate. The deputy minister cited the example of the Western Cape, the province with the most advanced rollout, as proof of the benefits of allowing patients to access care in a less advanced stage of disease. She said there was a decline in early mortality on the programme, from 13% in 2001 to 6% in 2005, for the first 6 months on antiretroviral therapy. TAC welcomed the government’s commitment to set new targets, but said it fell far short of the estimated 1 million South Africans who will need treatment by 2011, given that there are currently an estimated 5·4 million infections. Achmat said that the government would only be able to cope with the ever-growing burden of AIDS patients by allowing primary health care sites to administer antiretroviral therapy as in the highly acclaimed experiment in the
poor Eastern Cape region of Lusisiki, which suffers from a chronic shortage of health staff and resources. Médecins Sans Frontières (MSF), backed by the Nelson Mandela Foundation, launched the treatment programme 4 years ago. Their strategy is built around an innovative community-based model of care focused on all twelve of Lusisiki’s clinics and a local hospital. A mobile team supported nurses at clinics; adherence counsellors were trained to support those on antiretroviral therapy; and the community was encouraged to become more involved in supporting the health system. More than 2200 people are now on antiretroviral drugs and there is universal coverage, according to MSF, which handed over responsibility for the project to the local government in October. Nomalanga Makwedini, Chief Director of Primary Health Care of the Eastern Cape Department of Health, said the experience showed that decentralised HIV/AIDS care was the best model for rural areas which suffer from a lack of transport. ‘’At the same time, the model has brought many benefits to primary health care services as whole, with improvements in clinic and laboratory services, infrastructure, drug supply, training, and staff motivation”, she said. She said it proved that it was possible to “innovate in the public health system under the most difficult circumstances”. MSF’s Hermann Reuter, who coordinated the project, said the team needed many “out-of-the-box” solutions to overcome the challenges. But he said the experiment should serve as a wake up call to the rest of South Africa. “The only way to make this programme sustainable and replicable is to ensure that those solutions are urgently translated into policy changes at national and provincial levels”, he said.
Clare Kapp www.thelancet.com Vol 368 November 18, 2006
South Africans hope for a new era in HIV/AIDS policies With the new dominance of deputy president Phumzile Mlambo-Ncguka over HIV/AIDS policy in South Africa, there is an unprecedented united front between government, civil society, and communities to fight HIV. And, as Clare Kapp reports, positive changes are already being made.
www.thelancet.com Vol 368 November 18, 2006
antiretroviral campaigns by vitamin peddler Matthias Rath. TAC president Zackie Achmat said the movement was also willing to drop its longstanding demands for the dismissal of much-maligned health minister, Manto Tshabalala-Msimang, because it was satisfied with the new political leadership. The appointment of the deputy president to shake up government AIDS policy was widely interpreted as a snub for Tshabalala-Msimang, who earned scathing headlines at the AIDS conference in Toronto for including garlic, beetroot, and lemons on the South African stand. The minister was admitted to hospital in early October for a “lung infection” and has not so far returned to her official duties. Instead, Deputy Health Minister Nozizwe Madlala-Routledge, who commands widespread respect but was reportedly gagged by her boss, has emerged from the shadows. Madlala-Routledge wowed the audience at a civil society AIDS conference last month by her frank admission of the government’s failure to slow the epidemic and provide treatment for its victims. “Our country is in pain. We are all in pain”, she declared in unprecedented comments for a senior government official. “We are losing our children and youth, our future. We are losing mothers and fathers and seeing an ever-growing number of orphans and child-headed families. We are losing teachers and health-care workers and we are losing the lifeblood of our economy, the workers.” The deputy minister subsequently shared a platform at Cape Town university with Achmat—previously unthinkable for a top health ministry representative. “We have come to a
critical stage in the national response to the HIV and AIDS epidemic. South Africans are talking to one another and are making a commitment to work together to fight the epidemic that is threatening to roll back the gains of democracy”, she said. In a country where AIDS-related deaths remain largely taboo, MadlalaRoutledge spoke of her own personal agony in losing two cousins who did not get antiretroviral therapy in time. Madlala-Routledge’s Cape Town speech was remarkable not just for its content but also for the fact that it was—for the first time—posted on the health ministry’s web site. Although the government has dismissed talk of a palace coup in the health department, many commentators hope that the change in direction is irreversible.
The printed journal includes an image merely for illustration
AP
A new era of unity and action on HIV/ AIDS appears to be dawning in South Africa after years of confusion and conflict that made the health ministry the target of international ostracism and caused untold deaths. The government plans to unveil a new strategic 5-year plan for the prevention, treatment, and care of people with HIV/AIDS on World AIDS Day, Dec 1, amid reports that it aims to initiate 650 000 people on antiretroviral therapy in the public sector by 2011, up from the current 235 000. The Treatment Action Campaign (TAC) has urged the government to set ‘’bold, unambiguous but realistic targets’’ and has hailed the political leadership shown by Deputy President Phumzile Mlambo-Ncguka, who was appointed in September to spearhead a new drive against HIV/AIDS. In just a few short weeks, MlamboNcguka moved to revitalise the defunct South African National AIDS Council, which rarely even met under her predecessor Jacob Zuma. She also held talks with TAC leaders previously shunned by the government and spoke at a conference co-hosted by TAC. “We are now witnessing the emergence of a united front of government, civil society and communities in a common effort”, TAC general secretary Sipho Mthathi told a press conference on Nov 8. “Our task is to end 1000 new HIV infections daily and to reduce the AIDS death rate of more than 900 deaths every day”, she added. Mthathi said TAC and its supporters hoped for an end to the war of words over HIV/AIDS. She said that the movement was ready to reach outof-court settlements on suits filed to force the government to provide antiretrovirals to inmates at a Durban prison and to stop the misleading anti-
Deputy president Mlambo-Ngcuka is now leading the fight against HIV/AIDS
1759
World Report
AP
The printed journal includes an image merely for illustration
Health minister Manto Tshabalala-Msimang has been widely criticisised by activists
“There is definitely a shift. We have had years of conflict and arrogant dismissal from the minister and some of her staff”, says Francois Venter, an HIV/AIDS specialist who heads the South African Clinicians Society and recently called for compulsory HIV testing to try to slow the spread of the pandemic. “Suddenly, there are requests for help, acknowledgment of prior mistakes and policy problems, calm scientific statements, and, quite frankly, the sort of humility from the public service that none of us thought was possible. It is a long time coming, and thousands of people have died unnecessarily in the process, which is difficult to forgive and forget, but the state has the constitutional responsibility to look after its people, and we need to help them to get it right”, Venter says. Madlala-Routledge and MlamboNcguka have reportedly formed a close alliance ahead of the launch of the new strategic plan. A draft of this plan accorded top priority to reducing new infections, especially among people aged 20 to 39 years, and to reduce the impact of HIV/AIDS on individuals, families, and communities, according to the news service Health E-News. It described the lack of monitoring, evaluation and clear targets as “major weaknesses” of the previous plan, and 1760
set a new series of ambitious targets, including the provision of antiretroviral therapy for 650 000 by 2011, said Health E-News. The government has not confirmed the report, but has been far more open about figures than previously. It said at the end of September 235 378 people had been initiated on antiretroviral therapy, 10% of them children, at 273 accredited facilities in the public sector. An estimated additional 80 000 people are on antiretroviral therapy in private-sector health care. In her civil society speech, MadlalaRoutledge said far more needed to be done to boost prevention efforts by encouraging pop stars and other personalities to be tested and so help shed the stigma surrounding AIDS. She added that South Africa needed to “speak honestly” about the huge challenges it faces. These included: the shortage of health professionals; lack of infrastructure; more integration of the HIV/AIDS and tuberculosis programmes; better access to antiretroviral drugs for prisoners, children, pregnant women, and people with tuberculosis; and better calculation of the antiretroviral adherence rate. The deputy minister cited the example of the Western Cape, the province with the most advanced rollout, as proof of the benefits of allowing patients to access care in a less advanced stage of disease. She said there was a decline in early mortality on the programme, from 13% in 2001 to 6% in 2005, for the first 6 months on antiretroviral therapy. TAC welcomed the government’s commitment to set new targets, but said it fell far short of the estimated 1 million South Africans who will need treatment by 2011, given that there are currently an estimated 5·4 million infections. Achmat said that the government would only be able to cope with the ever-growing burden of AIDS patients by allowing primary health care sites to administer antiretroviral therapy as in the highly acclaimed experiment in the
poor Eastern Cape region of Lusisiki, which suffers from a chronic shortage of health staff and resources. Médecins Sans Frontières (MSF), backed by the Nelson Mandela Foundation, launched the treatment programme 4 years ago. Their strategy is built around an innovative community-based model of care focused on all twelve of Lusisiki’s clinics and a local hospital. A mobile team supported nurses at clinics; adherence counsellors were trained to support those on antiretroviral therapy; and the community was encouraged to become more involved in supporting the health system. More than 2200 people are now on antiretroviral drugs and there is universal coverage, according to MSF, which handed over responsibility for the project to the local government in October. Nomalanga Makwedini, Chief Director of Primary Health Care of the Eastern Cape Department of Health, said the experience showed that decentralised HIV/AIDS care was the best model for rural areas which suffer from a lack of transport. ‘’At the same time, the model has brought many benefits to primary health care services as whole, with improvements in clinic and laboratory services, infrastructure, drug supply, training, and staff motivation”, she said. She said it proved that it was possible to “innovate in the public health system under the most difficult circumstances”. MSF’s Hermann Reuter, who coordinated the project, said the team needed many “out-of-the-box” solutions to overcome the challenges. But he said the experiment should serve as a wake up call to the rest of South Africa. “The only way to make this programme sustainable and replicable is to ensure that those solutions are urgently translated into policy changes at national and provincial levels”, he said.
Clare Kapp www.thelancet.com Vol 368 November 18, 2006