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Question & Answers
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.
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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).
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What
are the elements of the comprehensive approach?
The
comprehensive programme includes prevention, treatment and care,
research and human rights:
- Prevention
of HIV infection is the bedrock of Government's approach to halt
the spread of HIV and the impact of AIDS, since there is no cure
for AIDS. We must ensure as a nation that the 40 million South
Africans who are not infected stay that way.
- Ensuring
that those who are currently infected with HIV but have not
developed AIDS progress as slowly as possible to this stage,
through enhanced efforts in dealing with opportunistic
infections, prophylaxis, improved nutrition and lifestyle
choices.
- Effective
management of those HIV-infected individuals, currently
estimated at 400,000 to 500,000, who have moved on to develop
AIDS, through appropriate treatment of AIDS-related conditions
(including using antiretroviral therapy in patients presenting
with low CD4 counts, and suitable care where treatment has run
its course.
- Important
in supporting these efforts are:
- Social
programmes that aim to reduce poverty, improve education and
bring about moral renewal.
- Strengthening the immune system, of critical importance for the
health of those infected by HIV.
- Promoting
a climate of acceptance of all people infected and affected by
HIV and AIDS; intensifying implementation of a policy and
legislative framework and community awareness to promote the
rights of all.
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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.
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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.
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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.
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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.
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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.
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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:
- A service
point project manager
- A trained
care team on site including clinicians, nurses, and counsellors,
- Easy
access to trained laboratory, pharmacy and nutritional staff,
and links to NGOs and other service providers
- Standards
of care according to the National Treatment Policy Guidelines
- 24-hours a
day access to care at the service point, or in the vicinity
- A staff
recruitment, training and skills development plan for health
care workers responsible for HIV and AIDS care and treatment
(including volunteers and lay counsellors) based on initial
needs and projected long-term patient numbers
- Consultation, treatment and counselling rooms to assure patient
confidentiality
- Access to
appropriate laboratory services, overseen by the National Health
Laboratory Service;
- Adequate
specimen preparation protocols
- Secure
pharmacy storage
- Adherence
to Drug Dispensing Standard Operating Procedures for
Opportunistic Infection prophylaxis and treatment, and ARVs
- Access to
patient nutritional status assessment and nutritional support
- Links with VCT centres, antenatal clinics, Family Planning clinics, TB
clinics, STI clinics, TB/HIV demonstration districts, and any
other patient referral facilities, to ensure that HIV-positive
patients are formally referred to the accredited service point
- A PMTCT
programme for service points providing antenatal care and a
referral system for sites without antenatal care facilities
- Linkages
with community resources and other support organisations that
complete the continuum of medical care and support services,
- A system
to track patients/treatments
- A system
to maintain medical records and transmit core data to a central
data collection point
- 24-hours
post-exposure prophylaxis (PEP) access, according to the latest
national guidelines
- Links with
the provincial HIV and AIDS Unit
- Participation in Information, Education and Communication
activities.
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What
will be needed to ensure that all areas are serviced?
- Strengthen
human resource capacity by recruiting and retaining thousands of
additional health professionals; and implement a training
programme for heath professionals, including traditional health
practitioners, as part of the accreditation process
- Upgrade
our drug distribution system including secure facilities and
training of personnel who handle and dispense drugs
- Strengthen
the National Health Laboratory Service, including better
coverage and expansion in specific capabilities to perform the
CD4 and viral load tests essential for high quality HIV and AIDS
care and treatment
- Improve
patient information systems
- Strengthen
the system which monitors the efficacy of drugs being used as
well as any adverse reaction to the drugs (pharmacovigilance)
- Establish
a research programme that will focus on practical questions and
help us better understand and improve the provision of
comprehensive care and treatment
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.
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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.
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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:
- Intensifying efforts to remove systemic constraints on access to ARV drugs such as cost and infrastructure
- Strengthening partnerships, especially via strengthening of SANAC
- Continued
use of nevirapine in Preventing Mother-To-Child Transmission,
and development of a universal roll-out plan
- Providing
a protocol for a comprehensive package of care for survivors of
sexual assault, including post-exposure prophylaxis with
antiretroviral drugs
- Ensuring
that no-one is turned away without appropriate treatment and
management of any infection or illness, irrespective of HIV
status
- Alongside
poverty alleviation and nutritional interventions, to encourage
investigation into alternative treatments, particularly
supplements and medication for boosting the immune system
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.
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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:
- Continuing
fall in prices because of new opportunities to manufacture some
drugs in South Africa; and successful negotiations with drug
companies;
- Increased
international and local experience in combating HIV and AIDS
- Growing
appreciation of the role of nutrition in enhancing health and
improving the efficacy of medical treatment, so that people do
not rely only on drugs.
- The
building of a critical mass in our country of scientists and
health workers with skills and understanding of the fight
against HIV and AIDS, as a result of the implementation of our
comprehensive strategy over the past few years;
- Initial
steps towards strengthening our health system in relevant areas,
though much remains to be done in this regard;
- More
resources in the budget to strengthen the national health system
and to pay for the drugs and testing needed and to improve
training and health infrastructure.
- A better
appreciation of the social dimensions of the pandemic, which
allows policies on health care interventions to be located
within a broader social and health context
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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 |
2005/06 |
2004/05 |
2006/07 |
2007/08 |
|
New Healthcare Staff |
21 |
322 |
432 |
662 |
1027 |
|
Laboratory Testing |
20* |
152 |
311 |
520 |
806 |
|
Antiretroviral Drugs |
42 |
369 |
725 |
1118 |
1650 |
|
Nutrition |
63 |
343 |
421 |
532 |
656 |
|
Other Health System Upgrades |
70 |
171 |
184 |
160 |
160 |
|
Programme Management (National & Provincial) |
16 |
103 |
128 |
128 |
128 |
|
Capital Investment |
30 |
75 |
100 |
100 |
0 |
|
Research |
34 |
55 |
55 |
48 |
48 |
|
Total |
296 |
1590 |
2358 |
3268 |
4474 |
*Note:
Includes R20 Million advance payment to NHLS through March '04.
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.
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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.
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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:
- The new
elements of the treatment programme will help extend the lives
of those who have reached the stage of AIDS - but antiretrovirals are not a cure
- Not
everyone who is infected with HIV needs antiretroviral
treatment- the majority with HIV can still live a healthy life,
with proper nutrition, treatment of any diseases and a
responsible lifestyle.
- Both
health workers and patients should adhere to the strict
guidelines - antiretrovirals can have serious bad side effects
and can be dangerous if not properly used, and the treatment
involves a life-long daily regimen.
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.
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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.
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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 Communications (GCIS)
19 November 2003
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Last modified: 23 September 2004 08:06:00.
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