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HIV/AIDS ]
Update on the National HIV and AIDS Programme
19 March 2003
HIV/AIDS is a challenge for all of us, one that we can
overcome by working together in the Partnership Against Aids.
The fight against the epidemic takes place on many fronts,
mostly out of the public eye. And so we need from time to time
to bring together all that is being done so that all of us can
know both that together we are making an impact and that we must
continue to intensify the campaign.
Is there a national plan for combating HIV and AIDS?
Our country has a comprehensive five-year HIV, AIDS and STI
strategy that addresses prevention, treatment and care, research
and human rights aspects. It is founded on the premise that HIV
causes AIDS and was formulated in consultation with major
stakeholders.
The Government's policy on HIV and AIDS was set out in the
five-year strategic plan adopted in 2000, and is further set out
in two more recent documents, the Cabinet statements of 17 April
2002 and 9 October 2002.
Because HIV/AIDS represents a challenge to all of us and
success depends on close collaboration, the national action
system is defined as a Partnership against AIDS. The Partnership
was formalised in October 1998 in a national launch by then
Deputy President Mbeki, and is now represented by the South
African National AIDS Council (SANAC) which has contributed
substantially to coordinating various sectors at the highest
level.
Government's commitment to intensify implementation of the
plan is backed by very large budgets for the HIV/AIDS programme.
In 2002/03 Government provided large additional allocations for
an Enhanced Response to HIV, AIDS and TB. These allocations,
estimated at above R1 billion for 2002/03, are again
strengthened in the 2003 Budget. Additional allocations of R3,4
billon for the next three financial years strengthen key
national programmes (such as condom distribution) as well as
bolster provincial budgets to extend prevention programmes and
treatment. Dedicated funding for HIV/Aids (that is, excluding
allocations from the provincial equitable shares) is set to
increase somewhat more than 10-fold from R342 million in 2001/02
to R3,6 billion in 2005/
[ Top ]
What is happening in relation to HIV prevention?
Since there is no known cure for AIDS, prevention of HIV
infection remains critical. Government's prevention strategy is
to promote public awareness, to make condoms widely available
and to develop the life skills of young people to deal with the
challenges of a world in which AIDS is prevalent. Government
also has an expanding programme to prevent mother-to-child
transmission of HIV through intensified efforts towards
universal access to Nevirapine, already the largest on the
African continent.
There have been several positive developments on the
prevention front in 2002/3.
[ Top ]
Awareness and life skills campaigns
Government campaigns are continuously increasing awareness
about HIV, AIDS, STIs and TB.
Research surveys indicate a high level awareness among South
Africans. Most recently the HSRC study released in November 2002
brought encouraging information that prevention messages
regarding condom use, abstinence and faithfulness are being
taken to heart, especially by the young.
During the past year awareness has advanced mainly through
the Khomanani campaign, and the life skills and HIV/AIDS
education programme in schools.
The Khomanani campaign, for which government provided R98
million, aims to move the nation to act, so that individuals see
themselves as part of a caring community, pro-actively
addressing the HIV, AIDS and TB epidemics.
Six Government awareness campaigns, using mass media and
community mobilization, are running side-by-side under the
single brand, "Khomanani - Caring together". Spread over
2001-2003 they focus on:
- Youth prevention.
- Support for vulnerable children.
- Living positively with HIV.
- Effective STI treatment.
- TB control.
- Supporting health workers.
The methods and the messages of the campaigns are based on
research conducted specially for the Khomanani initiative. This
has helped the campaign to shape messages taking account of age
and gender; to link prevention and care initiatives; and to
venture - successfully -- into mobilization of voluntary action
through mass communication. Follow-up research indicates that
during September 2002 to February 2003 the Khomanani campaign
reached half of the 21 million radio listeners and over 60% of
the 8,5 million TV viewers.
[ Top ]
Condom supplies
To support the behaviour change needed for safer sexual
practices, government has expanded access to both male and
female condoms. Various surveys - mainly by independent
researchers and most recently by the HSRC - have confirmed
increased use of condoms, easy access to condoms and Government
clinics as the major source of free condoms.
During 2002 Government purchased and distribute free of
charge 350-million male condoms and this will rise to 400
million in the financial year 2003/04. We will increase the
supply through non-traditional outlets - like clubs, shebeens
and spaza shops - and double the number of sites where female
condoms are available (the number of such sites has already
increased from 27 in 2000 to just over 200 in 2002).
[ Top ]
Improved access to voluntary HIV counseling and testing
(VCT)
Ensuring access to confidential and voluntary HIV counselling
and testing is one of the essential elements of the Strategic
Plan, as it provides an important entry into other health
interventions, e.g. TB and STI treatment. This goal focuses on
expanding access to VCT in both the private and public sector.
By the end of 2002, VCT was available in 982 sites throughout
the country, including the sites of the PMTCT programme. It is
planned to have VCT services available in 80% of public health
facilities by the end of the 2003/4 financial year. To this end
the conditional grant for HIV/AIDS to the provinces, including
expanding VCT and PMTCT, has been increased from R210 million in
2002/3 to R334 million in 2003/4.
[ Top ]
Preventing mother-to child transmission of HIV
The programme to prevent mother-to-child transmission of HIV
by providing Nevirapine to mother and baby has expanded and will
continue to develop in 2003.
The original research sites continue to function, providing a
full package of care and helping answer critical operational
questions such as the impact of infant feeding options and the
significance of drug resistance.
Most provinces are now extending this comprehensive package
to more facilities and at last count about 658 hospitals and
clinics were providing the service.
In addition, the Constitutional Court ruling gives all
doctors working in public sector maternity services the choice
to offer Nevirapine to HIV-positive women, provided that
adequate HIV testing and counseling facilities exist. Provinces
are therefore, as they implement the Constitutional Court
judgment - in line with the commitment by the President in his
State of the Nation Address in February -, also focusing on
upgrading testing and counseling services to take account of the
needs of PMTCT.
Researchers and public sector health workers have been
working hard to improve the quality of the PMTCT service and to
remove obstacles to access. Fear of discrimination still
prevents many women from using this service and we have been
developing a communication strategy that deals with this.
Establishing safe breast-feeding options is critically
important to obtaining the best results in terms of the ratio of
HIV-negative babies. South Africa is actively researching this
matter and exchanging experience internationally.
By the end of December 2002, over 101 202 women had visited
the facilities attached to the 18 PMTCT research sites, with 63
217 accepting voluntary counseling and testing, 17 274 of whom
tested HIV-positive. Nevirapine was dispensed, along with the
package of support, to 10 043 women who accepted it and to 6 947
babies born to women in the programme.
[ Top ]
What about care for rape survivors?
The decision taken by Cabinet last April to offer
anti-retroviral drugs to survivors of sexual assault as part of
a comprehensive package of support is being implemented. The
post-exposure prophylaxis programme (PEP) includes counseling on
the effectiveness and risks of using ARVs for this purpose.
Supplementary funding was voted for this programme last year
and increased funding was included this year in the conditional
grants to provinces.
All provinces are working to national protocols that were
distributed in June 2002. Provincial services for survivors of
sexual assault vary in their form. In some provinces, the focus
is on multi-disciplinary crisis centres or victim empowerment
centers, while in others the service is offered through the
emergency rooms of general hospitals.
[ Top ]
Post exposure services
The guidelines for needle stick injuries and occupational
exposure have been available since 2000. The relevant protocols
and drugs are available in the public sector for this
intervention. Universal precautions are also in place in health
facilities to reduce the risk of occupational exposure.
[ Top ]
Is an HIV vaccine any closer to reality?
The South African AIDS Vaccine Initiative (SAAVI) has made
unusually fast progress for a biotechnology project of this
nature. But even if its products were to be successful (and this
cannot be guaranteed), the manufacture of a vaccine for the
public would still be about eight years away.
SAAVI has two locally generated "candidate vaccines" ready to
begin Phase 1 trials in 2003.
The Department of Health has increased its funding to SAAVI
from R5-million a year to R10-million a year. This is matched by
R10-million a year from the Department of Science and Technology
(bringing the total Government contribution to R20-million
annually) while Eskom contributes R15-million a year.
South Africa is also involved in trials of candidate vaccines
that have been developed outside the country.
SAAVI is coordinated by the Medical Research Council and
involves a range of local research institutions. The Initiative
is a complex project extending well beyond the confines of
scientific research into protecting intellectual property,
developing manufacturing capacity, developing ethical research
protocols and communicating with communities.
[ Top ]
What is happening with regard to treatment?
Various forms of treatment can greatly improve the quality of
life of those infected with HIV. These include the early and
effective treatment of opportunistic infections, the use of
anti-retroviral therapy (ART) at appropriate stages of illness,
improved nutrition and the administration of complementary
medicines, some of which can have a positive impact on the
immune system.
[ Top ]
Treating opportunistic infections
Public health facilities have a responsibility to offer
treatment for opportunistic infections. There can be no
discrimination against anyone because of their HIV-status and
nobody should be sent away untreated.
Treatment for TB is free and available in the public health
sector. In addition antibiotics such as Bactrim are available at
innovative joint HIV/AIDS, TB, management sites to prevent the
onset of infection common in people infected with HIV. But there
is a need to:
- Detect cases much earlier. Presently many TB patients
report at an advanced stage of illness.
- Ensure completion of the course of treatment through a
nationwide system of treatment support.
- Facilitate access to good nutrition during treatment.
Improving our management of tuberculosis has become a top
priority for the Health Department. The urgency of pursuing this
objective and putting adequate resources behind the effort is
being communicated across the system at every appropriate
opportunity. In January 2000 Government decided that people
receiving TB treatment should also get better nutrients.
However, success in this area depends on increased public
awareness and collaboration among key social partners. Increased
allocations for NGOs and CBOs have been made in the coming
financial year, with a view to involving them more actively in
TB control.
Government is working with pharmaceutical companies to lower
the cost of drugs to treat such infections.
The Diflucan partnership, which provides free medication for
two significant AIDS-related conditions, has been extended
indefinitely. In the first two years of the Partnership
1,5-million doses of Diflucan were dispensed and 11 000 health
workers trained in managing relevant conditions.
Step-down wards were funded for the first time last year, to
ensure continuing in-patient care for patients too ill for
complete discharge.
[ Top ]
Strengthening the immune system
The immune system can be strengthened - and opportunistic
infections averted -- by a whole number of interventions.
Measures to alleviate poverty and improve nutrition are
critically important to improving the quality of life of those
infected with HIV or living with AIDS.
Government views its food security and poverty alleviation
interventions as an intrinsic part of its response to HIV, AIDS
and TB. The importance of good nutrition for the health of
people living with HIV an AIDS is stressed by the World Health
Organisation. A number of measures aimed at enhancing nutrition
were announced towards the end of last year. These included
measures to counter the impact of high food prices, announced in
October 2002, both short-term and medium term to long term, as
well as a Department of Health programme for enhancing the
cultivation and use of more nutritional food.
Close inter-sectoral co-operation will be pursued to ensure
that such measures benefit families affected by HIV and AIDS or
TB. A significant emphasis will be placed on improving nutrition
in 2003, for South Africans in general, as well as for people
living with HIV/AIDS more specifically.
Proposals for formal research into the effectiveness and
safety of certain complementary treatments will be channeled
through the Medical Research Council (MRC). In addition the MRC
will put in place a register for indigenous complementary
medicines, will establish their basic safety and recommend
general guidelines for administration.
[ Top ]
Anti-retroviral therapy
In April last year, Government re-affirmed the position that
anti-retroviral treatment could improve the health of people
living with AIDS if administered at an appropriate stage in the
progression of the condition in accordance with international
standards.
It was stated at the time that Government would continue to
address the barriers to introducing anti-retroviral therapy -
for example, high drug prices, weaknesses in health
infrastructure and concerns around treatment compliance.
Thereafter, a key process was mandated by Cabinet. It centred
on a joint technical team from the Department of Health and
National Treasury that was tasked to look into the resource
implications of an expanded response to HIV/AIDS , including the
comprehensive costs - and benefits -- of various AIDS treatment
options. These options include anti-retroviral treatment. The
work of the Team is nearing completion, and Cabinet will be
considering the findings.
Any policy option that could have major new costs must be
thoroughly examined. Government must ensure that its programmes
are sustainable. Hence no discussions on such issues, such as
those that commenced in Nedlac in September 2002, could be
completed without Cabinet having first pronounced on the key
policy issues involved.
There have been some other important developments to support
the safe and effective use of ARVs in our country such as:
- The Medicines Control Council, in partnership with
Medunsa, has created a system to monitor the safety of anti-retrovirals
in use in South Africa and to record and investigate any
serious adverse reactions to drugs of this kind. This
monitoring system will draw on experience already gained
doing similar work in relation to vaccines in partnership
with the University of Cape Town.
- There is a growing body of experience in relation to
Anti Retroviral Therapy (ART) in South Africa. This exists
in the private sector, in work place programmes and in a
fair number of clinical trials being conducted among public
sector patients by various academic institutions.
[ Top ]
Towards more affordable drugs
The cost of anti-retroviral drugs remains high and the cost
of essential tests to monitor those on therapy is also
considerable. However:
- Our Medicines Control Amendment Act went through
Parliament late last year and, together with its
regulations, drawn up in consultation with the main
pharmaceutical companies. It will come into force this year.
It will facilitate purchase of medicines at cheaper prices.
- The MCC has registered some generic ARVs in this
country. Multinational companies have granted voluntary
licenses for South African companies to manufacture several
generic ARVs. This may lead to lower prices in the medium
term.
- South Africa continues to apply itself, despite
resistance from some industrialized countries, to securing
an appropriate World Trade Organisation agreement that will
facilitate developing countries' access to essential
medicines for major health problems including HIV/AIDS, TB
and malaria. Such an agreement would give further substance
to the statement issued by the WTO in Doha a year ago on the
relationship between intellectual property rights and access
to medicines in health emergencies.
- Within NEPAD is a programme for a number of African
countries urgently to work with pharmaceutical companies
towards the manufacture on the continent of affordable drugs
for dangerous diseases, including HIV/AIDS and TB.
- Successful treatment by antiretrovirals requires regular
laboratory tests to monitor the condition of the immune
system. We will continue to work to reduce the high current
costs of tests.
[ Top ]
Training for better HIV/AIDS care
Training has taken place in the last two years in a variety
of areas, such as the 11 000 health workers trained on the
management of opportunistic infections. However, there has been
a problem of fragmentation in training and this is being
addressed.
Capacity building and training are key strategies for sector
support of the National HIV/AIDS programme. The following
sectors benefited from a range of workshops mainly centred
around advocacy and HIV/AIDS planning: National and provincial
government departments, NGOs/CBOs, local government, trade
unions, traditional healers, faith-based organisations,
traditional leaders, traditional healers, disability sector,
women sector and men sector.
The Integrated Training grant for 2003/4 will help ensure
collaboration between province and academic institutions to
standardise both undergraduate and in-service training. This
programme could also involve existing institutions with training
capacity such as the Southern African HIV Clinicians Society.
Through a partnership with the Foundation for Professional
Development, health workers will be trained in issues relating
to HIV/AIDS, STIs and TB. This includes a component on managing
patients on ARVs. This training will target 100 health workers
per province annually for 3 years.
Government will this year begin setting up Centres of
Excellence, one per province. Their main function will be to
develop curricula on HIV, AIDS and TB care and to align the
skills of health workers with the requirements of national
treatment guidelines.
[ Top ]
Better information on antiretroviral treatment
To date the Medicines Control Council has registered 17
antiretroviral drugs for use in the country, some of which are
generics.
Government will urgently start investigating the experience
of HIV/AIDS treatment in South Africa's health private sector:
the costs, the impact, issues of resistance, compliance with
drug prescriptions and so on.
Clinical trials in public sector hospitals are expanding our
understanding of these issues. The extension of the PMTCT
programme to include the whole families of mothers who take part
in the programme (PMTCT Plus) is also providing new data.
Interaction between the Department of Health and scientists,
including a two-day forum held in August 2002, has also focused
on how operational research in centres across the country
involved in the treatment of HIV and AIDS can assist the
development of policy.
Some of the projects detailed above will source their funding
from the Global AIDS Fund. But ultimately the decisions we take
should not rely on immediate opportunities. They must be
sustainable.
[ Top ]
What is the state of care and support for those affected?
Major challenges remain but there has been significant
progress in the last year or so.
Expanded access to the Child Support Grant and successive
increases in the amount of the grant, are of major benefit to
families affected by HIV and AIDS. By the end of 2002, a total
of 2,5-million child beneficiaries were registered. This number
will increase as the registration drive continues and as the
grant is extended over the next three years to reach children up
to the age of fourteen.
Progress with regard to Home and Community Based Care
includes the following:
- National and provincial structures have been set up -
i.e. provincial coordinators have been appointed in all
provinces. Training has been standardised countrywide.
- A rapid appraisal of home/community based care
programmes has been conducted and yielded the following:
- By March 2002 a total of 466 home/community based
care programmes were in place
- 370 172 people were accessing these services
- There were 955 volunteers attached to these
programmes
A second round of the appraisal is currently being
conducted jointly with the Department of Social
Development and is due for completion in May 2003.
Preliminary results show an increase in the number of
programmes in provinces.
- Additional funds have been made available in 2003/4
through the conditional grants for strengthening the
community home-based care programme. Apart from the health
grant, there is also a conditional grant of R66 million in
the Department of Social Development to focus on
home/community-based care, and specifically addressing the
issues of orphans and vulnerable children, social relief
including food parcels, counselling and child care.
- To further strengthen the collaboration between the
various services at community level provided by government
and other organisations, the Departments of Health, Social
Development and Education have contracted the Health Systems
Trust to map HIV/AIDS services at sub-district level. When
completed this should help strengthen existing HBC services,
and identify gaps in service delivery.
Research has revealed an untapped willingness among the public
to be of help in alleviating the suffering caused by the AIDS
epidemic. In the last year, Government has used its mass
campaigns to mobilise some of this help. In the build up to
World AIDS Day tons of clothing, toys and school materials were
collected and channeled to community care groups. Through the
Khomanani "Circles of Support Campaign" a hotline operated by
people living with HIV links volunteers to suitable
organisations.
The Government-sponsored free AIDS Helpline remains one of
the most accessible sources of information and counseling for
thousands of people. In addition, the range of information
leaflets available at clinics and through NGOs has been revised
to deal with aspects of care and support.
[ Top ]
How is Government intensifying the campaign to fight
discrimination against people living with AIDS?
Negative attitudes can result in people being denied the
treatment, care and support they need. They also discourage
people from being tested. Government is therefore intensifying
its campaign against discrimination.
Successfully addressing stigma and discrimination depends on
action by both government and society. The Khomanani mass
communication has this as one of its objectives.
A number of research projects initiated by the Department of
Health will inform action to address stigma and discrimination.
The Department itself has spearheaded the appointment of people
living with HIV/AIDS (PLWHA) in government departments.
There are a number of initiatives to deal with stigma and
discrimination in the workplace. This includes ongoing training
for worker organisations concerning HIV/AIDS and the law; and
the Code of Good Practice launched in 2001 by the Department of
Labour to set guidelines for addressing HIV/AIDS in the work
place.
Government works with people living with HIV/AIDS in
combating the epidemic. This includes a PLWHA toolkit, just
completed, focusing on advocacy and meaningful involvement of
PLWHA.
Government is drafting regulations under the National health
Act to give effect to a National Policy on Testing for HIV.
[ Top ]
What are we doing to expand the resources available for
combating HIV/AIDS?
Government's commitment to its multifaceted comprehensive
approach is backed by increasing resources. Expenditure by
Government on the Enhanced Response to HIV/AIDS, launched last
year, will be stepped up by R3,4 billion over the next three
years.
As noted above a technical task team between the Department
of Health and the National Treasury is working to give us the
full picture of the implications of an expanded response to the
impact of HIV/AIDS.
Funding for some of the projects within the comprehensive
programme will also be sourced from outside of government, from
the Global AIDS Fund to Fight AIDS, TB and Malaria, from foreign
government aid as well as other donor sources. What is critical
is that such funding aid should be utilised within the
parameters of national policy and in ways that are sustainable.
Funding from the Global Fund is channelled through SANAC as
the Country Co-ordinating Mechanism and National Treasury as
Principal Recipient. During the first round of applications,
submitted during 2002, the Global Fund allocated a total of $165
million to South Africa. This included $72 million to projects
in KwaZulu-Natal - an application originally submitted directly
to the Fund and now re-submitted by SANAC
R100 million was provided in February 2002 by the United
States Government for expansion of the PMTCT Programme.
The government has welcomed the recent announcement by the
President of the United States of the US government's intention
to provide aid for combating HIV and AIDS to the sum of $15
billion over a period of five years to Africa and the Caribbean,
including South Africa?
[ Top ]
How can we strengthen the Partnership Against AIDS?
Together we can overcome the disease by working in the
Partnership Against AIDS now represented by the South African
National AIDS Council (SANAC).
New sectors are constantly becoming involved with the
Partnership. Sectors that joined during 2002 or strengthened
their contribution included: traditional leaders; organisations
operating in high-risk environments, such as bars, taverns and
shebeens; commuters and drivers in trains, taxis and buses; the
hospitality industry came on board; and the scientific
community.
The Trucking against AIDS initiative is an example of a
partnership between the private sector, labour, national
government departments, provincial government departments, local
government and non-governmental organisations. The High
Transmission Area Project of the trucking industry was launched
in 2000. The six roadside STI clinics provide access to condoms
and treatment after hours. The policy for the road freight
industry was developed and adopted by the Bargaining Council of
the Road Freight Industry and has been distributed to all the
participating organisations of the Road Freight Association.
In October last year SANAC met to review its effectiveness
over the first two and a half years of its existence. It decided
to streamline its operations; strengthen its Secretariat,
broaden non-governmental sector representation and to move to a
position in which sector representatives are selected by the
sectors themselves in a transparent manner.
The new structure is in the process of being set up. An
interim executive management committee (Exco) meets regularly to
ensure implementation of decision between quarterly Council
meetings and to respond to urgent matters that cannot wait for
Council meetings. Civil Society sectoral representation will be
extended when a new council takes office after the term of
office of the current council expires in March, composed of
representatives chosen by the sectors themselves.
The Secretariat is being strengthened so that it can give the
council the support necessary to its fulfilling its functions as
the highest advisory body to government on HIV/AIDS and its role
as Country Coordinating Mechanism in relation to the Global
Fund. A strengthened Secretariat is being established and is due
to move to new offices in Pretoria this year.
[ Top ]
Abbreviations
| ARV |
Anti Retroviral |
| ART |
Anti Retroviral Therapy |
| HBC |
Home-Based Care |
| HSRC |
Human Science Research Council |
| MCC |
Medicines Control Council |
| MRC |
Medical Research Council |
| NEPAD |
New Partnership for Africa's
Development |
| PEP |
Post Exposure Prophylaxis |
| PLWHA |
People Living with HIV/AIDS |
| PMTCT |
Prevention of Mother to Child
Transmission |
| SAAVI |
South African AIDS Virus
Initiative |
| SANAC |
South African National AIDS
Council |
| STI |
Sexually Transmitted Infections |
| VCT |
Voluntary Counselling and
Testing |
| WTO |
World Trade Organisation |
[ Top ]
Last modified: 23 September 2004 09:25:18.
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