INTERIM REPORT OF THE PRESIDENTIAL AIDS ADVISORY PANEL
Early last year Cabinet endorsed a decision to invite a panel of experts to South Africa to pursue debate on questions relating to HIV/AIDS. The panel met on two occasions in Pretoria, in May and in July, and the propositions put at these two meetings were further explored through exchanges on the Internet.
The brief of the panel was to address the following questions:
* Evidence of the viral aetiology of AIDS, including:
What causes the immune deficiency that leads to death from AIDS?
What is the most efficacious response to the cause(s)?
Why is AIDS heterosexually transmitted in sub-Saharan Africa, while it is largely homosexually transmitted in the Western world?
* The role of therapeutic interventions in the context of developing countries, in relation to:
* Patients with AIDS; HIV-positive individuals; preventing mother-to-child transmission; preventing infection following occupational injury; preventing transmission arising from rape.
* Prevention of HIV/AIDS, particularly in the light of poverty, the prevalence of co-existing diseases and infrastructural realities in developing countries.
The panel, as you are aware, incorporated experts from diverse backgrounds and included individuals who hold diametrically opposing views on several key questions pertaining to the link between HIV and AIDS. Some adhere to the dominant position that there is a clearly established causal link and others are proponents of the dissident view that rejects the causal relationship. This basic difference was reflected in all debates, especially those relating to treatment, surveillance and diagnostic methods.
However, it was not assumed at the start of the exercise that the objective was to achieve consensus. The idea was to pursue debate on scientific and public policy issues in a dispassionate manner to provide the best possible advice to the South African government.
The fruits of the panel's interaction are to be found largely in the formulation of proposals for further empirical exploration. Such research would be original in the sense that it would not simply replicate in a local setting issues explored elsewhere, but would break new ground and contribute globally to a richer understanding of HIV/AIDS.
Some of this research is already underway -- but a number of potential research projects outlined in the list of recommendations have still to be assessed and potential researchers identified.
Pending the outcome of further research, the debates of the panel have not provided grounds for Government to depart from its current approach to the HIV/AIDS problem, which is rooted in the premise that HIV causes AIDS. The five-year strategic plan for 2000 - 2005 remains the foundation of our programme. If anything, the debate of the panel has shown a need to intensify activities in a number of areas contained in the plan.
While the division among panellists on the cause of AIDS was fundamental, certain commonly held views did emerge on the importance of various programmatic interventions. In particular, the significant impact of developmental issues - issues such as poverty, literacy, gender relations, nutrition, sanitation - was taken into account and acknowledged in a much more far-reaching way than hitherto.
Key areas of discussion
Impact of other factors on the progression of the disease.
Panel members concurred that factors like malnutrition and the presence of other infectious diseases (like TB, other STDs, malaria and parasitic infections) impacted on the progression of HIV/AIDS. They also concurred on the need to intervene vigorously to manage these factors - although they differed on whether such intervention was a sufficient response to HIV/AIDS.
Quality of testing for HIV.
There was much debate on the quality of testing to detect HIV antibodies. This gave rise at an early stage to the establishment of a team to investigate this issue.
Panellists generally agreed that a robust system for collecting data was essential to understand and manage the epidemic. The lack of accurate data on AIDS-related mortality in South Africa was highlighted as a gap. The need to understand the impact of factors like malnutrition and other infectious diseases makes it imperative to capture full data on each of these.
Peculiarities of South African HIV pattern.
Important debates related to the fact that the South African HIV/AIDS pattern differs from that in most other countries: We have a complex mixture of various strains of the virus while most countries experience a single viral strain. This has implications for the vaccine development initiative in this country.
Members of the panel construed prevention initiatives in different ways, but there was a surface agreement on useful interventions. These included: information, education and life skills programmes; the promotion of condom use; effective treatment of STDs; good management of TB and communicable diseases; and interventions to relieve poverty and improve quality of life.
Use of anti-retroviral
Views on this issue were obviously sharply divergent. Panellists who deny a causal link between HIV and AIDS regard the use of anti-retroviral as totally unjustifiable. Other panellists who believe anti-retroviral have positive effects still cautioned against their use in the absence of effective monitoring systems, including laboratory systems, and other supportive services. The latter panellists made a presentation on what they consider the benefits to be of using anti-retroviral to prevent mother-to-child transmission of HIV.
Recommendations and future research
Panel members made a variety of recommendations for future research. They identified a critical need for social and behavioural research in relation to HIV and AIDS, including investigation of risk-taking and health-seeking behaviours. Some recommendations made by panel members are already being implemented, either by the Department of Health or through research institutions.
In relation to surveillance:
* The Department of Health is collaborating with US Centre for Disease Control (CDC) to establish a system to determine the incidence of HIV (that is, the rate at which new cases occur. Presently we only measure prevalence or the total proportion of people with HIV in the population).
* Second generation surveillance is being instituted including behavioural surveillance among vulnerable groups to understand the relationship between HIV and personal behaviour.
* A task team has been set up by the Medical Research Council, the Department of Home Affairs and Stats SA to gain a better understanding of mortality trends over the last 18 months and the degree to which AIDS impacts on them.
* The impact of other infections is also being monitored, including the close relationship between HIV and TB.
Research currently in progress under the guidance of panel members includes a three-phase investigation into HIV testing.
Phase 1 aimed to establish the quality, reliability and validity of HIV testing in South Africa. It involved a comparison of results obtained in relation to South African blood samples when tested locally and in the United States
Phase 2 of this project will seek to establish the "robustness" of HIV tests - their ability to yield consistent results in the presence of interfering factors.
Phase 3 will focus on building capacity in South Africa to synthesise, purify and use molecular beacons. This technology will then be applied to the blood samples collected in phase 1 to further define what HIV testing actually establish.
Some additional avenues of future investigation were suggested by the panel debate. For instance, the stark contrast between the patterns of HIV/AIDS in the West and in Africa suggests that the possible role of genetic factors needs to be interrogated.
And constraints in relation to ARV therapy have pointed to the need to conduct research on alternative therapeutic strategies, focusing particularly on interventions to strengthen the immune system's response to infection.
Appreciation of panel members
The South African Government wishes to express its profound appreciation to the panellists - many of them eminent scientists - who gave of their time to assist us in this inquiry on matters, quite literally, of life and death.
The fact that, despite their differences, they were prepared to meet and engage each other speaks of their commitment to join the African continent in the crusade against AIDS. We are proud as South Africans that distinguished scholars saw in our humble request an opportunity to make a contribution.
The global search for answers to the many complex questions will continue and, we believe, it has been enriched and promoted by the research projects defined through the process of debate in this particular panel.
Issued by Ministry of Health
4 April 2001
Find the full report on Government Online (http://www.gov.za/reports/index.html)