Update on 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 co-ordinating 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.

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.

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.

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).

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.

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.

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.

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.

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 co-ordinated 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.

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.

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.

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.

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.

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.

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.

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.

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 co-ordinators 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.

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.

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?

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 co-ordinating 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.

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


Issued by: Government Communications (GCIS)

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