Despite much optimism, the training and resource shortcomings of rural hospitals and clinics may stymie antiretroviral rollout, writes Kerry Cullinan. People living with HIV/AIDS around the country are anxiously waiting to see whether Cabinet will approve an operational plan to introduce antiretroviral drugs into the public health sector.
The immediate priority is to prepare health facilities and provide training for health workers - the vast majority of whom have had absolutely no training in antiretroviral treatment.
While the detail of the operational plan has been a tightly guarded secret, insiders close to the task team say it proposes that each health district in the country should have a service point to deliver antiretroviral drugs.
This means that initially there will be 56 service points countrywide. These will be centred at hospitals, but may also include the clinics that the selected hospital serves. Metropolitan areas, which each count as a health district, are likely to be permitted to have more than one service point.
Initially, the task team had proposed that provinces should identify their own sites. However, the Department of Health apparently rejected this idea in favour of the district-based model, fearing a more ad hoc approach would be inequitable.
According to the current proposal, doctors will be in charge of the plan. They will assess patients, prescribe the antiretroviral drugs and check on patients every three months. However, patients will be expected to come to their service centre every month, where nurses will check their progress and drug adherence.
Before patients get their drugs, they will be expected to attend three treatment training sessions. These will explain how the drugs work and the common side effects and help patients to work out a treatment plan that will ensure they take the drugs every day at the same time.
Under-serviced rural hospitals pose a particularly tough challenge, as Dr Paul Pronyk, director of Wits University's Rural AIDS and Development Action Research Programme, based in rural Limpopo, knows only too well. He sees the chronic lack of health resources every day, and says, a systematic and cautious approach is necessary for the roll-out of antiretrovirals at Limpopo hospitals.
The antiretroviral roll-out is not simply about administering drugs, says Pronyk. Hospital laboratories don't work. Health workers need to be trained. Proper patient registers need to be kept. Patients need counselling. The drug supply must be safe and secure, because there will be a public health disaster if they get into the black market.
Nevertheless, Pronyk believes that universal access to antiretrovirals is possible - but only if there is full buy-in by government, which results in large-scale capacity building. He points out that there are massive funds available for the antiretroviral rollout, both from the South African government and international donors.
One thing that has lightened the government's load in recent weeks has been the dramatic lowering of antiretroviral prices. Last week the Clinton Foundation announced that it had brokered a deal with generic manufacturers, including the Johannesburg-based company Aspen Pharmacare, that would reduce the price of triple therapy to about R81 per patient a month for public-sector buyers. This is less than half the previous best price available.
The TAC has described this huge reduction as excellent progress, although it is concerned that some of the generic manufacturers have not been licensed by patent holders to produce generic versions of their drugs. This means that they could infringe patents if they do produce the drugs. In addition, the Medicines Control Council has not yet licensed some of the generic antiretrovirals that have been given the go-ahead by patent holders.
It may take a little while to sort out these complications, but the massive price reduction makes antiretroviral intervention far more affordable as a life-long treatment option.
But prevention is still the best medicine, and the Department of Health is concerned that the antiretroviral treatment rollout must go hand-in-hand with prevention.
While there are no miracle cures, British medical journal the Lancet published a study a few weeks ago demonstrating that antiretroviral treatment could buy patients at least 10 more years of life.
The thought of spending 10 more productive years with the people they love is a powerful message of hope for the 4.5-million South Africans living with HIV/AIDS. - Health-e News Service. (Source: Kerry Cullinan: The Sunday Times, 2 November 2003)
Determinants of survival following HIV-1 seroconversion after the introduction of HAART