Although antiretroviral treatment (ART) has been widely available in the so called developed world for the better part of the past decade, the possibility of getting treated for the life threatening HIV-disease in a developing country was far beyond the reach of the majority of people living in the developing world, despite their disproportionate burden of the disease. However, following successful lobbying initiatives by groups such as the Treatment Action Campaign and their support base of people living with HIV/AIDS and NGOs throughout the country, treatment for HIV with the use of ARVs is becoming a reality for some following the release of the national department of healths Operational Plan for Comprehensive HIV and AIDS Care Management and Treatment for South Africa. Building on the HIV/AIDS and STD Strategic Plan for South Africa, 2000-2005, which is structured around the four main areas of prevention, treatment, care and support, legal and human rights, monitoring, research and surveillance, the Operational Plan, launched in November 2003, goes further to explicitly include the provision antiretroviral drugs to those who qualify according to specific guidelines.
The Operational Plan aims to accomplish two interrelated goals - to provide comprehensive care and treatment for people living with HIV/AIDS, and to facilitate the strengthening of the national health system in SA. The following targets are articulated in the plan: To establish at least one service point in every health district (District Council or Metropolitan Council) in SA by the end of the first year of implementation, and to provide all South Africans and permanent residents who require comprehensive care and treatment for HIV/AIDS equitable access to this programme within their local municipal area within five years.
Although the initial timeframes were somewhat unclear and those set have been missed, President Mbeki announced in the May State of the Union Address in Pretoria that 113 facilities around the country would provide treatment to 53 000 people by the end of March 2005. This unequivocal statement now commits the government to deliver to a specific target within a specific timeframe.
In rolling out what should prove to the be worlds largest and most ambitious health programme, a number of key challenges have to first be identified and then systematically overcome if the equitable objective is to be attained and if provision of ART can successfully occur beyond the well resourced centre on the scale required.
Envisaging that this process would begin and that ART provision would become a reality, the Health Systems Trust established the Treatment Monitor project in mid 2003. The aim of the Treatment Monitor is to facilitate and support a set of research activities in South Africa that will monitor access to HIV treatment and care, as well as the impact that HIV has on health services across the country. Ultimately it aims to identify or share information on models of best practice and lessons learnt in order to stimulate and promote the ongoing improvement of effective and efficient HIV treatment and care and health services in general.
Having participated in the development of the Operational Plan through the submission of documentation to the Department of Health, the project has gone on to develop a comprehensive literature review to establish key challenges and lessons learned from pilot sites and initiatives to provide treatment in Southern Africa. A database on public ART projects throughout South Africa as of February 2004 has also been established to assist in the development of treatment networks and monitor rollout progress. Several key challenges have been identified in this process, which may be used to assist the implementation of the Operational Plan.
First and foremost, given the scale of the pandemic and the knowledge that more than 5 million HIV+ South Africans will die within the next 10 -15 years from the consequences of the infection unless treated, a comprehensive approach to treatment, including ARVs, is an absolute must. The implementation of the Operational Plan and those responsible for providing treatment should enjoy all the support possible from government, business, donor organisations and civil society alike. Lessons from countries including Botswana, Zambia, Zimbabwe and Mozambique as well as those from numerous pilot sites and non-profit projects in South Africa have identified several key areas requiring careful planning and forethought.
Probably the single greatest challenge facing the successful rollout of the operational plan and improvement in PHC services is the fact that a skilled human resource base is essential in order to underpin a strong public health system. A further 14 000 staff will be required over the next 4-5 years in order to meet the needs of the operational plan alone. The HSRC suggests that over the next 10 years there will be a shortage of 20 000 nurses. With HIV prevalence rates of 16% among this population group it is essential that the care-givers themselves are able to access the life-prolonging treatment. Given that recommendations from groups such as Medecins Sans Frontieres include centering treatment on a strong nurse based treatment model, these figures raise serious concerns. Adding to this is the pattern of continued movement of staff from primary to tertiary, rural to urban and rich to poor areas, further undermines the ability to provide care and treatment in underserved areas, while the poaching of SAs health care workers by the UK, the Antipodes and similar countries continues unabated.
However, the challenge goes beyond simply producing numbers of staff to ensuring that the curricula of our training institutions and courses contain appropriate materials and do not pander to international content that may become inappropriate to our own countrys needs. The training of and deployment of staff, ongoing training, tight management of operational units and ongoing support via public and private networks of providers are all elements of successful treatment approaches.
Strong programme management at all levels is also vital to ensure that programmes such as PMTCT, VCT, TB are actually implemented as required and along with ART are integrated into a continuum of care. The decentralised approach required for ART and the need for an inclusive approach of community based organisations, home based care, and the involvement of traditional healers require that vastly improved referral systems are operational to ensure that treatment and support occurs beyond the facility walls.
Adequate financial allocations have to be made towards the programme. However throwing money at a problem will not solve it and the careful consideration of planning, managing, and spending those funds appropriately is a pre-requisite for successful programme implementation. Numerous channels of funding are available including conditional grants, provincial budgets, equitable share allocations, and donor funds. While vast amounts of money are becoming available, there is a real need to map and monitor allocations and spending to ensure that budgets are spent in full and as effectively as possible.
The absolute requirement of continuous, uninterrupted drug supplies to assist with adherence to treatment regimes and the clinicians ability to deal with opportunistic infections is paramount. Strong trust-based relations between the different players in the supply chain as well as seamless communication between facilities, provincial depots and the suppliers are vital, as drug stock-outs will potentially hamper effective treatment efforts and may facilitate the mutation of the virus.
These activities require the ongoing availability of relevant, real time information upon which decisions of action may be made. An ongoing lack of capacity to monitor and evaluate the ART programme at all levels of delivery starting at the facility level can undermine effective responses and lobbying for change. Failure to develop and fully utilize comprehensive M&E systems containing relevant information for the end user will limit the ability of the health system as a whole to respond appropriately.
The ability to track and treat patients regardless of where they present is key to ensuring suitable levels of adherence and monitoring treatment outcomes. South Africa currently utilized a number of patient information systems, some paper based, some electronic. None are currently suitable for the needs of the ART rollout and integration of existing systems is many years away. Developing an integrated data platform that allows for a decentralized health systems, yet meets the needs of the clinician, provincial and national information systems will prove to one of the most challenging aspects of ongoing universal provision of care and treatment using ARVs.
The rollout of the Operational Plan presents a unique opportunity among the medical and health research sector to develop a systematic and co-ordinated response to informational needs and a strategic approach to research and research systems both within the country and regionally.
Larger structural deficits, such as lack of potable water, sanitation, and electricity to every household, transportation limitations and road conditions in remote areas are further impediments to delivery of successful health solutions in remote areas. Without these infrastructural and systemic improvements it will be extremely difficult to provide an adequate ART programme that extends well beyond the well-resourced centers and reaches those on the periphery of society and most in need of assistance. While an ambitious poverty reduction and public works programme has been announced by the Presidents office, it will be the better part of a decade before results are readily evident.
While there is clear evidence of a shift in the right policy direction in health delivery and the initial stages of rollout have begun, the key barriers to equitable access are no longer the cost of ARVs and associated testing materials, but the capacity to implement the ART programme effectively outside of the larger and well resourced sites on the scale required. Key areas that and currently barriers to service delivery need to be overcome to ensure that the goals of a highly ambitious programme may be met. A shift away from the traditional, facility based health delivery paradigm may well be required, with strategies incorporating both a short-term emergency response as well as long-term developmental approach.