Public HAART Projects in South Africa - Progress to November 2004

In November 2003, the National Department of Healths Operational Plan for Comprehensive HIV and AIDS Care Management and Treatment for South Afric was released publicly. The Operational Plan details a multi-sector response to the pandemic. It specifically recognises the critical role of antiretroviral drugs (ARVs) in the treatment of people with HIV/AIDS and aims to ensure free, universal access to ART through the public sector. The Plan aimed to establish at least one service point in each of the countrys 53 health districts by the end of the first year of implementation. Implementation is largely the responsibility of the nine provincial Departments of Health with support in key areas from the National Department of Health.

It is estimated that in 2004 about 500 000 South Africans had AIDS defining illness and were in need of life-saving antiretroviral therapy (ART). It is envisaged that within five years, all South Africans and permanent residents who require care and treatment for HIV and AIDS would have equitable access to this treatment.

As part of this research project, telephonic interviews were done with representatives of HAART sites across the country. The largely quantitative data from these interviews was supplemented by meetings with representatives within national, provincial and local government, and clinicians and researchers across South Africa. This information has been collated in a database and provides a picture of progress made towards achieving the objectives of the Operational Plan.

Covering 75 facilities which provide HAART to 10 181 patients in the public sector, information collected in this database demonstrates a clear trend towards rapid scaling up of treatment availability. Individual patient benefits, along with a marked impact on staff morale and a renewed positive approach to health care delivery were also observed. It is encouraging to note that in the majority of cases the introduction of ART services has not weakened, but has strengthened the drug supply and management system.

Support services, specifically those from laboratories, are generally functioning well, although the sheer quantity of testing and diagnostics and monitoring requirements will severely test their capacity in the near future. Data collection to inform both patient and programme monitoring remains fragmented and weak. Significant resources must be dedicated to strengthening approaches to Monitoring and Evaluation.

There is a clear trend towards greater availability of treatment for urban-based adults compared to adults in rural areas, while children are under-represented and pushed to the back of the queue.

While positive progress is evident, the sheer magnitude of the HIV epidemic results in demand for treatment continuing to outstrip supply. Successful integration of ART services with other essential programmes such as TB and PMTCT remains limited, resulting in resource inefficiencies and lost opportunities to improve treatment outcomes. Options for further integration with other primary health care services need to be established to facilitate a continuum of care.

The continuing absolute shortage of key professional staff compounded by too few support staff requires that greater attention is given to improving staff management and supervision systems, training of staff, and a review of the existing scope of work for each staff cadre. It is essential that existing staff are utilised most effectively, while every effort to improve job satisfaction and the working environment must be made. Options of developing new cadres that are less attractive to poaching countries, but relevant to South Africas needs should also be investigated. The long awaited strategic human resource plan may address some of these issues, but it remains unclear when and how this is to be developed.

Community level partnerships remain limited and greater effort is required to build relations between government departments, medical facilities and civil society. An improved understanding of current and potential roles of community based structures is needed. Patient support, through community outreach and support programmes was acknowledged as crucial by a number of respondents. Such programmes are at risk unless significant resources are committed.

Extensive partnerships with national and international organisations as funding agents and as providers of technical support have flourished. These require constant monitoring to ensure that the benefits of such partnerships are exploited, while avoiding possible pitfalls. The opportunity to design and implement a strategic research agenda at national and provincial levels remains to be capitalised on, while a national prevention plan and alternative testing policies need to be evaluated to keep pace with the changing needs of the population and health services.