South Africa has the biggest anti-retroviral treatment programme in the world, if both public and private sector patients are included. About 78 000 people are receiving anti-retrovirals through state health facilities and another 60 000 are receiving treatment through the private sector.
But these numbers pale in comparison to the demand for the drugs. The latest Health Systems Trust report estimates that between 750 000 and 837 000 people are in need of anti-Aids medication. Many of these people will die in months if they do not receive the drugs.
In late October, the national Department of Health said that at the end of August 78 000 people were on anti-retrovirals through 192 health facilities across the country. More detailed statistics about the programme are hard to find — which highlights one of the problems of the treatment programme.
Yet to be established is a comprehensive assessment and monitoring programme, which would enable both national and local departments of health to assess how well the treatment programme is running.
Without such an evaluation system, problem areas will live, and possibly propagate, into the future. Lack of monitoring of drug supplies, for example, means that efficient levels of stocks are not always kept, and there is less control over the theft of drugs. Without proper reporting on drug interactions, it is difficult to gather clinical and operational information on mass anti-retroviral treatment.
The Joint Civil Society Monitoring Forum is a group of NGOs which attempts to fill this information hole, with many of its members intimately involved in the design and implementation of sections of the treatment plan.
The national health department plays a coordinating role in the anti-retroviral roll-out, but much of the implementation is the responsibility of the provinces. Failure of different departments of health to give — or apparently to know — the numbers of patients means that the information has been culled from a variety of official and unofficial sources.
At its last meeting in August, the forum was told that Gauteng appeared to have the most number of patients on anti-retrovirals, at about 20 000, followed by KwaZulu-Natal with 19 000. The Western Cape had 11 147 patients by the end of August, while reports are that by mid-September the North West province had 7 578 patients and the Free State 2 500.
The laggards are Mpuma-langa, with 936 anti-retroviral patients in mid-August, and the Northern Cape, with 1 296. By the end of July, media reports are that the Eastern Cape was supplying 6 840 people with anti-retrovirals.
The unevenness of anti-retroviral provision across the country demonstrates the lack of capacity in the different provinces. This does not only include the lack of physical infrastructure and health workers, but also management. Healthcare workers involved in the roll-out complain that bureaucratic inertia is slowing down the process, ranging from ensuring that all required drugs are available, including those for opportunistic infections; implementing further training of healthcare workers; improving physical infrastructure; and helping patients get to and from the treatment sites.
Some doctors also argue that South Africa must move towards a more nurse-orientated and primary health-care approach, in which patients who are well established on chronic anti-retroviral therapy are monitored by specially trained nurses rather than by doctors. Delegating anti- retroviral therapy to primary health-care facilities makes it more accessible to patients, in terms of money, time and travel costs, than the big academic hospitals.
Diverting stabilised patients into primary healthcare facilities in local areas, such as Hillbrow, is one reason why Johannesburg General hospital has been able to pull down its waiting list. Last year, patients wanting anti-retrovirals had to wait months to get a first appointment — even when some of the would-be clients had a life expectancy of just weeks.
A major criticism of the anti- retroviral programme in South Africa, and worldwide, is the lack of paediatric treatment. Disproportionately few children receive the anti-HIV drugs, although they can have a dramatic effect on a child’s health and development. Doctors report that healthcare workers are nervous to treat children because drug dosages vary with the size and mass of the child. Ideally, children should be given special paediatric formulations of the drugs, which are not always available.
For many doctors, the arrival of anti-retrovirals in the public sector became a case of saving the dying. Although there are many people with final-stage Aids who have not yet managed to get on to treatment, public health experts warn that attention must also be paid to those people who still appear healthy.