The health department has admitted that it neglected a large number of people with HIV
Belinda Beresford
The Department of Health has warned that it is “politically dangerous” to fail to provide treatment to millions of people affected by HIV/Aids, and has recommended drug trials that could lead to the supply of anti-retrovirals to all who need them.
In a strikingly frank internal document, the department admits that it has neglected large numbers of people infected with HIV because it lacks resources. This, it says, is unacceptable in human rights terms.
It is asking for a cumulative total of R2,7-billion of additional funding over the next three years to finance an enhanced response to the HIV/Aids epidemic.
The aim, the document says, would be to “invest resources to shift the public health system from its present unsustainable and ultimately self-destructive coping responses to HIV/Aids, and to move it towards a more sustainable and cost-effective models of service provision”.
The document appears to confirm many anecdotal reports that state officials have grown increasingly frustrated by the government’s confusing public stance on the links between HIV and Aids, the extent of the epidemic and the use of anti-retroviral drugs. The paper accepts that millions of people are expected to die from Aids-related illnesses, and that anti-retrovirals postpone death.
The proposed programme to minimise the impact of HIV and tuberculosis includes funding for trials on the feasibility and cost-effectiveness of anti-retroviral therapy in the public health sector.
Dated July 2001, the document was circulated for comment among senior health department officials. The paper in the hands of the Mail & Guardian is an early version. It was prepared as part of the department’s funding requests for the three years to the end of financial year 2004/2005, the period of the government’s Medium Term Expenditure Framework.
According to the document, at least an eighth of the national health budget, or R3,6-billion, is to be spent on the hospitalisation of Aids patients this financial year. Last year a quarter of all public hospital admissions were Aids-related.
It says demand for health care is likely to continue for at least eight to 10 years under the pressure of rising infections. “To date this demand has been accommodated by three main mechanisms: crowding out of care for persons with non-HIV related needs, the provision of inadequate quality of care for many of those presenting with HIV-related needs, and not providing any meaningful care for a proportion of those sick with HIV/Aids, especially in areas with generally poor access to health care.”
These coping mechanisms will become increasingly untenable, the document says. The crowding out of non-Aids treatment “will rapidly reach unacceptable proportions which will become unsustainable politically and will result in major inefficiencies in health provision”.
“Failing to provide care for population sub-groups (primarily the rural poor with poor access to health care) will become increasingly politically dangerous, as the absolute number of people sick with Aids rises among poor and vulnerable groups.”
In an argument repeatedly made by private sector economists, the department warns that “continuing to provide low-quality care becomes self-defeating, as it results in re-admission and revolving-door patients”.
It adds: “Providing sub-standard care or failing to provide basic care is clearly also unacceptable from a human rights perspective, and in the current environment is likely to lead increasingly to legal challenge.”
The department’s fear of legal challenge has been shown to be realistic, as it is now being sued, on constitutional and other grounds, by the Treatment Action Campaign for its failure to provide anti-retroviral drugs at public health facilities to cut mother-to-child transmission of HIV.
Quoting a joint study this year by the departments of health, education and public service, the document says that cumulative Aids deaths will be between 3,4-million and 4,5-million by the end of this decade, barring a preventative or curative breakthrough.
It says “conservative models of HIV prevalence rates in South Africa suggest that, already, over 3-million South Africans are infected with HIV, with upper estimates exceeding four million”.
By 2010 more conservative models indicate that the number could be 6,9-million. Estimates from the 2000 antenatal survey of pregnant women at public health facilities are about 4,7-million South Africans have HIV.
The document reinforces fears about the inroads tuburculosis is making in South Africa, fuelled by HIV. Already nearly half of tuberculosis cases are likely to be HIV-positive.
Of particular concern is the growing threat of multi-drug resistant (MDR) strains of tuberculosis, with each case of MDR tuberculosis requiring R31 000 in drugs and six months’ hospitalisation.
The planned intervention programme to curb the HIV/Aids epidemic is divided into different levels depending on their cost and effectiveness.
Some of the root problems facing the health service are starkly demonstrated in the report’s description of “core” interventions those which are highly cost-effective. These include aiming to provide voluntary counselling and testing at all public health facilities over the next three years.
The document paints a picture of a health system in a parlous state, where the most basic improvement involves ensuring the availability of drugs to treat tuberculosis and sexually transmitted diseases at all health facilities.
The presence of other sexually transmitted diseases appears greatly to enhance the risk of catching HIV from sexual encounters, and many studies have shown that cutting sexually transmitted diseases is a cheap and simple way of curbing the spread of HIV. Yet the Department of Health admits there are “frequent stock-outs of drugs and poor uptake”.
Expanding the availability of male condoms to half a billion a year could avoid up to 660 000 new infections, the document estimates. The distribution of female condoms, funded by the European Union, had proved “highly popular, with comparable or better impact per condom than male”.
The document mentions the “urgent need” to obtain firm data on the feasibility and cost-effectiveness of anti-retroviral therapy under field conditions outside urban academic centres in resource-poor settings.To this end it recommends three trials in different district health areas.
The report refers to using “anti-retroviral drugs at Cipla prices”, a reference to generic drugs produced by Indian pharmaceutical company Cipla. This presumably means it is either looking to use generic drugs, or expects to be able to persuade brand-name manufacturers to sell drugs to the state at generic prices.
If anti-retrovirals were adopted by the public sector, there would be additional costs of introducing such treatment into the prescribed minimum benefits package which private medical schemes must provide to all members.