Don't hold your breath

So, the Cabinet has directed the minister of health to develop a “detailed operational plan” for an anti-retroviral (ARV) treatment programme. Does this mean that we are about to see a major “roll-out”?

Perhaps, but very unlikely, so don’t hold your breath. The Cabinet statement is a major breakthrough (ARVs are now explicitly recognised as beneficial), but it is cautiously worded about actual implementation.

The statement does not endorse the findings of the joint health and treasury task team’s costing report (as optimistically interpreted by the Treatment Action Campaign); the Cabinet merely “noted” some of its contents.

The only undertaking Cabinet makes is to “ensure that the remaining challenges are addressed with urgency; and that the final product guarantees a programme that is effective and sustainable”.

This is a positive statement, but it is vague and contains a host of worrying caveats.
What, for example, are the “remaining challenges”? If the government really wanted to start the roll-out it could do so almost immediately in many sites across the country. Waiting another six weeks for an operational plan — and then another (as yet undisclosed) period to implement it — is unnecessary in these cases.

Admittedly, the sites that could roll out treatment as soon as the drugs are available are concentrated in urban areas. But, as the experience of Brazil and Botswana indicates, a national treatment programme inevitably has to start where capacity exists. Ensuring more equitable access to Aids treatment is a longer-term goal, and one that can only be achieved through the steady expansion and improvement of the health service.

If greater equity is one of the Cabinet’s “remaining challenges”, then it is wrong to think that equity can and should be addressed up front. It makes no sense to delay the implementation of a treatment roll-out on the grounds that we cannot treat anyone until we can treat everyone.

Health systems consultants, predictably, disagree. They say there are a host of problems that need to be addressed before anything can be done. These range from developing drug delivery and storage systems to building infrastructure and ensuring adherence by patients to their drug regimens. But identifying these problems does not justify delaying the roll-out of treatment in sites where capacity to address them exists. Brazil and Botswana built up most of their infrastructure and support services as they rolled out treatment.

South Africa already has significant experience in ARV treatment. Aids patients in the Western Cape pilot projects have not been overwhelmed by the “complexity” of their treatment regimen and understand the importance of adhering to it. As is the case in Brazil, Botswana and Haiti, South African pilot projects show that good adherence is possible in resource-poor settings.

The waiting room at the Médécins sans Frontières clinic in Khayelitsha has become an informal “support area” with patients discussing adherence issues and problems relating to side-effects. Many of these patients have become powerful community advocates of Aids treatment. This, in turn, has helped reduce stigma and encouraged people to undergo voluntary counselling and testing.

At a recent workshop at Wits University, deputy director general of health in the Western Cape Faried Abdullah argued that medical professionals were so keen to provide ARVs to their Aids patients that a treatment roll-out would provide a much-needed boost to morale. Such positive effects of a treatment programme tend to be ignored by health systems consultants in South Africa.

It is, of course, possible that the Cabinet was not referring to health systems issues as one of the “remaining challenges”. Because the government has (inexplicably) yet to hold a press conference on the treatment programme, we can but speculate. Perhaps the Cabinet was referring to the need to ensure an adequate supply of low-cost ARVs? As medication comprises the lion’s share of the cost of the treatment programme, this is a major challenge indeed.

If the government is serious about rolling out ARV treatment, it should start negotiating immediately with the pharmaceutical companies over discounts. This could be done directly, as was the case in Brazil, or through the United Nations Accelerated Access Initiative. Neither approach requires any further detailed operational plan before being acted upon.

To strengthen its bargaining hand, the government should provide more support for the domestic production of generic ARVs. The Brazilian experience demonstrates that the threat of domestic generic production has a major impact on forcing drug price reductions. It is very disturbing that neither price negotiations nor the promotion of domestic production of generic medication was mentioned in the Cabinet statement. One could be forgiven for concluding that the government is not yet committed to acting decisively on the Aids treatment issue.

Another worrying caveat in the Cabinet statement is the requirement that a treatment programme be “effective and sustainable”. No one could disagree with such sentiment, but what, exactly, is meant by these terms? Is the government going to demand that each treatment site includes a major research project into the effectiveness of treatment? And is effectiveness to be understood in clinical terms only or is the intention to measure social impact — and, if so, over what period? These are important issues, because the more demanding (and expensive) the research requirement, the more limited the treatment roll-out.

Similarly, what is meant by “sustainable”? Judging by the ongoing discourse of “unaffordability” that has dogged Aids policymaking for five years, this is almost certainly code for “affordable”. If so, then we are back to the fundamental question of how much money the government is prepared to allocate to Aids treatment.

In the 2003/04 Budget, an additional R3,3-billion was made available to strengthen Aids prevention interventions and to provide a “substantial boost to care and treatment programmes”. This is probably sufficient to start a roll-out. However, as it is up to the provinces how they spend this money, there is no guarantee that it will actually be allocated to Aids treatment.

We need more than a cautiously worded Cabinet statement to believe that a treatment roll-out is on the cards. We need explicit government commitment at national and provincial levels.

According to the costing study I was involved in, Aids treatment costs could rise to a peak of R10-billion a year. This is a substantial allocation of resources, and it is possible that the government does not want to introduce a programme that will mushroom to this extent. Cabinet may thus have an incentive to portray Aids treatment as a very complex intervention requiring limited and carefully controlled implementation — hence the call for a “detailed operational plan”.

Rather than burying the issue of resource costs in a discourse of sustainability and complexity, the government should be facilitating a broader social discussion of the challenges posed by Aids and the sacrifices that will need to be made (for example, higher taxation) if we are to roll out a full-scale national Aids treatment programme. Aids is a major public health problem.

Providing treatment prolongs life, reduces the number of orphans and prevents many new HIV infections (because people on ARVs are less infectious and will have undergone counselling). We need greater deliberation about these costs and benefits, and how we as a society should be responding.

Nicoli Nattrass is a professor in the School of Economics and director of the Centre for Social Science Research at the University of Cape Town.

  • Read Peter Barron’s contrasting viewpoint.

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