With more than five million of its 47-million citizens HIV-positive, South Africa currently has more people living with HIV/Aids than any other country.
This brings with it a heavy burden as concerns providing anti-retroviral drugs (ARVs) to those in need. More than 500Â 000 South Africans require ARVs, according to Fatima Hassan of the Aids Law Project at the University of the Witwatersrand, in Johannesburg.
Less than half that number is receiving the medication, however — and despite substantial increases in public funding for ARVs, Aids activists remain concerned about the pace at which treatment is being made available.
A government fact sheet issued in November 2005 titled Implementation of the Comprehensive Plan on Prevention, Treatment and Care of HIV and Aids noted that 85Â 000 people were receiving ARVs in the public health sector by September of last year. (Hassan estimates that an additional 70Â 000 to 80Â 000 persons were being treated privately by August 2005.)
This marked a shortfall of some 300Â 000 in terms of the goal health authorities had set themselves. A blueprint for addressing the pandemic that was adopted by government in November 2003, the Operational Plan for Comprehensive HIV and AIDS Care, Management and Treatment for South Africa, notes that 381Â 177 persons were supposed to be on government-funded ARVs in the 2005/2006 period.
Hassan points out that there is also disquiet about the extent to which the drugs are reaching children.
“Most of the patients are women and about 10% are children. Paediatricians and children’s rights activists are particularly concerned that very few children are accessing treatment,” she notes.
“They estimate that at least 50Â 000 children need ARVs now, but that currently only about 10Â 000 are receiving them.”
Lack of funding is not the main obstacle to ARV provision, says Zackie Achmat of the Treatment Action Campaign, an NGO based in Cape Town. This sentiment is echoed elsewhere.
In a June 2005 update for the 3 by 5 initiative, the World Health Organisation (WHO) commended South Africa for committing $1-billion up to 2008 for increasing anti-retroviral treatment: “…by far the largest budget allocation of any low- or middle-income country.” (The 3 by 5 programme was started in 2003 by the WHO and the Joint United Nations Programme on HIV/Aids; it aimed to have 3-million people in low- and middle-income states on ARVs by the end of 2005.)
As Achmat sees it, the difficulty lies elsewhere.
“The biggest problem we have in South Africa is that we have a president who doesn’t believe that HIV causes Aids,” he said, in reference to head of state Thabo Mbeki. Achmat was speaking at a meeting held earlier this month in the commercial centre of Johannesburg to discuss making ARVs more widely available.
Mbeki has drawn fire for questioning whether HIV causes Aids, something the TAC believes has undermined efforts to contain the pandemic — and to distribute ARVs as efficiently as possible.
Shortages of doctors and nurses also pose a problem. “We pay our nurses little. We overwork them. We steal Zambian and Ugandan nurses — and the United Kingdom steals South African nurses,” Achmat noted.
Kim Teversham of the Cape Town-based CareWorks, a company involved in HIV/Aids testing and treatment, has much the same view.
“The money is there. The drugs are there. It’s the physical rollout which is still a problem,” he said. “The public delivery service is good, but slow.”
Rotimi Sankore of the Centre for Research, Education and Development of Freedom of Expression and Associated Rights, an NGO based in London, told the Johannesburg meeting on ARVs that about 100Â 000 health professionals — half of them medical doctors — had left Africa since the 1990s for other parts of the world.
In the absence of government-sponsored treatment, many South Africans who need Aids medication go without. The most common treatment, d4T, costs about $65 a month; this is often unaffordable in a country where, according to the Pretoria-based Human Sciences Research Council, half the population lives below the poverty line.
And “if there’s resistance, one has to go for the second line of ARVs — which becomes very expensive”, says Teversham.
A patient embarks on anti-retroviral treatment when a count of their CD4 cells, which regulate the immune system, dips below a certain level. The count falls as CD4 cells come under attack from HIV, making the body increasingly susceptible to opportunistic infections.
A normal CD4 count in adults ranges from 500 to 1Â 500 cells per cubic millimetre of blood.
In South Africa, ARVs are offered to those with a CD4 count below 200 — something Achmat, who is HIV-positive himself, takes issue with: “A 200 CD4 cell count is late. Botswana has it right: It starts at 350.” — IPS