South Africa is proud to boast that it has the highest number of people on anti-retroviral treatment (ART) should be a matter of shame, rather than pride. The state and private sectors have been successful in giving ART to about 220 000 South Africans, but this reflects just 20% of the people thought to need it.
South Africa is fairly well resourced in terms of policies, guidelines, good intentions, money, skills and knowledge. It is under-resourced in terms of ministerial enthusiasm, clear targets, monitoring and evaluation and implementation.
Sixteen years ago, communist leader Chris Hani warned of the damage HIV/Aids could do in South Africa. A decade ago Brazil introduced national anti-retroviral treatment, and levels of HIV there today are a fraction of South Africa’s. Yet it was only in 2004 that our government started rolling out ART in the state sector and it took a year for the tender for anti-retroviral drugs to be awarded.
Minister of Health Manto Tshabala-Msimang has been given the resources and Cabinet backing. What has conspicuously failed to appear is success in meeting targets.
Indeed, the Department of Health seems opposed to setting specific and measurable targets, preferring grand commitments such as supporting this May’s United Nations target of providing universal access to prevention treatment and care by 2010.
Where there have been targets, South Africa has fallen short. Writing in the Southern African HIV Clinicians Journal, Professor Nicoli Nattrass of the University of Cape Town points out that by the end of last year the South African public sector was treating less than 30% of the number of people planned for in the 2003 Operational Plan.
Money is not an immediate problem: in 2005/06 South Africa dedicated more than R3-billion to Aids. In addition, South Africa receives millions of dollars of external funding to improve access to ART.
Nattrass calculates that while the Treasury allocated enough funding for 150 000 patients to receive ART by March this year, donor organisations foot about half the bill. Nattrass told the International Aids Conference in Toronto that if available resources had been used, another 300 000 people could be receiving ARVs.
Symptomatic of the inertia surrounding the national ART programme has been slow drug provision. The tender for anti-retrovirals was only finalised in March last year — a year after the drug procurement plan was unveiled to Parliament.
The tender was worth R3,4-billion over three years, and generic drug-maker Aspen was contracted to provide about 58% of the drugs in return for about a third of the funding. However, media reports this week estimate that with the tender contract a third of the way though its lifespan, the government has spent only about 10% of its expected budget on anti-retrovirals. This was reportedly denied by the Department of Health, which said it could not provide figures.
While the health department has repeatedly emphasised its commitment to equity in the many court cases it has faced, access to ART is highly inequitable, with dramatic geographic variations.
But children are probably the most disadvantaged. Mortality is climbing among children aged 0 to four and in 2004 demographers estimated that 40% of deaths in this age group were HIV-related. A study released earlier this year estimated that 15 000 children are on ART, but that 50 000 need it.
Meanwhile, single doses of nevirapine are still standard in preventing mother-to-child HIV transmission, even though South Africa is capable of giving a more potent combination of AZT plus nevirapine to shield unborn children from infection and protect mothers from drug resistance. This happens only in the Western Cape.
The number of people on anti-retrovirals is far outnumbered by those dying without them — such deaths contribute the government-touted ”stabilisation” of HIV prevalence.
The Department of Health estimated that 30,2% of women attending public antenatal facilities were HIV-positive last year, translating into 10,8% of the population or 16,2% of adults aged 15 to 49.
At end-May this year, Statistics South Africa reported a 79% increase in registered deaths between 1997 and 2004. Some of this increase can be attributed to population growth and better recording of death data, particularly among black and rural South Africans. But one sub-group showed a 161% increase in recorded deaths between 1997 and 2004: adults aged 25 to 49 years. This prime economic and reproductive age group should account for less than a third of deaths, but in 2004 accounted for 43% of registered mortality.
Doubters argue that in the same year HIV was implicated in just 14 000 deaths. However the Medical Research Council has confirmed anecdotal reports of gross under-reporting of HIV-related mortality, with research suggesting that in 2000 and 2001, almost two-thirds of such deaths had been wrongly attributed to other causes. The World Health Organisation/UNAids has estimated that last year, more than 320 000 South Africans, or more than 800 people a day, died from Aids.
Publicly and privately there are repeated complaints about lack of interaction between departments of health and other stakeholders. This is not the whingeing of people excluded from power, but the concerns of experts who recognise that the Department of Health simply lacks the skills needed to successfully provide mass ART.