Roll-out, what roll-out?

Recently, the minister of health, officials in the department of health and in the Government Communication and Information System, President Thabo Mbeki and Medical Research Council head Anthony Mbewu stated that South Africa has the “largest treatment programme in the world” and the “fastest roll-out on the planet”.

This is simply not the case. According to the United Nations Joint Programme on HIV/Aids (UNAids), South Africa’s Aids epidemic is “one of the worst in the world” and “shows no evidence of a decline”.

UNAids estimates “5,5-million people were living with HIV in 2005 with an estimated 18,8% of adults (15-49 years) living with HIV in 2005”. Almost one in three pregnant women attending public antenatal clinics were living with HIV in 2004 and “trends over time show a gradual increase in HIV prevalence”.

Based on this, UNAids estimates that the overall number of people who need treatment in South Africa is 983 000. This means that we have the greatest absolute number of people in need of treatment, which is more than in any other country (Nigeria is second with 636 000 people still in need of treatment).

The government has stated that 175 000 people were accessing treatment in the public sector by July 2006. It is not clear if this figure is accurate given that there is no proper monitoring and evaluation system in place. Government has also admitted this in its report to UNGass (United Nations General Assembly Special Session on HIV/Aids).

From our work with the private sector we estimate that an additional 100 000 to 110 000 people are receiving treatment in the private sector. But it is difficult to collect accurate data because the national department of health is not collating data across all sectors including the not-for-profit sector.

What we do know is that in 2006, about two-and-a-half years after the Operational Plan was adopted, fewer than 20% of people who need treatment are accessing it.

But even if we accept that the government is correct and that 175 000 people are getting treatment in the public sector South Africa still does not have the fastest or biggest roll-out “on the planet”, as alleged by government officials and Mbewu.

A recent econometric analysis of the determinants of highly active antiretroviral therapy (Haart) coverage suggests that South Africa’s performance is relatively poor, given its economic, institutional and epidemiological characteristics. In other words, although South Africa has a large share (25%) of the total number of Sub-Saharan Africans on ARVs (whether in the public, private or not-for profit sectors), South Africa should be performing a lot better than it is.

Given the slow pace of the roll-out, we are now lagging behind other countries, even other African countries, in scaling up access.

According to UNAids, Namibia, Uganda and Botswana are the only three countries in Africa that are reaching more than 50% of those who need treatment. Countries with less than 50% (but more than 25%) coverage are Algeria, Benin, Libya, Mali, Mauritania, Morocco, Rwanda, Senegal, Swaziland, Togo, Tunisia, and Zambia. South Africa is near the bottom, reaching fewer than 25% of those in need of treatment.

What this means is that the pace of programmes in several other African countries are faster than that in South Africa. For example, even Malawi has managed to put 40 000 people on treatment in a short period of time.

So, we may have the largest absolute number of people on treatment, but we are very slow and lagging behind in meeting the real need. Even countries such as Kenya, Gabon, Cameroon, Burkina Faso are ahead of South Africa. This means that 19 countries in the region are doing better than South Africa in terms of the percentage of people on ART. According to UNAids, national adult HIV prevalence in Brazil was 0,5% in 2005.

At present, slightly more than 170 000 of the 209 000 Brazilians needing ARVs were receiving it in 2005, including 30 000 injecting drug users.

Simply put, South Africa’s is not the biggest or fastest programme in the developing world. Globally, the Latin America and Caribbean regions have the highest treatment coverage, delivering ARVs to 68% of the 465 000 people who need it.

Within Central America, ARV coverage ranges from 16% in Nicaragua to 97% in Panama and 80% in Costa Rica. But with Sub-Saharan Africa, which accounts for 72% of people globally who need treatment, ARV coverage reached 17% in 2005. In Sub-Saharan Africa treatment coverage ranges from 3% in the Central African Republic to 85% in Botswana and about 20% in South Africa.

So, South Africa has a long way to go reach universal access by 2010, as promised in the UNGass Political Declaration in June of 2006 and at Abuja by all the African heads of state in May 2006.

While monetary resources are set aside and a plan exists on paper, the roll-out is deliberately slow, without vigour and without creativity and infused with tremendous confusion.

Fatima Hassan is a senior attorney with the Aids Law Project

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