The government’s revised national guidelines for access to antiretroviral (ARV) therapy cast a wider net for treating Aids, but the Health Department needs systemic change to ensure the new protocol has an impact on the pandemic.
In his World Aids Day address this week, President Jacob Zuma announced that, from April 2010, pregnant women and patients who have both HIV and tuberculosis (TB) will receive ARV treatment if their CD4 count is 350 or less. At the moment, people are only eligible for ARVs if their CD4 count falls below 200.
In addition, all HIV-positive children under the age of one will get treatment, and pregnant women who are HIV positive will receive treatment from the 14th week of pregnancy. TB and HIV will be treated on the same site.
Activists say they’re encouraged by the change in direction but are not altogether surprised by it. ”It’s not out of the blue,” said Jonathan Berger, senior researcher at the Aids Law Project. ”It’s very consistent with the government’s new position.”
Implementing the new protocol will be expensive but researchers say it is achievable. According to Francois Venter, senior director of the HIV Management Cluster at Wits University’s Reproductive Health and HIV Research Unit, it costs between R6 000 and R8 000 a year to keep a patient on ARV treatment; 65% of that is drug cost, and the rest is for testing, labs, staff, buildings and infrastructure. ”If we can bring down the drug cost — and it looks like we can chop this by over a third — we can make substantial savings.”
Venter said additional savings can also be made by renegotiating drug tenders and using human resources more effectively. It is also much less costly to prevent mother-to-child transmission of the virus than to treat children for HIV.
Yogan Pillay, Deputy Director General in the Health Department, said the department has been working on amending the HIV treatment protocol for months. But he declined to comment on the cost of implementing the programme. ”We’ve been working with Treasury to look at costing and we’ve started to put a service-delivery plan in place. The minister of finance has to make a final decision [on budget] and will be announcing it in the budget speech next year.”
In addition to Treasury’s allocation for ARVs, the United States this week pledged R900-million in aid for the purchase of ARVs over the next two years. Mary Fanning, head of the US President’s Emergency Plan for Aids Relief (Pepfar) in South Africa, said: ”The money will be managed through Pepfar’s partners, who will help with procurement of the drugs and supply chain management.” The partners will also help the government identify project needs and costs, she said.
But it’s hard to put a price tag on implementing the new guidelines. There is poor monitoring and evaluation of HIV treatment programmes around the country and there are no accurate estimates of how many people continue their treatment.
”The biggest problem is dealing with people who aren’t symptomatic,” said health economist Alex van den Heever. ”Even with the current protocol, less than half of the people who are supposed to be on ARVs are on them.”
There are many reasons for this: a lack of rural clinics, insufficient capacity among staff, and long waiting lists. In addition, many people only seek treatment when their CD4 count is well below 200.
Van den Heever said even with the existing protocol, increasing the uptake of ARVs to the government’s target of 80% by 2011 would require an additional R10-billion in funding. ”The big unknown is how many more people will enrol for treatment,” he said.
Even so, finance may not the biggest challenge to implementing the plan. ”The problems in the Free State [which ran out of ARVs last year] manifested as running out of money, but those problems were much more about governance, accountability and a lack of ability to budget and forecast properly. These systemic problems need to be addressed if the shift is to be realised properly,” said Berger.