President Jacob Zuma’s move to extend HIV/Aids treatment in South Africa could mean that an additional 50% of HIV-positive patients will be knocking on the government’s door, at a potential cost of R10-billion a year, say leading health economists.
This is in a context where some provinces, notably the Free State, have persistently failed to provide antiretroviral (ARV) drugs to people who depend on state facilities because the provinces have exhausted their budgets.
On World Aids Day Zuma announced that HIV-positive patients with CD4 counts of 350 would be eligible for free ARV treatment if they had also contracted tuberculosis. Before the announcement, only patients with CD4 counts of 200 or lower were eligible for free treatment.
Health economist Alex van den Heever said increasing the uptake of ARVs to meet the government’s target of 80% provision by 2011 would require an additional R10-billion a year in funding.
”The big unknown is how many more people will enrol for treatment,” Van den Heever said.
Of the more than 5,5-million infected South Africans, only an estimated 700 000 with CD4 counts of 200 and lower currently receive ARV treatment — less than half the eligible patients.
Earlier this year Health Minister Aaron Motsoaledi told the Treatment Action Campaign (TAC) that six of the nine provinces were running out of funds needed for ARVs and that R1,2-billion was needed to close the shortfall.
In his October mini budget Finance Minister Pravin Gordhan earmarked an additional R900-million for HIV drugs for the next three years, while the United States government has pledged R300-million in aid for the purchase of ARVs over the next two years. This will be managed by the US president’s Emergency Fund for Aids Relief, rather than going into the South African fiscus.
However, the additional funding will cater only for currently eligible patients, rather than any new influx in terms of the Zuma plan. The state aims to put 500 000 new HIV-positive people on ARVs annually.
According to Francois Venter, senior director of the HIV Management Cluster at Wits University’s Reproductive Health and HIV Research Unit, the new measures will add 15% to 20% to the annual budget for ARVs.
But he argued that there would be savings in the longer term, as fewer people would need hospitalisation and treatment.
The biggest gain from ensuring that newborn babies are born HIV-free is that infected infants place a heavy burden on the health system and ”therefore it will take away a sub-population that will need care”.
However, HIV-positive babies contribute to about 10% of new infections in the country, meaning that this will not have much impact on the overall infection rate.
Van den Heever said the largest problem lay in treating people who are not symptomatic. ”Even on the current protocol, less than half of the people who are supposed to be on ARVs are on them.”
Reasons for this include a shortage of rural clinics and nurses’ inability to prescribe ARVs, insufficient staff capacity and long waiting lists. In addition, many people seek treatment only when their CD4 count is well below 200.
Innovative AngloGold strategy reaps rewards
Free KFC meals, boerewors rolls, cokes, T-shirts, caps and raffle tickets — these are among the incentives AngloGold Ashanti has used in the past three years to entice miners to test for HIV.
The company’s awareness strategy entails getting employees to test for the virus at least annually. The incentives appear to have worked.
In 2008 the number of HIV tests done exceeded the number of employees AngloGold had on its books. This year 28 000 tests had been conducted by the end of November.
AngloGold employs about 33 000 workers.
”When a concept such as HIV testing is introduced for the first time, people are often reluctant to go and ignorant about what the process entails,” said the company’s health manager for the West Wits region, Dr John Steele. ”Incentives help to break the ice; but it’s important that they’re not seen as the be-all and end-all.”
Steele said it is important that employers and other authorities are not ”lulled into a false sense of security that incentives alone lead to people going for HIV testsâ€. Enticements have to be combined with HIV campaigns and increased and free access to testing.
AngloGold’s strategy takes HIV awareness, in the form of voluntary counselling and testing, to the grassroots.
”We make it as easy as possible and take the counsellors with their test kits to where the workers are — whether that’s in hostels or mines — and make space available for testing right there and then,” Steele said.
The company also has additional free testing facilities at mine hospitals and on-site clinics and provides free transport for workers.
As a result, it said, 90% of eligible HIV-infected miners have taken up the free antiretroviral treatment the mine provides and the mortality rate of workers fell from 14 per 1 000 per year in 2004 to nine per 1 000 per year in 2008.
AngloGold is now trying to phase out incentives.
”The biggest incentive should be to know your status and to then access treatment if you need it — not a material reward for going for a test,” Steele said. — Jane Baldwin