Still an uphill battle against HIV

More than one million people in the country are now receiving antiretroviral therapy (ART) for the treatment of HIV/Aids. But South Africa still faces an uphill battle to keep up with the epidemic—much less turn the tide.

Médecins Sans Frontières (MSF) has been working with the government and local partners in Khayelitsha and Lusikisiki in the past 10 years to provide comprehensive, integrated HIV/TB care, including ART, and we are keenly aware of the immense challenges confronting the country.

A recent report titled: “The Long Run Costs and Financing of HIV/Aids in South Africa”, lays out the stark policy choices government must make today to reduce Aids deaths and avert millions of infections in the next 20 years.

The celebrated about-turn in the government’s Aids policy has lead to substantial increases in government funding for HIV/Aids—including R8,4-billion in the next three years—and the adoption of critical policy changes, including a drive to provide ART in every primary healthcare clinic and allow nurses to initiate treatment before their patients develop life-threatening HIV-related illnesses.

These should enable wider access to treatment, prevention and testing services. But government can and must do much more to turn these commitments into reality.

First, it should immediately adopt treatment guidelines that allow earlier initiation of ART for all people with CD4 counts of less than 350 cells/mm3 as per new World Health Organisation (WHO) guidelines.

The advantages of doing so have been widely reported in scientific literature. From our own experience in neighbouring Lesotho, where the government adopted these guidelines in 2008, we know the benefits have been dramatic.

In a two-year study we found that patients who started treatment earlier (at CD4 counts of less than 350 cells/mm3) were 68% less likely to die, 63% less likely to be hospitalised, 27% less likely to get new opportunistic infections such as tuberculosis and 39% more likely to remain in care compared with those who started when the disease was already advanced (CD4 counts of less than 200 cells/mm3). But, so far, South Africa has opted for only partial implementation of these guidelines due to resource constraints, even though the short-term cost increase could easily be offset.

Second, the welcome new national policy permitting nurses to initiate ART and allowing for task-shifting of non-clinical tasks to lay health workers needs to be transformed from policy to practice.

Our experience in Lesotho and other neighbouring countries has shown that nurse-driven HIV and TB services at the primary care level allows more people to access treatment, while maintaining good clinical outcomes for patients. Yet not one nurse in Khayelitsha, and only very few in the Western Cape and other provinces, has been authorised to initiate ART a year after the new policy was announced.

Third, South Africa should negotiate far better prices for its antiretrovirals. In spite of the fact that it has the largest number of people on ARVs in the world, it still pays significantly more for them than neighbouring countries where MSF is working, because these countries make use of the best international prices for quality generic ARVs, including fixed-dose combinations that need to be taken only once a day.

We need a tender system that will enable South Africa to access these prices and ensure that money now spent needlessly on expensive drugs can be stretched to reach more ­people who need treatment.

Researchers from the Health Economics and Epidemiology Research Unit at the University of Witwatersrand have shown that if new drug purchasing mechanisms are utilised and task-shifting is implemented, the full WHO guidelines will actually cost less than the old guidelines.

There is no reason for delay. These steps will go a long way towards increasing access to treatment. But science is now showing that we have a unique opportunity to make the quantum leap necessary to “bend the epidemiological curves”, with even more ambitious new strategies.

‘Treatment as prevention’
Pilot programmes to explore the feasibility and acceptability of “treatment as prevention” need to be considered with other prevention interventions, since ARVs are increasingly understood to have a major impact on reducing HIV transmission in addition to reducing HIV and TB-related illness and death.

This will require radical, out-of-the-box thinking about community-based, out-of-facility approaches to testing, drug distribution and adherence support. Economists are telling us these sorts of approaches could even be cost-saving in the long run.

And new “game-changing” technologies, which could help to ease the burden on patients, reduce the requirements of the health system and decrease the cost per patient per year, must be developed and implemented rapidly once they are validated.

These include new ARV drug delivery platforms and slower-releasing drugs, new molecular diagnostic technologies which will help to detect forms of TB that are otherwise difficult to diagnose in HIV-positive individuals, point-of-care CD4 and viral load tests and, following the promising results of the iPrEX trial, pre-exposure prophylaxis (PrEP).

After a decade of disastrous Aids denialism, the South African government is finally claiming back the leadership role everyone expected it to play in the fight against HIV/Aids. But it cannot do it alone. In addition to spending domestic funds more wisely, averting disaster will require greatly increased international financing at a time when the Global Fund to Fight Aids, Tuberculosis and Malaria is facing a budget shortfall and the United States government has ­virtually frozen Aids funding.

South Africa can and must step forward once again to lead the way in throwing off the mantle of cynicism and Aids fatigue that has set in rich countries and show that it is still possible to break the back of this epidemic.

Rachel Cohen is the head of mission for MSF in South Africa and Lesotho. Find out more about MSF and its work on HIV/Aids on

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