Mobile testing centres are part of the province's plan for getting diagnosis and treatment for chronic diseases out to the public
Accessibility to drugs to treat not just HIV, but also tuberculosis (TB) and other chronic illnesses is vital in the war against illness. The bottom line, however, is that people need to know their status and get properly tested, not just for HIV, but for other life-threatening silent killers such as diabetes and hypertension.
Tumi Molongoana, head of pharmaceutical services for the Free State Deptartment of Health, stressed: “People must go out, get tested and know their status, and if they are found [to be] HIV positive [they] must immediately go on and stay on treatment.”
Molongoana also emphasised that having HIV is not a death sentence any more, as long as people know their status and follow a strict programme of taking their medicine. This is unlike cancer, where even with treatment the outcome is not always remission.
The Free State department of health sources its chronic illness drugs via three-year cycle contracts, including one with the national department of health. Drugs are sourced both locally and internationally, with the active ingredients for some of them being only available internationally.
“It is vital that we have continued supply,” emphasised Molongoana. “We are currently issuing two-month stocks due to the holidays. We do replenish on a monthly basis with our service providers, but we also have contingency stock, especially first line fixed dose medication. Any patient who does not qualify for these first line medications — maybe if they are allergic to the ingredients or combinations — are given alternatives, but generally this is more the exception.”
Yolisa Tsibolane, director of HIV and Aids at the Free State department of health, said: “A programme of prevention of HIV amongst the high risk populations was launched by the deputy president in July 2016, and priority was given to sex workers. A few provinces have pilot sites that were identified to pilot and implement this programme but the Free State is not one of the provinces, however we are still fighting to also have a site. Currently our high risk populations, mainly truck drivers, are getting health services from Trucking Wellness clinics set up in partnership with some of our partners funded by business sectors.
“More testing is being done now in our health facilties. Our analysis indicates that more women than men are getting tested. While women have more reasons to visit a healthcare facility, such as for contraception, antenatal care, childbirth and infant and child care, we are concerned about reaching out to men.
“Some of our partnerships include the private sector and particularly businesses with men in big numbers. We send out roving testing teams that work outside of our health facilities to reach those target groups.”
Targeting men
Tsibolane said that even in their community outreach events, they still see more women.
“We have to target men, by going to taxi ranks and talking to industries,” stressed Tsibolane. “We must talk to occupational health and wellness clinics and develop those relationships. We already have huge HIV programmes in the mines and we work very closely with them.”
Molongoana said: “We have developed partnerships with the trade unions, such as Cosatu. They are doing outreach in terms of testing, promotion of Aids treatment and providing information about other non-communicable diseases. They are providing services for men, covering testing for HIV, TB, hypertension, diabetes and prostate cancer.”
Tsibolane said the South African Business Coalition against HIV and Aids (SABCOHA) is one of the partners that are focusing on HIV and Aids in the workplace.
Molongoana raised the big problem of testing by proxy, saying another dilemma is that the longer a couple are in a relationship, the more trust issues come into play, and couples stop using condoms. This is a real problem where either has two or more partners. Discordant couples are those where one partner is negative and the other is positive.
“If the viral load is undetectable, this does not mean you are negative, but merely suppressed to a point. The virus is not replicating and you can still transmit but are less likely to. The aim is to have 90% of those on treatment virally suppressed so that they don’t infect the next person,” said Molongoana.
“Those who are virally suppressed can lead long and healthy lives, with strong immune systems that do not attract opportunistic infections.”
The ‘three 90s’
“The Universal Test and Treat (UTT) programme was launched on September 1 by the national ministry, which is a World Health Organisation (WHO) strategy adopted by the South African government to encourage people to get tested,” said Tsibolane. “Once tested and found HIV positive, they can immediately be started on antiretrovial treatment (ART). The whole thing is to prevent waiting until people are too sick — the earlier they start treatment, the longer they live.
“The ‘three 90s’ by 2020 is a strategy used by the country as a milestone towards the elimination of HIV, Aids and TB by 2030.” Tsibolane said the first 90 is that 90% of people living with HIV must know their status, the second is that 90% of people living with HIV will know their status and be on ART, and the third 90 is that 90% of those on treatment with ART should be virally suppressed.
“UTT was launched as a way of achieving this milestone,” continued Tsibolane. “If we get all the people at risk to test and then onto ART, we will then be able to achieve the third 90.
Molongoana said: “To achieve the third 90, we need to introduce differentiated care so as to improve on treatment adherence. Some of the barriers to adherence of treatment are the availability of medications and ART, congestion in the clinics and in ways of accessing treatments and access to the services themselves.
“The Differentiated Care and the Central Chronic Medicine Dispensing and Distribution (CCMDD) programme was launched by the minister in 2014, through which it is intended that people can access treatment at facilities closer to homes and workplaces, ensuring treatment ability and adherence.
“Government now has contracted service providers throughout the country. Once a patient that has been tested and been on treatment for six months and is showing improvement with his or her CD4 levels, he or she is then enrolled on the CCMDD programme.
“CCMDD makes use of contracted pick-up points such as the postal services, Clicks, Dischem, Medi-Rite and Pharmacy Direct. Using nongovernmental organisations (NGOs) and community caregivers, we are slowly rolling this programme out. It was piloted in the Free State in the Thabo Mofutsanyana district and now has over 4 000 patients using it there. The next rollout is at Goldfields, where there are currently almost 3500 patients.”
Molongoana says there are in total over 44 000 patients on this programme and as the Free State rolls out programmes to the rest of the province, it is identifying pick-up points and willing general practictioners, occupational health nurses and NGOs.
In another way to defeat diseases, adherence clubs affiliated to a clinic are being established. “This is a buddy system of, say, 30 patients encouraging each other,” said Molongoana. “They will also be able to collect medicines on a patient’s behalf in the event they cannot go personally.
“This helps us to follow up on patients. Medication is picked up from the service provider and delivered to an identified point, such as the occupational health clinic at Nestlé, which means a large number of people do not have to leave their workplaces. This is not just for ART, but also for chronic diseases such as hypertension, diabetes and asthma.
Decanting
“Then we can also trace our defaulters, as the service provider informs the service team and advises them that they need to follow up on a patient. Once a patient has defaulted, they have to join the queue again, so adherence is encouraged. This also encourages responsibility.”
Tsibolane said that 90% of patients are on fixed dose combinations and deemed stable after six months of treatment. Once stabilised, they are transferred to the CCMDD programme in a process termed decanting. This will become even more essential because it is expected that the UTT programme will increase numbers, and nurses will be overwhelmed.
When asked about the disproportionate ratio of male to female nurses, Molongoana said that there are actually a number of operations managers who are qualified male nurses. “We do have them, but there is not a programme to actively recruit them. We also need nurses with specific skills, especially with the expected increase in numbers as awareness grows.
“We now have ward-based outreach teams who go out into our communities — care workers from the same community, with nurses as team leaders, working with community caregivers who refer back to the nurse if they cannot handle the levels. This forms part of the national strategy of primary care engineering,” said Molongoana.
Managing stock on the CCMDD programme is a critical factor for its success and to ensure continuity of supply, and there are a electronic monitoring systems in some hospitals and clinics.
All primary healthcare clinics are issued with a Samsung smartphone and have a partnership with Mezzanine and Vodacom. The phone is loaded with an application called the Stock Visibility Solution, which holds a stock list and facilities report, available on a weekly basis. If any of the stock items are at zero, then there is reporting showing where there is an alternative available. The bottom line objective is that no one leaves without treatment.
Where there are delinquent facilties that lose devices or chargers, the department steps in to assist. Molongoana said it is an on-going process, but they have seen a “tremendous” improvement in the availability of medication and transparency across the entire value chain — and there is better security.
“Yes, there are challenges, but a number of working strategies are in place, not just for supply, but supply of quality product. All drugs imported from India or China, for example, are from plants that are inspected by the WHO and if there are any deficiencies or non-compliance they will get shut down immediately. Medicines must be safe and effective,” said Tsibolane.
“We also have to strike a balance with beaurocratic controls, such as customs, constant checking for counterfeit goods and the vital component of paying our suppliers, which we have been able to do. Over the past four months, we have disbursed over R240-million to our suppliers up to the end of November, and in terms of the province’s ability to pay suppliers, we have made great strides. Our National Health Laboratory Services (NHLS) account is one of the most up to date in the country, and if not for the Free State, they would have closed shop long ago. We are trying our best.”
Easy HIV testing gets results
The process of testing is quick and painless, resembling the daily blood sugar test diabetics have to do. The screening test (Rapid Anti-HIV 1&2 Test) takes 15 minutes and, if positive, the Abon confirmation test (HIV Tri Line 1/2/0 Rapid Test) takes 10 minutes.
Testing goes far beyond the small prick required, as there is fear about the outcome. This highlights the importance of pre-testing counselling, where a patient is counselled about the implications should they prove positive. Then there is post-test specialised counselling, carried out by professional and specially trained nurses.
In the year to date, the Free State has 87 registered facilities and 81 medication pick-up points for chronic medication. There are 47 adherence clubs and 44 161 registered patients. To date, 344 113 medicine parcels have been delivered.
Working with SANAC
The Free State Provincial Council on Aids, which is chaired by Premier Ace Magashule, is accountable to the South African National Aids Council (SANAC), chaired by Deputy President Cyril Ramaphosa through a Cabinet decision.
“The rationale behind putting a politician here is to ensure that we have political commitment in terms of [a] multi-sectoral approach to implementing an HIV-Aids programme in this country,” said Tefo Tabi, head of the provincial council on the Aids secretariat programme.
“Furthermore, we have an arrangement that has been initiated by SANAC that we have to engage local councillors … the local level is [the] core where implementation lies. The ward councillor of ward x should understand its challenges and achievements. As a province, our strategic plans are mimicking the SANAC strategic plan.
“We are unique as provinces and our implementation plans differ … Our role is oversight and advice to government from local to national level, with possible solutions, to which government has been responsive. These include prevention [measures] such as condoms, medical male circumcision and pre-exposure prophylaxis after rape. We have spoken at length about these problems to ensure the strategic plan is implemented,” said Tabi.
Communal living over orphanages
Africans have historically lived in a communal setting. That is why the concept of orphanages is foreign to them, according to Mzonakele Fikizolo, deputy director general of strategic management and support systems for the department of health, Free State.
This phenomenon, he explains, is prevalent across Africa and not just southern Africa. “The issue of absence of orphanages was actually underpinned by the old adage that says ‘every child is my child’. This was how Africans lived and that created a safe environment for children.,” explains Fikizolo. “If one understands the concept and live by it, there is no way I can abuse my own child as every child is my own.
“That is why my mother would leave me with my uncle because I am his child, or with a brother, granny or aunty. Once we loose that understanding then we loose the moral fibre of our Africanism … We are also talking about issues of separation and separation anxiety. Now there is the orphaned child, and a child that is infected. If you remove a child or children living in a child-headed home and put her in a hospice or foster care home, you are actually delivering two blows at once. You are both separating [the child] from siblings [and placing them] in a new and strange environment, and the parents have died of Aids, so the child or children are grieving.
“We need to find a way of dealing with this, and the questions around orphanages need to be looked at from another angle. If we take one child in, we need to take them all, and arrange how you deal with them when they are there — but you [should try to] keep [a] semblance of family.”
Fikizolo believes that with children at risk of being exposed to and becoming part of the cycle of violence, it is important that there are places of safety, but it is also essential to look at African communal living, and letting children know that they are not alone.