Year ender - ARV rollouts in 2003 bring rising hope

The year 2003 saw several African governments rolling out national anti-AIDS drug treatment programmes, suggesting a significant shift towards improving access to antiretroviral (ARV) drugs. In a dramatic finish to the year, the World Health Organisation (WHO) unveiled its much anticipated "3 by 5" plan to treat three million HIV-positive people by 2005. Government officials are hoping the WHO target will strengthen existing treatment initiatives and accelerate what has been regarded as a slow response to the pandemic by African countries. OUT OF THE STARTING BLOCKS South Africa announced late last year it would undertake the world's largest treatment programme by providing anti-AIDS drugs free of charge in the public sector, ending years of controversial debate that delayed treatment for people living with the virus. This could mean that within a year, ARVs will be available from at least one service point in all of South Africa's 56 health districts. A plan to treat up to 10,000 people is currently underway in Zambia and "around 7,000 people are receiving the drugs," in nine provincial centres throughout the country, Minister of Health Dr Brian Chituwo told PlusNews. It was hoped that Zambia would provide treatment to 100,000 HIV-positive people under the WHO plan, he noted. Meanwhile, the Namibian government kicked off its treatment campaign at a few pilot sites last year, but the drugs have since become available at a growing number of regional and district hospitals. Malawi also unveiled plans to provide ARV treatment to as many as 50,000 people, using a grant from the Global Fund to fight HIV/AIDS, Tuberculosis and Malaria to provide the medication free of charge at public hospitals and clinics. The international community heightened expectations across the continent. The Clinton Foundation HIV/AIDS Initiative secured a deal with generic drug firms to reduce the cost of commonly used triple-drug regimens to US $0.38 per patient per day. The deal will also cut by half the cost of the ARV drug nevirapine - used to prevent mother-to-child transmission of HIV - for people in developing countries. By 2008 the Foundation intends to provide ARVs to as many as two million people in Rwanda, South Africa, Mozambique, Tanzania, and the Caribbean. The Canadian government announced late in 2003 that it would present legislation to change the country's patent laws to permit exports of lower-cost generic medicines to developing countries. But beneath the hype surrounding these and similar breakthroughs lies the growing realisation that for all these projects to succeed, more adequate planning will have to be done. THE DEVIL IS IN THE DETAIL "We have to pay attention to the details now. The world must not write off Africa and say these poor countries can't do it," Chituwo commented. One of the more pressing details is the shortage of trained workers in the region's ailing public health care sector. When embarking on its rollout, nine provincial hospitals in Zambia were identified as initial ARV distribution sites. "It didn't matter if it was a government or a missionary facility - as long as there was capacity," Chituwo added. For starters, each hospital was equipped with a physician, psychosocial counsellor, social worker and laboratory technician, with a community member appointed to assist. Chituwo said: "Now these centres are in all nine provinces and have now been adequately trained to spearhead treatment throughout the rest of the country." But country programmes would not be able to move beyond district hospitals without human capacity, he pointed out. "Now it has hit us that we really have to train people as quickly as possible." With limited resources and the ever-increasing problem of health care workers fleeing to developed countries, it remains to be seen how countries will cope with the lack of manpower. Zambia is experiencing the problems first encountered by Botswana. The Botswana government's decision to provide free ARV drugs to all its citizens living with HIV/AIDS attracted considerable international attention and approval in 2002. The programme, named Masa, a setswana word meaning "dawn", has been implemented at six sites in the country, enrolling more than 9,000 people in 18 months. A further seven sites were expected to open before the end of 2003. In a progress report released in August 2003, Masa identified the need for greater emphasis to be placed on planning and preparation; information, education and communication; training; laboratory capacity; pharmaceutical logistics, and ARV therapy services. In South Africa the final draft plan drawn up by the department of health's ARV task team set aside a significant portion of funds for the training of thousands of nurses, doctors, laboratory technicians, counsellors and other health workers. "All this talk about support and training for staff ... we don't have time to get training. The [staff] shortages have to be addressed first," Sister Sue Roberts, head nurse at the Helen Joseph clinic in Johannesburg, told PlusNews in August. The cost of the programme starts at US $45 million and is expected to rise to about US $687 million per year by 2007/08 - around 11.5 percent of South Africa's current public-sector health spending, according to Finance Minister Trevor Manuel. BOLSTERING PREVENTION EFFORTS Although some argued that the Namibian government should have introduced more pilot sites before the national roll-out of its programme, the country had taken a "bold step" by launching its campaign "very rapidly", Lucy Steinitz, national coordinator of the Namibian NGO, Catholic AIDS Action, told PlusNews. But this meant there were still a lot of "wrinkles to be ironed out". Most Namibians still do not understand "as much as they need to" about treating the disease. She warned that the country's "accelerated operating procedures" could not afford to ignore the role of prevention. "You need to correspond prevention messages and treatment messages, to prevent people from thinking in an over-simplistic way ... because there are ARVs, people could think there is no need to take prevention seriously," Steinitz said "If this happens, we will find ourselves moving two steps forward and then two steps backwards." One of the main features of South Africa's plan is the scaling-up of its prevention campaigns, "so that the 40 million South Africans not infected stay that way." "We are quite excited about the fact that the issue of ARVs will not be considered in isolation. The needs of our families, and those who choose not to take the ARVs, seem to have been considered," national director of the National Association of People Living with AIDS (NAPWA), Nkululeko Nxesi, told PlusNews. NUTRITION, CARE AND SUPPORT Adequate nutrition and positive living have been well-recognised as crucial to the success of any ARV drug regimen, but the challenge will be how these national programmes address this in their rollout. Steinitz pointed out that the region's drought and food shortages, affecting more than 6.5 million people, would make this even more difficult. According to Chituwo, Zambia's government has been in talks with the World Food Programme to assist with the supplementary feeding of vulnerable HIV-positive Zambians currently on treatment. "We can't run away from it - good food is part and parcel of any successful programme. This year, we have to ensure household food security as much as possible," he said. Specific details of nutritional support in government treatment programmes are lacking. "It is not quite clear how we are going to get around this, but we are working on it." Chituwo called for the greater involvement of community members and people living with HIV/AIDS to assist in the programme. Nxesi agrees. "For something like this to work properly, PWAs can not just be seen as passive recipients - they need to be a part of the campaign from day one," he noted. "They tell us that the traditional African community cohesion is under strain - but it hasn't been completely eroded, and that is what we are going to exploit," Chituwo added. THE YEAR FOR DELIVERY 2004 could be the year when people living with HIV/AIDS finally started to benefit from "all these long-awaited treatment promises" Nxesi predicted. "This is an exciting time for the region. It is obvious that everyone has realised that we have to treat people - but we also have to do it urgently," Chituwo stressed. Zambia has just received a World Bank grant of US $42 million, and a large part of this will go towards the country's treatment programme. "As we roll out the treatment, we are seeing more assistance coming in. But what is even more exciting, is that we have been allocated 100,000 patients to treat under the WHO 3 by 5 plan." After a sluggish initial response, the political will in the region had now been strengthened. "This is starting to filter down to all levels of government," Chituwo said. Nevertheless, as Steinitz pointed out, the problem was no longer the absence of political will. "The will is there - we now have to find out how we will act on this will."