After five years of groundbreaking work in the treatment of HIV/AIDS, medical humanitarian agency Medecins Sans Frontiers (MSF) are preparing to pull out of their most successful South African programme.
They began offering antiretroviral therapy (ART) in the poverty stricken Cape Town township of Khayelitsha in 2001, when the provision of anti-AIDS drugs in the public sector was still illegal. The South African government deemed the rollout too complex and expensive to implement.
"Doctors within MSF were frustrated by the positive impact antiretroviral therapy (ART) was having elsewhere, while thousands continued to die prematurely in South Africa," explained Dr Eric Goemaere, head of mission for MSF South Africa.
MSF committed to a five-year plan to treat 180 patients in Khayelitsha, which has the largest concentration of HIV/AIDS patients in South Africa. The organisation estimates that 70,000 of its half a million population are infected with the virus.
A national HIV treatment and prevention plan was eventually approved by the government in 2003. With extra financial support from the Global Fund to fight HIV/AIDS, Tuberculosis and Malaria, and a reduction in the cost of anti-AIDS drugs, MSF was able to enrol more patients in ART. The organisation established three dedicated HIV/AIDS clinics in Khayelitsha's public health facilities, where they now treat close to 3,000 people.
"The Khayelitsha experience has revolutionised HIV/AIDS treatment as we know it," Goemaere told Plus News. "Before treatment was introduced local people did not see the point in getting tested. Now they know if they are HIV positive, help is at hand." MSF figures showed there were fewer than 500 tests taken in 2000 - last year that figure increased to 28,000.
In 2004 the World Health Organisation (WHO) credited the Khayelitsha project as a model of best practice in implementing antiretroviral therapy. It had proven the feasibility of ART in the poorest conditions and with the weakest patients.
As the first NGO to provide ART in South Africa, MSF were regarded as trailblazers because there was no established strategy for them to follow. "When we went into the HIV/AIDS problem, we had little idea of how we would get out of it," admitted Goemaere, who set up the Khayelitsha project.
"There is always a great fear with aid agencies of substituting for government responsibility, but with HIV/AIDS it is far more complicated. The clarity between when you are meeting a critical need and when you are doing someone else's job is far less obvious."
Despite the uncertainty surrounding their exit strategy, MSF has insisted it was never their job to stay in Khayelitsha forever. "The idea was to kick-start the process, make it sustainable and then re-invest our resources elsewhere," said Nathan Ford, the Access to Medicines Coordinator for MSF South Africa. "As a private NGO our job is to go in, tackle an acute need and advocate that those properly responsible take over."
MSF have started reducing their role in providing drugs, staff and other resources to the Khayelitsha clinics. The provincial health authority for the Western Cape expects to take full control by mid-2007.
But, given the government's approach to HIV/AIDS treatment in the past, a deep-rooted scepticism remains amongst patients and staff about the province's ability to sustain the programme once MSF has pulled out.
Nurse Mpumie Mantananga is responsible for managing Khayelitsha's Ubuntu clinic in the heart of the township. "Running this site will only become more challenging as the numbers on ARVs not only get bigger, but get older and need more treatment options," she said, indicating a waiting room crammed with patients.
"My worry is that the number of clinical staff will not keep up with the increasing workload. We already have an insufficient number of nurses and their role is critical to the successful rollout of ARVs," she added.
The Western Cape provincial health authority acknowledged concerns about the nursing staff shortage, saying it was a problem they needed to address across the health service, but insisted they would provide a quality ARV service in Khayelitsha.
"The treasury says they are committed to giving money to the HIV/AIDS facilities there, and we are acting in good faith on that," stressed Neveline Slingers, the Western Cape province's antiretroviral programme coordinator. "It will take time though - Khayelitsha is our biggest site, and integrating MSF's treatment programme into the rest of the provincial health service is a major undertaking."
What both MSF and the provincial health authority recognise is that the role of grassroots organisations such as the Treatment Action Campaign (TAC) will remain critical. Since 2003 there has been a dramatic increase in TAC's activities in Khayelitsha, where they have built up strong relationships with those receiving ARVs.
"The management handover has been discussed at length with patients," explained TAC's district coordinator, Mandla Majola. "For them, it is not just about health workers handing out anti-AIDS drugs every month - they realise they need long-term support and are worried that over time, under government supervision, it will not be there."
To guard against this, MSF intends giving the TAC a more prominent role to fill the gap created by their departure. Goemaere told Plus News, "If the transfer of services is to stand any chance of success, TAC must be involved in the future. They act as a permanent monitoring body over treatment and will put pressure on the provincial health authority to maintain quality of service."
Khayelitsha is MSF's first HIV/AIDS treatment programme to be handed over to the authorities and the end result has implications for thousands receiving care elsewhere on the continent.
"Handing back is our biggest challenge, but this defines the pace of our handover. We are transferring the services gradually in our efforts to make it a success," said Goemaere.
In what is uncharted territory for them, MSF admitted that mistakes might be made during the process; but they will be important lessons the aid community as a whole can apply elsewhere.