Dr Aaron Motsoaledi, appointed South Africa's Health Minister about a year ago, is in charge of the world's largest antiretroviral (ARV) treatment programme. Many AIDS activists credit him with helping to usher in a new approach to HIV and AIDS, including changes to treatment guidelines announced by President Jacob Zuma on World AIDS Day 2009. Can the government deliver? IRIN/PlusNews spoke to the minister to find out.
QUESTION: Your target is to test about 15 million South Africans by 2011. What is the point of scaling up testing when the country's treatment capacity is still lagging?
ANSWER: Our treatment capacity has been markedly boosted since the president's announcement on World AIDS Day. We have increased our [health] budget from the previous financial year [March 2009 to February 2010] ... there's a difference of 33 percent, which is the biggest budgetary increase in any item in the budget.
When you are [HIV-]positive, you don't only gain from treatment, you also gain from a change of lifestyle. Some may not need treatment but they will know through the HIV testing and counselling (HCT) campaign that they are positive, and may start attending sessions about how they should change their lifestyle and how they should live.
Q: President Zuma has made some significant changes to HIV treatment guidelines to make more people eligible for treatment. Can the country afford it?
|In the past [we] never applied for ARV [funding]...The Global Fund never funded us for ARVs because...there was no internal willingness|
A: The new changes are the ones that caused the budget to increase by 33 percent, and Treasury has been able to make that money available, but PEPFAR [US President's Emergency Plan for AIDS Relief] has also helped [with] a contribution of 900 million rand [US$120 million] over a two-year period.
We are also hoping to apply to other multilateral organizations, like the Global Fund [to Fight AIDS, Tuberculosis and Malaria], which has been funding a lot of our HIV/AIDS campaign.
In the past [we] ... never applied for ARV [funding] ... The Global Fund never funded us for ARVs because ... there was no internal willingness to do so [on the part of government] ... in the next [Global Fund] round [of grants] we will definitely apply for funding for ARVs.
Q: When will we start treating HIV-positive adults with a CD4 counts of 350, in line with current World Health Organization guidelines?
A: We don't really have a timeframe ... [for starting ARVs sooner]. We decided, with the president: let's choose those living with HIV that are most problematic.
We chose pregnant women, the maternal mortality was troubling us; we chose tuberculosis (TB) co-infected people because TB is becoming an intractable problem in the country; we chose children under the age of one [year] because infant mortality is out of control; and we also chose prevention of mother-to-child services because we believe that it is possible to have zero percent of children born HIV-positive.
Those four we thought we could manage, and we've been able to manage them with our internal resources. Of course, if we get any other resources, we'll move everyone to [a CD4 count of] 350, but it just wasn't possible.
Q: What would you say in response to allegations that the government's previous HIV prevention and awareness campaign, Khomanani, has been a failure?
A: In June 2009, the Human Sciences Research Council launched a report ... on the four government-funded agencies handling messages on HIV. They ranked Khomanani [the worst], but said it was the most highly funded.
The Khomanani tender was supposed to be reissued in August  but I approached the deputy president and told him that Khomanani had been working in a different paradigm, and that there's a new paradigm after the World AIDS Day announcement by the president and our decision to launch a massive HCT campaign - we can no longer go on with the old message.
|You are running that hospital ... it's your duty to determine whether you have stocks for the next two weeks - you don't just sit there, like a child, waiting|
I said, 'We need to sit down within SANAC [South African National AIDS Council] and decide on the message we need to be sending to communities, and who must capture that message and disseminate it.' That has not yet happened and I am waiting for SANAC, because it is then that you develop specifications [for the tender] and then everyone, even Khomanani, can apply.
Q: What is being done to prevent ARV shortages?
A: [We commissioned] a review of our drug policy, and one of the briefs was to examine drug stock-outs – to follow our procurement method, from the time a tender is issued to the time someone gets a bottle of medicine in a village - and find out what is wrong.
In South Africa, it wasn't that drugs were running out at depots, it was a problem of logistics. When you go to the depots, you find lots of drugs - some that are even expiring.
Hospital CEOs [chief executive officers] will sit there and say, 'It's not my job [to guarantee drug supplies], it's that of government'. When the drugs run out, the provincial government will say, 'We were never told'.
I called the CEOs and said, 'You are running that hospital ... it's your duty to determine whether you have stocks for the next two weeks - you don't just sit there, like a child, waiting. I told them that 'When we come to judge the quality of care at your hospital, this [stock-outs] will be part of it'. CEOs must be able to show that they raised an alarm – and not on the day that drugs run out.
I also believe HIV/AIDS must be a special programme. Now, HIV falls under general pharmaceutical procurement, but ... [funds for ARVs] should be for ARVs and nothing else. Once we issue this tender, which has been sent to Treasury, we must make sure that provinces are not tempted to cannibalise ARV money whenever their health budget elsewhere is depleted.
Q: When will we get wider access to condoms in prisons?
A: There is ambiguity in the minds of people; it's not a scientific fact, it's just in people's minds. They believe that if you provide people with lots of condoms, you are encouraging them to engage in lots of sexual activities.
There was an argument among nurses - which I never agreed with - that if a girl comes to a clinic to ask for contraception, the nurses would say, 'No go and ask your mother, you are still too young'. The next time the girl visits, she's pregnant.
There was a [similar] argument about whether we should distribute condoms in schools ... I understand this is a sensitive issue for parents, but in prisons that's nonsense. We know sex is happening, and so we must provide them with condoms ... You can't play around, that's one area where condoms must be very abundant.