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Roll-out or cop-out on AIDS Drugs?
Nawaal Deane. 27 February to 04 March 2004. Mail and Guardian. Republished with kind permission of the Mail and Guardian.
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Pity the person with AIDS who is trying to find out where to go for anti-retroviral (ARV) treatment or how long it will take for the drugs to be available. The Mail & Guardian?’s attempts for the past month to obtain concrete information from each province suggest that public access to the life-prolonging drugs will be akin to a lottery and will depend on where you live.
Only in Gauteng, the Western Cape and, at a push, the Free State, are patients assured of ARV treatment within the year. KwaZulu-Natal, once a hopeful contender for rapid roll-out, appears to have fallen behind. Only six of the nine provinces have responded to the M&G?’s numerous faxes and e-mails sent. Of those that did respond, some were evasive.
It is evident that progress on roll-out depends on leadership within each province and the province?’s ability to take the initiative from the national Department of Health. Our snapshot view reveals confusion and delay, a vacuum in the political leadership driving the campaign, and the stark reality that access to ARVs will be very uneven across the country. The main delay has been in the accreditation of sites by the national health department. Basically, if you are HIV-positive, your life depends on which province you live in.
Challenges facing provinces include insufficient human resources, lack of training of health care workers, lack of treatment literacy, delays in the procurement of the drugs and the need for specialised equipment. With these constraints, one doctor told the M&G, the target set out last November in the national Aids plan ?— to treat 53 000 people by the end of March 2004 ?— is overly ambitious.
According to the plan, by the end of 2004 there should be 53 new ?“service points?” in operation, providing the first tranche of the roll-out. The accreditation process requires sites for ARV roll-out to be approved by a team from the national health department. This has caused delay. Also, tender processes for the procurement of the drugs, now under way, should have begun last year while the national plan was being drafted, say HIV/AIDS activists. The result is that even sites ready to implement the plan have to wait until the overall tender process is complete.
Accreditation has been criticised as an unnecessary delay. HIV/AIDS activists argue that there should be immediate treatment of emergency cases. ?“The MTCT [mother-to-child-transission] programmes give us sites where we can go ahead,?” said Nonkosi Khumalo, the Treatment Action Campaign?’s (TAC) treatment project coordinator. At these sites, mothers are receiving an ARV dose sufficient to prevent transmission to their unborn children, but do not have access to treatment for themselves.
Khumalo said the accreditation process is preventing those sites already providing MTCT programmes from procuring drugs to provide such ARV to the mothers: ?“Why not let them go ahead? They have already been providing Nevirapine.?”
The Ministry of Health says the accreditation process is almost two-thirds complete, and that more than 120 institutions needed to be visited for accreditation purposes. The Western Cape is the front-runner of all provinces, with 13 sites already providing treatment. Those sites, however, still have to undergo the accreditation process. ?“At first I was reluctant for the sites to go through accreditation,?” said Faried Abdullah, deputy director of health in the Western Cape, ?“but it was a worthwhile process in the end.?”
The province plans to get five more sites working within the next few months, and has applied to the Global Fund for HIV/AIDS, TB and Malaria for funds to expand its treatment plan. ?“The national department was helpful with the proposal and we received uniform protocols from Pretoria,?” he said. The Western Cape has created strong partnerships with NGOs in the United Kingdom and with Médécins sans Frontières, which has been providing ARV treatment in Lusisiki, Eastern Cape, as a rural pilot project for public health care.
The Eastern Cape did not respond to the M&G?’s questions, but media reports indicate that seven hospitals in the province are potential ?“service points?” or accredited sites.
The Northern Cape has five sites ready, but laboratory services for only two. It said provinces need support from civil society to provide information on HIV, AIDS, ARVs and nutrition, to be able to offer testing and counselling. When asked how soon the province will be able to roll out ARVs, the comment was: ?“When the national minister makes the announcement. But we are already giving treatment for post-exposure prophylaxis for sexual assault.?”
Rural provinces such as North West, one of the first to be visited by the task team, have submitted four sites for accreditation. ?“Challenges facing the province remain our ability to attract skilled health workers and doctors,?” said North West health spokesperson Barba Gaoganediwe.
He said the province has high levels of illiteracy and lack of access to mainstream mass media, which means that treatment literacy, necessary for adherence to drug programmes, will be a major obstacle.
Mpumalanga and Limpopo did not respond to the M&G?’s questions, despite repeated requests.
The Free State plans to start implementing the plan in May or June. Dr Ronald Chapman, executive manager of health support in the province, said this was ?“dependent on multiple factors, namely: the availability of drugs, the availability of trained staff, and accreditation of the ARV sites?”. The province envisages one site in each of its five districts by year-end. ?“The plan is to introduce one site per month, starting with the Bongani ARV site, which is in Welkom, on May 1 2004.?”
KwaZulu-Natal, generally seen as one of the more progressive provinces when it comes to taking the initiative, did not expand on its roll-out plans. It is rumoured to have four sites ready for accreditation. When asked about its progress, the province?’s health department, which admitted it was concerned about physical facilities and budget, said cryptically: ?“The plan of the province has been prepared together with the action plan.?” KwaZulu-Natal?’s progressive image is fast faltering: insiders point to the two- year delay in accessing funds from the Global Fund for the Enhancing Care Initiative, one of the largest potential treatment projects in the province.
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