In-depth: The Treatment Era: ART in Africa

SOUTH AFRICA: Rollout bogs down

Photo: IRIN
Rollout bureaucracy: ART is not just about drugs, but personnel and the health infrastructure
JOHANNESBURG, 6 December 2004 (IRIN In-Depth) - One year after the South African government launched its much-anticipated HIV/AIDS treatment programme, there is frustration at the slowness with which the plan is being realised.

In November 2003 the government committed to providing free antiretroviral (ARV) treatment to 53,000 patients by March 2004. The figure is a fraction of South Africa's HIV positive population, estimated at over five million, but was nevertheless an ambitious beginning to what was to be the world's largest ARV rollout to date.

That target date has since been moved forward a year, and by the end of November 2004 the number of patients receiving the life-prolonging drugs was estimated by the Joint Civil Society Monitoring Forum to be 18,500.


The department has attributed the disappointing pace of ARV rollout to a lack of capacity and trained staff at treatment sites, especially in poorer provinces. But leading AIDS activist and outspoken chairperson for the Treatment Action Campaign (TAC), Zackie Achmat, is convinced that the slow pace is less the result of a lack of resources or capacity, than a lack of political leadership stemming from the government's "denialism".

"There are enormous challenges in terms of human resources, but those will never be sorted out without political leadership," he said.

Achmat was speaking at a TAC event in Pretoria in November 2004, aimed at pressuring the government into making public an implementation timetable for its treatment plan that would make the health department more accountable. It is unclear whether such a timetable exists. In its weekly online newsletter, the government responded that TAC was in fact hampering the rollout by wasting officials' time, which could be better spent "at the forefront of service delivery".

The ANC conceded in its newsletter that the process of selecting a manufacturer to provide ARV drugs for the rollout was yet to be finalised. The tender should have been completed by June, and Andrew Boulle of the School of Public Health and Family Medicine at the University of Cape Town was not alone in suggesting that the delay had been a factor in limiting patients' access to treatment.

"For the provinces that are weaker, the delay in finalising the tender has been a barrier to getting started because they've deferred setting up their own procurement mechanisms," Boulle commented.

Even in the relatively well-resourced urban province of Gauteng, which has made impressive strides with its rollout and is expected to meet its patient targets, the numbers of people awaiting treatment are stretching hospitals to their limits.

Johannesburg General Hospital was among the large inner-city hospitals at the forefront of Gauteng's rollout launch in April. Professor Jeff Wing, who oversees the clinic, said the hospital had been able to halve its waiting list from six to three months since April because, unlike many hospitals, it was well staffed and had a dedicated ward for the clinic.

Despite this, he added, "there's this backlog of patients. I don't know the numbers but it must be millions, so even if we were able to work 24 hours a day, seven days a week, we'd still have a waiting list."


With its spacious ward devoted solely to antiretroviral therapy (ART), its full-time team of 15 doctors, six nurses and 10 counsellors, and its steady increase in patient numbers since April, Johannesburg General could deservedly be called a model example of how effectively ART can be administered to large numbers of patients.

But then there are facilities like the one at Natalspruit Hospital.

The antiretroviral clinic at Natalspruit services a large area that includes several former townships south of Johannesburg. When it was launched in late July as part of Gauteng's second wave of treatment sites, there was little infrastructure in place to handle the immediate demand for ART.

Four months later, little has changed. Only 180 patients are receiving ARV drugs, compared to Johannesburg General's 1,000, and the clinic is still housed in the small prefabricated structure without air-conditioning that it shares with the hospital's social work department, where the corridor is too narrow to roll a stretcher down.

The lack of space is compounded by a lack of full-time staff: the two doctors, three nurses and one pharmacist at Natalspruit who have received training in ART have to divide their time between the clinic and their responsibilities in other departments. Even the clinic's project manager, Sister Mavis Ngwenya, spends a good portion of her day crisscrossing the hospital grounds between the clinic and the outpatients' ward, which she also manages.

By 3.00 pm on a Tuesday, the one day a doctor is available to prescribe ARV drugs to adults, Ngwenya looks exhausted.

"You feel like not coming back tomorrow," she said, mopping perspiration from her brow with a handkerchief. "It's too much load on one person."

The provincial department of health has so far not made good on its promise to hire additional doctors and nurses. Overworked and overwhelmed by the numbers of patients trying to access treatment, Ngwenya fears that her staff are starting to lose the passion and enthusiasm needed for such work.

Dr Tolela Kitoko, who oversees paediatric treatment at the clinic, shares her concerns.

"There's a need for us to see more patients but, because of our staff, we're limited. We're seeing a small percentage of the people that should be seen. We'd like to have more doctors and nurses on a permanent basis, and a full-time pharmacist, so we could run the clinic more than once a week," he said.

A spokesperson for Gauteng's department of health, Simon Zwane, said his department had made no secret of its recruiting difficulties.

"There is a problem with recruitment that the country as a whole is facing. We're not getting enough applicants, especially for hospitals like Natalspruit that are in township areas."

The national department of health was working towards a programme to train more health workers to administer ARV treatment but, according to Fatima Hassan of the AIDS Law Project, the programme was several months away from being finalised, with no interim plan in place.

Zwane said Gauteng had managed to recruit 70 percent of the 214 additional staff needed to implement its rollout through head-hunting, increased pay scales and rural allowances. He denied that any of the 19 facilities currently offering ART in the province had the long waiting lists reported by groups like the AIDS Law Project.

Indeed, despite its lack of space and manpower, the clinic at Natalspruit had so far avoided having to turn patients away. Most patients who qualified for treatment completed their four adherence counselling sessions and began receiving the drugs within two months. Dangerously ill patients could begin treatment in two to three weeks.

But the number of patients arriving at the clinic was increasing weekly, Kitoko said, and without more trained staff, there was a limit to how many could be treated. Meanwhile, follow- up support from the health department had dwindled.

"Initially, when we went through the training course in July, they were very supportive," Kitoko said, "but now we feel like it's losing steam a bit; we feel like we're left on our own."

"They call to get statistics, but they don't come to see for themselves," Ngwenya agreed. "If only they could hire us to work here Monday to Friday full-time, and hire two full-time doctors, we could give ARV treatment five days a week."

[Resource: Treatment Action Campaign -]
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Links & References
  • The WHO 3 by 5 Initiative
  • The Global Fund to Fight HIV/AIDS Tuberculosis and Malaria
  • The President's Emergency Plan for AIDS Relief
  • World Bank AIDS site
  • Pan-African Treatment Access Movement
  • WHO Prequalification Project
  • Eldis Resource on ARVs
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