In-depth: Countdown to Universal Access

SOUTH AFRICA: No simple formula for universal access

Photo: Antony Kaminju

Some districts are using task-shifting to reach their targets for universal access

JOHANNESBURG, 3 August 2009 (PlusNews) - Nowhere is the goal of universal access to prevention, treatment and care more daunting than in South Africa, where an estimated 5.5 million people are living with HIV - the largest burden in the world.

While South Africa now has the largest treatment programme in the world, with about 700,000 people receiving the drugs, a further 760,000 are estimated to qualify for treatment under the current national guidelines, and there is limited evidence that the rate of new HIV infections has slowed.

Mark Heywood, director of the AIDS Law Project and deputy chair of South Africa's National AIDS Council (SANAC), said former President Thabo Mbeki's dissident views on HIV/AIDS resulted in the national response getting off to a damagingly late start.

"What we're seeing are the chickens of Mbeki's AIDS denialism coming home to roost," he told IRIN/PlusNews. "We wasted from 2000 to 2006 with the president putting it about that maybe there wasn't a thing called HIV at all. As far as prevention is concerned, that's the period when the epidemic was moving into its exponential growth phase."

The legacy of the Mbeki era was not only an inadequate prevention response, but a treatment programme that had to hit the ground running and is still playing catch-up.

The goal of universal access was born in December 2005 when the United Nations General Assembly adopted a resolution to assist governments, civil society and NGOs with "scaling up HIV prevention, treatment, care and support with the aim of coming as close as possible to the goal of universal access to treatment by 2010 for all those who need it."

Need for more innovation

The adoption of a five-year National Strategic Plan (NSP) in 2007 that aimed to put South Africa on a path to achieving universal access was welcomed by civil society as the beginning of a new era of greater government commitment. The NSP's goals included halving new HIV infections by 2011, providing treatment to 80 percent of people in need of it, and reducing mother-to-child transmission of HIV to less than 5 percent.

Opinion is still divided about whether the targets were overly ambitious, but most experts agree that they are now realisable only in the context of major health system reform and a more innovative approach to stretching limited resources.

"If we're really going to make the big leap, we need to completely change the way we work," said Dr Mickey Chopra, director of the Health Systems Research Unit at the South African Medical Research Council. "It's going to take a change in mindset and innovation, both technological and in terms of delivery."

Some districts have achieved universal access to ARV treatment by decentralizing services from hospitals to primary healthcare clinics, and training nurses to take over some functions from doctors (called task-shifting), but this has not been uniformly applied.

What we're seeing are the chickens of Mbeki's AIDS denialism coming home to roost ... We wasted from 2000 to 2006 with the president putting it about that maybe there wasn't a thing called HIV at all

"There are many pools of excellence in prevention, in care, in treatment, but there's completely insufficient coordination and generalization of best practice ... for that reason I believe we're failing in most areas on the NSP," said Heywood.

The NSP and SANAC's Treatment Task Team both recommended task-shifting, allowing nurses to initiate and manage ARV treatment, and lay counsellors to administer HIV rapid tests to alleviate the public health sector's shortage of professional staff, but the health department has yet to act on these recommendations; currently only doctors can provide ARV treatment and only nurses can do HIV testing.

Frequent changes in the health department have not helped. The removal of Mbeki ally Manto Tshabalala-Msimang as health minister in September 2008 was welcomed by AIDS activists, but her replacement, Barbara Hogan, only had seven months before newly-elected President Jacob Zuma moved her to another portfolio and installed Aaron Motsoaledi as the new health minister in May 2009.

Finding the money

To achieve and maintain universal access to treatment, South Africa would need to start an additional 450,000 people on ARVs every year, but a failure to properly cost the NSP or to manage provincial HIV/AIDS budgets are proving to be major hurdles.

The Treatment Action Campaign (TAC), a prominent lobby group, has pointed out that to start 285,000 people on ARVs in 2009 would require about R1 billion (US$122 million) more than the government has allocated.

Several experts note that universal access to treatment may be achievable by 2010, but it will become unsustainable unless there is significantly more progress on prevention.

Dr Susan Cleary, director of the Health Economics Unit at the University of Cape Town, estimated that by 2021, South Africa would need to spend R25 billion per annum - equivalent to about two-thirds of the current health budget - to keep up with the current demand for treatment.

"There's been a commitment to a particular course of action ... but now it's a question of facing up to the reality of what it actually implies," she told IRIN/PlusNews. Tough choices might need to be made between the most effective care and the most cost-effective.

Research demonstrates that patients who start treatment earlier have better outcomes, but already the National Health Council has rejected a recommendation from SANAC's Treatment Task Team to begin ARV treatment at a CD4 count of 350 rather than at 200. Heywood said the decision was "purely budgetary".

Leigh Johnson, of the Centre for Actuarial Research at the University of Cape Town, said changing the national treatment guidelines would widen the current treatment gap from about 760,000 to about 1.8 million.

If prevention has been the missing link in South Africa's efforts to achieve universal access, the 2008 national HIV survey by the Human Sciences Research Council revealed only limited proof of improvement: infection rates decreased among children and teenagers, but rose slightly in adults over the age of 25.

Overall, prevalence has flat-lined at about 11 percent for the last six years, but risky behaviours like having multiple partners and engaging in intergenerational sex are spreading among young people.

"We certainly don't have evidence we're succeeding on prevention," said Heywood. "We're not reaching any of the high-risk groups, and there's very little targeted programming for sex workers, refugees, and men who have sex with men."

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[This article is the first part of an IRIN/PlusNews series on "Countdown to Universal Access"]