SOUTH AFRICA: Interview with Dr Nomonde Xundu, head of govt's HIV/AIDS unit

JOHANNESBURG, 30 Mar 2005 (PLUSNEWS) - In November 2003 the South African government launched its much-anticipated HIV/AIDS treatment programme, committing itself to providing free antiretroviral (ARV) drugs to 53,000 HIV-positive people 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, to March 2005, but still seems unlikely to be met. PlusNews spoke to Dr Nomonde Xundu, chief director of the department of health's HIV/AIDS and TB unit about the challenges of rolling out the programme.

QUESTION: Can you give an assessment of the progress made in implementing the country's treatment plan?

ANSWER: [Our goal] in the first year (we started on the 1st of April 2004) [was to] have a service point in each health district - there are 53 of them. So we are now confidently in 51 of those, and we know by the end of March we'll have covered all 53 districts.

We had to implement a complex programme in an overstretched health system, with gross inequalities, that was faced with the AIDS epidemic.

Part of doing this was making sure that there are skilled people, additional resources, a well coordinated national health laboratory system and good quality of care, in terms of providing protocols, training, and monitoring what gets done on the ground.

So when you ask about progress, we need to report on all of those things.

Q: Could you describe the scale of the HIV/AIDS epidemic in South Africa?

A: With about 45 million people [in South Africa], the annual antenatal clinic surveillance shows us that, of the pregnant women who come to public health services, 29.6 percent of them are infected with HIV. But with additional information from other sources we can infer that about 16 percent of the 45 million may, in fact, be living with HIV, which makes it about 5.2 million. We are thinking that about 16 percent of the 5.2 million are actually living with AIDS, in terms of the progression of the disease, and would require antiretroviral (ARV) therapy, amongst other interventions for AIDS-related complications.

Q: According to the figures you've mentioned, between 500,000 and 750,000 South Africans need treatment - how many are currently on ARVs?

A: We have managed to get about 33,000 people on ARV therapy over a period of nine months. Some provinces are doing better than others because some have experience. We needed more intense interventions in some provinces - mainly your rural-based provinces - to get them to a point where they could start [implementation].

Q: Are you satisfied with the progress so far?

A: If you look at the complexities of administering a programme like this - what needed to be done to make sure that it works, and doesn't undermine other health services in the public health sector, I think we're not doing badly. But the plan is to have universal access for all the people who are eligible for therapy in the course of five years - it would be impossible to do that within a nine-month period. So, given the constraints, we are not doing badly.

Q: What are some of these constraints?

A: We developed a tool to assess the readiness of each service point ... to indicate that ... [it was] ready to implement. We were looking, for instance, at the human resources capacity, and within that ... for skills - people who know how to ... [treat patients] on ARVs. We looked at the laboratory services within a facility and the availability of basic HIV/AIDS services - voluntary counselling and testing (VCT), the prevention of mother-to-child transmission (PMTCT) and post-exposure prophylaxis (PEP).

We also looked at emergency medical services ... patient tracking ... and information systems. So with that tool we identified gaps, put together strengthening plans for each of those 119 [ARV] sites - in fact, [in the country's 53 health districts a total of] 214 service points will have been accredited by the end of March.

Now 119 facilities have been found ready to implement the programme in ... 51 districts. People [were required] to move from the national offices to the districts to assist ... and we are rethinking to see how can we streamline the accreditation process.

Another area is human resource capacity. We've managed to get 35 percent of the targeted additional resources that we had identified in the Comprehensive Plan.

We managed to get 111 additional doctors, which I think is excellent, but what I'm worried about is that we may be bleeding the very system we are saying is under-resourced. It may be that the doctors ... we are finding come mainly from the public sector, but we need to ... do some research and find out exactly where these doctors are coming from. We struggled specifically with pharmacists, who are a critical component of the programme, as they have to sit with patients and explain to them how to take treatment [wouldn't a health worker/nurse normally do this?].

Provinces are mainly running their own [skills development and] training programmes. We've said we would set up regional training centres, but these have not been fully set up yet. We find that provinces have been outsourcing [this] to external providers, which has fast-tracked the process. We've seen up to about 8,000 service providers trained countrywide through these kinds of interventions, but obviously we are working hard to make sure training centres are established, rather than relying on outsourced services, which are not sustainable all of the time.

We have a National Health Laboratory System (NHLS) in eight of the provinces. We've had to increase laboratories that can do CD 4 tests [measuring the strength of the immune system] and viral loads and other tests. But we struggled in rural areas with the transportation of specimens [to laboratories]. In some cases, we found that specimens were not being transported in acceptable conditions. In desperation people will put a bag of specimens on taxis. [?]

We have now offered more CD4 testing - previously that has not been accessible because of cost - but now that's budgeted for under the Comprehensive Plan.

In terms of pharmacovigilance [?], this is the area we are really struggling with. I cannot, for instance, tell you exactly how many people are experiencing adverse effects from ARV therapy. There's lots of anecdotal reports from the ground that people are not managing on treatment, and ... even reports of mortality ... [which] impacts negatively on this programme ... so we need to closely monitor that.

With patient information ... we are currently relying on the paper-based system. We have different systems in different provinces. We would need to standardise that across the country.

The nutrition component of the programme we thought was very important. We know that a large majority of the people who are affected are poor - the majority of the people who will be using the public sector are people who would need augmentation of nutrition. So we communicate [information about] healthy living and healthy lifestyles, to guide people as to what a reasonable diet would be for a person who has a chronic infection. But we're also providing supplements, like different forms of maize meal ... as well as multivitamins.

The biggest challenges are human resource capacity, patient information systems and pharmacovigilance.

Q: What about the challenges in informing people about the plan, getting them to come forward for testing and commit to the regimen?

A: The mistake we made was to put the cart before the horse. We do have ongoing ... [motivation] through the Khomanani campaign, but the messages on treatment and importance of adherence only came after we started implementing the programme. Be that as it may, I think to some degree we did catch up. [Would you have messages on treatment and adherence if it were not available because the sites were not yet operational?]

On an individual patient basis, people are taken through about three weeks of education about treatment itself, and they are given prophylaxis to monitor how they manage adhering over a period of time. If they ... are able to adhere, [they are ready to start treatment]. Also, we encourage disclosing to someone at home who will be a treatment supporter. Coupled with that, we have treatment supporters at the facilities themselves - the lay counsellors. People are [also] educated about the importance of adherence on an individual basis by the doctor, pharmacist and nurses. We have support groups at the facility where people sit together and share their treatment experiences.

These are people who need to take almost a bucketful of tablets home with them. In most cases they live in informal settlements, sharing one room with other people, and they have to explain why they have to take so much treatment. That's why it's important to encourage people to disclose to someone in the family, who is going to be supporting them along the way. We haven't had problems with adherence - from reports we're getting from the provinces, adherence levels are in the region of 95 to 97 percent.

Q: What are your impressions on the efficacy of ARVs?

A: We know there is scientific evidence, and are convinced of the efficacy and impact of using these drugs. We know that people are able to buy at least three years [of life] when eligible - and even more, in some cases - if it's coupled with other interventions, like positive living and so on. But we are finding, also, that it may have an indirect impact on the incidence of TB, for instance. As the immune system becomes better, people don't develop TB, as they often do. People have reported reduced number of AIDS-related admissions in hospitals after starting the ARV programme. People go back to work, feel better, they are more productive and the economy improves.

But we need to reiterate that there is no cure - even with provision of ARVs, people will eventually die. What is still being defined is how much time we're buying.

Q: Organisations, such as the lobby group, Treatment Action Campaign, have played a part in getting the country to where it is now in terms of providing ARVs. What do you see as their role?

A: The country recognised, when putting together a plan to deal with HIV/AIDS, that it would have to be a multisectoral strategy, so all of these organisations are important. Our national strategic plan, which ends this year, had input from stakeholders across the board. When drawing up the Comprehensive Plan, we consulted all these people.

Q: There's been criticism that, despite the good treatment strategy, the government started it too late ...

A: I don't understand what 'too late' is, but we needed to plan properly for a complex programme that was going to be implemented in a system that was being upgraded. Also, we were inhibited by costs, and the country was in the forefront of making sure that drug prices came down, and when they did come down, there was commitment from the country that we should then put in the additional component [?] - which is what we are currently busy doing.

Q: Any advice to other African health departments who are busy rolling out similar initiatives?

A: It's important to [motivate] society, educate people on what these drugs are about, how they should be taken when prescribed, and the level of commitment [required].

With regard to the health system itself: plan properly, particularly around human resource issues. We are fortunate in South Africa to have experts and human resource capacity to implement these programmes. [My observation of] other countries is that they are able to do a lot with little. But even so, they need to look at the human resources required, laboratory capacity, transportation of specimens to laboratories and the area of monitoring and evaluation.

A patient information system is critical to make sure that there is a unique countrywide identifier for each patient, so when people move around the country, they can easily access the service. You don't want ... treatment interruptions and people having to go on different regimens as a result.

While it is important to have links with NGOs and other stakeholders, I must caution that most of the programme should be implemented with the country's fiscus, to ensure it's sustainable. Yes, donations from the donor community are welcome, but this kind of programme is about putting lots of people on expensive treatment over a long period of time, so the country must be able to manage that.

It is also important to have a system for reporting on adverse effects and mortality, so we can understand what these drugs are doing, and are able to monitor resistance.

Q: What do you think is the single most important thing for establishing a rollout?

A: Good planning - with all relevant stakeholders.

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