Date: 27/10/2006
Source: Department of Health
Title: Madlala-Routledge: HIV and AIDS Civil Society Conference
Speech by Deputy Minister of Health, Mrs Nozizwe Madlala-Routledge, at the HIV and AIDS Civil Society Conference
The role of the Department of Health (DOH) in a national response to HIV and AIDS and healthcare
Thank you for the invitation to this important civil society initiative on "Building Solidarity, an Action Plan to Save Lives". Government welcomes the opportunity to share with you, our most important shareholder, our thoughts on the role of government through the Department of Health as the lead department in a national response to HIV and AIDS and healthcare. Represented here is labour through the Congress of South African Trade Union (COSATU), the churches through the South African Council of Churches (SACC), non-governmental organisations (NGOs) through South African National Non-Governmental Organisation Coalition (SANGOCO) and the National Association of People Living with AIDS (NAPWA), through the Treatment Action Campaign (TAC). Government sees you as representing an important section of our society.
Later this morning our Deputy President, the honourable Phumzile Mlambo-Ngcuka will be addressing you on the important issue of partnerships and building solidarity in a national effort to save lives. She addresses you with a full mandate from government which has tasked her to unite all of us as a country behind a common comprehensive programme to combat HIV and AIDS. Our Deputy President has attached much importance to this task. Government sees you as important partners, as leaders who helped us develop the National Strategic Framework for HIV and AIDS and Sexually Transmitted Infections (STI) 2000/05. You also helped us put together a comprehensive operational plan for HIV and AIDS care, management and treatment plan for South Africa. As partners your role remains huge, helping us to evaluate the National Strategic Framework and the Comprehensive Operational Plan. This is a process that has begun under the leadership of the Deputy President as Chairperson of South African National AIDS Council (SANAC), which is itself undergoing a review.
It has been a hard and bumpy road from Durban to Bangkok, to New York and Toronto. Having the process of reviewing our common commitment to helping our people conquer HIV, we can now march together and not against each other.
Our country is in pain. We are all in pain. Tremendous efforts are being made and resources being invested in combating HIV and AIDS by government and civil society, but we continue to see unacceptably high levels of new infections and deaths from AIDS defining illnesses. We are losing our children and youth, our future. We are losing mothers and fathers and seeing an ever growing number of orphans and child-headed families. We are losing teachers and health care workers and we are losing the life blood of our economy, the workers. Our health professionals are in pain facing a pandemic for which there is as yet not cure.
According to the World Health Organisation (WHO) report of 2005, globally more than 65 million people are infected by HIV, and 95 percent of them live in Africa. In South Africa the population is estimated at 46 million. The national HIV prevalence among pregnant women is 30,2 percent according to the 2005 Ante-Natal Care (ANC) report and 18 percent in the general population. The ANC report further indicates youth HIV prevalence (15+ years) is estimated at 16,2 percent. The estimated number of people living with HIV and AIDS is 5,5 million. The "Mortality and Causes of Death in South Africa" report based on the Statistics South Africa (StatsSA) study of about three million death notification forms received by the Department of Home Affairs, South Africa's adult death rate had risen by 62 percent in the five years between 1997 and 2002.
The 2005/06 Medical Research Council (MRC) estimates that every day in South Africa about nine hundred people die and there are one thousand new infections. The Public Service Commission report has warned, "By 2012 up to a quarter of the public servants may have died of AIDS". This will affect service delivery in a profound way.
As the Statistician-General has observed, the data provides indirect evidence that HIV is raising the mortality levels of prime aged adults in that associated diseases are on the increase.
However, since the adoption of the operational plan on HIV and AIDS care, management and treatment in November 2003 and the new efforts being put into streamlining our communication messages on HIV, there is new hope in this country. Our people now have the opportunity to come forward and test for HIV so that they know their status.
With more and more sites being accredited for the rollout of treatment, care and management of HIV and AIDS, more and more people have an opportunity to get free life saving treatment. Now is the time for unity and dialogue on HIV and AIDS in particular and healthcare delivery as a whole. Now is the time for all of us to provide decisive leadership in every way we can. It is in all our interests.
The beginnings of a co-ordinated public policy response to HIV and AIDS date back to 1992 with the formation of the National AIDS Coordinating Committee of South Africa (NACOSA). Progress in implementing the NACOSA plan was assessed in 1997 by the South African National STI and HIV and AIDS Review. This review identified major strengths in the response but also highlighted areas for substantial strengthening and improvement.
Building on this review and on an extensive consultation process, government launched its five-year strategic plan for HIV and AIDS in 2000. The plan provided the framework within which interventions geared towards initiating and executing a comprehensive response to the epidemic are undertaken. The strategic framework identified four key areas of intervention:
1. prevention
2. treatment, care and support
3. research, monitoring and surveillance
4. legal and human rights.
In April 2002, after reviewing its approach to HIV and AIDS, Cabinet reiterated its commitment to the strategic plan. Noting progress in the implementation of the plan and the impact beginning to be made with regard to the prevention campaign, Cabinet decided on a number of measures to strengthen and reinforce these efforts including:
* strengthening partnerships especially via the South African National AIDS Council (SANAC)
* continued use of nevirapine in preventing mother to child transmission
* development of a universal incremental expansion plan.
In 2003 the South African operational plan for comprehensive HIV and AIDS care, management and treatment was launched. Its main pillars were:
* to provide comprehensive care and treatment for people living with HIV and AIDS including the free provision of antiretrovirals (ARVs) in the public health sector
* to strengthen the national health system in South Africa.
In sharing with you the role of the Department of Health in a national response to HIV and AIDS and healthcare, I want to acknowledge the tremendous work that was put by various groups and individuals in developing the national framework, strategy and the comprehensive operational plan. It has been a national effort. I also want to acknowledge and appreciate the work being done by our frontline health professionals who are working under great strain to implement the plan and to look after people, all our patients.
I want to appreciate the volunteers and home based care workers who are, on an ongoing personal basis, helping so many of those infected with HIV and AIDS, including family members. I also want to appreciate 16 NGOs and various sectors' print and audio visual mass media, who continue to do sterling work in prevention and treatment literacy and support for people living with HIV. I salute organisations representing people living with HIV and AIDS for helping government to successfully wage a campaign against pharmaceutical companies, whose aim was to reduce the cost of ARV drugs. As a result of this joint campaign South Africa is now able to manufacture generic drugs and make them available at a much lower cost than the imported patented version. Your courage inspires hope that working together we can conquer the HIV epidemic.
In his State of the Nation Address in February 2005, the State President, honourable Thabo Mbeki urged us to accelerate the implementation of the comprehensive operational plan on HIV treatment, management and care. Clearly even with the successes we have achieved in accrediting treatment sites and putting people on the treatment programme, we must aim to improve access. The commitment to achieve universal access must drive all of us to work tirelessly until every South African who needs treatment can access it easily. This would help ease the financial and physical burden on those patients who presently have to travel long distances and at a high cost to get their treatment.
Former President Nelson Mandela once said, "AIDS is no longer just a health issue, it is a human rights issue." It is a human rights issue if people who need and qualify for treatment cannot get it because they have been put on a long waiting list or that they cannot afford transport costs to the HIV clinic. It is a human rights issue that babies continue to be infected by their HIV-positive mothers because the clinic sister has not bothered to tell the pregnant mother about how she could reduce the risk of her baby being infected.
It is a human rights issue when babies cannot access treatment and when people die because they are poor. It is a human rights issue that HIV has the face of a woman; that the female species and children get infected as a result of rape or other forms of gender-based violence.
Since January 2004 we have made progress in the implementation of the comprehensive operational plan. An estimated 178 635 patients were on antiretroviral treatment (ART) by end of June 2006. Around 10 percent were children.
Paediatric guidelines have been printed and distributed from the beginning of November 2005. A clinician's helpline is available at the University of Cape Town (UCT). The accreditation of new sites continues in all the provinces. All districts have at least one service point.
Two hundred and fifty-five facilities are accredited covering 53 health districts, 72 percent of 252 sub-districts have at least one service point and the target 2006/07 is 75 percent. Targets help us measure progress. The government's implementation and evaluation programme on various targets set by the President in his State of the Nation Address is done at least on a quarterly basis. This includes reporting on the implementation of the comprehensive plan.
National Health Laboratory Services (NHLS) has certified about 250 laboratories nationally. In two years, CD4 count machines were increased from 10 to 43 and the viral load machines were increased from three to 11. There are seven laboratories performing Polymerase Chain Reaction (PCR). The average tests per month are as follows: CD4 count is 60 000: viral load (VL) 15 000: PCR 4 000. Laboratory Information System (LIS) is in place in some provinces.
Three correctional services' facilities, Grootvlei, Qalakabusha and Westville have been accredited. The Department of Health has the responsibility for the health of all, including offenders. In partnership with the Department of Correctional Services, the Department of Health is taking steps to improve the delivery of healthcare services in the correctional facilities.
We see these both as a human rights issue and a public health issue. About seven South African National Defence Force (SANDF) facilities were accredited to provide antiretroviral treatment services. The SANDF programme caters for members of the SANDF and their immediate families. This has helped extend access, illustrating that working together we can scale up treatment.
Nationally, there are 45 step down care facilities, 732 support groups and 1 176 home-based care organisations.
In 2005/06 financial year 391 206 patients were served including 59 799 orphaned and vulnerable children. To ensure sustainability, government funds 90 percent of the HIV programme. The total budget for HIV and AIDS programmes in all government departments is R11,2 billion. The DOH budget allocation increased form R264 million in 2001 to R2,8 billion in 2007/08.
Nutrition assessment and screening of all HIV positive and tuberculosis (TB) patients is done routinely in all public health facilities. Nutrition counselling and education is offered at clinic level and also by home and community-based care organisations.
Targeted nutritional supplements and provision of food aid or other resources has been strengthened. Micro and macronutrients have been provided to more than 480 000 qualifying TB and HIV positive patients. It is important that we protect this programme from abuse. Identification of destitute and food insecure individuals is the task of the Department of Social Development, in partnership with community leaders like you. While health can give advice on good nutrition, the Department of Agriculture has the overall responsibility for ensuring food security.
Research into traditional medicines forms part of the national strategy on HIV and AIDS, and is ongoing. Funded by the Department of Health, the Medical Research Council (MRC) is doing research on the safety and efficacy of some traditional medicines.
The Traditional Health Practitioners Act passed in 2004 sets the legal standards for the practice of traditional medicine. According to this law all traditional health practitioners must be registered with the interim health council in order to practice. It is a criminal offence for people who are not registered with the interim council to be seeing patients and administering medicines.
The interpretation of patient numbers on comprehensive HIV and AIDS treatment plan should take into account the effects of patients who are lost to follow up, de-registered and those who died after the commencement of treatment. This information is not currently captured. Provinces are in the process to start reporting on these indicators, including assessment.
The Western Cape Monitoring Report of their ARV programme which covers the period up to March 2006 illustrates the importance of monitoring the implementation of the comprehensive plan.
From a total of 16 234 patients on treatment in the province, it has been shown that seven out of 10 treatment-naive patients are still in care. Without treatment almost all of these patients would have died in this time period. Looking just at those who are known to have died, cumulatively 15 percent of adult patients had died by four years duration on ART, although some of the patients lost to follow up may in fact have also died. Of children followed up for three years, eight out of 10 are still in care.
The simple paper based standard of data capturing in the Western Cape has been shown to be a feasible and appropriate system though cumbersome in bigger facilities.
Although an electronic patient information system is nearing completion, this is likely to bring infrastructural and human resource challenges of its own.
As has been shown in other countries the e-health record is not the panacea of all health information problems. Computers need staff that know how to operate and manage them. The staff need regular training in data capturing and storing. Machines don't run themselves.
The rapid expansion of services in the Western Cape has resulted in patients accessing care with less advanced disease in more recent years, which in turn has seen a decline in early mortality on the programme, from 13 percent in 2001 to six percent in 2005, in the first six months on ART. The programme has demonstrated the dramatic impact on the health of those accessing ART. However, the overall patient numbers accumulating on ART poses a huge service challenge and the increase over time in the proportion of patients lost to follow up in the first six months on ART is an early signal pointing to the health system challenges in this regard.
The location of ART services within primary healthcare (PHC) appears to have contributed to the success of the Western Cape provincial programme; however, innovative approaches to sharing the service load across the entire primary care service platform are urgently required.
Although access to Voluntary Counselling and Testing (VCT) services in our health facilities has reached almost 80 percent nationally, we have not seen any serious uptake. As a way to kick-off this campaign, we need leaders at all levels to lead by example by offering themselves for public voluntary counselling and testing. I am encouraged to see that in the entertainment industry this is picking up momentum with musicians and radio deejays testing publicly.
When more and more leaders come forward to test, this sends a positive message and reduces the stigma around HIV and AIDS. It has been shown worldwide that knowing your status is one of the key strategies of preventing the spread of HIV and behaviour change.
We need to assess the impact of all our interventions. While much money has gone into condom distribution, we do not know the impact this is making. The implementation of the prevention of mother to child transmission (PMTCT) programmes has been most uneven, with some provinces showing positive trends, while others have performed dismally. Although the PMTCT is available at 80 percent of our fixed health facilities, coverage of target population remains high. The prevalence of HIV among the antenatal care clinic attendees indicates that large numbers of babies are at risk of infection by their mothers. In 2005, a national household survey estimated that 3,3 percent of children aged 2 to 14 years are HIV positive. Yet only about half of all pregnant women receive an HIV test and only 13 percent of those who are HIV positive receive ARV prophylaxis to help prevent their babies becoming infected.
The success of the programme in the Western Cape indicates that the use of dual therapy in the PMTCT programme can save large numbers of babies from getting infected by their HIV positive mothers. We need to amend the protocols on monotherapy, as per the recommendations of the Medicines Control Council (MCC) and MRC in order to remove the lack of clarity in the provinces. Very importantly we have identified the great need to monitor those babies we have saved to see that they are properly supported to stay HIV negative. ART programmes for those born HIV positive need to be scaled up and adequately monitored. It has been shown that treatment does not always target our children.
Post exposure prophylaxis for occupational accidents and sexual assault must be evaluated to assess impact. Our infection control measures must be evaluated for effectiveness.
The WHO has declared 2006 a year for accelerated prevention of HIV. The African Union (AU) has adopted a framework on reproductive health and HIV which aims to reach the goal of providing universal access to comprehensive sexual and reproductive health services in Africa by 2015.
The Department of Health has participated actively in the development and adoption of this policy which we regard as a critical aspect of preventing the spread of HIV. Strengthening the delivery of sexual and reproductive health will enhance the schools-based life skill and HIV and AIDS education programme, which has resulted in the training of 41 872 teachers covering 14 545 primary and secondary schools in 2005/06 financial year.
The Youth Risk Behaviour Survey 2002 indicated that about 74 percent of learners (12 to 19 years) have high levels of HIV and AIDS awareness. The learners' awareness needs to be translated into sustainable change. Awareness is only the first step.
The high teenage pregnancy rate indicates that a huge challenge remains to achieve behaviour change. We need to understand this problem and to address it. We need to get the youth and parents to engage in a frank dialogue and joint action. We must courageously confront the problem of drug and alcohol abuse in our country which is on the increase, and is contributing to the spread of HIV and AIDS and other STI. Addressing drug and alcohol abuse needs the co-operation of the community, churches, business and government. Parents must be taught how to identify the signs of drug and alcohol abuse. Health and social development must invest in facilities for detoxification and rehabilitation.
The criminal justice system needs specialised training to deal effectively with drug offenders.
We have begun an important process, under the leadership of our Deputy President on behalf of government, of assessing our work on HIV and AIDS. We need to speak honestly about the challenges we face as we begin to experience the strain resulting from the growing burden of disease and staff shortages. It is right that you use this platform to engage government and to show us our blind spots.
Some of these challenges are:
* the shortage of doctors, pharmacists, dieticians and ordinary nurses especially in the remote areas
* there are infrastructure problems in most facilities
* slow expansion of PIS to other provinces
* acquisition of portable lactate test machine in the remote areas for ADR Management (Lactic Acidosis)
* integration of comprehensive HIV and AIDS care, management and treatment with other services like PMTCT, VCT, post-exposure prophylaxis (PEP) and TB
* collaboration with other departments including correctional services which has special needs
* management of conditional grants
* the Traditional Healers Council (THC) has not yet been established
* down referral of ART patients to PHC and Community Healthcare (CHC) needs urgent attention
* offenders access to ART
* children, pregnant women and TB patients access to ART
* marketing of the comprehensive plan
* adherence rate calculation or estimation
* conduct post accreditation visits in all facilities.
These challenges can be solved if we co-operate. I had occasion to address doctors at two recent events of the South African Medical Association (SAMA). I gained a distinct impression that doctors are keen to help us solve the problems we are experiencing with the shortage of doctors and other health personnel. They want to be part of the solution. Similarly nurses want to be part of the solution. We cannot address these problems without listening attentively to their problems and seeking their active participation in finding solutions.
The success of the implementation of the comprehensive operational plan needs researchers to work closely with government in scientific investigation and monitoring and evaluation. It needs doctors, nurses and pharmacists. It needs volunteers and home-based caregivers and it needs each and every one of us, providing leadership and mobilising all the people of South Africa.
As we review the national strategy and the operational plan, we must look at how we strengthen our health systems including health information and laboratory services. We must strengthen our monitoring and evaluation framework. Health technology must be improved so that it responds to our growing health needs. When we look at the diagnosis and treatment of TB, one of the problems is that technology and pharmaceutical research and development have fallen far behind. This has been brought into sharp focus recently with the development of multi and extreme drug resistance (XDR) for the treatment of TB.
These are problems that indicate the (Abstain, Be faithful, Condomise) ABC strategy of prevention is not succeeding in stopping the spread of new infections.
Repackaging and strengthening of prevention messages requires a targeted messaging approach. A United Nations (UN) report has acknowledged the intersection between gender inequality, poverty and HIV and AIDS. According to the report women make up 57 percent of those living with HIV. Young African women aged 15 to 24 years are three times more likely to be infected than their male counterparts: transactional and trans-generational sex with older men; high levels of gender based sexual violence. The report suggests promoting concrete actions to address the reality of women's lives. The interventions aimed at fighting poverty and gender inequality will help improve the status of women.
As we build partnerships and solidarity we must strengthen co-operation between the public and private health sector which will see greater sharing of resources. There is enough goodwill in our country. The World Bank, the South African Business Coalition on HIV and AIDS (SABCOHA) and Standard Bank have joined hands to launch guidelines for building business coalitions against HIV and AIDS throughout sub-Saharan Africa. Many businesses have adopted workplace based treatment programmes and are seeing reduced levels of absenteeism and improved morale and productivity. These are the coalitions government seeks to encourage.
We must strengthen the co-ordination of all our efforts and learn from best practice in this country and elsewhere. A recent study by the Health Systems Trust showed a very low level of HIV treatment literacy among South Africans. Low levels of treatment literacy result in people not getting reliable, evidence based treatment information and thus they fall prey to charlatans who charge them dearly for unproven remedies. The role of the Department of Health is to protect our people and to help them make informed decisions about their lives.
Together we can beat the hopelessness and resignation in our communities. We can do this by sending a message of hope. That message is contained in the government's comprehensive operational plan and the national strategy on HIV which emphasise prevention and research, balanced nutrition, treatment of opportunistic infections and ART for those who qualify and the prevention of mother to child infection.
The South African Constitution has set down some basic values and principles governing public administration, of which the Department of Health is part. According to our Constitution public administration must be governed by democratic values and principles. Some of these principles are:
* efficient, economic and effective use of resources must be promoted
* people's needs must be responded to and the public must be encouraged to participate in policy making
* public administration must be accountable
* transparency must be fostered by providing the public with timely, accessible and accurate information.
Specifically on healthcare, the Bill of Rights says everyone has the right to have access to healthcare services including reproductive healthcare. The State must take reasonable legislative and other measures within its available resources to achieve the progressive realisation of each of these rights.
As I conclude, I want to leave you with the words of Virchow, a German doctor who was sent to Poland to investigate why people there were dying of the bubonic plague. His answer was simple. "The people of Poland need democracy." He further explained, "Medicine is a social science and politics is nothing but medicine on a large scale. Physicians are the natural attorneys of the poor and social problems should largely be solved by them." Inspired by Virchow, Paul Farmer, a Harvard trained medical anthropologist went to Haiti to work with the poor in their fight against diseases that are fuelled by poverty like TB. He is presently working with the Russians and Rwandans. I seriously believe we need him in South Africa. As we look to develop an effective strategy for the campaign to free our country of HIV and AIDS, and as we seek to mobilise all our people, I am reminded of how Antonio Gramsci inspired us in the mass democratic movement. We need to form a united front against the HIV and AIDS pandemic.
Issued by: Department of Health
27 October 2006
Source: Department of Health
Title: Madlala-Routledge: HIV and AIDS Civil Society Conference
Speech by Deputy Minister of Health, Mrs Nozizwe Madlala-Routledge, at the HIV and AIDS Civil Society Conference
The role of the Department of Health (DOH) in a national response to HIV and AIDS and healthcare
Thank you for the invitation to this important civil society initiative on "Building Solidarity, an Action Plan to Save Lives". Government welcomes the opportunity to share with you, our most important shareholder, our thoughts on the role of government through the Department of Health as the lead department in a national response to HIV and AIDS and healthcare. Represented here is labour through the Congress of South African Trade Union (COSATU), the churches through the South African Council of Churches (SACC), non-governmental organisations (NGOs) through South African National Non-Governmental Organisation Coalition (SANGOCO) and the National Association of People Living with AIDS (NAPWA), through the Treatment Action Campaign (TAC). Government sees you as representing an important section of our society.
Later this morning our Deputy President, the honourable Phumzile Mlambo-Ngcuka will be addressing you on the important issue of partnerships and building solidarity in a national effort to save lives. She addresses you with a full mandate from government which has tasked her to unite all of us as a country behind a common comprehensive programme to combat HIV and AIDS. Our Deputy President has attached much importance to this task. Government sees you as important partners, as leaders who helped us develop the National Strategic Framework for HIV and AIDS and Sexually Transmitted Infections (STI) 2000/05. You also helped us put together a comprehensive operational plan for HIV and AIDS care, management and treatment plan for South Africa. As partners your role remains huge, helping us to evaluate the National Strategic Framework and the Comprehensive Operational Plan. This is a process that has begun under the leadership of the Deputy President as Chairperson of South African National AIDS Council (SANAC), which is itself undergoing a review.
It has been a hard and bumpy road from Durban to Bangkok, to New York and Toronto. Having the process of reviewing our common commitment to helping our people conquer HIV, we can now march together and not against each other.
Our country is in pain. We are all in pain. Tremendous efforts are being made and resources being invested in combating HIV and AIDS by government and civil society, but we continue to see unacceptably high levels of new infections and deaths from AIDS defining illnesses. We are losing our children and youth, our future. We are losing mothers and fathers and seeing an ever growing number of orphans and child-headed families. We are losing teachers and health care workers and we are losing the life blood of our economy, the workers. Our health professionals are in pain facing a pandemic for which there is as yet not cure.
According to the World Health Organisation (WHO) report of 2005, globally more than 65 million people are infected by HIV, and 95 percent of them live in Africa. In South Africa the population is estimated at 46 million. The national HIV prevalence among pregnant women is 30,2 percent according to the 2005 Ante-Natal Care (ANC) report and 18 percent in the general population. The ANC report further indicates youth HIV prevalence (15+ years) is estimated at 16,2 percent. The estimated number of people living with HIV and AIDS is 5,5 million. The "Mortality and Causes of Death in South Africa" report based on the Statistics South Africa (StatsSA) study of about three million death notification forms received by the Department of Home Affairs, South Africa's adult death rate had risen by 62 percent in the five years between 1997 and 2002.
The 2005/06 Medical Research Council (MRC) estimates that every day in South Africa about nine hundred people die and there are one thousand new infections. The Public Service Commission report has warned, "By 2012 up to a quarter of the public servants may have died of AIDS". This will affect service delivery in a profound way.
As the Statistician-General has observed, the data provides indirect evidence that HIV is raising the mortality levels of prime aged adults in that associated diseases are on the increase.
However, since the adoption of the operational plan on HIV and AIDS care, management and treatment in November 2003 and the new efforts being put into streamlining our communication messages on HIV, there is new hope in this country. Our people now have the opportunity to come forward and test for HIV so that they know their status.
With more and more sites being accredited for the rollout of treatment, care and management of HIV and AIDS, more and more people have an opportunity to get free life saving treatment. Now is the time for unity and dialogue on HIV and AIDS in particular and healthcare delivery as a whole. Now is the time for all of us to provide decisive leadership in every way we can. It is in all our interests.
The beginnings of a co-ordinated public policy response to HIV and AIDS date back to 1992 with the formation of the National AIDS Coordinating Committee of South Africa (NACOSA). Progress in implementing the NACOSA plan was assessed in 1997 by the South African National STI and HIV and AIDS Review. This review identified major strengths in the response but also highlighted areas for substantial strengthening and improvement.
Building on this review and on an extensive consultation process, government launched its five-year strategic plan for HIV and AIDS in 2000. The plan provided the framework within which interventions geared towards initiating and executing a comprehensive response to the epidemic are undertaken. The strategic framework identified four key areas of intervention:
1. prevention
2. treatment, care and support
3. research, monitoring and surveillance
4. legal and human rights.
In April 2002, after reviewing its approach to HIV and AIDS, Cabinet reiterated its commitment to the strategic plan. Noting progress in the implementation of the plan and the impact beginning to be made with regard to the prevention campaign, Cabinet decided on a number of measures to strengthen and reinforce these efforts including:
* strengthening partnerships especially via the South African National AIDS Council (SANAC)
* continued use of nevirapine in preventing mother to child transmission
* development of a universal incremental expansion plan.
In 2003 the South African operational plan for comprehensive HIV and AIDS care, management and treatment was launched. Its main pillars were:
* to provide comprehensive care and treatment for people living with HIV and AIDS including the free provision of antiretrovirals (ARVs) in the public health sector
* to strengthen the national health system in South Africa.
In sharing with you the role of the Department of Health in a national response to HIV and AIDS and healthcare, I want to acknowledge the tremendous work that was put by various groups and individuals in developing the national framework, strategy and the comprehensive operational plan. It has been a national effort. I also want to acknowledge and appreciate the work being done by our frontline health professionals who are working under great strain to implement the plan and to look after people, all our patients.
I want to appreciate the volunteers and home based care workers who are, on an ongoing personal basis, helping so many of those infected with HIV and AIDS, including family members. I also want to appreciate 16 NGOs and various sectors' print and audio visual mass media, who continue to do sterling work in prevention and treatment literacy and support for people living with HIV. I salute organisations representing people living with HIV and AIDS for helping government to successfully wage a campaign against pharmaceutical companies, whose aim was to reduce the cost of ARV drugs. As a result of this joint campaign South Africa is now able to manufacture generic drugs and make them available at a much lower cost than the imported patented version. Your courage inspires hope that working together we can conquer the HIV epidemic.
In his State of the Nation Address in February 2005, the State President, honourable Thabo Mbeki urged us to accelerate the implementation of the comprehensive operational plan on HIV treatment, management and care. Clearly even with the successes we have achieved in accrediting treatment sites and putting people on the treatment programme, we must aim to improve access. The commitment to achieve universal access must drive all of us to work tirelessly until every South African who needs treatment can access it easily. This would help ease the financial and physical burden on those patients who presently have to travel long distances and at a high cost to get their treatment.
Former President Nelson Mandela once said, "AIDS is no longer just a health issue, it is a human rights issue." It is a human rights issue if people who need and qualify for treatment cannot get it because they have been put on a long waiting list or that they cannot afford transport costs to the HIV clinic. It is a human rights issue that babies continue to be infected by their HIV-positive mothers because the clinic sister has not bothered to tell the pregnant mother about how she could reduce the risk of her baby being infected.
It is a human rights issue when babies cannot access treatment and when people die because they are poor. It is a human rights issue that HIV has the face of a woman; that the female species and children get infected as a result of rape or other forms of gender-based violence.
Since January 2004 we have made progress in the implementation of the comprehensive operational plan. An estimated 178 635 patients were on antiretroviral treatment (ART) by end of June 2006. Around 10 percent were children.
Paediatric guidelines have been printed and distributed from the beginning of November 2005. A clinician's helpline is available at the University of Cape Town (UCT). The accreditation of new sites continues in all the provinces. All districts have at least one service point.
Two hundred and fifty-five facilities are accredited covering 53 health districts, 72 percent of 252 sub-districts have at least one service point and the target 2006/07 is 75 percent. Targets help us measure progress. The government's implementation and evaluation programme on various targets set by the President in his State of the Nation Address is done at least on a quarterly basis. This includes reporting on the implementation of the comprehensive plan.
National Health Laboratory Services (NHLS) has certified about 250 laboratories nationally. In two years, CD4 count machines were increased from 10 to 43 and the viral load machines were increased from three to 11. There are seven laboratories performing Polymerase Chain Reaction (PCR). The average tests per month are as follows: CD4 count is 60 000: viral load (VL) 15 000: PCR 4 000. Laboratory Information System (LIS) is in place in some provinces.
Three correctional services' facilities, Grootvlei, Qalakabusha and Westville have been accredited. The Department of Health has the responsibility for the health of all, including offenders. In partnership with the Department of Correctional Services, the Department of Health is taking steps to improve the delivery of healthcare services in the correctional facilities.
We see these both as a human rights issue and a public health issue. About seven South African National Defence Force (SANDF) facilities were accredited to provide antiretroviral treatment services. The SANDF programme caters for members of the SANDF and their immediate families. This has helped extend access, illustrating that working together we can scale up treatment.
Nationally, there are 45 step down care facilities, 732 support groups and 1 176 home-based care organisations.
In 2005/06 financial year 391 206 patients were served including 59 799 orphaned and vulnerable children. To ensure sustainability, government funds 90 percent of the HIV programme. The total budget for HIV and AIDS programmes in all government departments is R11,2 billion. The DOH budget allocation increased form R264 million in 2001 to R2,8 billion in 2007/08.
Nutrition assessment and screening of all HIV positive and tuberculosis (TB) patients is done routinely in all public health facilities. Nutrition counselling and education is offered at clinic level and also by home and community-based care organisations.
Targeted nutritional supplements and provision of food aid or other resources has been strengthened. Micro and macronutrients have been provided to more than 480 000 qualifying TB and HIV positive patients. It is important that we protect this programme from abuse. Identification of destitute and food insecure individuals is the task of the Department of Social Development, in partnership with community leaders like you. While health can give advice on good nutrition, the Department of Agriculture has the overall responsibility for ensuring food security.
Research into traditional medicines forms part of the national strategy on HIV and AIDS, and is ongoing. Funded by the Department of Health, the Medical Research Council (MRC) is doing research on the safety and efficacy of some traditional medicines.
The Traditional Health Practitioners Act passed in 2004 sets the legal standards for the practice of traditional medicine. According to this law all traditional health practitioners must be registered with the interim health council in order to practice. It is a criminal offence for people who are not registered with the interim council to be seeing patients and administering medicines.
The interpretation of patient numbers on comprehensive HIV and AIDS treatment plan should take into account the effects of patients who are lost to follow up, de-registered and those who died after the commencement of treatment. This information is not currently captured. Provinces are in the process to start reporting on these indicators, including assessment.
The Western Cape Monitoring Report of their ARV programme which covers the period up to March 2006 illustrates the importance of monitoring the implementation of the comprehensive plan.
From a total of 16 234 patients on treatment in the province, it has been shown that seven out of 10 treatment-naive patients are still in care. Without treatment almost all of these patients would have died in this time period. Looking just at those who are known to have died, cumulatively 15 percent of adult patients had died by four years duration on ART, although some of the patients lost to follow up may in fact have also died. Of children followed up for three years, eight out of 10 are still in care.
The simple paper based standard of data capturing in the Western Cape has been shown to be a feasible and appropriate system though cumbersome in bigger facilities.
Although an electronic patient information system is nearing completion, this is likely to bring infrastructural and human resource challenges of its own.
As has been shown in other countries the e-health record is not the panacea of all health information problems. Computers need staff that know how to operate and manage them. The staff need regular training in data capturing and storing. Machines don't run themselves.
The rapid expansion of services in the Western Cape has resulted in patients accessing care with less advanced disease in more recent years, which in turn has seen a decline in early mortality on the programme, from 13 percent in 2001 to six percent in 2005, in the first six months on ART. The programme has demonstrated the dramatic impact on the health of those accessing ART. However, the overall patient numbers accumulating on ART poses a huge service challenge and the increase over time in the proportion of patients lost to follow up in the first six months on ART is an early signal pointing to the health system challenges in this regard.
The location of ART services within primary healthcare (PHC) appears to have contributed to the success of the Western Cape provincial programme; however, innovative approaches to sharing the service load across the entire primary care service platform are urgently required.
Although access to Voluntary Counselling and Testing (VCT) services in our health facilities has reached almost 80 percent nationally, we have not seen any serious uptake. As a way to kick-off this campaign, we need leaders at all levels to lead by example by offering themselves for public voluntary counselling and testing. I am encouraged to see that in the entertainment industry this is picking up momentum with musicians and radio deejays testing publicly.
When more and more leaders come forward to test, this sends a positive message and reduces the stigma around HIV and AIDS. It has been shown worldwide that knowing your status is one of the key strategies of preventing the spread of HIV and behaviour change.
We need to assess the impact of all our interventions. While much money has gone into condom distribution, we do not know the impact this is making. The implementation of the prevention of mother to child transmission (PMTCT) programmes has been most uneven, with some provinces showing positive trends, while others have performed dismally. Although the PMTCT is available at 80 percent of our fixed health facilities, coverage of target population remains high. The prevalence of HIV among the antenatal care clinic attendees indicates that large numbers of babies are at risk of infection by their mothers. In 2005, a national household survey estimated that 3,3 percent of children aged 2 to 14 years are HIV positive. Yet only about half of all pregnant women receive an HIV test and only 13 percent of those who are HIV positive receive ARV prophylaxis to help prevent their babies becoming infected.
The success of the programme in the Western Cape indicates that the use of dual therapy in the PMTCT programme can save large numbers of babies from getting infected by their HIV positive mothers. We need to amend the protocols on monotherapy, as per the recommendations of the Medicines Control Council (MCC) and MRC in order to remove the lack of clarity in the provinces. Very importantly we have identified the great need to monitor those babies we have saved to see that they are properly supported to stay HIV negative. ART programmes for those born HIV positive need to be scaled up and adequately monitored. It has been shown that treatment does not always target our children.
Post exposure prophylaxis for occupational accidents and sexual assault must be evaluated to assess impact. Our infection control measures must be evaluated for effectiveness.
The WHO has declared 2006 a year for accelerated prevention of HIV. The African Union (AU) has adopted a framework on reproductive health and HIV which aims to reach the goal of providing universal access to comprehensive sexual and reproductive health services in Africa by 2015.
The Department of Health has participated actively in the development and adoption of this policy which we regard as a critical aspect of preventing the spread of HIV. Strengthening the delivery of sexual and reproductive health will enhance the schools-based life skill and HIV and AIDS education programme, which has resulted in the training of 41 872 teachers covering 14 545 primary and secondary schools in 2005/06 financial year.
The Youth Risk Behaviour Survey 2002 indicated that about 74 percent of learners (12 to 19 years) have high levels of HIV and AIDS awareness. The learners' awareness needs to be translated into sustainable change. Awareness is only the first step.
The high teenage pregnancy rate indicates that a huge challenge remains to achieve behaviour change. We need to understand this problem and to address it. We need to get the youth and parents to engage in a frank dialogue and joint action. We must courageously confront the problem of drug and alcohol abuse in our country which is on the increase, and is contributing to the spread of HIV and AIDS and other STI. Addressing drug and alcohol abuse needs the co-operation of the community, churches, business and government. Parents must be taught how to identify the signs of drug and alcohol abuse. Health and social development must invest in facilities for detoxification and rehabilitation.
The criminal justice system needs specialised training to deal effectively with drug offenders.
We have begun an important process, under the leadership of our Deputy President on behalf of government, of assessing our work on HIV and AIDS. We need to speak honestly about the challenges we face as we begin to experience the strain resulting from the growing burden of disease and staff shortages. It is right that you use this platform to engage government and to show us our blind spots.
Some of these challenges are:
* the shortage of doctors, pharmacists, dieticians and ordinary nurses especially in the remote areas
* there are infrastructure problems in most facilities
* slow expansion of PIS to other provinces
* acquisition of portable lactate test machine in the remote areas for ADR Management (Lactic Acidosis)
* integration of comprehensive HIV and AIDS care, management and treatment with other services like PMTCT, VCT, post-exposure prophylaxis (PEP) and TB
* collaboration with other departments including correctional services which has special needs
* management of conditional grants
* the Traditional Healers Council (THC) has not yet been established
* down referral of ART patients to PHC and Community Healthcare (CHC) needs urgent attention
* offenders access to ART
* children, pregnant women and TB patients access to ART
* marketing of the comprehensive plan
* adherence rate calculation or estimation
* conduct post accreditation visits in all facilities.
These challenges can be solved if we co-operate. I had occasion to address doctors at two recent events of the South African Medical Association (SAMA). I gained a distinct impression that doctors are keen to help us solve the problems we are experiencing with the shortage of doctors and other health personnel. They want to be part of the solution. Similarly nurses want to be part of the solution. We cannot address these problems without listening attentively to their problems and seeking their active participation in finding solutions.
The success of the implementation of the comprehensive operational plan needs researchers to work closely with government in scientific investigation and monitoring and evaluation. It needs doctors, nurses and pharmacists. It needs volunteers and home-based caregivers and it needs each and every one of us, providing leadership and mobilising all the people of South Africa.
As we review the national strategy and the operational plan, we must look at how we strengthen our health systems including health information and laboratory services. We must strengthen our monitoring and evaluation framework. Health technology must be improved so that it responds to our growing health needs. When we look at the diagnosis and treatment of TB, one of the problems is that technology and pharmaceutical research and development have fallen far behind. This has been brought into sharp focus recently with the development of multi and extreme drug resistance (XDR) for the treatment of TB.
These are problems that indicate the (Abstain, Be faithful, Condomise) ABC strategy of prevention is not succeeding in stopping the spread of new infections.
Repackaging and strengthening of prevention messages requires a targeted messaging approach. A United Nations (UN) report has acknowledged the intersection between gender inequality, poverty and HIV and AIDS. According to the report women make up 57 percent of those living with HIV. Young African women aged 15 to 24 years are three times more likely to be infected than their male counterparts: transactional and trans-generational sex with older men; high levels of gender based sexual violence. The report suggests promoting concrete actions to address the reality of women's lives. The interventions aimed at fighting poverty and gender inequality will help improve the status of women.
As we build partnerships and solidarity we must strengthen co-operation between the public and private health sector which will see greater sharing of resources. There is enough goodwill in our country. The World Bank, the South African Business Coalition on HIV and AIDS (SABCOHA) and Standard Bank have joined hands to launch guidelines for building business coalitions against HIV and AIDS throughout sub-Saharan Africa. Many businesses have adopted workplace based treatment programmes and are seeing reduced levels of absenteeism and improved morale and productivity. These are the coalitions government seeks to encourage.
We must strengthen the co-ordination of all our efforts and learn from best practice in this country and elsewhere. A recent study by the Health Systems Trust showed a very low level of HIV treatment literacy among South Africans. Low levels of treatment literacy result in people not getting reliable, evidence based treatment information and thus they fall prey to charlatans who charge them dearly for unproven remedies. The role of the Department of Health is to protect our people and to help them make informed decisions about their lives.
Together we can beat the hopelessness and resignation in our communities. We can do this by sending a message of hope. That message is contained in the government's comprehensive operational plan and the national strategy on HIV which emphasise prevention and research, balanced nutrition, treatment of opportunistic infections and ART for those who qualify and the prevention of mother to child infection.
The South African Constitution has set down some basic values and principles governing public administration, of which the Department of Health is part. According to our Constitution public administration must be governed by democratic values and principles. Some of these principles are:
* efficient, economic and effective use of resources must be promoted
* people's needs must be responded to and the public must be encouraged to participate in policy making
* public administration must be accountable
* transparency must be fostered by providing the public with timely, accessible and accurate information.
Specifically on healthcare, the Bill of Rights says everyone has the right to have access to healthcare services including reproductive healthcare. The State must take reasonable legislative and other measures within its available resources to achieve the progressive realisation of each of these rights.
As I conclude, I want to leave you with the words of Virchow, a German doctor who was sent to Poland to investigate why people there were dying of the bubonic plague. His answer was simple. "The people of Poland need democracy." He further explained, "Medicine is a social science and politics is nothing but medicine on a large scale. Physicians are the natural attorneys of the poor and social problems should largely be solved by them." Inspired by Virchow, Paul Farmer, a Harvard trained medical anthropologist went to Haiti to work with the poor in their fight against diseases that are fuelled by poverty like TB. He is presently working with the Russians and Rwandans. I seriously believe we need him in South Africa. As we look to develop an effective strategy for the campaign to free our country of HIV and AIDS, and as we seek to mobilise all our people, I am reminded of how Antonio Gramsci inspired us in the mass democratic movement. We need to form a united front against the HIV and AIDS pandemic.
Issued by: Department of Health
27 October 2006
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