Opening speech by the Minister of Health of South Africa, Dr Manto Tshabalala-Msimang at the Global Partners Forum, Johannesburg

Programme Director
Ministers and Deputy Ministers of Health from various countries present here
Permanent Secretaries and other health officials
Vice-President of the World Bank
The two Assistant Directors
Generals of World Health Organisation (WHO) present
Deputy Executive Director of UNAIDS
The United Nations Children's Fund (Unicef) Chief of HIV and AIDS
Distinguished guests
Ladies and gentlemen

I would like to welcome all delegates and co-operating partners to South Africa. Thank you for choosing our country as a venue for this high level Global Partners Forum on Prevention of Mother-to-Child Transmission of HIV. This meeting comes at an opportune time for two reasons. Firstly, we are currently participating in a Campaign of 16 Days of Activism against violence against women and children. We believe that domestic and sexual violence has to be addressed as one of the risk factors in the spread of HIV infection.

Secondly, the world is gearing up for the commemoration of the World AIDS Day on Saturday, 1 December. There is an intense focus on HIV and AIDS as one of the major challenges facing the international community and more importantly, Sub-Saharan Africa. For us as citizens of this region with high burden of disease, we are encouraged by the indications that the challenge of HIV and AIDS is stabilising. This stabilisation must be enhanced and translated to a decrease in the prevalence of HIV in our region.

For several years, South Africa has been monitoring HIV prevalence mainly through an annual survey of HIV prevalence among pregnant women attending public health facilities. There is still a need to extend this to private health facilities as well. Two population-based household surveys were also carried out in 2002 and 2005.

It appears from these surveys that the peak of infections was reached in the late 1990s. Although new HIV infections are regrettably still happening, available scientific evidence and modelled estimates suggest that the new infections have slowed down considerably. In this regard, we concur with the findings of the recent United Nations (UN) Global Epidemic report. In the past three years, there has been a sustained decline in prevalence among young people of less than 20 years of age. The decrease in HIV prevalence in this age group suggests a possible decline in the annual number of new infections.

There is consensus that even though all sexually active adults are at risk of HIV infection if they do not practice safer sex, there are sub-populations that are at higher risk. Our position as the South African government is that poverty, underdevelopment and the many forms of inequality are some of the drivers of HIV infection and the impact of AIDS.

As the current government was preparing itself for a new dispensation in the early 1990s, it didn't lose sight of the need to address HIV and AIDS. During the time when the rate of new infections were the fastest, we responded by organising and funding national activities for social mobilisation, focusing on the ABC message i.e. Abstinence, Being Faithful and Condom use.

Our response evolved from basic awareness campaigns to a fully comprehensive prevention, treatment, care and support strategy with all the elements of evidence-informed interventions, guided principally by the principle of partnerships. A national multi-sectoral Strategic Plan for HIV and AIDS and sexually transmitted infections (STIs) was developed through an extensively consultative process and adopted for 2000 to 2005 with four primary areas which are:
* prevention
* treatment care and support
* monitoring and evaluation
* as well as human and legal rights.

Several interventions were introduced during the period of the first National Strategic Plan including:
* the Voluntary Counselling and Testing (VCT) and rapid testing
* Prevention of Mother to Child Transmission (PMTCT)
* post exposure prophylaxis

And in 2003, we endorsed the Comprehensive Management, Care and Treatment Plan which included strengthening of treatment interventions including the introduction of antiretroviral treatment programme for those who qualify in the public health sector. We have based our interventions on best available scientific evidence.

However, the evolution of science around HIV and AIDS has been and still remains complex. Recommendations made over time do not seem to hold for long enough periods before new suggestions are made. This makes it difficult for developing countries with limited resources and a heavy burden of disease to keep up with these changes.

One of the complex issues has been policy recommendation on the best infant feeding practices. It is encouraging to see that the recent policy recommendations seek to protect breast-feeding and reduce infant and child mortality. However, the challenge is how to communicate to ordinary people in a manner that ensures that the infant mortality gains from breast-feeding are not eroded. This is after infant formula was promoted as advised by scientists and researchers in this area.

After more than two decades since HIV and AIDS was discovered, there is still no promising HIV and AIDS vaccine candidate with the latest vaccine trial having being halted because of possible risk to participants. There have also been unfortunate findings relating to microbicide research. We have to approach new research with caution including the testing of ARV based microbicides to protect the health of women.

All these incidents raise a question whether we really understand the biology of this virus, the human immune system, and therefore the pathogenesis of the disease as was raised during the recent Sydney Conference on HIV pathogenesis, care and treatment. Why were the unfortunate developments in microbicide research not established during preclinical testing? Did we have to take so many women through clinical trials for these things to be discovered? As governments responsible for health and safety of citizens of our countries, we are often called upon to explain why these things happen to our people. Often there are no convincing answers.

Programme Director, despite these challenges, South African National HIV and AIDS strategies and programmes are informed by the available scientific evidence. Outcomes reported on the implementation of these strategies attest to the commitment of the South African government to deal with the major challenge of HIV and AIDS.

During the period of our first National Strategic (2000-2005), the annual budget allocation for HIV and AIDS increased from R200 million to R1,2 billion.
This budget is standing at R2,1 billion for the current financial year for the Health Department only. When you add other government expenditure relating to HIV and AIDS, the total government HIV and AIDS budget rises to R4 billion for the current financial year. South Africa relies on its own fiscus for over 90% of the national HIV and AIDS programmes.

The South African National AIDS Council (SANAC), chaired by the Deputy President of our country, was established in the year 2000. It has recently been restructured to ensure that it functions effectively and efficiently. The revived SANAC was launched in April 2007, together with the multi-sectoral National Strategic Plan for HIV and AIDS and STIs for the period 2007-2011. Both of these developments have been useful in strengthening partnerships and ownership by the majority of South Africans, of the HIV and AIDS problem and the national response to it. The implementation and scaling up of the elements of these programmes have exceeded our expectations in the context of a country which is faced with many competing social needs. These urgent needs relate largely to the imbalances caused by discrimination and lack of access to basic service including health and education, for the majority of our people up until 1994.

We now can confidently say that we have a PMTCT programme with the largest coverage in the region at 50 to 60% of targeted population. The technical details regarding the geographic access and other relevant programme indicators will be shared with yourselves during the two days of the Forum. In the same breadth, we also can proudly say that we have enrolled the largest number of people on anti-retrovirals (ARVs) worldwide. More than 370 000 people had been initiated on antiretroviral therapy by September 2007. Programme Director, more than 32 000 of these are children under 14 years.

We can say with pride that the awareness level is high. Condom distribution and reported use continues to increase. All hospitals now offer Post Exposure Prophylaxis (PEP) for sexual assault clients, management of opportunistic infections. Screening and treatment of tuberculosis (TB) has been improved considerably. We are supporting communities in initiating food production initiatives to address challenges of food insecurity and nutritional supplementation is provided in health facilities to patients with TB and/or HIV and AIDS.

We emphasise good nutrition and healthy lifestyle in general as important interventions in prolonging progression from HIV infection to development of AIDS defining conditions. It is not a substitute for an appropriate medical treatment, but it forms a solid foundation for the effectiveness of treatment when this becomes necessary. Another encouraging recent development is the adoption by all stakeholders of the National Strategic Plan for HIV and AIDS and STIs for 2007-2011.

The latest plan builds on the Strategic Plan for 2000 to 2005 in a continuous manner to intensify the implementation of the four key priority areas I have already mentioned.

The latest National Strategic Plan provides an extensive analysis of the nature, dynamics and character of the challenge of HIV and AIDS as it manifest itself in our environment. Having defined our problem, the country then identified an appropriate response in the form of evidence-based interventions as well as targets aligned with our international commitments with regard to addressing HIV and AIDS. These targets are adapted by each sector according to their means, particularly the availability of resources and in line with the provisions of our Constitution.

We continue to emphasise prevention as the cornerstone of our response to the spread of HIV and PMTCT programme is part of the interventions in this regard. The recommendation of mono-therapy as a model for PMTCT has been a challenge regarding particularly the limited effect of this approach and the possibility of resistance that is associated with it. The National Health Council, which is the highest health decision making body made up of the Minister and Members of Executive Council responsible for health in our nine provinces, are interrogating the guidelines that which proposes improvement of the treatment regimen for this programme.

In an effort towards attaining this target, we have expanded PMTCT programme to over 90% of our public health facilities. Primary prevention among women of childbearing age constitutes the cornerstone of this programme. All antenatal clients are offered PMTCT services as part of a comprehensive approach to maternal, child and women's health services. Antenatal attendance is high at about 80% and all these women are providing with appropriate counselling after which they take their individual decisions.

All pregnant women testing HIV positive are offered CD4 count testing. Women with CD4 counts below 200 are offered antiretroviral treatment. Again emphasis is made on the need for informed individual decision based on the choices available. There is a need to strengthen our ability to follow up on the babies and mothers that have been part of the programme. This remains a challenge for us because high levels of migration amongst our communities. HIV exposed babies need to be tested for HIV at six weeks and six weeks post-breastfeeding for those mothers choosing to breastfeed. Mothers and babies need to be assessed during wellness visits and treated appropriately.

We will be conducting an extensive evaluation of the programme and the findings of this review should inform the further strengthening of the programme in an effort to achieve Universal Access targets. We are glad to note from the 2007 Report Card on PMTCT and Paediatric HIV Care and Treatment in low and middle-income countries that forms part of the documentation for this meeting recognises the progress we are making as a country.

The report card indicates that South Africa is one of 17 low and middle-income countries that are set to achieve the UN 2010 target of reducing mother to child infections by 50%. It also acknowledges that South Africa and Kenya were the only two of the countries with the high burden of HIV that were reaching 40% of HIV positive mothers in need of antiretrovirals for PMTCT by 2006.

These findings clearly demonstrate our commitment as a country to meet the global targets in addressing HIV and AIDS. We are determined to do everything possible to protect women and children from HIV infection and to offer a comprehensive package of care and treatment to those who are infected and affected. The health of women and children is our priority as country. This forum provides a great opportunity for sharing of best practice and reaffirming our commitment as the world to improving the health of women and children.

I wish this forum fruitful deliberation over the next two days.

Thank you.

Issued by: Department of Health
26 November 2007