Contrary to President Thabo Mbeki’€™s earlier hardline stance against drug treatment for HIV/AIDS, government is now seriously considering a range of drug options as the epidemic eats into the population.

Today (Dec 1) government is to announce a deal with pharmaceutical company Pfizer, which will see the drug fluconazole donated to the public sector for distribution to HIV/AIDS patients who suffer from crytococcal meningitis and thrush ‘€“ common opportunistic infections

Dr Nono Simelela, Chief Director of the national HIV/AIDS Directorate, said fluconazole will be placed on the Essential Drug List which will ensure that it is available at primary healthcare clinics countrywide.

The Treatment Action Campaign (TAC) ‘€“ which fights for access to drugs for HIV positive people ‘€“ says it will only claim the deal as a victory when fluconazole actually reaches people in clinics and hospitals.

Simelela said that the other drugs to treat other common opportunistic infections such as herpes were also on the newly expanded Essential Drug List.

This week, the Joint United Nations Agency on HIV/AIDS (UNAIDS) revealed that South Africa has the largest HIV positive population in the world.

“People keep thinking that treatment is just anti-retrovirals but that’€™s not true,” said Simelela in a wide-ranging interview on the eve of World AIDS Day.

“We can rigorously manage the opportunistic infections. The only weakness in the chain is we don’€™t know who is HIV positive so we don’€™t know where to put our emphasis.

“If two people have diarrhoea and one is positive and the other negative, they will obviously respond differently. You need to be more intense with the positive patient. That is why we are encouraging people to know their status.”

“We need to still push the ABC ‘€“ abstain from sex, be faithful, use a condom. The only way we are going to get on top of the epidemic is if no new infections occur,” said Simelela.

“But the campaign is shifting to care and support strategies for those infected,” she noted.

“The reason why the care and support messages have been low key is that we are trying to ensure that services are there, so that we can say to those who are positive, ‘€˜go here or go there’€™ and they will find a supportive and nurturing environment.

“To do this, we have had several meetings about access to care and treatment and what the problems are in getting drugs to facilities in the provinces.

“Also, voluntary HIV testing and counselling can only take place where there are services and support groups.”

Government is also convinced that nevirapine is effective in reducing mother-to-child HIV transmission, but it wants to ensure that babies saved by the drug do not then become infected by their mothers’€™ breastmilk.

“The nevirapine aspect of mother-to-child transmission is the easy part. It’€™s the feeding options that are much more challenging,” said Simelela.

“Even providing the infant formula might not be the answer,” she said. “We are dealing with very impoverished communities. What stops the poor woman from giving other babies in the house the formula or even diluting it?

“If it comes out [from research] that exclusive breastfeeding is feasible, then we will feel comfortable to put that as policy. But we think this will also be very difficult for women.”

A decision on whether it is feasible to provide free nevirapine is only likely to be taken in a year’€™s time when all provinces have administered the drug at two local sites and assessed the infrastructure needs and costs of the programme.

Negotiations with other pharmaceutical companies for cheaper anti-retroviral drugs have not made much progress, said Simelela.

“A contact group made up of African health ministers and UNAIDS was set up to take these negotiations forward. But the pharmaceutical companies are by-passing this and trying to negotiate with individual countries.

“If we negotiate only as South Africa, then there will be cross-border flow like you won’€™t believe from SADC countries as people try to get access to the drugs and the black market opens up. It is better if there is equitable access to these drugs for all countries.

“If we negotiate en bloc, companies might drop their prices even further. But this is almost a divide and rule tactic.”

So far, Senegal and Botswana have gone into separate negotiations with drug companies and Senegal has already concluded deals with at least two companies.

Simelela said that those who call AZT “poisonous” are unscientific, as “this is a term that suggests you will kill people with it”.

“As a medical practitioner, I cannot use the word poisonous because by this definition, then aspirin is poisonous. But all drugs have side-effects, but one cannot underestimate that these drugs are potent.”

However, provincial lack of capacity is proving to be a headache in the fight against HIV/AIDS, admitted Simelela.

“People get impatient. But they are looking at their clinic. I am looking at the whole country. There’€™s lack of capacity like you won’€™t believe. We have had to put so much into building people’€™s ability to think creatively and to plan long-term.”

However, she agreed that government needs to allocate more money to fighting the epidemic.

According to the medium term expenditure framework released recently, the finance department has decided not to increase health expenditure for the next three years.

Simelela said the finance department’€™s “excuse” that it could not allocate more money as it did not know what the impact of the epidemic was, “is no longer valid”.

“We’€™ve just got impact studies from Abt Associates that show the impact of the epidemic on health and education, and from what I’€™ve seen the Treasury will have to find the money. The studies are going to blow their minds.”

As the most prominent government official dealing with the epidemic, the soft-spoken and elegant Simelela has been on the receiving end of a lot of harsh criticism, particularly at the height of the “does HIV cause AIDS” debate.

However, she believes the media blew the debate “out of all proportion” and that things have improved since the Minister of Health met with the SA National Editors’€™ Forum.

“I think we are our own worst enemies when it comes to publicity. People are surpised when they hear of all the things we are doing. So we are going to be putting a lot more information about what we are doing in the media.”

She jokes the before a recent meeting with HIV/AIDS NGOs she told her mother “if you get a call that I am dead you will know that the NGOs have lynched me”.

“But we had a good meeting. They are critical of some issues and rightly so sometimes, but there was no bad vibe. We have much in common.

“People say it slow, and sometimes things should move faster. But we will get there.”