The operational plan has been substantially reworked since the task team
headed by Dr Tony Mbewu presented its proposals to Health Minister Dr Manto
Tshabalala-Msimang and provincial MECs on 30 September.

One key difference, according to insiders, is that government no longer
wants the roll-out to take place in phases.

This was the task team’s initial plan, which would have meant that only
about 20% of those who need the drugs would be able to get them in the first
year of operations.

Politicians and health officials were apparently concerned that this would
be inequitable and that those sites offering the drugs would be flooded.

The new proposal is for a “service point” to be identified in every one of
the country’s 56 health districts. This point will be based at a hospital,
but could also include clinics served by that hospital.

The operational motivation for this is that the plan needs to be integrated
into the current health system, rather than be a “vertical programme” that
is out of sync with district needs.

TAC vice-chairperson Mark Heywood says the change of plan is positive as it
is “much more equitable”.

However, said Heywood, “we also recognise that this will present a greater
challenge to the health department and repeat our offer to work with
government to ensure that all these sites are able to deliver”.

Another change to Mbewu’s plan has been government’s insistence that
provinces must get the support of traditional healers for the rollout.

In addition, Tshabalala-Msimang has also insisted that patients testing HIV
positive are counselled about non-medical means of boosting their immunity,
such as garlic, olive oil and the African potato.

Potential patients who are too poor to buy adequate nutrition will be given
food supplements including fortified mielie meal.

For the past two weeks, task team members and health officials have been
driving and flying all around the country, trying to visit every single
service point to check whether they are in a position to deliver the plan.

Each service point has to be certified by the task team before it can start
dispensing the drugs.

The roll-out has the potential to be the biggest ARV programme in the world.
This is a far cry from the situation a few years back when President Thabo
Mbeki warned the nation about the toxicity of first AZT then nevirapine,
both ARVs that government intends to use in its roll-out plan.

While many speculate that the turnaround has come about because there is a
general election next year, Heywood says that the issue “does not pose a
threat to the ANC’s support base”.

“I think the ANC simply does not want to fail to deliver on such a major
issue as the AIDS epidemic and it does not want the discomfort of a fight
around such a sensitive issue.”

The decision to extent ARV access may also be driven by the memory of the
2002 Constitutional Court ruling. This supported an earlier High Court
decision that government was acting unconstitutionally by restricting access
of ARV drugs to prevent mother-to-child HIV transmission to 18 pilot sites.

Legal experts have told the health department that they cannot ration the
ARV drugs or “deselect patients” unless this is based on the behaviour of
the patient.

“According to legal advice, deselection on the basis of things under the
control of the individual are justifiable but not for things they do not
have control over,” said former director general of health, Dr Ayanda
Ntsaluba, speaking before he left the department. This means that a drug
addict may be excluded, but someone too poor to afford food may not.

Meanwhile, the biggest worry for TAC is the lack of a communication campaign
to educate people about treatment.

“For us, treatment literacy is the biggest campaign now. We are busy
fundraising for large amounts of money so that communities can move from
little knowledge to a high level of knowledge in a short space of time. It’s
not enough that people get on-site counselling. There must be a barrage of
information on radio, TV, everywhere,” says Heywood.

How accessing ARVs will work, if Cabinet agrees to the plan

If Mary X would like to get antiretroviral (ARV) drugs, she will need to
present herself at one of the “service points” where she will get voluntary
HIV counselling and testing.

If she tests HIV positive, Mary will then be advised to have a CD4 test –
particularly if she has opportunistic infections. The CD4 cells co-ordinate
the body’s immune response so the test measures the strength of her immune
system. Her viral load (level of virus in the body) will also be measured.
Most provinces will rely on the national laboratories to process these
results.

If Mary’s CD4 count is less than 200 copies per millilitre of blood, she
will be advised to go onto ARV treatment. If her CD4 count is higher than
200 but she has AIDS-defining illnesses (according to the World Health
Organisation definition) she will still be eligible for the drugs. A doctor
will need to assess her and prescribe the drugs.

These drugs will have to be ordered from the provincial pharmaceutical
stores and will take about three weeks to be delivered.

During that three-week wait, Mary needs to attend three treatment literacy
training sessions. These will explain how the drugs work and the importance
of adhering strictly to the treatment.

Once she is on the ARVs, she will need to return for monthly check-ups and
her CD4 count and viral load will be tested every six months. If her viral
load does not fall to undetectable levels within six months, this might mean
that she is not responding to the drugs and her regimen will be changed.

E-mail Kerry Cullinan