To do so it needs a healthy injection of staff, including 28 doctors, 90 nurses, 44 pharmacists and 132 counsellors for the next year alone.

“In the first phase, anti-retroviral drugs will be offered at all tertiary hospitals, some regional and district hospitals and at five large clinics,” says Dr Nomonde Xundu, the province’s project leader on the ARV rollout.

She expects most of the eligible patients to be identified by health facilities themselves, such as hospitals that have admitted AIDS patients, TB clinics, prevention of mother to child HIV transmission and the voluntary HIV counselling and testing programmes.

“By November 2008, we aim to have 100% coverage,” says Xundu. “Even the mobile clinics will stock the drugs and we expect to treat around 150 000 patients by then.”

Every person who tests HIV positive in the province should be offered a CD4 count, at a cost to the state of around R200 a time. A CD4 test measures immunity in the blood, and is normally above 500 counts per millilitre of blood. These CD4 tests will then be repeated every six months.

Those who have a CD4 count of 200 or less will be eligible for the drugs, which have the potential to transform the killer virus into a manageable chronic illness. Those who suffer from AIDS-defining illnesses yet have CD4 counts of above 200 will also be able to get the drugs.

The National Health Laboratory Services (NHLS) is a crucial part of the ARV programme. It has promised to provide phlebotomists (people qualified to draw blood) at some service points and it will pick up and process blood specimens for the CD4 tests, viral loads and other safety monitoring investigations.

“We expect a turn-around time of around two to three days for clinics to get the CD4 results, while the hospitals will get them the next day,” says Xundu.

But Xundu says that “non-biological” factors will also be considered in the selection of people for the drug programme.

“We will need to assess their psychological and social well-being,” she says. “Their ability to disclose their HIV state to someone, family support and previous health-seeking behaviour.”

This “health-seeking behaviour” will include looking at patients’ clinic records to see whether they keep appointments and take tablets. Should such a record not be available, the health facilities may want to monitor the potential ARV patient for three months to see whether they are reliable, and this able to adhere to ARV treatment.

Unless ARVs are taken at the same time every day 95% of the time, they will not work and there is a danger that the patient will develop drug resistant HIV, which is much more difficult to treat.

“A lot of education is needed so that a patient understands the implications of taking ARVs,” says Xundu. “We have asked for six counsellors per facility to counsel patients to help with drug adherence.”

“We will encourage patients to form treatment support groups and really hope that the Treatment Action Campaign will assist us with community mobilisation, education and support,” adds Xundu.

Gauteng already has offers food parcels to people on chronic medication who cannot afford to eat properly, and this will be extended to those on the ARV programme.

Xundu admits that the rollout is a huge undertaking and prefers to describe it as a “continuum of care” rather than a drug programme.

“Research tells us that only about 15% of those who test HIV positive will need the drugs. But the remaining 85% need a range of interventions to keep them well.”

Thus, the roll-out programme includes support for those who are HIV positive and healthy. This includes nutritional advice, TB screening and giving Bactrim, a drug shown to protect people from getting pneumonia and other bacterial infections.

In addition, clinics will be encouraged to start support groups and counsel people about positive living.

While Xundu is calm in the face of the impending storm, she identifies two major challenges. The first is employing the necessary staff. “The money may be there, but I just don’t know if we are going to find the people,” she says.

The second is to get the support of all the different stakeholders, from the pharmaceutical services to ensure a smooth and safe drug supply to politicians, who “need to communicate to communities about the importance of ARVs”.

  E-mail Kerry Cullinan