Still many pitfalls, but impressive progress

It is shocking that a young, intelligent man like Sandile should die of HIV-related TB in 2012, when TB and ARV treatment is freely available and the government has ploughed massive resources into addressing these twin epidemics that feed off one another.

But Sandile slipped through one of the many holes that still exist in the health system. Like many people with HIV, his tuberculosis was not in his lungs so it did not show in the usual sputum (spit) test so it took a while to be diagnosed.

He attended a clinic in uMgungundlovu, the health district with the highest HIV rate in the country, where staff and resources are over-stretched. In addition, like many other South African men, he started his ARVs late, when his immune system was already weak and it was very hard to build it up again.

The government, under the energetic leadership of Health Minister Dr Aaron Motsoaledi, has made impressive progress in the fight against HIV/AIDS in the past few years guided by the aims of ‘€œZero new infections, Zero deaths and Zero stigma’€, the cornerstones of our National Strategic Plan for HIV, STIs and TB.

Unlike many other government programmes, progress can be directly counted in lives saved. About 100 000 fewer South Africans died of AIDS last year in comparison to 2005, according to the Joint UN Committee on AIDS (UNAIDS) 2012 World AIDS Day.

South Africa has also increased its scale up of HIV treatment by 75% in only two years, ensuring that 1.7 million people are now on ARVs, according to the UNAIDS report.

New HIV infections have also fallen by 41 percent in the past two years, meaning that some 50 000 fewer people have become infected with HIV. Health experts attribute this to massive progress in preventing mother-to-child HIV infection as well as ‘€œtreatment as prevention’€, namely that people on ARVs are unlikely to transmit HIV when their viral load is rendered undetectable by the medication.

The price tag for South Africa’€™s success has been in the region of US$ 1.6 billion, the highest expenditure of any low- and middle-income country and a fivefold increase since 2006.

While it is a relief that government is serious about moving to a point of zero new infections, trying to manage almost six million people with HIV is not easy ‘€“ particularly when provincial governments are the implementing agents and many are dysfunctional and plagued by corruption.

There are many worrying reports of a number of clinics, particularly in the Eastern Cape and Gauteng, running out of medicine, including ARVs. A break in ARV treatment can cause the HI virus to mutate and become drug-resistant, meaning that patients will need other, more expensive drugs to keep HIV in check. This is entirely a health system failure that is beyond the control of patients.

However, the biggest gap in the fight against HIV is still in preventing new infections. While massive progress has been made in reducing the transmission of HIV from mothers to their babies (down from 8% to 3.5%), not enough is being done to prevent adults from infecting one another.

The reason adults do still infect one another is not usually out of malicious intent but ignorance. Unless there is mass, continuous HIV testing easily available to all, people will continue to be ignorant of their HIV status. In 2010, government launched a massive HIV testing campaign that reached an estimated 13 million people, but this has fizzled out in many provinces.

Medical male circumcision, which has the potential of reducing a man’€™s risk of getting HIV by 60%, is only really being pursued on a large scale in KwaZulu-Natal, and other high prevalence provinces such as the Free State and Mpumalanga should follow suit.

Adults living in informal settlements are the most vulnerable to HIV, according to a number of surveys. Priority should be given to providing free HIV testing in informal settlements and easier access to treatment.

In July, the US Food and Drug Authority approved a commercial HIV test that can be done at home using saliva. While the test costs around R250 commercially, it is something that should be considered here to maximize South African’€™s access to HIV tests.

Unfortunately, the money that international agencies have contributed to fighting against HIV is drying up ‘€“ and one of the areas affected is prevention. Innovative media prevention campaigns, such as the television series Intersexions and the campaigns ‘€œScrutinise’€   and Brothers for Life, supported by Johns Hopkins Health and Education SA (JHHESA) are to be affected when JHHSA’€™s grant from the US President’€™s Emergency Plan for AIDS Relief (Pepfar) ends next year.

Some of the most innovative and oldest HIV treatment and care programmes have closed, including HIV care for non-medical aids patients at McCord Hospital in Durban.

While there is general consensus that government can afford to cover ARV treatment for all citizens, government’€™s refusal to take over some of these facilities where the best-practice was forged, with highly experienced staff, seems short-sighted.

There are still many challenges ahead, and many cracks through which people like Sandile are going to fall in resource-stretched provinces. But there is a united front against HIV/AIDS with strong national government leadership, and that is a cause for celebration this AIDS Day.


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