Dhirisha Naidoo remembers the “look of HIV” vividly. She saw it on a daily basis when she was a nurse at a mission hospital in Durban just out of college in 2004.

“People were usually very thin, skin and bone, emaciated completely. You’d see these hopeless, helpless patients lying on stretchers and wheelchairs,” says Naidoo. Almost 20 years later, Naidoo is now Chief of Party at APACE BroadReach, a PEPFAR-funded USAID program sustaining HIV epidemic control in South Africa. 

Health-e News Hannah Zhihan Jiang caught up with her in Mpumalanga while the organisations marked 20 years of collaborative effort fighting the HIV epidemic. 

She recalls many of the patients could not get treated in time due to the ART medical criteria 20 years ago. Up until 2011, patients in South Africa would receive antiretroviral treatment, a combination of anti-HIV drugs, only if they had a CD4 count of fewer than 200 cells per cubic millimetre or if they have late-stage HIV. CD4 count is an indicator of immune function in patients living with HIV. The CD4 count criterion was raised to lower than 350 in 2011, to 500 in 2015 and eliminated in 2016. 

In 2004, the mission hospital in Durban where Naidoo worked was one of the only hopes for HIV patients. Naidoo says seriously ill patients used to travel all across the country to access treatment in the hospital, which was funded by PEPFAR, a U.S. government initiative to address the global HIV/AIDS epidemic. The project covered the majority of transport and treatment costs for the patients. 

“We had huge caseloads of patients. It was scary seeing the patients. They had this look of giving up,” says Naidoo. 

20 years of miracle making

As grim as it looked for HIV patients in 2004, it was also the year PEPFAR launched, which marked a significant increase in funding towards battling the epidemic. To date, PEPFAR funding for the global AIDS crisis has totalled $110 billion, the largest commitment by any nation to address a single disease in the world. 

Together with civil society organisations, the National Department of Health and business partners such as BroadReach, PEPFAR has worked in local South African communities to conduct testing and treatment of HIV.

“What do you see now on patients’ faces? Now you don’t see it. Now people are healthy. We can’t even tell who’s HIV positive,” says Naidoo.

According to UNAIDS HIV statistics in 2021, AIDS-related deaths have reduced by 68% since the peak in 2004. Out of the 38.4 million people living with AIDS globally, 28.7 million of them were accessing antiretroviral treatment by the end of 2021, up from 7.8 million in 2010. 

With 7.5 million people living with AIDS, South Africa has the largest number of infected adults and children in the world. 74% of them are receiving antiretroviral treatment in 2021, according to UNAIDS.

“PEPFAR was a game changer of game changers. I remember at the time, resources available to do this work were practically non-existent,” says Dr Ernest Darkoh, co-founder of BroadReach.

“A New Set of Challenges Approaching the Finish Line”

With the UN’s goal to end AIDS globally in 2030, Dr Darkoh says we are getting to see the finish line, but he cautions new sets of challenges would appear as we approach it.

One challenge is treatment fatigue for HIV patients who have been on ART for close to or more than 20 years. HIV-positive people cannot stop the treatment even if their viral load is undetectable, as ART is not a cure and the virus remains in the body. 

“We need to push it out faster: home delivery, pick up points. We need to expand the resources,” says Dr Darkoh.

Other speakers such as Dr Lucas Ndhlovu, Head of the Department of Health in Mpumalanga, have emphasised supporting priority populations through lifelong HIV treatment. 

Key communities including sex workers and their clients, men who have sex with men, people who inject drugs, and transgender people account for 70% of HIV global infections and 51% of new infections in sub-Saharan Africa, according to UNAIDS. 

Provinces face unique challenges

Mpumalanga, where the 20-year PEPFAR anniversary event is held, is one of the provinces that have the largest mining workforce. This means that the province has a good amount of mobile workers, says Nkosi Tshabalala, BroadReach Technical Advisor overseeing Mpumalanga.

“A high number of patients on ART get lost in the system because they move back home or to other provinces. If they continue treatment, we, in Mpumalanga, do not know about that,” says Tshabalala. 

Having worked with BroadReach and PEPFAR for 15 years, Tshabalala helped develop the digital reporting and treatment system for HIV data tracking. He says now facilities are able to see HIV data from the month before so they could make decisions as local situations change.

However, Tshabalala says a national system of medical history tracking needs to be built, so mobile patients can be better monitored and treated. “So if someone comes in, we don’t need to build the information from scratch. Something can get missed. If the patients don’t mention their historical, chronic illness, it doesn’t get tested at the time.”

Linda Dlamini, Director of the Department of Health of KwaZulu-Natal, says the recent severe flooding in the province destroyed the patients’ homes as well as their medications. She points out the importance of expanding outpatient facilities such as drop-in centres and pick-up points.

“Ultimately, those unplanned events affect the patients. So for me, front and centre are always about how we plan to mitigate the shocks so that you lessen the impact on your patients,” says Naidoo. – Health-e News