Optimism over possible ARV rollout

The Western Cape was the first province to defy South African government policy by providing AIDS drugs to HIV-positive pregnant women in the public health sector. Two years later, the rollout campaign has achieved universal coverage and now babies and children living with HIV/AIDS are also to get access to treatment. The next step will be to provide antiretrovirals (ARVs) for all people living with HIV/AIDS through the public health sector "soon", Western Cape health minister, Piet Meyer, said last week. In March 2003 the province announced that all HIV-positive pregnant women could access the antiretroviral drug, Nevirapine, at their nearest clinic. This meant that even women in hard-to-reach rural communities could prevent mother-to-child transmission (PMTCT) of HIV by visiting the monthly mobile clinic, Western Cape health director general, Fareed Abdullah, told journalists during a workshop on anti-AIDS drugs recently. The uptake of women into the programme has been very high, with between 90 percent and 95 percent of pregnant women in and around Cape Town enrolled in the PMTCT project, Cape Town's Director of Health Dr Ivan Toms told IRIN. In the rest of the province, 90.9 percent of women accepted voluntary counselling and testing in 2002. ARV ROLLOUT The challenge for the provincial government is to replicate this success when implementing a treatment plan for adults. "We need to put between 50 percent and 60 percent of the people living with HIV/AIDS, who need drugs, on treatment, and we need to do it right," Abdullah said. But introducing ARV treatment was "not an emergency", it needed "planning and support". "You can discuss and debate when to access treatment, but at least have a sense of strategy and direction," he urged. The first step would be through PMTCT "Plus". Previously, PMTCT initiatives focused on infants, with very little being done for the rest of the family. But mothers and other family members would soon be able to get ARV therapy, care and support services. "It has just been agreed that Cape Town will introduce this [PMTCT Plus] in Langa [one of the city's townships] for up to 1,000 people. There will be a commitment to provide ARVs for life, to ensure the project's sustainability," Toms said. Although a national ARV rollout was "relatively close", it was important to have an effective health system in place first, he noted. Nevertheless, tuberculosis (TB) remains the province's biggest problem. The province had the highest TB rate nationally, and one of the highest in the world. About half the 21,000 TB cases in Cape Town in 2002 were also HIV-positive. One of the biggest hurdles would be to effectively integrate TB and HIV/AIDS programmes, as the rising HIV prevalence is likely to increase the number of deaths due to TB. This had led to the recent introduction of voluntary HIV counselling and testing in TB clinics. The TB programme's "good cure rate" would be an invaluable lesson for future ARV programmes - particularly in treatment adherence, Toms said. Consequently, the province was well-positioned to "take things forward" in terms of treatment, he added. Findings from the Medecines Sans Frontieres' (MSF) ARV therapy pilot programme in the Cape Town township of Khayelitsha demonstrated that treatment campaigns were possible in poor communities, and the provincial health authorities had taken note of the project's success. For Abdullah "the greatest complexity lies in the importance of adherence", as opposed to logistics. Drug compliance is critical for antiretroviral regimens, as it can prevent or forestall the development of drug resistance. "In the last two years, Khayelitsha has shown [us] not to exaggerate the meaning of 'complex' - it can be done." THE WAY FORWARD According to projections, the Western Cape will be providing treatment to 30,000 HIV-positive people by 2010. Before this happens, compromises would have to be made. The province will start off with one ARV site per health district, taking budget constraints into account. Staffing was a potential "Achilles heel" Abdullah noted. "Staff will always be a concern because budget constraints mean staff constraints," Toms pointed out. Until the rollout takes place, issues such as overcoming stigma and discrimination would also have to be addressed, as this could prevent many people living with HIV/AIDS from accessing the drugs, Toms said. "Another thing we can never let up on is prevention. The city plans to distribute 18 million condoms this year - but this is still a drop in the ocean," he added. Meanwhile, the South African cabinet is expected to discuss a national ARV costing report this week, ahead of a meeting between AIDS lobby group the Treatment Action Campaign and the National AIDS Council on 14 June. AIDS activists hope recommendations handed down by the report will end months of a bitter stand-off between them and the department of health over its refusal to implement a treatment policy. But the Western Cape's health department is optimistic. "When government makes the decision to provide treatment, all hands will need to be on deck," Abdullah said.