The world's biggest ARV Programme?

To be HIV positive and living in South Africa is to be part of a national lottery that puts your current chances of accessing antiretroviral (ARV) treatment at about 25 percent. If you cannot afford private healthcare, make that just under 20 percent. Aside from your income bracket, the next best indicator of whether you will get your hands on those vital drugs is the province and the district in which you live.

If you are lucky enough to be living in the Western Cape, the first province to defy national government and begin providing treatment, your odds improve considerably.

Gauteng, the wealthiest province, is also not a bad bet. But if you are poor, HIV positive and residing in the largely rural province of Mpumalanga, your chances of being part of what the national government has called "the largest ARV treatment programme in the world" are not so good.

By June 2006, more than 175,000 people were receiving free medication in all 53 districts of the country, certainly putting the country's treatment programme among the world's most extensive.

Activists believe this is nothing to brag about, as the pace of progress in rolling out free ARVs has been slow and riddled with problems.

According to Dr Nomonde Xundu, head of the health department's HIV/AIDS and TB unit, "Based on the figures, it is indeed the largest programme in the world.

If you look at need as a proportionality of that figure, then perhaps there's a lot of work that still needs to be done; but if you look at the fact that in a matter of two and a half years this country has managed to put on treatment the largest number of people in the world, I think that needs to be encouraged."

DOES SIZE MATTER?

Superlatives are nothing new when describing South Africa's pandemic. In 2005 the country had the dubious distinction of recording the world's highest number of HIV/AIDS deaths - 320,000 - and over five million HIV-positive people, the second highest total.

So far, the treatment programme has failed to reflect the urgency that the scale of the problem demands, analysts insist.

A recent study by Prof Nicoli Nattrass, director of the AIDS and Society Research Unit at the University of Cape Town, suggests that South Africa's performance is poor, "given its economic, institutional and epidemiological characteristics."

"Although South Africa comprises a large share [25 percent] of the total number of sub-Saharan Africans on HAART [Highly Active Antiretroviral Therapy], whether in the public, private or not-for-profit sectors, this comparative analysis indicates that South Africa should be performing a lot better than it is with respect to HAART coverage," the report commented.

So why is South Africa underperforming?

According to the UN Secretary General's Special Envoy for HIV/AIDS in Africa, Stephen Lewis, a major constraint is political leadership. At the international AIDS conference in August 2006 in Toronto, Canada, he said the South African government was "still obtuse, dilatory and negligent" about delivering HIV/AIDS treatment.

Mark Heywood, of the AIDS lobby group, Treatment Action Campaign, also told conference delegates that South Africa's response to HIV was chaotic. "There has been an absence of moral, political and strategic leadership from the [ruling] African National Congress [party] and the government."

Health minister Dr Manto Tshabalala-Msimang has been overly cautious - if not outright sceptical - about antiretrovirals ever since the state finally agreed to provide the life-prolonging medication in the public sector in October 2003.

To this day, she continues to warn about the dangers of taking the drugs, emphasising nutrition as an "alternative" to ARVs.

Nattrass points out that in such a politically charged environment it is "probably unsurprising" the rollout has proceeded far more slowly than expected.

Unlike its less well-off neighbours, money is not a major prohibiting factor in South Africa. According to Nattrass, the national treasury has allocated sufficient resources to the public sector for the ARV rollout, "yet these resources are not being fully or appropriately utilised and, instead, one of the main driving forces for the public sector rollout appears to be external assistance from donors."

QUALITY AND QUANTITY

The Joint Civil Society Monitoring Forum, a coalition of academic, medical and private-sector organisations compiling progress reports on the government's ARV delivery, has warned that the ability to expand and sustain the national treatment plan depends on recruiting and training more health workers, as "shortages of all categories of healthcare workers continue to bedevil the programme".

Although the rollout has gathered some steam in the past year, what is increasingly clear is the inequality in access, even when the drugs are free.

This is particularly evident in poorer provinces such as Mpumalanga, ranked second to last of the nine provinces in terms of treatment coverage, where few HIV-positive pregnant women receive drugs to reduce their chances of passing the virus to their babies.

In January 2006, the HIV status of just nine of the 320 women who delivered at Mapulaneng Hospital in Mpumalanga was known.

After they gave birth, most of them agreed to be tested and 47 were found HIV positive, but only three had received nevirapine.

As the health of more and more people improves as a result of treatment, another problem is emerging: the loss of disability grants. Around 40 percent of South Africans are unemployed and poverty is deeply entrenched, with the poorest of the poor typically rural women.

Many HIV-positive South Africans whose CD4 counts have dropped to below 200 receive a monthly disability grant of R800 (US$115) to ensure that they can afford appropriate nutrition and medical check-ups; in practice the grant often supports entire families.

Another persistent problem is that around 7 out of every 10 adults accessing treatment are women, and NGOs are calling for the government to consider innovative approaches to attract men to the treatment programme.

HIV-positive children are also often sidelined because of the additional cost of paediatric ARVs, and in their absence, the difficulty of calculating the correct dosage of adult ARVs for them while they are growing.

Local NGO, the Health Systems Trust estimated that about 14,000 children were on ARVs in January 2006 - a significant increase from a year before, when only 3,000 were receiving treatment.

Nevertheless, healthcare workers and activists feel more could be done to scale up access to paediatric treatment. "It's as if the adult epidemic overwhelms and sometimes squashes out the children needing treatment," said Dr Tammy Meyers, who runs the Harriet Shezi Children's Clinic at Chris Hani Baragwanath hospital in Soweto, a sprawling township on the outskirts of Johannesburg.

This is part of a series of stories in a new PlusNews Special: 'South Africa - The world's biggest ARV Programme?'