Your daily Selection of IRIN Africa PlusNews reports, 3/30/2005

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CONTENT:

1 - SOUTH AFRICA: Interview with Dr Nomonde Xundu, head of govt's HIV/AIDS unit

2 - UGANDA: Rights group criticises emphasis on abstinence

1 - SOUTH AFRICA: Interview with Dr Nomonde Xundu, head of govt's HIV/AIDS unit

JOHANNESBURG, 30 March (PLUSNEWS) - In November 2003 the South African

government launched its much-anticipated HIV/AIDS treatment programme,

committing itself to providing free antiretroviral (ARV) drugs to 53,000

HIV-positive people by March 2004. The figure is a fraction of South Africa's

HIV positive population, estimated at over five million, but was nevertheless an

ambitious beginning to what was to be the world's largest ARV rollout to date.

That target date has since been moved forward a year, to March 2005, but still

seems unlikely to be met. PlusNews spoke to Dr Nomonde Xundu, chief director of

the department of health's HIV/AIDS and TB unit about the challenges of rolling

out the programme.

QUESTION: Can you give an assessment of the progress made in implementing the

country's treatment plan?

ANSWER: [Our goal] in the first year (we started on the 1st of April 2004) [was

to] have a service point in each health district - there are 53 of them. So we

are now confidently in 51 of those, and we know by the end of March we'll have

covered all 53 districts.

We had to implement a complex programme in an overstretched health system, with

gross inequalities, that was faced with the AIDS epidemic.

Part of doing this was making sure that there are skilled people, additional

resources, a well coordinated national health laboratory system and good quality

of care, in terms of providing protocols, training, and monitoring what gets

done on the ground.

So when you ask about progress, we need to report on all of those things.

Q: Could you describe the scale of the HIV/AIDS epidemic in South Africa?

A: With about 45 million people [in South Africa], the annual antenatal clinic

surveillance shows us that, of the pregnant women who come to public health

services, 29.6 percent of them are infected with HIV. But with additional

information from other sources we can infer that about 16 percent of the 45

million may, in fact, be living with HIV, which makes it about 5.2 million. We

are thinking that about 16 percent of the 5.2 million are actually living with

AIDS, in terms of the progression of the disease, and would require

antiretroviral (ARV) therapy, amongst other interventions for AIDS-related

complications.

Q: According to the figures you've mentioned, between 500,000 and 750,000 South

Africans need treatment - how many are currently on ARVs?

A: We have managed to get about 33,000 people on ARV therapy over a period of

nine months. Some provinces are doing better than others because some have

experience. We needed more intense interventions in some provinces - mainly your

rural-based provinces - to get them to a point where they could start

[implementation].

Q: Are you satisfied with the progress so far?

A: If you look at the complexities of administering a programme like this - what

needed to be done to make sure that it works, and doesn't undermine other health

services in the public health sector, I think we're not doing badly. But the

plan is to have universal access for all the people who are eligible for therapy

in the course of five years - it would be impossible to do that within a

nine-month period. So, given the constraints, we are not doing badly.

Q: What are some of these constraints?

A: We developed a tool to assess the readiness of each service point ... to

indicate that ... [it was] ready to implement. We were looking, for instance, at

the human resources capacity, and within that ... for skills - people who know

how to ... [treat patients] on ARVs. We looked at the laboratory services within

a facility and the availability of basic HIV/AIDS services - voluntary

counselling and testing (VCT), the prevention of mother-to-child transmission

(PMTCT) and post-exposure prophylaxis (PEP).

We also looked at emergency medical services ... patient tracking ... and

information systems. So with that tool we identified gaps, put together

strengthening plans for each of those 119 [ARV] sites - in fact, [in the

country's 53 health districts a total of] 214 service points will have been

accredited by the end of March.

Now 119 facilities have been found ready to implement the programme in ... 51

districts. People [were required] to move from the national offices to the

districts to assist ... and we are rethinking to see how can we streamline the

accreditation process.

Another area is human resource capacity. We've managed to get 35 percent of the

targeted additional resources that we had identified in the Comprehensive Plan.

We managed to get 111 additional doctors, which I think is excellent, but what

I'm worried about is that we may be bleeding the very system we are saying is

under-resourced. It may be that the doctors ... we are finding come mainly from

the public sector, but we need to ... do some research and find out exactly

where these doctors are coming from. We struggled specifically with pharmacists,

who are a critical component of the programme, as they have to sit with patients

and explain to them how to take treatment [wouldn't a health worker/nurse

normally do this?].

Provinces are mainly running their own [skills development and] training

programmes. We've said we would set up regional training centres, but these have

not been fully set up yet. We find that provinces have been outsourcing [this]

to external providers, which has fast-tracked the process. We've seen up to

about 8,000 service providers trained countrywide through these kinds of

interventions, but obviously we are working hard to make sure training centres

are established, rather than relying on outsourced services, which are not

sustainable all of the time.

We have a National Health Laboratory System (NHLS) in eight of the provinces.

We've had to increase laboratories that can do CD 4 tests [measuring the

strength of the immune system] and viral loads and other tests. But we struggled

in rural areas with the transportation of specimens [to laboratories]. In some

cases, we found that specimens were not being transported in acceptable

conditions. In desperation people will put a bag of specimens on taxis. [?]

We have now offered more CD4 testing - previously that has not been accessible

because of cost - but now that's budgeted for under the Comprehensive Plan.

In terms of pharmacovigilance [?], this is the area we are really struggling

with. I cannot, for instance, tell you exactly how many people are experiencing

adverse effects from ARV therapy. There's lots of anecdotal reports from the

ground that people are not managing on treatment, and ... even reports of

mortality ... [which] impacts negatively on this programme ... so we need to

closely monitor that.

With patient information ... we are currently relying on the paper-based system.

We have different systems in different provinces. We would need to standardise

that across the country.

The nutrition component of the programme we thought was very important. We know

that a large majority of the people who are affected are poor - the majority of

the people who will be using the public sector are people who would need

augmentation of nutrition. So we communicate [information about] healthy living

and healthy lifestyles, to guide people as to what a reasonable diet would be

for a person who has a chronic infection. But we're also providing supplements,

like different forms of maize meal ... as well as multivitamins.

The biggest challenges are human resource capacity, patient information systems

and pharmacovigilance.

Q: What about the challenges in informing people about the plan, getting them to

come forward for testing and commit to the regimen?

A: The mistake we made was to put the cart before the horse. We do have ongoing

.... [motivation] through the Khomanani campaign, but the messages on treatment

and importance of adherence only came after we started implementing the

programme. Be that as it may, I think to some degree we did catch up. [Would you

have messages on treatment and adherence if it were not available because the

sites were not yet operational?]

On an individual patient basis, people are taken through about three weeks of

education about treatment itself, and they are given prophylaxis to monitor how

they manage adhering over a period of time. If they ... are able to adhere,

[they are ready to start treatment]. Also, we encourage disclosing to someone at

home who will be a treatment supporter. Coupled with that, we have treatment

supporters at the facilities themselves - the lay counsellors. People are [also]

educated about the importance of adherence on an individual basis by the doctor,

pharmacist and nurses. We have support groups at the facility where people sit

together and share their treatment experiences.

These are people who need to take almost a bucketful of tablets home with them.

In most cases they live in informal settlements, sharing one room with other

people, and they have to explain why they have to take so much treatment. That's

why it's important to encourage people to disclose to someone in the family, who

is going to be supporting them along the way. We haven't had problems with

adherence - from reports we're getting from the provinces, adherence levels are

in the region of 95 to 97 percent.

Q: What are your impressions on the efficacy of ARVs?

A: We know there is scientific evidence, and are convinced of the efficacy and

impact of using these drugs. We know that people are able to buy at least three

years [of life] when eligible - and even more, in some cases - if it's coupled

with other interventions, like positive living and so on. But we are finding,

also, that it may have an indirect impact on the incidence of TB, for instance.

As the immune system becomes better, people don't develop TB, as they often do.

People have reported reduced number of AIDS-related admissions in hospitals

after starting the ARV programme. People go back to work, feel better, they are

more productive and the economy improves.

But we need to reiterate that there is no cure - even with provision of ARVs,

people will eventually die. What is still being defined is how much time we're

buying.

Q: Organisations, such as the lobby group, Treatment Action Campaign, have

played a part in getting the country to where it is now in terms of providing

ARVs. What do you see as their role?

A: The country recognised, when putting together a plan to deal with HIV/AIDS,

that it would have to be a multisectoral strategy, so all of these organisations

are important. Our national strategic plan, which ends this year, had input from

stakeholders across the board. When drawing up the Comprehensive Plan, we

consulted all these people.

Q: There's been criticism that, despite the good treatment strategy, the

government started it too late ...

A: I don't understand what 'too late' is, but we needed to plan properly for a

complex programme that was going to be implemented in a system that was being

upgraded. Also, we were inhibited by costs, and the country was in the forefront

of making sure that drug prices came down, and when they did come down, there

was commitment from the country that we should then put in the additional

component [?] - which is what we are currently busy doing.

Q: Any advice to other African health departments who are busy rolling out

similar initiatives?

A: It's important to [motivate] society, educate people on what these drugs are

about, how they should be taken when prescribed, and the level of commitment

[required].

With regard to the health system itself: plan properly, particularly around

human resource issues. We are fortunate in South Africa to have experts and

human resource capacity to implement these programmes. [My observation of] other

countries is that they are able to do a lot with little. But even so, they need

to look at the human resources required, laboratory capacity, transportation of

specimens to laboratories and the area of monitoring and evaluation.

A patient information system is critical to make sure that there is a unique

countrywide identifier for each patient, so when people move around the country,

they can easily access the service. You don't want ... treatment interruptions

and people having to go on different regimens as a result.

While it is important to have links with NGOs and other stakeholders, I must

caution that most of the programme should be implemented with the country's

fiscus, to ensure it's sustainable. Yes, donations from the donor community are

welcome, but this kind of programme is about putting lots of people on expensive

treatment over a long period of time, so the country must be able to manage

that.

It is also important to have a system for reporting on adverse effects and

mortality, so we can understand what these drugs are doing, and are able to

monitor resistance.

Q: What do you think is the single most important thing for establishing a

rollout?

A: Good planning - with all relevant stakeholders.

[ENDS]

2 - UGANDA: Rights group criticises emphasis on abstinence

KAMPALA, 30 March (PLUSNEWS) - The policy shift towards " abstinence-only

programmes " to curb the spread of HIV/AIDS could reverse significant gains made

by Uganda in the fight against the pandemic, Human Rights Watch (HRW), warned on

Wednesday.

In a new report, titled: 'The Less They Know, the Better: Abstinence-Only

HIV/AIDS Programs in Uganda', HRW said the Ugandan government had removed

critical HIV/AIDS information from primary school curricula, including

information about condoms, safer sex, and the risks of HIV in marriage.

" These abstinence-only programmes leave Uganda's children at risk of HIV, "

Cohen, an HRW researcher, and co-author of the report, said in a press

statement on Wednesday.

" Draft secondary school materials state falsely that latex condoms have

microscopic pores that can be permeated by HIV, and that pre-marital sex is a

form of 'deviance', " the statement added.

Ugandan government officials however strongly denied the claims made in the

report, with the Primary Health Care Minister, Kamugisha, saying HRW was

" peddling blatant lies " .

" Uganda has never abandoned the ABC [Abstinence, Be Faithful and use Condoms]

strategy, we educate our population on all methods of prevention of HIV, "

Kamugisha told IRIN on Wednesday. " ABC was created by our AIDS control programme

almost two decades ago, long before the US began funding abstinence programmes

in Uganda.

" For younger primary school children, the appropriate thing is to focus on

abstinence - but later, we teach them all the ways to avoid contracting the

disease, including the use of condoms, " he added.

Uganda has been widely acclaimed for its success in the fight against HIV/AIDS,

managing to bring its prevalence levels down from over 20 percent in the late

1980s, to around six percent by the end of 2003.

Much of this success has been credited to the ABC strategy. However, HRW said

condoms were being left out of the equation, especially for young people, an

approach the report claimed was orchestrated and funded by the US government.

" As the largest single donor to HIV/AIDS programs in Uganda, the United States

is using its unparalleled influence to export abstinence-only programs that have

been an abject failure in its own country, " the report stated.

It added that as of November 2004, the US embassy in Kampala had budgeted about

US $8 million for " abstinence and behaviour change " in the country. That same

month, HRW alleges, the Uganda AIDS Commission drafted an " Abstinence and Being

Faithful " (AB) strategy, saying that the inclusion of condoms in the strategy

could be confusing to young people.

At an international AIDS summit in Bangkok, Thailand, in 2004, Ugandan President

Yoweri Museveni decried condoms as encouraging promiscuity, and lashed out at

them as inappropriate for Ugandans.

" I look at condoms as an improvisation, not a solution, " Museveni said, adding

that he preferred " optimal relationships based on love and trust instead of

institutionalized mistrust, which is what the condom is all about. "

The report said Ugandan first lady, Janet Museveni, one of the leading

proponents of abstinence in Uganda, was using her position of influence to

" intimidate organisations that promote condoms to young people " .

Uganda, it added, was faced with a nationwide condom shortage due to new

government restrictions on condom imports. The report added that when the health

ministry recalled a batch of condoms due to failed quality, rather than address

the shortage, some ministers suggested that Ugandans adopt abstinence as a

preferable HIV-prevention strategy.

" Uganda is gradually removing condoms from its HIV/AIDS strategy, and the

consequences could be fatal, " Tony Tate, an HRW researcher and co-author of the

report, said in a statement.

Opio, the assistant commissioner for Uganda's national disease control

programme, told IRIN that any claims that the government was against the use of

condoms were false, as the government was actually the leading importer of

condoms in the country.

" Out of 120 million condoms used in the country each year, over 60 percent are

imported by government, " Opio said on Wednesday.

Museveni's spokesman, Onapito Ekomoloit, defended the president and first lady,

saying they had remained consistent in advocating for a multi-pronged approach

to fighting HIV/AIDS.

" They have been saying that those who are sexually active should be faithful to

their partners, but others who are single should abstain until marriage, and

those who cannot abstain should use condoms, " Ekomoloit told IRIN.

Uganda has seen close to one million people die due to the pandemic, 78,000 of

them in 2003 alone. More than 700,000 children have lost at least one parent to

the disease, according to government and UNAIDS statistics.

[ENDS]

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