From the Front Lines of the Global AIDS Fight
Peter Navario, PhD, MPH and Alan Whiteside, DEcon, MA
The picture of the current state of AIDS in South Africa is ambivalent. There are some notable successes in preventing mother-to-child transmission and access to antiretroviral treatment (ART), but a worrisome lack of progress in preventing new adult infections. Prospects for resourcing and financing over the next five years are equivocal at best.
Earlier this year a group of South Africa's leading HIV experts, the authors among them, gathered to reflect on progress, identify challenges, and recommend strategies and tactics for surmounting obstacles in the fight against HIV and AIDS. The Special Report on the State of HIV/AIDS in South Africa summarizes the analysis and recommendations that emerged from that meeting.
One theme was transcendent - winning the AIDS fight requires a paradigm shift on the part of all South Africans. Two strategic objectives were mooted again and again as essential to galvanize this shift: 1) The South African department of health must change the way it does business; and 2) Reversing the trend of new infections requires a mass social movement. At a glance, these objectives appear as inchoate as they do intractable, though they reflect several fundamental truths about the current state of AIDS. With five infections for every two people started on ART, HIV incidence remains too high. Extant public sector health staff, including doctors, pharmacists and laboratory technicians, cannot cope with the 3 million plus people needing ART by 2015. Finally, there is not enough money in the AIDS budget to treat everyone needing ART.
The success of prevention and treatment programs in South Africa hinges on leadership from the department of health at national and provincial levels. Management capacity within the health sector merits a great deal more attention than it currently receives. Far too few people in leadership and management positions have any management training; the drug stock outs in Free State Province and high rates of ART patients, who are lost to follow-up, are just two indicators of the current state of health system management. Fiscal management is also a major concern. The independent Budget and Expenditure Monitoring Forum reports that provincial health departments routinely incur large amounts of unplanned expenditures, fail to budget based on estimated service needs, and suffer widespread corruption.
Doctors, nurses and other key leadership staff should be incentivized to receive management training. Better management should lead to more efficient use of resources, improved supply chain efficiency and reliability, greater levels of accountability, improved working conditions, and ultimately, better patient care at lower cost. For example, given the talk of clinic overcrowding and health worker burden, it is curious that clinics across the country are empty every day by three o'clock and closed after one o'clock on Fridays and on weekends. Moreover, the public health system does a notoriously poor job of holding non-performing and/or negligent health professionals accountable, jeopardizing patient health and program efficacy.
The health department's policy options to cut costs and reduce workload and patient burden include better use of community health workers; modification of the current treatment guidelines to permit quarterly dosing for patients who are adherent and stable on treatment; and less intensive laboratory monitoring - recent research from Uganda and Zimbabwe found twice-yearly laboratory monitoring to be cost-ineffective.
Finally, data management is a shambles. Public sector data are poor quality and not used to inform program management or even future budgets, which are just carried over from year to year with small annual increases. Worse still, some provincial health departments have undermined facility-based efforts to implement their own data management systems, citing fragmentation and quality concerns. The time has come to either expedite the database selection process or publish data standards and guidelines and let the facilities select the database that best suits their needs.
Changing the course of the South African epidemic cannot be the sole responsibility of government, and a commensurate effort by individuals and communities across the country is essential. All South Africans should know their HIV status. The new testing campaign announced by President Zuma is a start, but HIV testing must become habitual for all sexually active adults and adolescents. The Botswana model of opt-out testing, where doctors and nurses automatically suggest an HIV test during consultations - and the patient may elect to decline - resulted in the highest treatment coverage in Africa.
In the absence of a "game-changing" bio-medical intervention (e.g. vaccine), it is up to all South Africans to cut the infection rate. Even under the rosiest of scenarios, 5 million are expected to contract HIV over the next 10 years. But this need not be a fait accompli. New research estimates that incidence among young women aged 15 to 24 dropped by 60 percent between 2005 and 2008, driven in part by higher rates of condom use. Significant reductions in new infections are possible through behavior change. A national social movement for behavior change, rooted in a national dialogue led by national and local leaders, churches, traditional healers, chiefs, private sector companies and others should focus on prevention in the context of epidemic drivers: intergenerational sex, multiple concurrent sex partnerships, and discordant couples. Indigenous leadership and organic, context-specific prevention initiatives are crucial: all prevention is local.
Government has two options to address the HIV program financing gap: increase investment and reduce costs. In reality, it needs to do both. The new budget allocations from the Treasury show a clear commitment to grow domestic investment in HIV. However, with the U.S. President's Plan for AIDS Relief (PEFPAR) - South Africa's biggest AIDS donor - budget essentially frozen, and the Global Fund for AIDS, TB and Malaria facing its own multi-billion dollar budget gap, the prospects for additional donor money are bleak. Cost cutting and improved efficiency is imperative, starting with HIV drugs, which typically comprise more than 50 percent of total treatment costs. Incomprehensibly, South Africa pays more for drugs than its neighbors despite having the largest ART drug market in the world. The next biggest cost driver is staff - training lower level staff to perform more of the routine aspects of HIV care should yield savings without compromising quality.
The current PEPFAR law expires at the end of 2013. Increased domestic spending shows the U.S. Congress that South Africa is serious about addressing AIDS, and should put it in a favorable position as it requests an extension of PEPFAR funds through 2015 (at which point the number of patients starting treatment should level off). The government would do well to organize an "all donors" financing meeting to secure longer-term commitments, coordinate funding streams and harmonize domestic and donor-funded programs.
The demand for HIV services in South Africa is beginning to exhaust the financial and human capacity to provide them. Tough choices need to be made to close the demand-resource gap, but it's not clear just how willing leaders and citizens alike are to engage in HIV/AIDS realpolitik. What is the government willing to pay for HIV and AIDS care? What is required of communities and individuals? The role of the private sector? And civil society?
At the January meeting in Cape Town, there was consensus that South Africa is exceptional, not just for the scale of its epidemic, but also for its ability to lead the region and the world in responding to the global AIDS crisis. Its ability to succeed requires bold leadership and an engaged populace: the paradigm shift begins now. The success of the World Cup shows this is indeed possible.
ONLINE EXCLUSIVE
Special Report on the State of HIV/AIDS in South Africa: The country's leading HIV experts weigh in on the status of treatment, prevention and resourcing at the epicenter of the pandemic
Peter Navario is a fellow in global health at the Council on Foreign Relations and Alan Whiteside is a professor in the Health Economics and HIV/AIDS Research Division at the University of KwaZulu-Natal in Durban.
I want to encourage the political leaders and health workers in South Africa to continue to work with the school systems, libaries, community leaders and parents to accelerate practical HIV/AIDS prevention mass education to prepare all citizens especially the youth and young adults to avoid contact to a new HIV infections, and at the same time, encourage those who have HIV/AIDS to protect themselves and their sex partners from new HIV infection and comply with treatment and the prevention of HIV spread efforts.
Behaviors that are well known to increase risk of HIV infection must not be justified, or explained by theories rather a practical approach to prevent them as a source of spread of HIV/AIDS must be researched and the practical solution communicated to the citizens through writting of practical, easy to read HIV/AIDS prevention books, journals, news articles, advertisements, billboards and other social marketing strategies. Let’s continue to prepare our citizens all over the world to value the need to protect themselves and their sex partners and also think about who pays the high financial bills we get HIV/AIDS.
We hardly see any practical book about the dynamics of the spread of HIV/AIDS in the school and library systems. Since most people are going have sex in their life and more than 75% of HIV infection is transmitted by having unprotected sex in the setting of dependent behaviors which invariable includes sexual favors to survive has been part of our lifes and the cultures around the entire world especially in poor neighborhood and communities, a practical HIV/AIDS prevention education from home by parents, in schools by well trained teachers and in clinics and hospitals by health workers must be a rite of passage through adolescent life and for all citizens. Every government must make it a priority or will be paying a high financial cost in addition to a lost of human talents, suffering and death from HIV/AIDS.
An example of a practical HIV/AIDS prevention communication efforts to citizens by health workers at the forefront of treating and preventing the spread of HIV/AIDS is the book title STD/HIV PREVENTION ACTION. Let’s Protect Each Other. Available and accessible at: http://www.iuniverse.com; http://www.barnesandnobles.com; http://www.amazon.com
Practical and consistent action of all citizens to avoid contact to the germ (virus, bacteria, etc) that cause infectious disease (avoiding sexual and contaminated needle and syringe contacts, baby contact to HIV infected mother’s blood and breastmilk in the case of HIV/AIDS) is the best and cheaper means of preventing infectious disease epidemic in the absence of effective vaccine and HIV/AIDS is no exception.
Let’s find ways to solve the problems of the dynamics like poverty, literacy levels, dependent behaviors, multiple unprotected sex partners without disclosure of HIV status that makes application of these basic HIV prevention efforts difficult for citizens.
— Dr. Samuel Frimpong MD MPH on 2010-07-21
Time to consider WHO suggested strategy of ARV treatment for all HIV +ve in South Africa, independent of CD4 count. This would interrupt both HIV and TB spread. HIV incidence could drop from 600 000 to 30 000. TB incidence in 2008 (WHO) was 461 000, and rising with cure rate falling to 58% in 2005 [Prof M Edginton. TB, the disease that won’t go away. Specialist Forum. Vol 10, No 5:p 22-30]
— Gerald Levin on 2010-07-23
This makes very good reading but also makes one realise we have work to do to stop AIDS. The news of a reduction in new infections among young women in South Africa is great news. Looking at it from a a paradigm of social awareness, the fact that condoms are being accepted and used effectively is commedable. But the trouble with the crippling ART versus existing and new infection is a problem that may obliterate such successes in no time. A change in the way public institutions and all constituents in their - the people in all lines - operate is cardinal to this change. I feel that behavioural change should not be taken as a reserve of the social masses, but rather for the people as it where. To start with let those with access to means to help; because of their position in society (politicians)and those in the front line services in the health system, Doctor, nurses, lab people and so on and those instructing the delivery of money from the fiscal perspective; all need this behavioural change. If you allow me, many are the times that they become complacent and in so doing cause the mayhem in HIV/AIDS care and treatment. Its easy to forget about the money and use it for workshops and so on just to fulfil spending targets on budgets for instance. COrruption creeps in first as a trial that gets into a habit and then the attitude is fixeted. Once this happens, and this is the case with the many health workers that feel they are over worked - and smetimes it is true though not an axcuse - complacency in HIV/AIDS kills. If behavioural change starts here, it can easily work in the community, remember in Africa we live as collective societies, we still fear shame and you know the implications that has for AIDS already. Used in this space, no one wants to be recognised as corrupt either, its shameful, but its happening in the health sector and it has just gotten suvvy over the decades of HIV/AIDS presence in the health systems of our African governments. If one can stop and think that corruption kills, and further helps kill, they would know the double tragedy they cause, but the question is how many even stop to think? In management training, if emphasis could be placed on sustianble issues such as a demand fro responsibility for both resource and human resource. In HIV/AIDS non can work without the other.
The way you have described the behavioural change channels, if followed, can help a great deal to stop the further spread of HIV. We shold know that donor money can dry up any time. What can happen if that happened. It is a bad thing to think about but an important and even a thing to still think about. USA is USA and has other issues including the oil spill. Our issues in Africa include AIDS. It kills human resource, the greatest resource the continent has ever had.
In all, i feel behavioural change is cardinal. If we let other facets of social science (pyschology and sociology)in society to join in and help, there we will be on the way. A wholistic approach that nonetheless recognises each element of society as exemplified could be rather important and yes if through collective responsibilty South Africa could hold the first ever World Cup in Africa then it can also lead in winning the HIV/AIDS problem for the first time in Africa. I would be happy to her how this progresses.
— Mwiika Malindima on 2010-07-23
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— THOMAS JEFFERSON on 2010-12-13