Antiretroviral Treatment (ART) Rollout PDF Print E-mail

The South African government endorsed the use and rollout of free ART in public health facilities in August 2003. The ‘Operational Plan on Comprehensive HIV and AIDS Care, Management and Treatment’ was launched in November the same year, with broad commitments to provide ART to over a million people with AIDS by early 2008, along with nutritional assistance and a continuum of care within the public health system to people living with HIV and AIDS. While there has been much progress since then, there have also been frustrating delays and problems in accrediting ART public health facility sites, providing appropriately trained health personnel and registering antiretroviral drugs (ARVs), and it is unlikely this target will even be half met. Estimates by both UNAIDS and the Department of Health put the number of people living with HIV and AIDS in South at around 5.5 million (end of 2005), with around one million requiring immediate ART in order to stay alive. Approximately 800 people are dying each day as a result of AIDS-related diseases. A new National Strategic Plan (NSP) to deal with the HIV epidemic has been drafted by the government, in consultation with all relevant stakeholders, and this outlines their strategies and targets for the next four years until 2011. The full document can be accessed under Useful Publications on this website.

The following topics are covered in this section:

The situation within the public health sector
By early 2005 official government figures indicated that at least 42 000 people were receiving ART from more than 100 designated HIV service points throughout the country. By the end of September 2005 this figure had more than doubled to around 86 000. Exactly a year later in September 2006 the Department of Health issued a statement that over 235 000 people had been initiated on ART throughout the country and that there were 273 public health facilities providing ART. However the number initiated on treatment is not the same as the number who are currently on treatment. Due to death and people leaving the ART programme this figure is closer to 180 000. The latest government figures (February 2007) indicate that 257 108 people have been enrolled on treatment. This figure is only 36% of the operational plan's target number (716 771) for this period. However, there has been a big improvement in the government's delivery of treatment as in 2005 less than 25% of the target number were enrolled on treatment.
 
The large majority of these patients are receiving treatment from academic hospitals and clinics in urban areas; comparatively fewer patients are accessing treatment in remote and rural sites. Women make up the largest percentage of people receiving treatment (seven out of 10 adults accessing treating are women), and children make up the smallest, indicating that more work needs to be done in targeting men and children.
 
Unfortunately accessing accurate information about the numbers of people receiving ART in the public health sector has been, and continues to be, extremely difficult because of a lack of co-operation from some provinces and inadequate national reporting procedures and openness.
 
Donor-funded ART programmes
These estimates include people receiving donor-funded treatment at public health facilities. The main donors include PEPFAR (the US President’s Emergency Plan for AIDS Relief), Right to Care, MSF (Médecins Sans Frontières) and ARK (Absolute Return for Kids, UK). These donors work through existing public health facilities, and some not only fund the drug and/or healthcare costs, but also help to ensure the sustainability and adherence of the ART programme. Donors have collected data regarding their own programmes, which indicate excellent outcomes for both adults and children receiving ART. There have, however, been communication problems between donors and the government, which have limited the potential effectiveness of such partnerships. Many of the donors also fund treatment projects through non-profit organisations and private organisations.
 
Donor ART statistics (2006):
 
PEPFAR:                                       50,226 (75% in the state sector)
ARK:                                              14,423 (in both state and non-profit sector)
Right to Care:                              13,026 (60% in the state sector)
MSF:                                                 6,200 (all patients are in the state sector)
NDLVOVU HAART:                          714 (all patients are in the non-profit sector)
TAC:                                                    291
 
The situation within the non-government sector
The government figures do not include people who are receiving treatment within the non-government sector (through medical aid schemes, workplace treatment programmes, donor-funded non-profit organisations and the private sector). The number of patients receiving ART in this sector by the end of March 2005 was estimated to be between 50-60 000. A more recent estimate puts the total figure at around at round 90 000, including 30 000 receiving treatment through medical schemes.
 
Even if both sets of the most recent estimates are totalled it still falls drastically short of the estimated one million who require immediate treatment. The demand for ART therefore drastically outstrips the supply, and there are repeated reports of long treatment queues and of people being turned away at government treatment sites. Effective partnerships between the government, the private sector and donor agencies are crucial to making sure that the public health system and other sectors can dramatically increase their collective capacity to provide ART to all those who are desperately in need.

Provincial breakdown of numbers receiving ART in the public health sector from early 2005 to Sept 2006
(Joint AIDS Law Project/TAC Monitoring Report June 2006; JCSMF 4-5th Meeting Reports 2005; DOH 2006).

Province
4th JCSMF 
(March 2005)
5th JCSMF 
(mid-year 2005)
Health Dept  
(Sept 2006)
KwaZulu-Natal
 11,000
19,000
59,404
Gauteng
 12,412
20,000
55,580
Eastern Cape
   2,749
6,840
24,920
North West
   2,645
7,578
21,579
Western Cape
7,670
11,470
21,270
Limpopo
935 (Jan)
5,000
11,660
Mpumalanga
936 (Jan)
936
7,989
Free State
1,115
2,500
6,950
Northern Cape
515 (Jan)
1,296
4,476
Total
± 42 000
74 297
213 828

Clearly some provinces had a more successful initial rollout than others. The Western Cape and the North West did particularly well, easily exceeding initial targets. Five provinces failed to reach their 2004 targets by January 2005, particularly Limpopo and KwaZulu-Natal. The latest Department of Health figures, however, point to a turnaround in performance for all five under performing provinces.

 

The table below illustrates the number of ART sites within each province and the percentage of sub-district coverage (2006) 

Province

 

Number of sites

Sub-district coverage

% of coverage

Eastern Cape

38

18 over 24

75%

Free State

 

16

12 over 20

60%

Gauteng 

 

43

9 over 10

90%

KwaZulu- Natal 

54

32 over 50

64%

Limpopo

 

35

20 over 22

91%

Mpumalanga

18

14 over 19

74%

Northern Cape

10

8 over 21

38%

North West 

 

20

17 over 25

64%

Western Cape

39

25 over 33

76%

Total

 

273

155 over 224

68,75%

 


The main barriers to treatment access

  • Severe shortage of trained people, especially doctors, nurses, pharmacists and counsellors.
  • Delays in accrediting public health facilities as treatment sites.
  • Interruptions in the supply of drugs, mainly due to the government not placing orders with pharmaceutical companies in time. 
  • Lack of access to laboratory services for CD4 and viral load testing. These tests are a critical part of ART as patients need to be regularly monitored to see if the treatment is working properly. 
  • Patients who are stable and doing well on ART need to be referred down to primary health facilities for monitoring and care. This will free up hospitals to recruit new people onto the treatment programme.
  • Lack of knowledge about treatment options amongst people living with AIDS, as well as their caregivers. There is no public information campaign telling people where or how they can access treatment and a list of treatment sites. There is also confusion amongst the population about the necessity and effectiveness of ART, which needs to be urgently addressed by the government.
The situation regarding children and ART
There have been growing concerns about the small number of children receiving ART. The March 2005 figures revealed that less than 4 000 of the 42 000 people receiving ART were children. The latest Department of Health statistics for September 2006 show that while the absolute number of treated children has increased significantly to over 21 000, only 8-18% of children requiring ART are currently accessing treatment. The reasons that so few children are receiving treatment include the following: 
  • Delays in the development of treatment guidelines for children by the Department of Health.
  • Insufficient training on ART for children and the belief that only paediatricians can give the treatment.
  • Shortage of healthcare professionals in rural areas.
  • The drugs for young children are given in a syrup form, which is not as stable as tablets and is more difficult to administer in accurate quantities.
  • Children are often not diagnosed in time to benefit from treatment.
The Joint Civil Society Monitoring Forum (JCSMF)
The JCSMF was founded in June 2004 by the AIDS Law Project (ALP), Idasa, Health Systems Trust, Centre for Health Policy, Open Democracy Advice Centre, Treatment Action Campaign (TAC), UCT School of Public Health and Family Medicine, Public Service Accountability Monitor, and Médecins Sans Frontières (MSF). The forum was formed to monitor and support the implementation of the government’s Operational Plan. Further information (including full briefs of all the JCSMF’s meetings and the ALP/TAC joint reports) can be accessed from the ALP website at: www.alp.org.za.
 
Further information about the government’s HIV and AIDS plan and treatment statistics can be obtained from the Department of Health’s website at: www.doh.gov.za
  
Details of the Catholic Church ART rollout 
The Catholic Church is present in all communities and can therefore often reach people not being reached by the government. After the government, it is the single largest provider of healthcare services within South Africa. The Church’s ART programme, which is free or highly subsidised, began in 2004.
  • 22 Catholic Church points of service have been selected around South Africa, including hospices, clinics and a hospital, as well as a number of home-based care organisations. 
  • Each point of service is staffed by a medical doctor, a professional nurse and a project coordinator, all of whom have been trained in government-accredited ART management courses.
  • Home-based caregivers are trained as adherence counsellors. They check treatment adherence and monitor the patients for side effects. 
  • Each patient who qualifies for ART must complete a three-week adherence-training course before starting treatment.
Progress to date:
  • All 22 points of service became operational in 2005, with a total of over 3 000 patients receiving ART. 
  • More than 100 doctors and nurses have been trained in ART management 
  • All points of service have formalised referral arrangements with local government clinics and hospitals. 
  • All points of service have home-based care networks in place, with trained caregivers. Very high compliance rates are being reported.
Future Plans
This number will be doubled to a total of 6 000 in the second year, and doubled again to 12 000 in the third year. Cordaid (Netherlands) and PEPFAR are currently helping to fund the ART programmes.
 

For further information contact Sr Alison Munro at:
Tel:  012 323 6458
Fax: 012 326 6218
Email:     This e-mail address is being protected from spam bots, you need JavaScript enabled to view it
Website: www.sacbc.org.za
Address: Khanya House, 399 Paul Kruger Street, Pretoria, 0002