Gary Maartens is an infectious diseases physician and professor of clinical pharmacology at the University of Cape Town. His main research interests are in HIV and tuberculosis.

There was a variety of scientific presentations in this track which was very gratifying. Research was also not limited to a few major centres or research groups and indications show that HIV basic and clinical scientific research is in a very healthy state in South Africa.

HIV-1 consists of a number of different strains (also called clades) and there is a concern that an HIV vaccine may only protect against a limited number of these strains. This is important as many industrialised countries are developing their vaccines from their predominant clade B viruses, but in Africa, clade C is the predominant strain. Zembe and colleagues (1), examined immune responses to different HIV-1 clades in South African HIV-infected patients . Their findings showed that although responses were best to clade C, there were good immune responses to others too. This suggests that if an effective vaccine is developed, it should provide protection for a number of clades.

A number of important studies will serve to advance our understanding of how to prevent mother to child transmission. For example, Paximadis (2) and colleagues discovered a genetic marker that appears to protect against intrauterine transmission of HIV. This finding could be used to design individual interventions that would identify women at higher risk of intrauterine transmission - they could then begin antiretroviral therapy earlier in pregnancy. Mphatswe (3) and colleagues studied a group of infants who acquired HIV after failing single dose nevirapine therapy. Most of the infants who were infected in utero, experienced rapid disease progression. This data supports early diagnosis in infants, which can only be done using the relatively expensive PCR test. Moodley (4) and colleagues carried out the PCR tests in infants by using dried blood spots - their reports showed that this correlated well with standard testing on whole blood. This is a useful method for isolated rural areas.

It is well established that patients with sexually transmitted infections are more likely to be HIV-infected. It is thought that the genital tissue injured by sexually transmitted infections facilitates HIV transmission. One of the most important sexually transmitted infections in South Africa is genital herpes, which frequently recurs and cannot be cured. Delany-Moretlwe (5) and colleagues conducted a randomized controlled trial to determine whether acyclovir (which suppresses genital herpes) has an effect on genital shedding of HIV in women. They were unable to show this, but did show a reduction in genital ulcers caused by herpes as well as a modest reduction in HIV viral load in the blood. There is a lot of interest in this intervention as it may reduce sexual transmission of HIV and could also slow HIV disease progression. Further studies will be necessary to determine whether suppressive therapy for genital herpes can achieve these objectives.

Boulle (6 & 7) and colleagues presented temporal trends from a collaborative cohort of 7 large African antiretroviral clinics. They showed over a 5 year period that the CD4 count at initiation of antiretroviral therapy increased and that death rates declined. However, losses to follow up increased over 5 years, suggesting that these clinics are reaching their capacity. Adherence to antiretroviral therapy is the key to long term success. Matoti (8) and colleagues presented alarming data on low adherence levels in adolescents from the South African private sector. Good adherence, which they defined as at least 80% (many would regard 95% as a better cut off), occurred in 16% of adolescents compared with 41% of adults. Symptomatic hyperlactataemia is a potentially fatal side effect of the nucleoside reverse transcriptase inhibitor class of antiretroviral agents. Stavudine, which is a component of the first-line antiretroviral regimen in South Africa, is associated with a higher risk of developing symptomatic hyperlactataemia than other nucleoside reverse transcriptase inhibitors. Osler and colleagues conducted a case-control study to determine risk factors for symptomatic hyperlactataemia. They found that women, obesity and rapid weight gain within the first 3 months of antiretroviral therapy were risk factors for symptomatic hyperlactataemia. Cases occurred within 18 months of initiating antiretroviral therapy. Features suggestive of symptomatic hyperlactataemia, which could allow for earlier detection, included nausea, vomiting, abdominal pain, and recent weight loss.

Hepatitis B virus infection progresses to chronic liver disease more rapidly in HIV infection, and administration of antiretroviral therapy in patients with both infections is frequently complicated by hepatitis. Firnhaber (9) conducted a survey of hepatitis B infection in a cohort of HIV-infected patients. They found a 5% prevalence of hepatitis B infection assessed by a positive surface antigen. This relatively high prevalence would justify baseline screening in all HIV-infected individuals prior to the initiation of antiretroviral therapy, and is a strong argument for allowing access to antiretroviral agents that also have activity against hepatitis B.

Dr Najma Shaikh is trained as a public health specialist and infectious disease epidemiologist. She is currently the HIV/AIDS Epidemiologist in the HIV/AIDS Directorate of the Western Cape Department of Health.

Track 2 of the conference programme titled "Epidemiology, Prevention and Health Systems" covered a wide scope of research on the epidemiology of HIV, the determinants of HIV transmission and risk factors, progression of the disease, the evaluation of biomedical and behavioral interventions and public health strategies. The rich mix of presentations reflected the theme of the conference namely, Building Consensus on Prevention, Treatment and Care and the depth of discussions and debates reflected how the field of HIV/AIDS is evolving in South Africa. The key highlights from this track are presented below.

Epidemiology

In the opening plenary, Dr Olive Shisana showed that the HIV pandemic was concentrated in Sub-Saharan Africa and affected mainly young, sexually active adults. Despite collective efforts over the last two decades, the epidemic continues to grow and therefore the need to prioritise our efforts. South Africa is also beginning to experience the impact of the epidemic, with an estimated 737 000 deaths due to AIDS and more than a million children orphaned as the result of AIDS in 2006.

New evidence was presented on HIV incidence, which essentially is the gold standard indicator for tracking the progress of the HIV epidemic. This is particularly relevant in the terms of monitoring and evaluation the implementation of the National Strategic Plan of South Africa (NSP), as one of the key goals is to reduce by 50% the HIV incidence (rate of new infections) by 2011.

The findings from the National Household Survey reported an HIV incidence of 1.4% amongst South Africans aged 2 years or older (Rehle et al). Over a third (34%) of the new infections occurred in young people aged 15-24 years, with women accounting for 90% of new infections in this age group. The incidence of HIV amongst women aged 20-29 years was 5.6%, which was more than 6 times that of males of the same age group (0.9%).

Evidence from the first prospective population-based HIV survey in rural KZN, reported a crude incidence of 3.2 per 100 person years. The highest levels of new infections were observed in men (8.7 per 100 person years) and women (8.0 per 100 person years) aged 25-30 years. New infections peaked at 25 years for women and at 30 years of age for men (Barnighausen et al.).

The latest trends on AIDS mortality for South Africa during the period 2000-2006, showed a marked increase in deaths up until 2004, followed by a slowing down in the rate of increase, which the authors attributed to better survival as the result of the Anti Retroviral Therapy (ART) interventions (Laubscher et al.). The mortality patterns showed variation in terms of age, gender and province - the highest levels of mortality occurred in KZN, Mpumalanga and the Free State. Mortality trends in a demographic surveillance area in rural KZN (2001- 2006) showed a significant decline in adult mortality soon after the introduction of a local ART programme (Herbst et al.). However, HIV - Related mortality amongst patients on ART in low income settings compared to high-income settings showed that, patients starting ART in sub-Saharan Africa experience substantially higher mortality in the first months on ART and this was attributed to the late start of treatment. (Egger et al.). These findings emphasized the need for more timely diagnosis of HIV infection, assessment of treatment eligibility, and earlier enrollment on ART programmes.

Prevention

As the HIV epidemic matures, it is speculated that the epidemic may be shifting to the older age groups. A study examining sexual behaviour and partnership formation in South Africans (aged 40 years and older) showed the majority were sexually active (McGrath et al.). Almost two thirds of the older women (59%) said that their partners would not use condoms on a regular basis and 30% agreed that these days most men are faithful to their wife/regular partner (McGrath et al.). This underscores the need to explore ways of engaging with older people, particularly older men, to promote less risky sexual behaviour. It also highlighted the constraints and limited control women have in terms of their reproductive health choices.

Age differentiation, inter-generational sex, transactional sex and "sugar daddies", were some of the risk factor terms used to describe the reasons younger women were at risk of acquiring HIV infection through partnership with older men. A study examining a hard to reach group of men, who live in a peri-urban Cape Town settlement revealed that men who reported to have multiple, younger female sex partners, showed a median of six sexual partners (range: 2-39) during the past three months, used condoms inconsistently with their casual partners (51%) and the majority of them socialised in shebeens and consumed high levels of alcohol (Chopra et al.).

Several plenary speakers indicated that the paediatric HIV epidemic is the single biggest failure in the global response to the epidemic, especially in terms of translating evidence into action. Although we have available a proven prevention technology for the Prevention of Mother To Child Transmission (PMTCT), there remain many leakages in the implementation and scale-up of these interventions. The challenges include increasing coverage, infant feeding and follow-ups. The PMTCT studies have shown that the disease stage of the mother both in terms of high viral load and reduction of CD4 counts can impact on transmission to the infant. The HSRC incidence study showed that pregnant women had notably a high risk of HIV incidence (5.2%), as well as from a study from KZN, which showed rapid progression and a high transmission during pregnancy (Rehle et al. Moodley et al.). This underscores the need for strengthening of primary prevention and HAART for sero-converters.

The Stepping Stones Study, which is modelled on a successful Ugandan intervention, examined a behavioural intervention conducted in 70 villages in the rural Eastern Cape. There was a significant reduction in number of partners, less transactional sex, increased condom use, less perpetration of interpersonal violence and reduced alcohol consumption and drug use in men (Jewkes et al.). For women, although there was a significant improvement in knowledge & HIV awareness, there was no evidence of a positive impact on their reported behaviour.

A study to examine determinants of uptake of Voluntary Counselling and Testing (VCT), to assess changes in sexual risk behaviour following VCT, in Zimbabwe showed that motivation for VCT uptake was driven by knowledge and education rather than sexual risk. Increased sexual risk following receipt of a negative result may be a serious unintended consequence of VCT. It should be minimised with appropriate pre- and post-test counselling (Sher et al.).

The sessions on prevention technologies raised the role of male circumcision in reducing female to male transmission of HIV and it was highlighted that more operational research is needed for broad scale interventions. Social and behavioural economic research has become more urgent now as it was raised that prevention technology goes beyond ABC.

Delivery Care

Whilst we know that adequate resources, capacity building, infrastructure and human resources shortages are the key challenges to a wide scale-up, we can learn from the innovative approaches being undertaken locally (Yarrow, Lethola et al.). A study in a rural district in the Eastern Cape showed that access to ART within a poor, dispersed, rural community in SA is achievable, with simple system improvement methods such as access to ART for an estimated 1 600 new ART cases/year, without adding healthcare resources. Between March 2005 and December 2006, sites performing CD4 counts increased from 15% to 93%, and sites providing full pre-ART preparation and chronic nurse-based ART care increased from 15% to 67%. Within 12 months, the capacity of the system for initiating ARVs increased from 16/month to 63/month and the backlog of patients waiting for ART was cleared (Green et al). This demonstrated that much could be done to improve access to ART in resource-constrained settings by involving Primary Health Clinics (PHCs) in providing nurse-based care and with structured local problem solving.

One of key challenges for the delivery of ART is Loss To Follow Up (LTFU). A study from the Eastern Cape showed that with well-defined and coordinated patient identification and tracking systems, trained staff dedicated to counselling and home visits as well as strong use of PLWHA support groups, led to more than half of 55% of patients being traced and 34% re-entered into care (Worley et al.). This demonstrated that managing clinical ART patient LTFU challenges in resource-constrained settings is feasible and achievable, provided that we are prepared to seek local solutions.

Can the public sector rise to the challenge of delivering ART within a district health system? Evidence from the Gauteng Province highlighted that motivated and skilled site managers, effective drug supply, laboratory services; high levels of treatment knowledge amongst patients and good communication with providers are essential.

However, problems of saturation (especially staffing and space) and burnout were also evident (Rees et al.). The study also revealed higher costs of accessing services in hospitals (mean R30/patient) than in a community Health Clinic (mean R18/patient).

In summary, the key points that emerged included that prevention is critical for making the provision of care, support and impact mitigation possible. The innovative local studies highlighted the need to strengthen and improve care, whilst at the same time explore prevention approaches and seek local solutions for local level application, given that the epidemic is not homogenous.

Of the 20 presentations, 3 rounds tables and 75 posters the following issues and consensus emerged:

Gender violence and relations

While we all know and accept that violence against girls and women is a problem, studies confirmed that a key determinant in increasing the vulnerability of women to HIV infection is gender violence. Research presented at the conference, worryingly revealed that where gender based violence is common, young women often regard it as normal and even worse - sometimes feel that it is an 'act of love'. For example, a study carried out in a rural area of South Africa showed that many female students believed males to be the superior sex, while the males were in agreement - believing themselves to be 'in charge' of women.

Recent findings emphasise prevalent gender dominance where men have authority in decisions regarding trial participation of women partners. Trial outcomes showed that women taking part without their partner's consent dropped out or were forcibly removed by their partners under threat of terminating their domestic relationship.

These studies showed that couple counselling is a crucial contributor towards successful trial participation by women participants. If couple counselling is provided at the outset of Phase 3 Trials (and incorporates male involvement) there should be a visibly increased level of co-operation amongst communities and researchers.

Future research

A potential threat to further HIV/AIDS Non-Therapeutic Research (NTR) is a provision in the National Health Act (NHA), which is yet to be enacted. The provision unreasonably provides that ministerial approval is required in all trial research involving children, which is further exacerbated by the different interpretations of what constitutes a child (age). A detailed paper examining the impact that this will have on future research was presented.

Trial participation and access to health services

Evidence was presented to confirm that access to better clinical services, rather than cash re-imbursements influenced community enrolment in microbicide studies. Communities were more willing to take part in such trials when the benefits are not only financial.

Access to services is also influenced by a number of factors ranging from :

• Living conditions which have a direct impact on both treatment and disease outcomes, as well as the incidence of opportunistic infections;
  
• Socio-demographic factors that influence rates of infection and responses to antiretroviral treatment (ART) - some studies were presented that showed that older and widowed individuals had lower immunological responses post ART initiation but that over time this improved;
  
• The mental health of women - which is compounded by a persons HIV status and level of poverty - studies showed that women who are living with HIV often exhibit more signs of depression but that initiation on ART reduced this somewhat.

Law and Human rights

There are a number of hindrances in the process of rolling out ART, for instance, several life-saving prevention, care and treatment medicines are available and are urgently needed in order to strengthen the scale-up of prevention. The law could be used to ensure that a sustainable supply of affordable medicines is made available; however, the unwillingness on the part of government (and pharmaceutical companies) to act on this need is drastically undermining access to treatment.

Registration and false claims are also proving problematic and a call was made for the establishment of a commission of inquiry into the functioning of the Medicines Control Council (MCC) and in particular the slow registration of essential medicines.

Social support

Unfortunately, a study of social support and ART adherence in public sector rollout sites did not find a convincing association between access to social support and ART adherence. Another study however showed that the potential loss of Disability Grants (DG) amongst women threatened their well-being. For this reason calls were made for a review of the Social Security (SS) system with a view to implementing the Chronic Disease Grants (CDG) for people with chronic illnesses. Studies also confirmed that government and non-profit organisations have successfully worked together to promote access to poverty relief and social support in order to assist families without a regular income.

Children affected by AIDS

A superb study of 1 025 AIDS and non AIDS related orphans and vulnerable children (OVC) showed that AIDS related OVC leads to greater psychological distress including depression, peer problems and delinquency. Of the test group, statistics showed that 60% of AIDS orphans and adolescents were stigmatized while 83% experienced psychological distress (both problems were exacerbated by hunger). This reinforced the need for a proper, rational and reasonable social security system.

Sex and sexuality - attitudes of the youth

A study of teenage perceptions on dating and sexual relationships (canvassing 1 620 adolescents) showed that 46% of teenagers felt it necessary to engage in dating. 77.9% of the group believed that it was possible for a girl to fall pregnant during menstruation. Of the sample, 21.8% believed that their main sex partner (MSP) was faithful, while 13% were unsure - all of these statistics point to a desperate need for realistic sex education in schools. A qualitative study on factors influencing sexual abstinence among primary school learners in KZN concluded that with guidance and support from parents, schools, and community members, young people can be encouraged to delay their first sexual encounter - thereby reducing their risk of contracting STIs or falling pregnant.

3 Major issues that emerged from lively and robust round tables on scaling up HIV testing; including vulnerable groups and bridging the health divide agree that:

1. Proper policies and programmes need to be implemented through the National Strategic Plan in order to protect vulnerable groups such as drug users, prisoners and sex workers.

2. Consensus must be reached regarding scaling up HIV testing - there is a need to scale up Provider Initiated Testing and Counselling (PITC) efforts at clinical and non-clinical settings in order to reach the National Strategic AIDS Plan (NSP) testing targets instead of debating over and over models of scaling up testing.

3. Given massive health inequities in South Africa between the public and private sector, the policy issues and debates on around universal health coverage (national health insurance) must be prioritized.

Kerry Cullinan is Managing Editor of Health-e News Service, a specialist health news agency. She won a number of journalism awards and fellowships including the Sunday Times Bessie Head Fellowship and overall winner of the US/SA Excellence in Health Journalism Award . She has worked for a range of newspapers including The Star, City Press and New Nation. She has an MA in Culture, Communication and Media Studies from the University of KwaZulu-Natal.

It is very difficult to do justice to the "best practice" track, which was vast in its scope and comprised of 24 oral presentations and 154 posters. Submissions were selected mainly on the basis of being large scale projects, innovative projects or showing effective monitoring of existing programmes. Four oral sessions looked at prevention of mother-to-children transmission (PMTCT), children, the health systems and workplace and public-private partnerships.

In the PMTCT session, the biggest programme showcased was the University Research Company's Quality Assurance Programme (QAP), presented by Dr D Jacobs-Jokhan. This is working to improve HIV/AIDS and TB services in 120 facilities in five provinces, including 106 facilities providing PMTCT projects. After a year of working with the 106 facilities, the QAP had managed to increase HIV testing uptake by pregnant women from 55% to 71%. In addition, in the first quarter of 2007, all 2854 babies born to pregnant HIV positive mothers received nevirapine along with their mothers. Jacobs-Jokhan said that key to the project' success was the training, support and supervision of healthworkers. She also remarked that the data collection of the District Health Information Service needed to be improved as the uptake of PMTCT was higher than recorded by the Department of Health.

The KwaZulu-Natal's PMTCT Quality Assurance team's study of 20 PMTCT sites in KwaZulu-Natal also found that nevirapine uptake is high but poorly recorded in PMTCT registers. University of KZN's Professor Dhaya Moodley reported for the team that women did not get nevirapine because: they were tested after delivery, attended clinic too early to be given it, lost or forgot it and were not given it in labour, or that nevirapine was not issued in the antenatal clinic. She also reported that 40% of the sites had experienced at least one stock-out of nevirapine. Among the recommendations made were that women be offered VCT in early labour or immediately after delivery and that HIV support be included in routine antenatal care for women who book early.

Interestingly, Stellenbosch University's Professor Gerhard Theron reported that VCT in labour wards is feasible and accepted by pregnant women. Reporting on a study of 241 eligible women, 161 agreed to test, 19 were HIV+ and 18 accepted ARVs.

In an example of good monitoring of poor practices, Dr Kimesh Naidoo and team did an audit of paediatric deaths at Durban's four regional hospitals and found a high burden of advanced HIV disease with the majority of children dying apparently not accessing PMTCT or HAART. Of the 875 child deaths examined, the majority died before reaching their first year and most were underweight. In only 57% (495 children) of cases was their HIV status known. Some 52% were HIV positive and 38% were HIV exposed (born to an HIV positive mother). In a staggering 72% of cases, there was no information about whether the children had received nevirapine at birth or not. Only 8% of children and 7% of their mothers were known to be on antiretroviral treatment. Naidoo concluded that the deaths of the children "reveals a high burden of advanced HIV disease" and "despite the availability of established PMTCT and HAART programmes, the majority of children dying in Durban's Regional hospitals appear not to be accessing these interventions".

Habitat for Humanity's Kate Bistline said her organization never expected to be at an AIDS conference. However, it was compelled to become involved in providing housing for 70 families of orphans and their caregivers after seeing the need in KwaXimba in KwaZulu-Natal. Their houses were unhygienic and conducive to spreading disease as well as unsafe, particularly for girls. The KwaXimba Women's Outreach organization helped to select the families, choosing those with at least one orphan and those under the age of 14. The success of the KwaXimba project has lead Habitat for Humanity to expand its programme to other areas.

Phillipe Denis and Beverley Killian also focused on orphans, but on their psycho-social wellbeing by evaluating the impact of memory boxes (12-15yrs) and group therapy (10-12yrs) programmes in Pietermaritzburg, aimed at building the children's resilience. They found that the children found it painful but positive to be involved in the interventions, saying that they could share their stories, break the sense of isolation and this helped to ease the emotional burden of grief.

"Loss to follow-up" is a term used to describe patients who have disappeared. Doctors in the Klerksdorp/ Tshepong Hospital complex decided to find out why 21% of their patients who had started on ARVs had disappeared. Some 300 "lost" patients were traced and it was found that 126 of these had died.

Two of the health systems sessions focused on the effectiveness of introducing antiretroviral treatment at primary health care level. After four years of ARV treatment, the Western Cape has been able to retain 75% of its patients and concluded that its nurse-based model for ART works well for adults, but less so for children as not enough children were being started on ARVs. Increased access to care resulted in patients getting treatment earlier and thus having better early outcomes, but more patients being started on treatment also meant more were being lost to follow-up.

• Dr Keith Cloete of the provincial department warned, however, that the province was falling behind in its targets as a resut of "complex challenges" posed by ARV treatment.

• Meanwhile, the rural district of Umkhanyakude in KZN has managed to reach 80% of those who need ARVs in the district by using a Primary Health Care nurse-based model from the start, and extensive community involvement with visionary leaders.

• Professor Dingie van Rensburg warned that the supposed strengthing of health systems, in particular human resources for ART is perceived, rather than real in Free State as many of the new posts remain vacant. In other cases, health professionals moved from other programmes to the ART programme, thus weakening non-ART programmes.

• In the workplace session, Andrew van Zyl's 10-firm study of the value of preventing HIV infection, and found that one infection per 390 people needed to be averted to be cost-effective.

• The Tshepang Trust reported back on how it has involved GPs in sessional work in the public sector, enabling 5 385 patients to get ART. GPs are also managing public sector patients in their rooms in Gauteng, and have initiated 439 patients on treatment. While there are many challenges, the work has huge potential as there are over 5 000 HIV trained GPs in the country.

The oral presentations and posters were very rich and varied and reflect the depth of innovation in the country. But there was criticism that too much variety could dilute focus, there should have been more focus on outcomes, scaling up and implementation and that there wasn't enough time for discussion.

Ingrid Meintjes-Moakes
Ingrid Meintjes-Moakes is an HIV/AIDS and women's rights activist. She has worked for the Treatment Action Campaign and currently writes and researches on the intersection between women's rights and the HIV/AIDS epidemic with an emphasis on community interventions. She served as Rapporteur for Track 5 at the South African AIDS Conference 2007.

Siphokazi Mthathi (Sipho)
Siphokazi Mthathi (Sipho) was, until recently, the General Secretary of the Treatment Action Campaign. She has been with TAC since 1998 and developed the internationally renowned Treatment Literacy Programme at TAC, which has been recognised by UNAIDS as a best practice. She is currently continuing her work with communities and pursuing her writing career.

Track 5 at the South African AIDS Conference 2007, entitled Community Exchange Encounters, provided a unique and timely focus on the HIV/AIDS epidemic from the perspective of South African communities.

Over the past 25 years, HIV/AIDS has brought a great deal of suffering to individuals, families and communities, but they have also brought new opportunities for transforming relations with, between and within communities. Community advocacy has contributed much to the progress which has been made in the arena of human rights, access to treatment, technological interventions for treatment and prevention and best practices for care and support.

In this track, communities were broadly defined to include people living with HIV/AIDS, impacted by HIV/AIDS, people vulnerable to HIV infection, and those who interact with communities on issues relating to HIV/AIDS. The Track had three main threads:

• Taking stock - Thinking futures: This thread looked at what HIV is doing to our communities, the specific points of vulnerability and how to deal with the realities brought by HIV/AIDS.

• Where communities lead: Community-led interventions and best practices were identified in areas such as prevention, treatment, care and support; human rights, stigma and discrimination; community participation in policy-making processes and health systems; advocacy and community mobilisation and building community HIV/AIDS literacy.

• Communities in dialogue: This section of the track explored how best to ensure community participation in policy making, research and priority identification processes.

Communities - Where the battle will be won or lost

Community Exchange Encounters highlighted where the substantive work to curb the epidemic must be done. The voices, experiences, knowledge and realities of those at the coalface of this epidemic have, for too long, been ignored in medical, behavioural and policy interventions. As the public health system buckles under the pressures of the epidemic, the sick are being sent home to be cared for by family and community members. In this way, the burden of the epidemic is being shifted onto communities, usually those least able to afford it. Volunteer home-based carers and community health workers, grandmothers, wives and children are unpaid, unsupported and unprotected as they try to save lives. The poor are taking care of the poor. It is imperative to understand what is happening to our communities if we are to make inroads into curbing this epidemic.

Academics, medical professionals, HIV/AIDS experts and politicians have, to a large extent, developed theories, strategies and programmes in isolation of the realities evidenced at the community and grassroots level. We are increasingly aware that structural factors, including socio-economic and gendered power relations, are barriers to effectively curbing the epidemic. But each community has its own mix of social, economic, cultural, political and gendered norms, which creates a multi-faceted contextual reality which must be understood in each instance for HIV/AIDS interventions to be successful.

As South Africa begins to grapple with the implementation of the new National Strategic Plan for HIV and AIDS & STIs 2007 - 2011 (NSP), communities cannot be an afterthought. Intensive mobilisation across communities and sectors is fundamental in our approach to implementation; mobilisation to raise awareness of the NSP, of the rights and duties it places on us all - from state organs to community members, and of the barriers and challenges to achieving full implementation in our communities.

Most importantly, this Track highlighted the experiences of communities which show that the country is failing to deal with the socio-economic impact of this epidemic. As we move toward implementing the NSP, it is critical that this failure not be repeated.

Another revelation was that while programmes have been developed in isolation of the realities experienced in our communities, communities have developed their own responses.

A community response - Sihlenga Izimpilo Zama Zimela Home-Based Carers

One such example was the moving and eye-opening presentation delivered by Sihlenga Izimpilo Zama Zimela, a community home-based care organisation from the rural village of Zimela, KwaZulu-Natal.

Sihlenga Izimpilo Zama Zimela is a community-led intervention borne of the horrors and devastation brought upon their rural community by the HIV/AIDS epidemic. In Zimela, with a population of 80 000, tucked away in the mountains deep in Northern KwaZulu-Natal, 120 people die of AIDS each month - mostly youth.

The nearest town, with a clinic and services, is 50km away and transport costs are exorbitant for the mostly unemployed villagers. There is no electricity and water is collected from a stream, shared with cattle, goats and donkeys.

In 2000, the extreme drought - which still plagues the region - caused a cholera outbreak. The community thus formed a small collective of home-based carers (HBCs) to care for the sick and dying. But it was not long before these volunteers saw that HIV/AIDS and TB posed the real danger to their survival. Seventeen carers thus formed the community organisation Sihlenga Izimpilo Zama Zimela. They have grown to 80 carers, who visit those sick with AIDS and TB in their homes, providing care, information and as much assistance as possible. From carrying water and fire wood, to feeding, bathing and providing treatment information, these volunteers - mostly women - are trying to save their village. They do so without basic resources; without gloves, the carers only have plastic bags with which to protect themselves.

With little more than initiative, this organisation has networked, built alliances, received training and developed a community programme to meet the unique needs of their community. Yet these volunteer HBCs receive no stipend or support from the government, despite protocol that makes provision for community health workers.
The care and support responsibilities of the HIV/AIDS epidemic are turning the conceptions of "health work" upside down. Home based care is health work and should be remunerated as such.

The NSP must be informed by work being done in communities by communities. Implementation strategies, rather than reinventing the wheel, must evaluate and understand what is already happening in our communities and recognise, strengthen and support these initiatives. Such interventions are invaluable as they understand the nature of the epidemic in the community - the context, the culture, the language, the challenges, what works and what does not. Imposing "pre-packaged" programmes or programme employees from outside the community are no match for the commitment and local knowledge of community members dedicated to their own community.

Sihlenga Izimpilo Zama Zimela has shown the success achievable through collaboration with community members, NGOs, CBOs and FBOs. It is particularly noteworthy that the village Chief is integral to the organisation, working actively with and supporting volunteer HBCs to save the lives of his people.

An audience member summarised this presentation succinctly: This presentation sheds light on the 'positive spin' we hear at these conferences. Communities are being forgotten, therefore we must be cautious when told about the gains being made in the fight against HIV/AIDS. Huge challenges remain in our communities, especially in rural areas. This is the real face of the epidemic, and this is where we will either win or lose the battle.

The story of the Zimela group is just one example of how communities are taking on the challenge of HIV/AIDS and in some instances overtaking the state in responding to the epidemic. Many such examples of initiative and leadership can be seen when travelling in different parts of the country.

The role of employers and business

Every employer and business owner can have an immediate and far-reaching impact on the community in which they conduct their business or where their employees live. In addition, the sustainability of their enterprises and productivity of their workforce can be significantly improved by investing in these communities. More so than organisations and institutions alien to the community, community-led interventions have proven hugely successful in fighting the epidemic.

For example, a community outreach intervention in Madwaleni, Eastern Cape, which provides voluntary counselling and testing services, was reaching HIV-positive community members with higher CD4 counts (338 on average) than those presenting at the Madwaleni Hospital (184 on average). This is enormously significant. Not only can huge inroads be made into HIV prevention, but earlier testing allows for earlier treatment, ensuring that community members stay healthy and productive.

Healthy communities ensure healthy employees. Employers can do much for their employees by understanding the additional pressures posed by the epidemic in their personal lives. Ensuring the health of breadwinners also ensures that communities are protected from the additional vulnerabilities to HIV/AIDS posed by poverty. Most importantly, healthy communities build a healthy nation. Investing in and supporting community-led interventions through donations, skills-sharing, training, providing food security measures or service delivery can have an immediate, tangible, valuable and life-saving impact.

At the launch of the NSP in April 2007, every sector of the South African National AIDS Council (SANAC) pledged to do all they can to achieve the ambitious goals of halving the rate of new infections and providing treatment, care and support packages to 80% of those who need them. If we locate the response in and support, enable, resource and mobilise every community to respond to the needs of the epidemic, we can succeed.