This edition of AAAO focuses on treatment, care and support: the second priority area of the National Strategic Plan. With close to half a million people on antiretroviral treatment, South Africa has one of the largest HIV treatment programmes in the world. I remember working on AIDS statistics in 2004 and realising that we only had an estimated 80 000 people on treatment whereas around half a million were in the final AIDS sick stages of the disease and in need of treatment. Have we managed to upscale our treatment and reach all those in need? The simple answer is no. The numbers of people progressing towards AIDS sickness have increased since 2004. Current estimates by the Actuarial Society of South Africa show that around 1 million South Africans are in need of antiretroviral treatment.

Dr Ashraf Grimwood, a well-known HIV clinician and executive director of Absolute Return for Kids, shares with us his views on the burden of AIDS in South Africa. His article provides us with an insightful summary of the relative roll-out of ART in the different provinces in South Africa – with some approximations he points out where the greatest gaps are. The article includes excellent pointers on areas in which the private sector can get involved in order to support the NSP.

Two groups that often fall through the cracks when it comes to AIDS treatment are orphans and immigrants. The NSP specifically mentions both these groups in achieving its targets. Jo Vearey, a Doctoral Research Fellow at the Forced Migration Studies Programme (Wits) writes that non-citizens – including refugees and asylum seekers – are often denied ART in the public sector. Her research findings dispel some popular myths and expose the contradiction between policy and policy implementation in the inner-city of Johannesburg.

The International AIDS Candlelight Memorial on May 18 urges leaders to ensure communities get equal access to treatment, evidence-based prevention, and care and support. This includes meeting the needs of orphans and vulnerable children, strengthening public health systems and fighting discrimination.

With this 25th anniversary of the AIDS Candlelight Memorial let us live the theme to “Never give up” and “Never forget”.

Nathea

Background
South Africa has a progressive urban refugee policy whereby refugees and asylum seekers are encouraged to self-settle and integrate, rather than be confined to camps. A range of rights are provided to such individuals through the Refugee Act (1998) and the South African Constitution, including access to basic healthcare. The current HIV, AIDS and STI National Strategic Plan for South Africa (NSP) specifically includes non-citizen groups, outlining their right to HIV prevention, treatment and support. Additionally, in September 2007, the National Department of Health (NDOH) released a Revenue Directive clarifying that refugees and asylum seekers – with or without a permit – shall be exempt from paying for antiretroviral treatment (ART) in the public sector. This is particularly appropriate given the right that individuals have to access ART, and the challenges that asylum seekers face in accessing documentation from the Department of Home Affairs.

A key guiding principle to the successful implementation of the NSP is towards ‘ensuring equality and non-discrimination against marginalised groups’; refugees, asylum seekers and foreign migrants are specifically mentioned as having ‘a right to equal access to interventions for HIV prevention, treatment and support’. However, many challenges are experienced by refugees and asylum seekers as protective policy is not transformed into protective practiceRecent research conducted in Johannesburg indicates that non-citizens in need of ART – including refugees and asylum seekers – report more challenges in accessing ART within the public sector than citizens.

Research findings
Study findings indicate that protective frameworks and NDOH policies are not applied uniformly as public institutions appear to determine their own policies that counter existing legislation.

Non-citizens – including refugees and asylum seekers – report being denied ART in the public sector as they are not in possession of a green bar-coded South African identity booklet, as well as for 'being foreign'. Rather than referring to an appropriate government ART roll-out site, local government clinics refer refugees, asylum seekers and other non-citizens out of the public sector and directly into the NGO sector in order to access ART. Many non-citizen individuals, regardless of immigration status, who test positive for HIV at government clinics, are referred out of the public health sector as soon as they are in need of ART (which in many cases is at the time of testing). This results in a dual-health care system, public and non-governmental, providing ART through separate routes, to different groups of people. This raises concern in terms of (1) logistical issues, particularly through cross-referrals, and (2) the responsibility of the public sector being met by NGO providers.

The gender distribution observed in the study reflects the gendered nature of HIV as well as gendered patterns in health seeking behaviour, in particular for ART; roughly one third of respondents were male and two-thirds female. The percentages are very similar for both citizens and non-citizen and no significant difference was observed in gender distribution between the two groups.

The study found that these individuals are not health migrants; they mostly first tested for HIV in South Africa, having been here for a period of time. The majority of respondents reported first testing for HIV only when they were already sick, this was found to be the same for the citizen group with no significant difference observed between the two groups. Campaigns encouraging early testing have not been effective for the South African population, or for migrants. Another important finding that lends support to the provision of ART to all individuals within South Africa is that no significant difference was found between non-citizen and citizen clients in their reports of either not collecting treatment, or not taking treatment.

Recommendations
HIV is a public health issue and ensuring the free provision of ART to all individuals within South Africa who are in need of treatment will have a public health benefit, particularly from an infectious disease control perspective. Whilst the numbers of non-citizens within South Africa are small, they are significant. Without providing ART to those who require it, morbidity – and ultimately mortality – will increase. It is important to ensure that individuals are encouraged to know their status and are able to access treatment early; the burden upon the health system will be greater for untreated, sick individuals.

The South African public health sector has a responsibility to provide free basic health services, and ART, to refugees and asylum seekers, with or without a permit. The NSP can assist in guiding appropriate responses to the challenges presented; priority area 4 of the Plan encompasses human rights and access to justice, with goal 16 being to ensure ‘public knowledge of and adherence to the legal and policy provision’. It is essential that both national and local government make use of the goals outlined within the plan to create and deliver appropriate training responses and awareness campaigns.

The NDOH Directive must be targeted to senior public health officials, particularly the Chief Executive Officers and managers of clinics and hospitals. Without the support from senior public health officials – especially those responsible for the public institutions that are rolling out ART - the intentions of the recent Directive may not be met. It is essential that all levels of staff within the health system receive appropriate, ongoing training relating to the rights of refugees and migrants to access healthcare. National and local government must monitor access to ART to ensure that the rights of all within South Africa are upheld.


Jo Vearey is a Doctoral Research Fellow at the Forced Migration Studies Programme (Wits) and is undertaking a PhD through the School of Public Health (Wits). Her PhD research is investigating the persistent urban health challenges of migration and informal settlements in the context of HIV, through which she is working towards a framework to guide appropriate local level developmental responses. Her research interests involve developing country urban public health challenges: the context of HIV, informal settlements, migration, access to health services, developmental responses, and urban local government.
 

I-Ref: BI 4/29 REFUG/ASYL 8 2007 For further discussion see Landau, L (2006)
II-Protection and Dignity in Johannesburg: Shortcomings of South Africa's Urban
Refugee Policy Journal of Refugee Studies 19(3) 308
III-Department of Health (2007a) HIV & AIDS and STI Strategic Plan for South Africa, 2007 – 2011. April 2007: Pretoria: Department of Health, p56
IV-Vearey, J. and Palmary, I. (2007) Assessing non-citizen access to antiretroviral therapy in Johannesburg, Forced Migration Studies Programme, University of the Witwatersrand
V-See Wilson, D., & Fariall, L. (2005). Challenges in managing AIDS in South Africa. In S. Abdool Karim, & Q. Abdool Karim (Eds.), HIV/AIDS in South Africa Cape Town: Cambridge University Press.
VI-Department of Health (2007a) HIV & AIDS and STI Strategic Plan for South Africa, 2007 – 2011. April 2007: Pretoria: Department of Health, p119

Recent analysis indicates that with over 5.6 million people living with HIV and AIDS in South Africa and 408,000 initiated on antiretroviral treatment (ART) in the public sector, there is a long way to go to address its critical treatment gap. It’s not clear how many people (100 000 to 125 000) are receiving treatment in the private sector and the military. Despite SA having the largest public sector treatment programme in the world, there is currently a conservative estimate of 500,000 people in need, who are not yet on treatment. With such a large burden of illness and inadequate number obtaining ART, added to the 10% annual increase, it is no surprise that 71% of all deaths in the reproductive age group were due to AIDS. This is a segment of the population that is dying prematurely and as a result, many orphans are left behind. This is the economically active population and their increased mortality has the greatest impact on those left behind who subsequently fall into secondary poverty as they struggle to survive with less income.

No national department of health data has been published regarding how many of those initiated who remain in care, are lost to follow up or have died since the Comprehensive Plan for ART was launched in November 2003. At best, estimates are that 380 000 people remain in care. Despite increasing provider-initiated counseling and testing of pregnant women in antenatal clinics, South Africa has a 22% vertical transmission rate, with 64,000 infants infected in 2006.

1 NDOH communication December 2007
2 ASSA AIDS Model 2003

1) Estimation: Adults (Sum of district populations x 50% x district prevalence rate x 10%) + Children (10% of Adult Estimate)
2) National Department of Health, August 2007
3) Antenatal Prevalence Survey 2006

South Africa is in urgent need of expanding ART rollout to meet the National Strategic Plan (NSP) goals of 80% care coverage, less than 5% transmission from mother-to-child by 2011, and reducing new infections by 50%. To achieve these goals, it is estimated that over a million more people need to be able to access ART by 2011 if we continue to use the <200CD4 cells/ml cut off. If we increase this up to 350CD4 cells/ml even more people will need ART. To get another million people onto ART by 2011 based on current estimates, the number of accredited sites would need to more than quadruple to about 1500 if we are to ensure that sites are treating at least 1000 patients on ART, with another 1500-3000 receiving wellness services. The infrastructure, health systems (including HMIS) and human resource needs required to address this treatment gap, present SA with huge challenges. It has taken the NDoH over 4 years to accredit over 363 sites managing the current treatment load.

The NSP Goals:
> Reduce number of new HIV infections
> Reduce impact of HIV & AIDS on individuals, families, communities & society
Priority areas
> Prevention
> Treatment, Care & Support
> Human & Legal rights
> Monitoring, research and surveillance

National Summary Data	KZN	MP*	FS*	NW	EC*	GP	LP*	NC	WC	TOTAL
Adults and Children in Need of ART	224,184	64,571	47,681	54,942	101,246	180,132	60,701	8,879	42,200	784,537
Adults and Children Initiated ART	128,354	20,561	16,944	38,563	40,787	102,263	26,470	7,026	33,518	414,486
Treat-ment Gap	95,830	44,010	30,737	16,379	60,459	77,869	34,231	1,853	8,682	370,051
% In Need	50.80%	68.16%	69.60%	41.93%	64.66%	50.62%	65.17%	20.87%	27.87%	47.17%

*These provinces have the worst treatment gaps (less than 35% ART coverage) and account for 49% of the people currently in need of treatment in South Africa.

How can the private sector assist government in meeting its NSP targets?

• Partner with local and provincial governments, treat the employed, who are medically uninsured, through workplace programmes or provide work based clinics. This will ensure that employees have access to testing early, where they can be clinically staged and receive appropriate care timeously while their families are able to access care either at these treatment sites or at local community clinics.
• Large industrial operations like smelters and new mining operations have to do HIV environmental impact assessment studies in order to ensure that vulnerable communities are best prepared to prevent HIV transmission where there is an influx of male wage earners.
• Short term interventions can capacitate local clinical services through the provision of sessional skilled staff like nurses and doctors, counsellors and community adherence supporters as the Department of Health prepares to fill critical posts.
• Ensure that services which support primary level care provide an integrated family centred approach within a district based health system with a central hub of expertise with spokes of feeder clinics coordinated to ensure quality health service coverage.
• Ensure that there is community involvement through the employment of trained and accredited adherence workers like patient advocates, community health care workers and home based carers linked to clinic services and public benefit organisations.
• Focus on reducing vertical HIV transmission through the support and development of PMTCT programmes. These programmes should provide the optimal reduction of transmission utilizing appropriate triple therapy regimens for all pregnant women for life for those who need this or for the duration of the pregnancy and lactation where mothers are not in need of long term care and choose to breastfeed.
• Ensure that there are programmes addressing the needs of children at risk of orphan hood and secondary poverty through illness and disease of their carers by for example ensuring that employees have adequate knowledge of death and disability benefits due to them in the workplace. Offer educational policies to employees and ensure that Employee Assistance Help Lines are adequately utilised.

• Increasing access to care that includes PMTCT, paediatric care, TB and other related illnesses.
• Infrastructure development at clinics and local NGOs providing treatment, care and community adherence support.
• The development of the Health Monitoring and Information Systems to ensure accurate and useful data collection at site and district level.
• Capacity development of existing staff as well as assisting with the provision of sessional or full time staff to alleviate the workload.
• Support the development and implementation of adherence measures that include the development of tools to enhance adherence as well as the monitoring and measuring of adherence.

Ashraf Grimwood is currently the Executive Director of Absolute Return for Kids SA, a British based charity that assists in transforming the lives of children. The focus in South African and Mozambique is assisting governments with their national ART rollout programmes, increasing access to care with the focus being on mothers, spouses and their children. Previously he was Deputy Director of South African AIDS Vaccine Initiative and the Scientific Director of Secure the Future, BMS. He continues to practice after hours part time in HIV care and treatment. Ashraf has been working in HIV since the late eighties, setting up HIV clinics in Australia as well as for the WC Provincial and Local governments.

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