Kerry Cullinan says thousands of patients risk becoming resistant to ARVs as clinics run out of drugs because of mismanagment.
There is a big hole in the middle of South Africa’s HIV treatment programme that is undermining government’s remarkable achievements since 2009, when Aids denialist president Thabo Mbeki was ousted.
This hole is called medicine stock-outs. It is caused mainly by poor management, and no matter how good our national programme and health minister are, unless the implementers – the provinces – can improve health service delivery, we will not only fail to overcome HIV, but stand to develop a monster called drug-resistant HIV.
Between 2009 and 2011, there was a 75 percent increase in South Africans getting access to antiretroviral (ARV) treatment – and we now have the world’s biggest treatment programme, with about 2.4 million people started on the lifelong, life-saving medicine.
But medicine shortages over the past year have jeopardised the programme. One in five health facilities polled recently reported ARV shortages, potentially affecting 420 000 patients. This is according to a report released yesterday by Stop the Stock-outs campaign, based on a recent phone survey of 2 139 health facilities.
The human immunodeficiency virus mutates as it grows, so it can easily develop resistance to a single medicine. People on HIV treatment therefore get three medicines – triple therapy – that target different parts of the virus’s life cycle. Treatment interruptions give the virus an opportunity to adapt to the medicines and develop resistance, which means the medicine will no longer stop the growth of the virus, which will spell weakened immunity and even death.
Before World Aids Day tomorrow, Aids doctors and activists all listed the medicine stock-outs as the biggest challenge facing the HIV fight.
“There has been a lot of progress against HIV, but this is being undermined by provincial dysfunction,” said the Treatment Action Campaign’s Marcus Low, who described the shortages as “shocking”.
According to the Stop the Stock-outs report: “The extent of medicine shortages, especially of ARVs, is enormous, far beyond previous estimations, and affects most provinces. Medical consequences and costs to the health system and patients can be grave, including drug resistance, decreasing immunity, increased risk of opportunistic infections and transmission of HIV and tuberculosis, leading to more illness and death.”
Dr Francesca Conradie, president of the Southern African HIV Clinicians’ Society, listed stock-outs as the biggest problem, followed by “a health care system that is not able to deal with the volume of patients”, and TB, which preys on people with weak immune systems.
Referring to TB, she said: “South Africa has a population of hyper-susceptible individuals and a poorly functioning TB programme. We have one of the highest incidence rates (new cases) of TB in the world – about 1 percent a year – and an increasing number of multi-drug-resistant TB and extensively drug-resistant TB cases.”
South Africa has one of the worst burdens of drug-resistant TB – a problem caused by people not taking their medication properly. We cannot afford the same thing to happen to HIV, leaving few medical options for the 5.6 million HIV-positive people. Although it is predicted about 200 000 people will die this year of Aids-related infections, according to Statistics SA, huge advances have been made in the fight against HIV.
One of the most striking achievements is the reduction, to about 2.5 percent, in the proportion of HIV-positive mothers passing the virus on to their babies. HIV was one of the biggest causes of deaths in children under the age of five, so this mortality rate is slowly going down. The extensive ARV roll-out is keeping more people alive and our life expectancy, which was lower than that in the war-torn Democratic Republic of Congo a few years ago, has inched up to 58 years.
In the provinces most affected by HIV, the improvement in life expectancy has been striking: in rural Umkhanyakude District in KwaZulu-Natal, life expectancy jumped by 11 years between 2003 and 2011. In 2003, the average person died at 49 but, by 2011, lived to 60.
This is according to research carried out by the Africa Centre and published earlier this year in Science, a leading international scientific journal.
“The public sector scale-up of antiretroviral therapy has transformed health in this community,” said the study’s lead author, Jacob Bor, of the Africa Centre and Harvard School of Public Health.
“Before ART became widely available, most people were dying in their 30s and 40s. Now people are living to pension age and beyond.”
The Africa Centre’s director, Professor Marie-Louise Newell, said the wider provision of ART in Umkhanyakude had achieved “massive results”.
“The reduction in mortality has been very visible to the community. Whereas six years ago there was at least one funeral every weekend, now this is more like one a month,” said Newell.
But keeping millions of people on ARV treatment for life and managing the inevitable drug resistance that will result require a robust health system.
Gauteng has doubled the number of people on ARVs in the past year, to half a million. Yet one fifth of the province’s health facilities polled reported ARV stock-outs in the past three months. Nationally, we don’t know how many of the patients who started taking ARVs are still on them and, if not, why not.
Low said the roll-out of the national health insurance scheme, supposed to improve health service delivery, was moving too slowly in the pilot districts .
The international slogan of “towards zero HIV infections” this World Aids Day will amount to zero unless our serious health system challenges are addressed.
Health-e News Service