AIDS in South Africa An interview with Hoosen Coovadia and Ashraf Grimwood

South Africa’s approach to HIV drew severe criticism from international opinion leaders at the XVI International AIDS Conference (AIDS 2006) in Toronto last year, where Health Minister, Manto Tshabalala-Msimang opted to exhibit beetroot, garlic and lemon juice as a treatment solution for HIV. Since then, the country has seen a number of highs and lows in its response to the epidemic. The IAS spoke with Hoosen Coovadia[1] and Ashraf Grimwood[2] – two South Africans at the forefront of the epidemic – to discuss recent events, and to forecast the future.

 
IAS: What is working well in South Africa?
Coovadia: Despite the absence of strong leadership from the President and the Health Minister, Manto Tshabalala-Msimang, there has been gratifying progress. This includes the involvement of the NGO and academic sector in the national body dedicated to policies on HIV/AIDS – the South African National AIDS Council (SANAC).  That leadership is shared between the Deputy President, Phumzile Mlambo-Ngcuka, and Mark Heywood of the AIDS Law Project. 
SANAC has set in place many serious steps for implementation and a commendable National Plan on AIDS for the country. In addition, programmes are moving forward on treatment and some advances on prevention have been made. 
The brief “honeymoon” when the Deputy Minister of Health, Nozizwe Madlala-Routledge, was in charge – while Tshabalala-Msimang was ill – is now over. However, much was done by Madlala-Routledge to re-establish links with researchers and civil society; and as a result she became the “darling” of the AIDS community in the country.
 
Grimwood: The critical factor over the last year has been strengthening SANAC. Both individuals at its helm are passionate and driven to achieve the goals of the newly launched National Strategic Plan (NSP). The NSP aims to reduce new transmissions of HIV by 50 per cent, including ensuring that 80 per cent of people who need therapy receive it by 2011 (including people with a CD4 count under 200 or who present with stage 4 clinical disease according to the World Health Organization guidelines). The process of developing the NSP has been a critical factor in galvanizing civil society involvement with government; and one can truly say that the country is united behind this plan. SANAC appears to be functioning well and, with its new structure and leadership, I hope that critical progress will be made in overcoming the large treatment gap and improving the abysmal rates achieved to date by the national prevention of mother to child transmission (PMTCT) programme.
South Africa has the largest ARV treatment programme in the world, which appears to be running well. Where there is NGO support, the numbers remaining in care, lost to follow up or who die are in keeping with similar programmes in more developed countries.
 
IAS: what are the main challenges you face in providing HIV treatment?
Grimwood: Absolute return for Kids (ARK) currently supports 67 treatment facilities and has, over the last four years, assisted government in getting over 30,000 people onto treatment, and reports 83 percent remaining in care after two years in care. The government health service has over 260,000 people on treatment, although the need is about three times this number, and about 1.8 million people will need ARVs by 2011. How does a country get over a million people on therapy in four years with the human resources, infrastructure and capacity constraints facing it at present?
A current challenge facing ARK’s support of the government’s ARV programme is human resources required to increase care, as well as training, infrastructure and data systems required to measure adherence and treatment outcomes. To address these needs we need a streamlined system that increases accreditation for community health centres and clinics to initiate treatment.  We are not achieving the treatment needs of children, who make up less than 10 per cent of those on treatment, and there is a concerted effort to have the PMTCT programme integrated into other programmes. 
Care, treatment and support of health care staff must be creatively addressed because we are losing up to 10 per cent of staff through AIDS-related complications in some facilities.
 
Coovadia: Scale-up of prevention and treatment remains a challenge. We need more emphasis on prevention interventions. People appear to be obsessed with treatment, which is not surprising given the prominent battles for ARVs in this country since the XIII International AIDS Conference in Durban and the activism of the Treatment Action Campaign.
Current Programmes are often not based on strict scientific evidence and all opinions are treated as equal, which is not how medicine works. 
Stigma, discrimination, shame,harassment and victimization in communities are still evident, and must be overcome. Violence is a horrendous influence in society, and contributes greatly to the spread of AIDS. Indeed, the three main causes of disability and/or death are AIDS, interpersonal violence and trauma. A change in behaviour to prevent the spread of HIV and counteract stigma and violence is vital.
The corporate sector,except for a few notable examples, is not really doing enough to contribute to combating HIV. And finally, open political commitment from the very top is needed.
 
 
IAS: How is research functioning? Are researchers finding ways to collaborate despite the fractured political leadership?
Coovadia: Absolutely. We get more external funds for research than almost any other country in the world. And there is a vibrant research community in the country. One failing is that a very large proportion of the studies are not the original contribution of South Africans, but designed elsewhere and merely implemented here, with a perfunctory nod to local ownership.

Grimwood: National leadershipin research is an area of critical need. South Africa has access to data that could answer many of the challenges facing clinicians locally and in other countries, but that requires coordination and systematic evaluation. Newer treatments are untested in large populations and it is critical to see how these [treatments will have an] impact, and what the longer term effects on particular population groups are. Research on prevention tools like microbicides and vaccines continues, but appears to need immense resources. With our limited scientific capability and resources, [pre-clinical work] may best be left to better resourced countries, while we assist with later developments. 

IAS: Does the government show a commitment to HIV research?
Grimwood: There is no current research into the “snake oil cures” which are being peddled in local communities and what impact this has on AIDS denialism, the general health of infected people, and the interaction of these with ARVs. “Treatments” like Virodene (dimethyl formamide), the organic solvent which was discredited [as an HIV treatment] several years ago, have just resurfaced, indicating ongoing evaluation by unnamed organizations.  Support of vaccine and microbicide research continues.
 
Coovadia: While some research is supported, I suspect – although I have no proof – that there is a tendency to use the Medicines Control Council, which regulates research activities, to delay work of which the government does not approve. 

IAS: What impact has the removal of the Deputy Health Minister had on the national AIDS campaign, and what are the implications for the future?
Coovadia: If we were able to maintain the momentum created by the deputy minister’s actions, we could have gone much faster and achieved more as a joint exercise between state and society, than we are able to now. The manner in which she was discharged speaks ill of our democratic processes.
 
Grimwood: Business continuesas usual. There is acute civil society monitoring of the national programme and the NSP. If there are any signs that these goals are being delayed or reduced, there will be mobilization of civil society to correct the situation.
 
 
 
IAS: How much support does the Minister of Health, Manto Tshabalala-Msimang, hold among health care workers and researchers in South Africa?
Grimwood: There is great support from certain traditional political structures, as well as some health care workers in critical positions. This support, though, is not universal.
 
Coovadia: She has little support. However, given the sharp racial divide in the country exacerbated by the African National Congress (ANC) and its new elites and die-hard supporters, there are some people who will see attacks on Manto as being racially motivated, and may support her.
 
 
IAS: What are the most pressing HIV-related issues which South Africans (health-care workers, governments and NGOs) should be focusing on?
Coovadia: Besides those already mentioned, fundamentally, it’s the same as with the rest of the continent: health personnel and infrastructure such as facilities, labs, clinics and equipment, are needed. The task is to stop complaining and do the very best we can with whatever we have, because what we have is a whole lot better than what the rest of the continent has to deal with.
 
Grimwood: We should focus on positive prevention and ensuring maternal health through well-run PMTCT programmes that are integrated with general HIV treatment, care and support programmes.  We need to address the treatment gap in the most urgent and creative ways without sacrificing quality of care. This would require meeting the needs of human resources, infrastructure, health management information systems and capacity development. The focus needs to be at the primary level of care with care worker involvement at the community level. If we are able to do this well, we will meet our HIV treatment needs, and have a positive impact on the TB epidemic as well. â– 
 
 
This article was first published in the International AIDS Society’s Newsletter – November 2007.

[1] Victor Daitz Professor of HIV/AIDS Research and Scientific Director at the Doris Duke Medical Research Institute at the University of KwaZulu-Natal in Durban, South Africa; IAS Governing Council Member for Africa.
 
[2] Executive Director of Absolute Return for Kids (ARK) South Africa, based in Cape Town