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Southern Africa: AIDS Plans Updates

AfricaFocus Bulletin
Feb 11, 2004 (040211)
(Reposted from sources cited below)

Editor's Note

Little more than two months after the announcement of a national plan for providing AIDS treatment, South African President Thabo Mbeki and Health Minister Manto Tshabalala-Msimang have raised new doubts about the commitment of top political leaders to rapid implementation of the plan. A statement by the Treatment Action Campaign issued today accuses the two government leaders of "serious factual misrepresentations" and "causing confusion in the public and despair among people with HIV/AIDS and health professionals."

See for the February 11 TAC statement, and for an article in the Cape Argus noting the health minister's backtracking on commitments made in November to enroll 53,000 patients in therapy by the end of February. For a report on the November announcement, see

At the same time the TAC acknowledged "tangible progress by government in improving policies, budgets and plans to prevent and treat HIV infection." And treatment access advocates acknowledge that there are enormous practical problems as well as leadership issues involved in providing treatment.

This issue of AfricaFocus Bulletin contains excerpts from two articles from the HIV & AIDS Treatment in Practice (HATIP) Newsletter, a twice-monthly publication, evaluating both political will and practical obstacles facing AIDS treatment programs in Botswana and South Africa.

Another AfricaFocus Bulletin today contains excerpts from the keynote speech delivered by UN AIDS Envoy Stephen Lewis in San Francisco at the 11th Conference on Retroviruses and Opportunistic Infections

++++++++++++++++++++++end editor's note+++++++++++++++++++++++

Learning from Botswana

A report from Botswana's First National Research Conference on HIV/AIDS/STI/Other Related Infectious Diseases

[Excerpts from HIV & AIDS Treatment in Practice #20, last updated Jan 16, 2004. See for full report. For more information on AIDS in Botswana visit]

This article was written by Theo Smart with additional contributions from Keith Alcorn.

Botswana Reviews its Progress

... the First National Research Conference on HIV/AIDS/STI/Other Related Infectious Diseases held [in December] in Gaborone, Botswana, was one of the most dynamic meetings this reporter has ever attended. The conference demonstrated that the Government of Botswana and its international collaborators and development partners have put into place a model programme, the most sophisticated response to the HIV/AIDS epidemic on the African continent to date. As it is still ramping up, the programme is far from perfect, however, and has encountered unanticipated and complex problems from which other nations can learn.

But much of the meeting was dedicated to honestly assessing the gaps between the "needs" the programme is meant to meet and its actual performance, and then to the design and testing of interventions or policies to tackle those obstacles or gaps in provision. ...

Why Is Botswana So Seriously Affected?

... Participants at the conference devoted much discussion to the reasons why Botswana has been so severely affected, and what can be done to improve prevention efforts.

Ten or fifteen years ago in southern Africa, hardly anyone was worried about HIV. Although, the first cases of AIDS were diagnosed in 1982 in South Africa and in Botswana in 1985, the disease spread very slowly in the 1980s. In fact, most people in the region thought AIDS was a white man's disease, an effect of malnutrition, or even worse, a fiction. To a surprising extent, these perceptions still persist in many areas.

What is shocking is how swiftly and deeply HIV got its hooks into the population during the last ten years - in many areas 30-40% of the population has been infected, and the majority of people in some age brackets. Similar data were reported at this month's meeting by the Local Government Minister, T Shipinare, from the most recent Botswana HIV/AIDS Surveillance report.

275,000 adult (15-49 years) Batswana are now estimated to be living with HIV/AIDS (out of a total population of ~1.6 million). 37.4% of adult pregnant women are HIV-positive, tens of thousands of their children become infected and even more will become orphans. ,,,

According to the Surveillance report, "condom use in the last sexual act with a non-marital and non-cohabiting partner was over 60%." Cultural practices which encourage intergenerational and multiple partner sex also persist, according to the survey. "The proportion of people with multiple partners is still high at 32% for men and 17% for women." ...

Several presentations highlighted the woman's unequal role in Botswana. They all added to evidence that has been highlighted for years, but evidence nevertheless worth restating: women often have little control over sex. If they refuse sex from their partner, he could interpret it as a sign of unfaithfulness, and the partner could then rape her. These patterns are not merely applied to marriages but in affairs, dating couples and intergenerational relationships as well.

The woman has no right to refuse sex, and therefore winds up being put repeatedly at risk, and yet, if she tests positive she is condemned as adulterous or a prostitute.

Fear of the male partner's reaction if he found out that she was positive came up again and again in Botswana as a reason for women not to get tested, to not return for test results, to not disclose her results, to not go into PMTCT studies, and not to go onto treatment. If they did get treatment, they might be poorly adherent because they would try to conceal pill taking. ...When we talk about stigma as an obstacle to treatment scale-up, we are talking about a phenomenon that is largely structured by gender.

Sub-type C HIV-1

Dr. A B. Khan who is the head of the National AIDS Coordinating Agency (NACA) and was also the doctor who diagnosed the country's first AIDS case concurred that being both a woman and a doctor had sometimes placed her in dangerous situations. But there must be other factors besides male chauvinism that explain the severity of the epidemic, because that isn't unique to Botswana. ...

"There's growing evidence for genotypic/phenotypic differences for HIV-1C of southern Africa to help explain differences in epidemics," Dr. Max Essex said during the opening plenary of the conference. Dr. Essex is Chair of the Harvard AIDS Institute, and the Botswana Harvard Partnership, just one of the several international collaborations that Botswana has set up. Harvard has built a $30,000,000 lab, partly to study these basic science questions. Dr. Essex also happens to have discovered HIV-1C.

"AIDS deaths are at a new high, reflecting HIV infections that happened 5-10 years ago and the lack of widespread use of HAART. But sub-Saharan Africa, especially southern Africa, has much higher rates than any other area. HIV-1C accounts for as many infections as the other major subtypes (A, B, D, A/G, A/E) combined."

Dr. Essex first detected HIV1-C, in 1989 but at the time there wasn't very much of it about. But since that time, it has spread so rapidly that it is by far the most common subtype. No one's really sure why this is the case, but Dr. Essex noted a number of unique features of HIV-1C.

First, the countries with HIV-1C have the highest HIV prevalence rates regardless of cultural differences. In general, non-subtype B viruses are more efficiently transmitted heterosexually than subtype-B. Meanwhile, subtype-C seems to be more readily transmitted perinatally than subtypes A and D. ...

... Botswana isn't satisfied with [prevention and treatment]. They want to go beyond that to become a country doing cutting edge research. A centre of excellence, because they've realised that HIV is a formidable enemy. And it isn't exactly the same HIV as is common in the West - they certainly can't take it for granted that the solution to their problem will be the same as in the rest of the world. ...

The Masa Antiretroviral Therapy Program in Botswana

The successes and frustrations of Masa were described by its operations manager, Dr Ernest Darkoh, at the opening plenary.

In 2001, the challenge posed by offering free antiretroviral therapy was immense. The epidemic in Botswana was full blown and out of control. There were approximately 300,000 HIV positive people in the country. At least 35% of these were in the primary income earning stage of life. 110,000 would probably be eligible for therapy immediately, based on clinical criteria. But more than 90% of these didn't know their HIV status, and there were steep socio-cultural barriers to getting them tested.

The country did not have the capacity to offer treatment yet. There were few trained doctors, nurses, or lab personnel. There was no infrastructure or equipment. They would need to create systems and policies for the programme.

They established a dedicated implementation team (based on a public/private model) and supporting structures. They decided to build four strategically located centres in Gaborone, Francistown, Maun and Serowe to serve patients who met the eligibility criteria (a CD4 count of 200 or less and/or the presence of an AIDS defining illness). They would establish a system to monitor early uptake and adjust eligibility criteria as necessary. They would build more capacity nationwide as rapidly as possible to address the full burden of disease. At the same time, they would try to strengthen ongoing prevention initiatives.


... As of November 2003, the combined [ten] Masa sites had tested a total of 16,400 eligible patients, 10,264 are on treatment and a total of 994 (9%) had passed away on treatment.

Masa has been criticised for the very large gap between the perceived need for treatment and its ability to deliver. Dr Darkoh pointed out however, that they could only scale up gradually and that the number of patients over the last several months has increased dramatically, ...

Others have worried about the high rate of death on treatment, but Dr. Darkoh pointed out that these were very advanced patients with an average CD4 cell count of only 50-60 cells. However, the programme has shown that it can you can get good patient follow-up in Africa, with fewer than 10% lost to follow-up. Also, patient adherence, using a zero tolerance standard for missing or being late on a dose is high, at over 85%. Less than 7% had to switch medication due to toxicity. Complete viral load suppression was achieved in 85% of the patients.

The plan is to continue scaling up and expanding as long as necessary. Sites have been completed at two mining hospitals, and three more are planned at Botswana Defense Force facilities. The plan is to identify ten other potential sites for rollout by the end of fiscal year 2004 ...

But the key challenges going forward? The first and foremost is that most people in the country (including patients) still do not know their HIV status. Socio-cultural factors and stigma remain barriers.

Dr Darkoh says that they've learned several lessons from the experience.

  • "Capacity or capability build-up ... takes time in the beginning."
  • Each new site experiences the same "teething problems" therefore spread the net as wide as possible after an initial "pilot."
  • "The sickest come forward first: so we may need to "split" the queue to allow some healthier patients onto treatment before they become severely ill.
  • VCT should be supplemented with routine testing to enable more rational demand management; we need to convince people that it would save their life AND livelihood.
  • Much of the workload is follow-up of patients rather than initial assessment.
  • Set up monitoring and evaluation systems early.


South Africa's HIV Treatment Programme:
Is Slow Progress a Sign of Lack of Commitment?

[Extract from HIV & AIDS Treatment in Practice #23, February 6, 2004 - full text will be available at]

Distributed by See for list archive with full text and subscription information

This article was written by Theo Smart (Cape Town) with contributioms from South African members of HATIP's advisory panel.

South Africa Seems to Change Direction on ART

People were guardedly optimistic last August when the South African Cabinet issued instructions to its Department of Health to develop an operational plan to provide ART in the public sector. Many were surprised. For years, the current administration had delayed taking any clear-cut positive actions and often seemed hostile to the idea.

Activists initially may have questioned the composition of the team appointed to develop it but when the very aggressive "operational plan for comprehensive HIV and AIDS care, management and treatment" - including the "roll-out" of antiretroviral therapy (ART) - was presented and then approved by the Cabinet, people were literally dancing in the streets.

The plan promised to distribute free ART within a year to at least 50,000 people in the nation's 77 health districts and to reach every South African in need of treatment within five years. It also committed government to investing substantial finances into upgrading the national healthcare system via "recruitment of thousands of professionals and a very large training programme to ensure nurses, doctors, laboratory technicians, counsellors and other health workers have the knowledge and the skills to ensure safe, ethical and effective use of medicines."

Initial Reactions

After the plan's approval, HATIP queried South African members of its Advisory Panel on what they thought of the new treatment programme. Responses ranged. ...

Dr. Catherine Orrell of Somerset Hospital, a public hospital in Cape Town had doubts. "While I'm quite happy that the plan has finally been approved my excitement is tempered because it is going to be very difficult to implement and is going to take years to get treatment out to everyone who needs it, particularly in areas that are already under-resourced. ...

To offer HIV care, the OP requires facilities to meet stringent accreditation criteria. "It's a big list and quite a tall order. It might be possible to achieve in some districts in Gauteng or the Western Cape but what of the Northern Cape or Limpopo or Mpumulanga? The program is going to have to be driven at the national level."

Dr. Norman Nyazema who works at least half the year in Limpopo Province said bluntly. "People are playing games. It's not going to happen."

Most of the operational plan can be downloaded from: .

Not Even Out of the Starting Gate

So far, a little more than two months after its approval, there is little evidence that tasks are being implemented in a timely fashion. No one has received treatment except in the Western Cape, which has little to do with the operational plan because the province had already allocated funds to provide ART on its own. In fact, the drug procurement process has only just begun. This week the government began tendering requests for proposals to drug suppliers to shop around for the best price. Treatment probably won't become available until April.

But aside from the drug supply, Dr. Conradie doesn't think the situation is so bleak. "We have been gearing up our system for the roll-outs interacting with people in the national government who are quite actively working on the implementation of the plan."

It should be noted that Dr. Conradie works at what could be considered a flagship site [Helen Joseph Hospital]. Still other South African clinicians contacted concur that they are working closely with the Department of Health on improving infrastructure for the rollout. However, one of these, a HATIP panel member who wishes to remain anonymous, said that parts of the Department of Health "seem to be in complete disarray and the right hand often doesn't know what the left is doing."

Given the grand scale of the treatment programme and the effort needed to coordinate its implementation, a slow start is perhaps to be expected. But is this merely a slow start, or the first of many such delays? It is very difficult to say, because of one central problem: a lack of communication between the government and the HIV community.

Storm Brewing

Frustration is building amongst those who actively want to work with government to secure the implementation of the plan.

* Communication Breakdown.

TAC complains that the operational plan commits to communication of its details, but this hasn't happened. Perhaps the government felt that posting most of the operational plan and other materials online on November 19 fulfilled that commitment. However, there has been no further communication about the operational plan since that day. ...

* The community has already become disillusioned.

Virtually the day after the operational plan's approval, TAC had mobilised to do its part. They began marshalling community-based organisations and other non-governmental organisations to fight stigma, encourage voluntary testing, scale up treatment education, home-based care and other related activities. They believed that the government was acting in good faith and that there would be a new era of cooperation between TAC and the national government. TAC offered an olive branch but has been rebuffed. Now the organisation demands to know what is going on.

* Funds have not been allocated.

According to a recent TAC National Executive Committee report, only R90 million of the R296 million requested by the operational plan for the fiscal year ending March 2004 has been allocated. None of that appears to have been disbursed to the provinces. ...

* Site accreditation problems.

TAC also feels that the accreditation process for service points in the operational plan "is unduly onerous and the NEC was reliably informed that sites that were accredited by the operational plan task team are being re-evaluated for accreditation." Is the goal to accredit or discredit sites? What is the national government doing to help these sites become accredited? ...

* Who is training the healthcare workers?

Around the country various groups have or are developing training programmes locally. In the strategic management chapter of the plan, the responsibility for training seems to be delegated to the provinces. But there have been no appropriated funds disbursed for this purpose, which is crucial if the treatment programme is ever going to provide care to people with HIV outside of a few flagship sites in the nation. ...

* Accountability

All too often secrecy is simply a fear of public accountability. Conspicuously, a crucial piece of the operational plan has still not been released to the public: Annex A. This document details the implementation schedule and week-to-week tasks required to implement the treatment program. TAC is calling on the government to make Annex A public. ...

* Who is driving the process? Where is the leadership?

The operational plan is well designed and doubtless there are many in government working hard to make it happen. But as the task force acknowledged, its implementation can be delayed or undermined if even one strategic manager does not do his or her essential task in a timely manner. Openness or strict oversight by a strong manager or leader who is committed to the programme could prevent such delays and help drive the process. But who is leading the charge for the South African treatment rollout? Who in the government is committed put and keep the plan in motion? ,,,

AfricaFocus Bulletin is an independent electronic publication providing reposted commentary and analysis on African issues, with a particular focus on U.S. and international policies. AfricaFocus Bulletin is edited by William Minter.

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