A more unified South African AIDS conference

For the most part, there seemed to be a rather harmonious tone set last week between the South African Government, civil society, scientists and health professionals at the Fourth South African AIDS Conference held in Durban. This in itself is remarkable. A barometer for whatever is going on in the fight against HIV in the country, the conference has always been marked by controversy.

But there has been a change in the country’s administration since the last national conference in 2007, with a new Minister of Health, Barbara Hogan, who is known for her strong managerial skills, warm relations with civil society, and a respect for the skills and know-how of the dedicated researchers and healthcare providers working at the coalface of the struggle against HIV/AIDS. The messages coming from the Government have clearly shifted. Even so, with a national election only weeks away, it is unclear whether she will be in the next administration.

Whoever is in charge, the challenges facing the healthcare system in South Africa are unparalleled and enormous.

Despite an ambitious national strategic plan to combat HIV and the rollout of antiretroviral therapy (ART), hundreds of thousands die from the disease each year. Most South Africans remain unaware of their current HIV status, and efforts to get people to test regularly have had, at best, only patchy success. A steady influx of new infections is refuelling the epidemic among adults and even infants, despite the scale-up of the prevention of mother-to-child transmission (PMTCT) programme. And HIV has been a major driver in the region’s resurgent epidemic of tuberculosis (TB) including increasingly drug-resistant TB.

Although South Africa is better resourced to meet these challenges than most other African nations, and now has the largest free ART programme in the world (with around 700,000 people placed on ART), there have been some serious hiccups in implementation and the delivery of services. For instance, in the Free State Province, the ART programme grew so fast that it outstripped its allocated budget and the enrolment of new patients into treatment ground to a halt.

Elsewhere in the country, there are reports of stock-outs of drugs and medical supplies, and it is not clear yet how the global recession will impact on the country, or affect the ability of the health services to grow to meet the need for HIV services.

The one major demonstration at the meeting, organised by the Treatment Action Campaign (TAC) and others was mostly in response to these issues. There are indeed worrying signs that as the number of patients grow, costs could limit efforts to improve the quality of services delivered, and that, in some areas, the programme might be pressured to ‘cut corners'.

Despite this, the general sense at the conference was one of hope borne out of the feeling that (for now at least) the government and society may finally be working towards a common purpose.

Durban has been associated with AIDS conferences ever since the XIII World AIDS Conference, held in 2000, focused attention on the disparities between the industrialised world, where ART was making HIV a chronic manageable disease and Africa “where $1000 a month determined whether you lived or died,” as Dr Gustaaf Wolvaardt of the Foundation for Professional Development noted at a pre-meeting press conference.

Since the Durban World AIDS Conference, there has been a paradigm shift in the world’s response towards HIV in resource-limited settings – partly made possible by a dramatic fall in the price of antiretroviral drugs driven by activism – resulting in large-scale public-health ART programmes.

But one of the most memorable things that happened at the 2000 World AIDS Conference was the confrontation between a young boy with HIV, eleven-year-old Nkosi Johnson, and the former President of South Africa, Thabo Mbeki. Nkosi gave an address at the opening ceremony, challenging his president for treatment, and better PMTCT services (Nkosi died later that same year). But his president went on to shock conference goers by questioning the link between HIV and AIDS – something he persisted in doing publicly despite (or perhaps partly because of) the backlash.

“We’ve had a difficult period over the past few years, with a situation almost unique for a modern democracy: to have the challenges between science, on the one hand, and the state on the other,” said Professor Hoosen ‘Jerry’ Coovadia, of the Nelson Mandela School of Medicine, University of KwaZulu-Natal, at the pre-meeting press conference. “This conference has been the crucible of major disputes between the state and society.”

ANC party leadership eventually persuaded the administration to cut back, at least somewhat, on the denialist rhetoric. Three years after the World AIDS Conference, the first national South African Conference was held, and at the close of the meeting, the MEC for Health announced plans to launch a national ARV programme.

But mixed messages from the government persisted, with some officials seeming to obstruct advancement at every available opportunity. Then, during a period in which the former Minister of Health, Dr Manto Tshabalala-Msimang had to step down for health reasons, the Deputy Health Minister Nozizwe Madlala-Routledge worked to create a new partnership with civil society and medical experts that led to the development of a progressive National Strategic Plan on HIV/AIDS 2007-2011 (NSP).

Accordingly, the organisers of the Thirrd South African AIDS Conference gave Ms Routledge a position of honour to speak at the opening plenary. But with Minister Tshabalala-Msimang having resumed her post, this was quashed by the Ministry of Health. Not long afterwards, President Mbeki fired Ms Routledge from her post, allegedly for attending an HIV vaccine conference against his will.

Last year, President Mbeki was himself forced out of government by his own political party, and Minister Tshabalala-Msimang then given a promotion to a much less visible post in the cabinet.

An indication of how much times seem to have changed? In Durban this year, South African journalists Kerry Cullinan and Anso Thom of the Health-e news service released a new book, The Virus, Vitamins and Vegetables: The South African HIV/AIDS Mystery, which chronicles the often bizarre goings-on when AIDS denialism held sway in the government of South Africa. Addressing the crowd at the book’s launch, Ms Routledge, now the Deputy Speaker of the South African National Assembly, suggested that it was time for the country to have “a truth and reconciliation commission on HIV/AIDS”.

Minister Hogan could not open the conference as originally planned, because she was attending a high-level meeting in Beijing on drug-resistant TB. In her stead was Ms Baleka Mbete, the Deputy President of South Africa, who was quite forthright about some of the challenges the country faces:

“Approximately 250,000 people die annually from a variety of AIDS-related illnesses and nearly double that number become newly infected,” she said. “Women and girls are still raped almost everywhere, which makes it necessary for our health system to address the health needs of rape survivors. The NSP has set clear targets for access to health services by rape survivors and SANAC must ensure that this target is reached.”

She even mentioned groups many politicians continue to marginalise:

“Despite our constitutional provisions, discrimination based on sexual orientation persists, resulting in rapes of gays and lesbians. The NSP requires that we develop 'a supportive legal environment for the provision of HIV and AIDS services to marginalised people'. In this regard, I want to congratulate the Western Cape Health Department, the Paediatric HIV Research Unit and PEPFAR for opening the Ivan Toms Men's Health Clinic at Woodstock Hospital in Cape Town, which provides health services to gays. It will hopefully be a model for other regions planning the same facility.”

When Minister Hogan didn’t appear at the opening plenary as stated in the programme, there were concerns that she was being censored by the government for her comments criticising the decision to refuse to issue the Dalai Lama a visa to visit South Africa (and this may indeed have repercussions down the road). However, conference-goers were clearly relieved when she made it back from the TB meeting for the closing of the conference.

Giving a thank you to all “the healthcare and community workers, activists, scientists, academics, researchers, volunteers and clinicians for spending enormous amounts of energy to respond to the AIDS epidemic in our country in the last decade.” And then she added “If not for you, where would we be now?”

Indeed, the activists and healthcare workers had to lead the way, with the government often working at cross-purposes.

This may be particularly true of the activists and people with HIV, who, through Professor Linda-Gail Bekker’s efforts, were at the conference in greater force than usual, with the community accorded their own track of conference sessions.

But an AIDS conference isn’t complete without at least one march or group act of civil disobedience. The protest, called 'HIV is not in recession!', focused on financial resourcing in the scaling up of healthcare service delivery.

The protest was quickly shut down in a heavy-handed way by security, and the protesters threatened with eviction. This was probably more of a reflection on the security team than on the conference organisers or chair, who had made an effort to involve more people with HIV. Even so, if it is indeed a new era of co-operation between civil society, government and the medical establishment, the people working or involved in these events need to be more sensitised to the fact that, were it not for the actions of AIDS activists, there would be no ART programme and little reason to host such a conference. Their engagement should be encouraged, if not celebrated.

The activist’s message was an important one.

“Wealthy countries are spending multiple trillions of dollars on bailouts, but only a fraction of this could have provided access to comprehensive healthcare for millions of poor people in the world,” said TAC’s spokesperson Victor Lakay. And yet, he pointed out, the Global Fund for AIDS, TB and Malaria is having difficulty securing funding, and resources that are available are being shifted away from HIV programmes to primary healthcare (even though HIV treatment should be an essential part of primary healthcare.)

Meanwhile, within South Africa, the activists noted that the budget allocations for antiretroviral drugs in the provinces are short of what was initially budgeted; but the moratorium on putting new patients on ART in the Free State, and similar shortages in drugs and medical supplies that are occurring in provinces across the country – including in Gauteng, the wealthiest province – have mostly been ignored.

Minister Hogan acknowledged the issue in her speech: “With the coming financial year, I hope that we will be able to address many of these issues, but there are no quick fixes… As a community of health promoters, we must ensure that health services are not cut, but sustained. For every job that is cut, for every sector that buckles, for every health cent cut, there will be consequences for public health… We must be aware that we are, for the first time, experiencing real resource constraints.”

Indeed, it is hard to see how the programme will continue to expand, begin to treat people with higher CD4 cell counts (rather than waiting for people’s CD4s to fall below 200), or improve the quality of care. For instance, many clinicians and activists at the conference called for the programme to switch from d4T-containing ART regimens, as d4T is associated with most of the toxicity on treatment in South Africa, to the much safer tenofovir. But, as one DoH official pointed out, tenofovir costs about 10 times more.

The South African government suggests it will be taking a more aggressive role.

“At the current medicine price regime and escalating private health costs, the provision of antiretroviral therapy will not be affordable,” said Deputy President Mbete. “As government, we will exploit various options to make medicine affordable, including through the amendment of the Patents Act and regulating the private health sector.”

In another talk, Dr Susan Cleary, a health economist at the University of Cape Town addressed these issues in considerable detail. She concluded that the scale-up could continue – but it will take careful planning.

Minister Hogan also noted this “The issue for all of us is how to spend the resources we do have with efficiency and increase the pot; with maximum public health benefit… so that the NSP and the TB Strategic Plan targets are met.”

This will require exceptional management skills – yet another reason to keep Minister Hogan in her post.

It would be a shame if the financial crisis holds back the progress that South Africa has been making. The general mood of the conference was pride in the scale-up and relief that state and society were now working together without reservations.

Perhaps more than anyone, the conference chair Professor Linda-Gail Bekker, of the Desmond Tutu HIV Foundation, voiced this optimism: “We have a national strategic plan that is both ambitious and comprehensive, we already have the biggest treatment programme in the world, which urgently needs extension and to be sustained. We have proven tools, interventions and strategies today that can make a dent in the joint HIV and TB epidemics in this region... We just need to roll up our sleeves collectively, turn on the scale-up and start to roll the numbers back.”

Noting that the conference is increasingly becoming regional (about a quarter of the delegates came from other countries), she said she hoped this progress would sweep from South Africa north up through the Southern African region. “It is high time to start pushing back the ‘red zone’ covering southern Africa on maps that indicate the high prevalence and incidence of AIDS and TB. Can we do it? Yes, we can.”

But the high point once again may have been the speech given by a young man with HIV, 16-year-old Luyanda Ngcobo, who gave the Nkosi Johnson Memorial Lecture — and provided a testimony of the difference that ART makes. Luyanda was born with HIV, but in stark contrast to Nkosi nine years ago, Luyanda is now healthy on ART. Well-spoken and witty, he enjoys playing video games with his friends, and says he just wants to be seen as a normal teen. His plans for the future? He wants to be an archaeologist.