AIDS Alert International: South Africa begins implementing ambitious HIV program 

Government-funded initiative faces great challenges on several fronts

With the waning of the publicity hoopla over international support for providing antiretrovirals to sub-Saharan Africa and other developing regions, the actual work of bringing antiretroviral medications to millions of people has begun, and experts say it shows both great promise and great challenges.

While the United States’ program is not yet available, American researchers and government officials in South Africa have begun to implement that nation’s ambitious roll-out of antiretrovirals for millions of HIV-infected citizens.

"It’s a national plan, but it’s in the hands of the provinces to make it happen," says Gerald Friedland, MD, director of the AIDS program at Yale New Haven (CT ) Hospital and a professor of medicine and epidemiology and public health at the Yale School of Medicine.

Slow process to set up infrastructure

Friedland is involved in research that integrates antiretroviral therapy into existing tuberculosis programs in South Africa, and he visited the country in May 2004.

"It’s moving very, very slowly, and it will take a long time for antiretrovirals to get to most if not all of those who will need them," he says.

"They’re trying to put together the appropriate infrastructure to do this, and there still isn’t a secure supply of drugs," Friedland explains.

Integration of treatment and prevention services will be one of the major challenges of the new program, says Salim Abdool Karim, MD, PhD, a professor at the University of Natal in South Africa.

"We have strong support to scale up treatment and prevention and are doing both," he says. "Treatment tends to be provided to individual patients attending government hospitals or private health care services, while prevention is at the nongovernmental level."

The key will be to get both groups to integrate strategies, Karim points out.

While the South African government decided to start the program less than a year ago, it began with the ambitious goal of putting a large number of people on antiretroviral therapy this year, he adds.

"It’s proven more difficult than originally planned," Karim notes. "We have complex government processes to procure drugs."

Entirely government-funded

The drugs will be commercial products, and there are details to work out about who will supply them, whether or not they are generic drugs, and this has led to a bottleneck with a lot of bureaucratic frustrations over what will happen, Friedland says.

The program is funded entirely by the government of South Africa with a little support from different organizations, he says.

"All potential sites for administration have been inspected to see if they meet certain standards for administering antiretrovirals, including expertise, pharmacy, monitoring for toxicity, etc.," Friedland explains.

"Four sites have been selected for the first sites for rollout, and those sites now are beginning to put on antiretrovirals," he says.

Patients who will receive drugs include those who have AIDS, as well as those who are asymptomatic but have CD4 cell counts of 200 or less, according to Friedland.

They’ll be given a first regimen of efavirenz, D4t, and 3TC, except for women of childbearing age, who will receive nevirapine, D4t, and 3TC, he says.

"They made a decision, which I think is the appropriate one, and picked the best regimen and made sure that will be available across the board," Friedland says. "This is provided through the government, and the government will provide the drugs for free."

All patients will attend several sessions on adherence to medication before they begin the antiretroviral therapy because public health officials recognize the need for education to improve patients’ treatment literacy, he adds.

"We didn’t do anything like that in the United States, so at least there’s attention to the issue of how to successfully take the medications," says Friedland.

Some South African patients already receive free antiretroviral treatment through grant-funded projects, including some of Friedland’s studies.

"Through these projects, some patients have received antiretrovirals for a couple of years," he says. "Now that the government’s rollout is happening, you actually can feel a change in attitude on the part of health care workers."

Hope begins to replace despair 

For instance, the despair that many health care workers had been experiencing as part of their work in treating AIDS patients is slowly being replaced with a positive attitude and hope, Friedland explains.

"We hope the availability of treatment will reduce some stigma and discrimination, too," he says. "But it’s too early to know that."

International researchers, including Friedland, have paved the way through research studies in identifying the most efficient ways to administer antiretroviral therapy.

Friedland’s research involves integrating antiretroviral therapy into existing tuberculosis programs that use direct observational therapy (DOT).

Patients who are coinfected, and an estimated two-thirds are, receive their TB drugs along with a once-daily antiretroviral regimen under observation by clinic staff, he explains.

"We are looking for an entry point to start antiretrovirals, and this is a very good entry point," Friedland notes. "There already is an infrastructure, and it’s better to strengthen it than to start from scratch."

For six months, TB/HIV coinfected patients will take drugs for both diseases, with the TB drugs given five days a week and the antiretrovirals being self-administered on Saturdays and Sundays, he says.

"When TB treatment is finished or as it’s approaching being completed, you transition patients to self-administration of antiretrovirals," he adds.

"You have a boost of experience in a structured environment that will extend beyond that, and demonstration projects have shown it is feasible to do that," Friedland explains.

The next step is for research to move this strategy to setting where more patients will be treated, he says.

"I’m hoping this will become one of the strategies used for South Africa’s rollout," Friedland says.

While challenges remain, the fact that South Africa has taken this big step is very positive, he notes.

"There’s an African proverb that says the best time to plant a tree is 20 years ago; the second best time is now," Friedland says. "It will take a while for this to be up and running, and there’s tremendous stress and strain in implementing it in a careful and expert way, and the expertise is not there yet — but it’s a major step forward."