Colwyn Poole. 1 and Rob Stewart. 2. March 2004. Funded by Henry J Kaiser Family Foundation. 1 Treatment Action Campaign/ GARPP. 2 Health Systems Trust ...
Public Sector HAART Projects - A Summary Report
Prepared by Colwyn Poole1 and Rob Stewart2 March 2004
Funded by Henry J Kaiser Family Foundation
1 2
Treatment Action Campaign/ GARPP Health Systems Trust
Background: The National Department of Health’s “Operational Plan for Comprehensive HIV and AIDS Care Management and Treatment for South Africa”, launched in November 2003, emphasises the provision of comprehensive care and treatment for people living with HIV/AIDS and the need to strengthen the national health system in South Africa. The plan aims to establish at least one service point in every health district (District or Metropolitan Council) in South Africa by the end of the first year of implementation, and to provide all South Africans and permanent residents who require care and treatment for HIV/AIDS equitable access to this programme in their municipality within five years. Over the remainder of the decade, services to an estimated 1.4 million people will have to be rolled out. i In September 2003 an audit of HAART projects was undertaken by the Generic Antiretroviral Procurement Project (GARRP). In February and March 2004, the HST’s Treatment Monitor undertook a rapid follow up study of these projects and identified new projects. For the purposes of the study, the public HAART projects were defined as public sector programmes if: The HAART project provides full subsidisation of HAART drug-costs and routine monitoring test to persons without medical aid and/or utilise existing public sector resources for the provision of a HAART. Projects therefore often incorporated sites assisted by MSF, academic and other institutions. Questionnaires were sent, per email to the principle investigators and/or project co-ordinators of all projects listed in the database. Additional contact was made with key stakeholders to encourage participation and to identify additional or new projects. Information was requested for the period ending 29 February 2004. The status of the project was defined as three discrete categories: • Current – projects providing persons with ARVs. • Prospective (funded) – projects with confirmed funding, but have not started providing persons with ARVs • Prospective (not funded) - projects without funding Findings: From about the year 2000, various ‘operational research’ projects, primarily investigating the integration of HAART with public sector services, were started at different levels of care within the public sector and in different provinces of South Africa.3 By October 2003, only 1 925 persons were accessing HAART through public sector facilities. The expansion of HAART provision to scale, following the initial work on operational research, was delayed by the absence of a national treatment plan. Between December 2002 and February 2004, the number of such projects increased from 16 to 39 and the number of persons on treatment from 596 to 3 759 within current HAART projects. The projects had the capacity to treat a maximum of 9 575 people with the 3
Projects included paediatric treatment programs at tertiary level, adult treatment programs at primary and tertiary levels. HAART Projects Database, February 2004.
existing resources available. Ten out of 39 (25.6%) of the projects are treating mainly HIV+ children. The number of people started on HAART per month in these projects had increased from 79 between November 2002 and April 2003, to 158 between May and July 2003, to 235 between August to September 2003 and finally to 322 between October 2003 and February 2004. This reflected a trend towards the establishment of new HAART projects in the public sector, more persons accessing treatment at these sites, reduced cost inputs to HAART provision4 and an improved policy environment for implementation nationally and internationally.5 These projects had 30.47 years cumulatively of HAART provision experience when the Operational Plan was published.
45
10 000
39 40 35
No. of people
12 000
8 000
30 27
6 000 4 000
22 17
19
25 20 15
No. of projects
Figure 1: Number of people on HAART, and number of people the current projects have capacity to treat with existing resources
Number on HAART Capacity to treat Number of Projects
10 2 000
5 0
0 Nov 02 Apr 03 Jul 03 Sep 03Feb 04
Location of HAART projects Provinces: The projects operate in 5 different provinces (Table 7). It is likely that this is an underestimate of current HAART projects, particularly if projects are located in the Northern Cape, Free State, North West, Limpopo or Mpumalanga.
4
Cost inputs that have experienced reductions during this period include ARV drug costs and monitoring packages (including CD4 Tcell counts, Viral Loads and adverse drug event monitoring). 5 These include the establishment of the Global Fund to fight AIDS, TB and Malaria, the WHO ‘3 by 5’ campaign, Pan African Treatment Access Movement and others.
Figure 2: Provincial distribution of HAART projects
Fig 2: Provincial distribution of HAART projects (Nov 2002 - Feb 2004) 18 Number of projects
16 14 12 10 8 6 4 2 0 Nov 02
Apr 03
Jul 03
Sep 03
Feb-04
Eastern Cape
Gauteng
KwaZulu-Natal
Mpumalanga
Western Cape
Multiple provinces
Rural and urban HAART projects: In February 2004, among the 39 treatment projects, 6 (15.4%) were located in rural health facilities, 15 (38.5%) in peri-urban township health facilities6 and 18 (46.2%) in urban health facilities. The number of rural-based HAART projects has doubled since September 2003. Location of projects by level of care: In February 2004, of the 39 projects, 14 were located at a primary, 10 at a secondary and 13 at a tertiary health care facility levels respectively. Eleven of the twelve projects that commenced between September 2003 and February 2004 were located at primary or secondary levels of care. Table 1: Distribution of HAART Projects by level of care
Primary Secondary Tertiary Inter-referral Total
Sep 2003 Feb 2004 Increase (%) 9 14 5 (67%) 4 10 6 (150%) 12 13 1 (8.3%) 2 2 27 39 12 (44%)
Although there is a great increase in the number of primary and secondary level of care sites for ARV roll-out projects, the bias is still urban / peri-urban (85% of projects). Also, the highest number
6
Three current projects operate in multiple sites. The HAART service points for these are mainly located in peri-urban township facilities.
of the projects, 17 (44%), are located in Western Cape, although it has one of the lowest prevalence levels (12.4%) of HIV in the country. The available data on people accessing ART programmes are not segregated into gender, race and socio-economic status, therefore it is not possible to comment on these equity aspects. ART and access to the continuum of care: All current projects provide or facilitate access to: community mobilisation, treatment and rights literacy, life orientation skills; VCT (stand-alone and incorporated into key recruiting services STI, TB, MCH, Family Planning); PMTCT; management of HIV-related illnesses; HAART; step-down care and palliative care, and social security (nutrition and income support). Selection criteria for ART enrolment: As of February 2004, all public HAART projects reviewed have medical criteria including clinical, immunological and/or virological selection criteria or combinations of these before recommending HIV-positive people to start HAART. In addition to medical criteria, certain projects include social, adherence and geographical criteria or combinations of these in their selection procedures. In addition all projects located at primary care level have social selection criteria and the majority has both adherence and geographical selection criteria.
Conclusion There has been an upsurge in the numbers of projects providing ART to a substantially increased number of people between September 2003 and February 2004. Given that there are more than 80 projects that have funding and are soon to become operational, South Africa is likely to see a mushrooming of antiretroviral treatment projects in the next few months. If combined with the treatment projects planned for the military and prisons and barring excessive political interference, the opportunities for treatment access are unprecedented and significantly increased coverage is a reality.
