Politics
DEMOCRATIC PARTY
POLICY ON HIV/AIDS
EXECUTIVE SUMMARY
South Africa has the fastest growing HIV/AIDS epidemic in the world and the second highest number of infections. AIDS experts say that the government's response has been so ineffective that our infection rate is as high as it would have been had it taken no action at all. This document analyses the government's failures and outlines the principles and practices which the DP believes should form the basis of a successful AIDS prevention and treatment programme.
1. Prevention
The ministry of health has vigorously established ownership of the AIDS
prevention campaign, but conspicuously failed to provide the leadership
and vision required. As a result, South Africa's AIDS prevention efforts
are fractured and disjointed. NGOs and the government are failing to co-ordinate
activities, resulting in gaps and duplications. We propose to take responsibility
for the campaign away from the department of health and place it in the
hands of a multi-sectoral National AIDS Commission. This commission will
be independent of government and its function will primarily be to devise
a national AIDS strategy and allocate funds to AIDS organisations in accordance
with this strategy. Priority focus areas for the commission will be: ·
Increasing knowledge about infection rates by improving procedures and
facilities for testing and counselling. · Motivating all government departments
to enhance and consolidate their anti-AIDS efforts. AIDS is too readily
regarded as only a health issue. · Overhauling the AIDS budget to direct
more resources towards NGOs. · Provoking more vigorous efforts from religious
groups, employers, trade unions and other groups well positioned to change
behaviour patterns. · Practical interventions to lower infection rates,
including ensuring a safe blood supply, an adequate condom supply, access
to preventative drugs, controlling STDs, and tackling tuberculosis.
2. Wellness management
A plan for keeping AIDS-infected people healthy for as long as possible
must address, firstly, the question of access to life-preserving drugs
and, secondly, the crisis around hospital care and the lack of adequate
facilities for AIDS patients. The government's efforts to make anti-AIDS
drugs more widely available have, in the words of Justice Edwin Cameron,
been guided by "the lure of misguided, quick-fix solutions". Instead of
seeking workable solutions to the problems of drug supply and hospital
care, the government identified allegedly exorbitant prices charged by
pharmaceuticals as the root of drug supply problems and devoted its energies
to reducing these prices. The Medicines and Related Substances Control
Amendment Act allows the government to circumvent international patent
laws to import drugs from other countries, and it waters down the independence
of the previously highly regarded Medicines Control Council - the body
which evaluates the quality of new drugs and approves them for use in
South Africa. Both of these provisions have severe implications for the
integrity of South Africa's drug regulation system and international trade
relations. But the underlying assumption - that South Africa's drug prices
are high - is doubtful. Evidence suggests that South African public sector
drug prices are already amongst the cheapest in the world. Furthermore,
for countries with poor populations and high infection rates, cost is
only one of many problems limiting access to anti-retrovirals. A policy
which aims to broaden access to drugs such as AZT must be accompanied
by specific measures to improve distribution systems and health care facilities,
and the government has failed to do this. The DP's approach to drug access
is based on three principles: · The safety of drugs must be guaranteed.
· South Africa must comply with international trade agreements. · The
principle of not killing the goose which lays the golden egg must be followed.
Within the framework of these principles, policy should focus on harnessing
international resources and expertise for South Africa's fight against
AIDS more effectively, through the development of a real partnerships
with research-based industry, with foreign governments, with drug importers
and with all other relevant bodies. Accompanying this there must be a
concerted effort to improve distribution systems within South Africa to
ensure that drugs actually reach the intended beneficiaries. The key to
this is the creation of greater autonomy for individual components of
the health system. Huge demands are being made on the health care system,
and hospitals are not coping with the flood of AIDS patients. There is
room for structural changes to the system to allow for greater efficiency.
The DP proposes, for example, that provincial health services be established
as independent statutory bodies, with maximum decentralisation and devolution
of authority and responsibility. This will allow for direct responsibility
and control. But this on its own will be inadequate, and alternatives
to hospital care must be found. Home care initiatives have been developed
to some degree of sophistication by some NGOs. Public-private partnerships
are required to strengthen and extend these efforts. A special effort
must also be made to provide support for the increasing number of AIDS
orphans. Current practices, largely based on institutionalisation, reach
very few. Children are becoming more dependent on community support structures,
and these must be strengthened so that they can cope. We propose to shift
most of the work currently done by social workers to community volunteers
so that social workers can focus on monitoring and support. Where community
support is not available, we believe that government should either operate
or provide support for child care committees in as many communities as
possible, which will identify vulnerable children and channel support
to them.
INTRODUCTION
What is HIV/AIDS?
The Human Immunodeficiency Virus (HIV) is a virus which attacks the body's immune system by entering and destroying the cells which control immune response. The body is gradually less and less able to defend itself against many infections or clear away certain cancer cells. A person is described as having AIDS when the immune deficiency caused by HIV is so severe that various life-threatening infections and/or cancers occur. The period between infection and manifestation of symptoms may last anything from a few months to many years. There are three main ways in which the virus is transmitted: · by sexual contact; · when infected blood is passed directly into the body; and · from an infected mother to her child during pregnancy, childbirth or breast-feeding. The AIDS emergency In excess of 33m people world-wide are estimated to be HIV-positive, and the number grows by 16 000 a day. Around 10% of these cases are in South Africa - we hold the record for the fastest growing AIDS epidemic in the world, and for having the second highest total number of infections after India (a country which has a population more than 40 times the size of South Africa's). Because of the lag between infection with HIV and the manifestation of symptoms, we have yet to feel the full force of the epidemic. But this does not mean that the implications are not measurable: this year, South Africa fell twelve positions from last year's position in the United Nations human development index update because of shortened life expectancy due to anticipated AIDS deaths. In western European countries, North America and Australia, AIDS has become a manageable condition. High awareness levels amongst the population are resulting in falling infection rates, and relatively easy access to drugs prolongs the lives of those already infected. But there is no room for complacency regarding AIDS prevention efforts in Africa, and particularly South Africa. Resource constraints and socio-economic factors pose a complex web of problems; problems which are themselves exacerbated by failure to reduce HIV/AIDS infection levels. World Bank president James Wolfensohn states that "confronting the AIDS epidemic in developing countries has become critical to all our efforts for poverty reduction, growth, and improved quality of life". South Africa's shameful record Three years ago, in November 1996, a headline in the Cape Argus proclaimed that "AIDS programme a shambles: 500 HIV infections a day". Three years on, South Africa's continuing failure to get to grips with the problem has resulted in a tripling of the daily infection rate. The response of the South African government to the AIDS pandemic continues to be dismal - to the extent that AIDS experts say infection rates have reached the same levels as they would have had there been no intervention at all. The ministry of health has vigorously established its ownership of the battle against AIDS. There have been several Government initiatives, including and the "Beyond Awareness Campaign" in 1997, the establishment of an Inter-ministerial Committee on AIDS in 1998 and the most recent campaign - "Partnership against AIDS" - in October 1998. But policies and public pronouncements have not been matched by actions of any real effectiveness. The government's official AIDS policy is generally acknowledged to be good, but its implementation has been severely deficient. The ministry has not given AIDS the attention, commitment and funding it requires. At the same time, its refusal to allow other bodies to take on greater responsibility has denied funding and resources to those organisations which do have the necessary commitment. There is no plainer evidence of former health minister Dr Nkosazana Zuma's unwillingness to prioritise AIDS than her inexplicable approach to offers of help from elsewhere. In one of her final acts as minister, she stopped a $100m (R600m) donation from pharmaceutical company Bristol-Myers-Squibb for fighting AIDS in the Southern African countries, on the grounds that she "would not be dictated to by any private organisation". This was not the first time she had rejected offers of foreign assistance on grounds which appear to have had more to do with conceit and complacency than pragmatism. The unwillingness to take responsibility for AIDS has been accompanied by an energetic counter-attack mechanism when this lack of action is criticised. "There's an idea that if you disagree with the government, you are betraying the liberation struggle", says Mary Crewe, director of the Centre for the Study of AIDS at Pretoria University. The department is taking the Pan-Africanist Congress's health spokesperson to court for criticising the government's refusal to grant AZT to pregnant mothers. Dr Zuma's habitual response to the DP's queries on the AIDS campaign was to level accusations of racism against the party. New health minister Manto Tshabalala-Msimang promised us a fresh approach when she took over the reins of the health department after the post-election Cabinet reshuffle. But her defence of President Mbeki and his bizzare championing of long-discredited and scientifically disproven theories on the toxicity of AZT does not suggest a fresh approach. It suggests rather that there is a long way to go before this government will be willing to move from confronting its critics to confronting the disease.
TAKING IT FROM HERE
Success stories
It is not only South Africa that has battled to come to grips with AIDS: universally, it has proved to be a difficult issue to address. Denial, resistance to condom use, women's powerlessness to negotiate sexual relationships, cultural and religious barriers, and many other factors present major obstacles. Unlike housing, job creation, or health care, safer sex is not a popular political platform. But it has been done. World-wide examples show that HIV infection rates have been stabilised, and even lowered, in places where focused and sustained prevention programmes have been implemented. Uganda has provided the most notable examples of anti-AIDS strategies which do work. In ten years, condom use has gone up from 12% to 42%. A decline in ante-natal infections has been reported in ante-natal clinics around the country. Although the overall infection rate in Uganda is still high, the decrease in HIV-prevalence has been significant. In the Nsambaya district, the infection rate has dropped from 24,5% to 13,4% of pregnant women, while nationally the age of sexual debut has risen from 14 to 16 . Thailand has also produced comprehensive evidence that prevention works. Annual surveys in young men showed both large drops in risk behaviour and lower HIV infection levels. Between 1991 and 1995, visits to sex workers were cut from 28% to 15%; and those who reported not using a condom on the last visit dropped from nearly 40% in 1991 to slightly over 5% in 1995. HIV prevalence amongst this group has gone down as a result - from 8% in 1992 to less than 3% in 1997 . The first signs of a turnaround are also being seen in Tanzania in areas with active prevention programmes. In these specific areas, prevalence in young women fell by 60% over a period of six years . The message is that the obstacles, although daunting, are not insurmountable. They are being overcome by countries with vastly lower resource and skills levels than South Africa, and evidence of strategies that work is readily available. With the application of sufficient political will and judicious use of skills and resources, it is within this country's capabilities to radically slow the epidemic.
What must be done?
A successful AIDS policy must accomplish three objectives:
At each level, the need will be far greater than the resources available, necessitating hard decisions about allocations and priorities. But tough choices can be mitigated by policies which maximise the use of available resources by using them efficiently and productively.
1. Prevention
A failure of leadership
The failure of South Africa's AIDS efforts can largely be attributed to the absolute lack of constructive leadership on the part of the Government. After many years of government neglect, the campaign is conducted by a coalition of forces consisting of service organisations, grassroots movements, representatives of unions, of business, of churches, and of the government. It comprises a myriad of efforts by organisations and individuals working largely on their own. Many of these efforts are highly valuable, but there is no cohesive strategy or effective leadership to sustain them and build on them. The Aids Advisory Group, appointed to provide such leadership, was summarily fired during Dr Zuma's tenure, despite the fact that they were widely believed to be the best group of AIDS advisors available in the country. The campaign is fractured, under-resourced and disjointed. A recurring refrain of the Medical Research Council's National AIDS Review - undertaken in mid-1997 at the behest of Dr Zuma - was that NGOs and the government were failing to co-ordinate activities, resulting in gaps and duplications. South Africa's government has conspicuously failed to take on any leadership role. High profile failures - Virodene and Sarafina II spring to mind - suggest that decision-making takes place in a vacuum. Redefining responsibilities AIDS prevention is too monumental a task for government on its own; the disease poses a complex challenge, with many psychological, social, ethical, economic, and political dimensions that transcend the usual focus of healthcare. It requires a co-ordinated and coherent effort, making maximum use of the work and creativity of everyone involved. But a recognition that AIDS is too big for government alone does not mean, as Mary Crewe states, that the Government has no role. "Someone must take responsibility, someone must give leadership, someone must drive it." Responsibility for managing the campaign must be vested in a body which has the capacity and capability to manage and direct the process. Currently, this responsibility lies with the department of health. But, whether through inertia or unwillingness to address sensitive issues forcefully, the anti-AIDS campaign has fallen far short of expectations. There is no practical reason why AIDS prevention should fall under the department of health. While treatment of people living with AIDS is clearly a health issue, AIDS prevention requires a wider response and the involvement of every component of government and civil society, including schools, the media, churches, businesses of all kinds, welfare services and the justice system. The DP believes that direct responsibility for running a prevention campaign needs to be taken out of the hands of the department and placed in the hands of a body which has the commitment, the flexibility and the authority to manage it successfully.
A National AIDS Commission
The DP proposes the establishment of an AIDS Commission, set up in terms
of an Act of Parliament, which will be directly responsible for managing
a strategy and channelling funds, and which will operate as a consultative
body. The commission will be independent of the department of health,
but it will supplant and probably take on many of the resources and staff
from the current AIDS Directorate. Additional funding could be obtained
from the closure of the National Youth Commission. The AIDS Commission
will have control over the current budget for prevention measures, and
it will also act as a vehicle for the channelling of funds from other
sources in accordance with its objectives. It's tasks will be the determination
of a national strategy for AIDS prevention, the determination of priorities
within this strategy and the allocation of funding for prevention and
education initiatives in accordance with these priorities. There are large
inflows of money into South Africa from foreign governments and local
and foreign aid organisations going towards AIDS prevention. But donors
are not always sure that their money is going to legitimate or appropriate
causes, and it is difficult for foreign donors to establish the value
of their choice. The commission would operate as a channel through which
aid money could flow to causes which donors could be sure were legitimate
(it would not in any way prevent NGOs from raising funds individually).
It would also be a channel for government allocations to the private sector.
In the words of Peter Piot, executive director of the Joint United Nations
Programme on HIV/AIDS, the kind of leadership required involves "informing,
advocating, even provoking. Building consensus, re-orientating priorities
and approaches, forging partnerships, leveraging new resources, re-engineering
bureaucracy. Supporting those in the front line of the epidemic, helping
them learn from their own successes and failures and those of others"
.
The commission would be funded by a government allocation, so no donor
money would support it. It would also be obliged to be fully transparent
about decisions. The commission must be headed by a person of the necessary
moral authority, experience in the field and intellectual capacity to
take on this role. In Uganda, retired Anglican Bishop Misaeri Kauma was
appointed to head their commission. There are a number of people in South
Africa of equivalent stature, and with a close involvement in AIDS prevention,
who could to take on such a role. The committee would be obliged to have
a member with sufficient knowledge of financial matters to cope with heavy
financial management demands. Membership must be closely defined in order
to ensure wide representation and prevent government domination. Of crucial
importance is that the legislation lays out terms which will create a
broadly representative body. It must not simply become an alternative
venue for the same health department officials who are currently in charge
of the government's failed efforts.
Doing a few things well
The DP has drawn up guidelines which we believe should form the basis of
actions taken by the commission and by public officials - the establishment
of a commission in no way absolves government at all levels from an active
role in AIDS prevention. The influence of the AIDS epidemic over so many
components of society and so many aspects of public policy raises the danger
that activists and policy-makers will try to do too much, and do none of
it well. It is crucial that the most viable options be identified and prioritised,
taking into account both the need and the implementation costs.
The DP believes that the priorities for the national anti-AIDS campaign
should be the following:
Before an effective anti-AIDS campaign can be implemented, there must
be adequate knowledge of infection rates. In order to generate this
knowledge, a much greater effort to improve testing and counselling
is essential. These two aspects go hand in hand - without adequate support
systems, the cycle of denial and unwillingness to be tested continues.
Counselling facilities in South Africa are inadequate: only 56% of clinics
nation-wide have sufficient facilities and staff to provide AIDS counselling
. The department of health must take responsibility for training enough
counsellors so that all clinics at least have some access to their services.
The focus of the department must be on ensuring that every clinic and
hospital has at least one trained counsellor. If this cannot happen
immediately, a plan for the progressive realisation of this goal must
be implemented. At the same time, the department must be more proactive
about providing support structures; burn-out rates are high, and the
pressures and stresses are resulting in a reluctance to enter the profession.
There are huge differences in the way that AIDS develops in different
countries, and even in different regions, which means that focused prevention
programmes depend on detailed information about how the disease is spreading
. South Africa's lack of reliable information in this regard is hampering
our prevention efforts. The country has no country-wide population-based
data from which the size and shape of the HIV epidemic can be mapped
out reliably. With a few exceptions, the only available national statistics
are extrapolations from surveys conducted on women attending ante-natal
clinics. But these women do not represent a cross-section of the South
African population at large. The result is that key policy decisions
are largely made on the basis of assumptions and guesses. The government's
first attempt to improve this situation was to publish, in April 1999,
regulations making AIDS a notifiable disease. The regulations encompass
both anonymous vertical notification (a health care worker notifies
the department of an infection, but not of the name of the person) and
named horizontal notification (health care workers must inform family
and care-givers of the patient's status). The department argues that
notifiability will generate more detailed and accurate information,
which in turn will allow for better prevention techniques. It also argues
that horizontal notification will help to protect family and care-givers
of people with AIDS from infection. However, although notifiability
is of clear benefit on medical grounds, there is a large body of evidence
to suggest that it does not in practice achieve the theoretical objectives:
*Past experience in making tuberculosis and malaria notifiable has shown
that patients tend to hide their health status when they are compelled
to report it. Several countries which have implemented notification
measures have reversed them after finding that they simply drove the
epidemic underground.
South Africa's poor medical infrastructure will affect the reliability
of statistics. In areas with poor medical facilities, AIDS is often
incorrectly identified as TB or one of a variety of other diseases.
Furthermore, vertical notification requires universally available testing
facilities - which is lacking in South Africa.
Non-disclosure of names may lead to multiple notifications. Finally,
given the stigma attached to HIV/AIDS, notification poses a threat to
the freedom, security and even life of infected persons.
Given the pitfalls associated with notifiability, the DP will not support
this step until a proper infrastructure is in place and the population
is more tolerant of people living with AIDS. Responsibility for notification
of sex partners should lie with the individual, and confidentiality
should remain intact between doctor and patient. Where a patient's behaviour
puts others at risk, intervention should take the form of counselling
within a therapeutic situation. This does not mean that no action should
be taken towards developing a more reliable information base. Alternative
surveillance mechanisms exist which do not have the negative consequences
of notification: Sentinel testing, where detailed clinical and questionnaire
research is undertaken in particular communities, is already undertaken
in a few parts of the country. Where statistical gaps need to be filled,
it would be relatively cheap and easy to extend the system and set up
further sentinel sites.
* Incentives are likely to have a higher success rate than unenforceable
regulations. Consideration must be given to developing such incentives.
· Sex workers are highly vulnerable to AIDS infection, but very little
information is available on the pattern of the disease in this group.
The emphasis should move from prosecution to the development of plan
for the proper regulation and monitoring of this sector as part of the
overall plan to improve information. The DP calls for a recognised body
like the MRC to look at a system of national surveillance protocol which
is both legal and ethical, and which gives accurate statistics about
the prevalence, incidence and demographics of HIV/AIDS in South Africa.
Commitment from the
top
The value of commitment from the top levels of government is one of the
most important lessons to be learnt from Uganda. President Yoweri Museveni
has made an unambiguous commitment to making AIDS his government's number
one priority. No minister or public servant is allowed to make a speech
without mentioning AIDS. President Museveni frequently visits rural areas
personally to speak about the disease and its effects. No opportunity
is lost to underscore the importance of AIDS awareness. In contrast, neither
former President Mandela, nor President Mbeki have been willing to unhesitatingly
throw their weight behind the cause. Nor have the majority of other ministers
adopted the campaign with any sincerity or conviction. When President
Mbeki launched the Partnership Against AIDS campaign he declared: "HIV
is no longer the responsibility of only the health ministry - everyone,
in every government department, has to get involved ." But there has been
scant evidence of real determination to extend the scope of the campaign
beyond the health department. The most recent demonstration of the lack
of real inter-ministerial involvement was the record of attendance at
the International Conference on AIDS and STDs in Africa, held in Zambia
in October 1999: although invitations were extended to all African Heads
of State, South Africa was amongst the overwhelming majority of countries
which sent only a health minister to attend proceedings. At the very least,
the ministers of finance, education and welfare should also have been
present. One of duties of the commission should be to motivate ministers
to consolidate and enhance their efforts. This would necessitate, firstly,
demanding a progress report and plan of action from each ministry. This
must specify exactly how and where AIDS will impact on its functions,
what action has been taken and is to be taken and what budget has been
allocated for this action. These plans must be available for public scrutiny
and the commission must hold ministers accountable. Some ministers will
not need much prompting. The Department of Transport, for example, recently
announced a policy for publicising AIDS prevention on trains. But most
have not yet begun to think about the implications of AIDS on their functions,
and their role in prevention. The department of correctional services,
could have taken a leaf out of the transport department's book. Despite
a high incidence of sexual activity prisons, the Medical Research Council's
National AIDS Review reported that only seven out of 7 000 Pollsmoor prisoners
were receiving condoms. The department of education has a particularly
important role to play. Children of school-going age are a crucial target
group. Unless a heavy investment is made in educating the youth about
AIDS, there is no hope of containing the epidemic. Sex education in schools
is not popular amongst many parents, and AIDS education at school will
be controversial. But it cannot be avoided. The Department of Education
must urgently involve itself in ensuring that a proper plan for the integration
of AIDS education into the syllabus is implemented. Furthermore, it must
not simply delegate responsibility to teachers, who frequently lack the
skills to deal adequately with this sensitive subject. The plan must be
implemented by experts in the field. The same effort must be demanded
of provincial level MECs and of local councils. The Gauteng legislature
has recently launched a campaign aimed at involving all portfolios. Each
department has determined what its contribution should be, based on core
business, service provision, prevention and impact . This has allowed
the development of a multi-pronged anti-AIDS effort which could be used
as an example by many other provinces.
Make space for NGOs
In countries where AIDS campaigns have succeeded, the success has had
much to do with the role played by institutions of civil society and particularly
NGOs. It is not hard to see why. NGOs tend to be strongly rooted in the
communities from which their members come. This means that they are close
to their audience and are likely to be well endowed with local knowledge
and experience. They tend, therefore, to have the kind of access to communities
that government officials rarely have. Furthermore, they are often small
and not bureaucratically structured, which means that they can be more
innovative and flexible in their responses and diverse in their programs.
South Africa has a rich heritage of many thousands of NGOs- more than
660 of which are involved in AIDS, in many different ways. The National
AIDS Review concluded that "one thing that has come out strongly is that
NGOs are really reaching into communities and are able to deliver services
far more effectively than government" . An important role for the commission
will be an overhaul of the AIDS budget with this in mind: resources for
prevention measures must be directed away from government efforts and
towards the efforts of NGOs. The sole responsibility of the health department
in terms of prevention will be the tasks already identified. At the same
time, the commission will develop guidelines to ensure that funding is
allocated to NGOs which have the capacity to meet their commitments.
Getting the media on
board
Until recently in Uganda, there were AIDS jingles before and after all
news broadcasts. Added to this, messages would be played two or three
times a day on all stations. These messages include anything from visuals
showing the state of people living with the disease to people speaking
on safe sex. The commission must concern itself with involving all the
various broadcasting media on a far greater scale than has been the case
until now. We have a public broadcaster - we must use it. The SABC must
be persuaded to donate free advertising time to this cause. We must use
SABC TV and radio to advertise the threat that AIDS poses to every citizen.
Private radio and TV stations not already involved in AIDS prevention
initiatives should be more fully exploited; they must also be convinced
of the need to allocate some of their air time to the campaign. Much more
effective use could be made of community radio stations - they reach right
into the heart of the communities most at risk.
Role models
Part of the commission's tasks should be the development of a network
of role models who would make a significant contribution to removing the
stigma of AIDS and making it a publicly visible and openly discussed issue.
Role models play a vitally important role in shifting behaviour patterns.
Ugandan citizen Millie Katana reports that only after seeing a prominent
Ugandan, Major Rubaramira Ruranga, disclosing his HIV status on television
did she disclose her own infection to her family. It is thanks to people
like him that the stigma of people living with AIDS is no longer so prevalent
in Uganda. The active role played by basket-ball player Magic Johnson
in the United States has worked in the same way. The Government Communication
and Information Service reported earlier this year that "more than 20"
prominent South Africans had volunteered to be AIDS ambassadors. But these
ambassadors are never seen, and twenty is far too few, anyway. Role models
from every sector of society, and in particular sports and entertainment,
must be out preaching the message through as many different media as possible.
Religious groups
Religious institutions have the capacity to play a major role in strengthening
capacities for community-based prevention and care programmes. Religious
leaders can have great influence in preventing discrimination against
HIV-positive persons in their communities. In addition, much can be done
by religious institutions to strengthen life-skills training approaches
to HIV/AIDS in schools operated by their congregations. The Catholic church
in Argentina has taken on a major role in information and prevention of
HIV through its parishes, educational institutions and a powerful communications
network. It has also sought alliances with the business community . We
therefore welcome the initiative taken by representatives of several religious
denominations in September 1999 to assess the progress of faith-based
organisations to address HIV/AIDS, and to conduct a nine day campaign
to raise the issue in sermons. Initiatives such as these must be actively
encouraged.
The workplace
The direct implications of AIDS for businesses are enormous. It is estimated
that even if only 10% of South Africa's HIV-positive inhabitants are treated
next year, the cost could come to R5bn. Apart from the spending on health
care, a similar amount might be forfeited indirectly through productivity
losses, reduced buying power, the costs of retraining and absenteeism
. HIV and AIDS are still too broadly regarded by businesses as someone
else's problem", says political analyst Willie Esterhuyse . The founder
of the AIDS in the Workplace consultancy, Juan Kirsten, says that companies
appeared to treat the disease as "purely a human resources issue", thus
neglecting the potentially devastating effect on markets and productivity.
Few companies, he said, knew how to develop an education programme or
monitor its success . On the other hand, some companies have thought ahead
and do have policies and programmes in place. For example, in November
1998 Eskom was one of five companies world-wide to be presented with an
award by the Global Business Council on HIV/AIDS for its initiatives in
the field of AIDS education . Aggressive management of this issue is crucial:
businesses must become fully aware of the implications of AIDS and their
responsibilities towards their employees. A unified private-public initiative
would make it easier for government, through the commission, to proactively
support private-sector initiatives such as these and encourage business
that do not have such initiatives to develop their own. Nedlac, as the
most significant body representing the interests of "the golden triangle"
- business, labour and the government - has a role to play in developing
guidelines for industry regarding human rights issues on HIV/AIDS. These
guidelines should aim to achieve a balance in protecting the rights of
all parties, including those with and without HIV, employers, employees,
state and others. This will include obtaining a balance between rights
and responsibilities, and between individual protection and co-operation
between parties.
Non-discrimination
The DP does not believe that people suffering from HIV/AIDS should be
discriminated against in any way in the workplace. We would actively encourage
all companies to have a policy addressing specific issues around discrimination
and wellness management. In cases where the disease has progressed to
the point where the person is no longer able to work, the workplace procedures
applying in that particular work environment regarding incapacitating
conditions should apply equally to AIDS-infected employees.
Trade Unions
Trade unions have been remarkably silent about AIDS, although they are
ideally positioned to access a crucial target market. Their voice carries
much weight in a sector of the population which is heavily affected by
AIDS, and they have structures in place which make access to their audience
very easy. Up until now they have been getting off lightly: their failure
to respond has not been challenged. Trade union leadership must be called
upon to deepen their role and take some responsibility for spreading the
message on AIDS.
Regional and inter-regional
co-operation
HIV transmission is largely unaffected by national boundaries. South Africa's
porous borders mean that we are greatly affected by the status of the
epidemic in neighbouring countries, and likewise our neighbours feel the
consequences of South Africa's exploding epidemic. This necessitates the
strengthening of multilateral ties, specifically focusing on AIDS. The
SADC Employment and Labour Sector has established a code on industrial
relations standards on HIV/AIDS to enhance co-operation and establish
uniform standards in this regard. But there are many other elements to
inter-regional co-operation on AIDS that demand attention even more urgently.
One such area, for example, concerns national immigration laws and policies
and related administrative procedures. The Foreign Affairs Department,
in conjunction with their counterparts in other SADC countries, must ensure
that SADC member states develop common national codes on all matters relating
to HIV/AIDS that jointly affect them.
2.PRACTICAL INTERVENTIONS
Raising the consciousness of the population and bringing about behaviour
changes is not on its own sufficient. An important component of prevention
measures is practical interventions which minimise the risk of infection
amongst risk groups.
A safe blood supply
In this regard, South Africa has been relatively successful and from early
on in the epidemic, blood supplies have been routinely tested for the
presence of HIV. The government must strive to ensure that control of
blood supplies is rigorous and consistent.
An adequate condom supply
Policy should focus on making condoms everyday items, routinely and freely
available in shops, public buildings and all public places. Anecdotal
evidence points to an adequate supply of condoms. But the example of the
government-issue stapled-through condoms earlier this year points to an
absence of know-how, even on the part of government officials. This must
be addressed through publicity campaigns.
Preventative drugs
Two drugs (AZT and 3TC) administered during birth and for one week after
can reduce the present risk of mother-to-child transmission of HIV by
between 37 and 50%. This means saving approximately 30 000 children from
HIV infection every year . A new drug, Nevirapine, has shown promise as
a drug which is even more effective. The benefits of giving these drugs
to rape survivors is less clear, but many doctors work on the presumption
that they do minimise risk and the DP supports this. The DP accepts that
South Africa cannot afford AZT for all infected citizens. But a one month
supply to pregnant mothers is cheap and will save many lives. In addition,
the government owes it to rape survivors to do everything that it can
to protect them from further harm. There must be no compromise in providing
AZT, or an acceptable alternative, to these two categories. Active steps
must be taken to ensure that AZT is available in all public and private
hospitals. Rape survivors must also be informed of the real risk of being
infected with HIV as a result of rape, and they must be specifically informed
that drugs are available.
Tuberculosis
Tuberculosis has long been recognised as the major opportunistic infection
in sub-Saharan Africa. It is therefore important to integrate AIDS and
TB programmes, as happens elsewhere in Africa. TB treatment centres can
be utilised as counselling and testing facilities because of the close
interaction between the two epidemics.
Controlling STDs
The transmission rate of HIV between healthy adults is less than one percent.
But the presence of other sexually transmitted diseases dramatically increases
the chance of infection. For example, AIDS transmission increases to 5%
if one partner has a discharge associated with gonorrhoea, chlamydia or
trichomoniasis. If both partners have such a discharge, this increases
by another factor of five to 25%. With multiple STD infections, the transmission
rate might rise to well over 50%. The prevalence of STDs in South Africa
is contributing hugely to the spread of AIDS. Studies show that 30% of
adults in urban communities are infected with an STD . Between three and
four million episodes of STDs occur annually in South Africa, and more
than one in ten adults are infected with at least one STD a year. In approximately
half these cases there are no visible symptoms, so no treatment is sought
. Aggressive educational programmes focusing on sexually transmitted diseases
must be an integral part of the AIDS campaign. Symptoms are recognisable
and curable, which makes behaviour change in response to awareness-raising
much more feasible. STD treatment should be aggressive and pro-active,
particularly with high-risk groups such as sex workers, migrant workers
and truck drivers. This means ensuring that patients with an STD who seek
care are treated correctly, the first time. It is estimated that only
about a quarter of patients with STD infections receive the correct drugs
. It also involves informing communities through mass media campaigns
that STDs are treatable at a clinic or a doctor, that partners should
be treated too, and that condoms can prevent infections.
3.WELLNESS MANAGEMENT
More than 3.5 million
South Africans already infected with HIV/AIDS, and the number increases
by 1500 a day. This means that many are already in need of medical care
and many millions more will need care in the coming years. Even with more
strenuous prevention efforts, until a vaccine or a cure becomes available,
AIDS will be with us.
It is essential, therefore, that an AIDS policy incorporate a plan for
keeping AIDS-infected people healthy for as long as possible. This requires,
firstly, developing a policy on access to life-preserving drugs and, secondly,
resolving the crisis around hospital care and the lack of adequate facilities
for AIDS patients.
Drug access options
Two broad alternatives exist regarding drug treatment. Antiretrovirals
delay or prevent the development of opportunistic infections. Alternatively
or in addition, a variety of treatments are available for opportunistic
infections which are the direct cause of death in AIDS-infected patients.
Many permutations of the two alternatives appear around the world. Brazil
provides free antiretroviral drugs to all people living with AIDS, financed
by a huge World Bank loan. But most other underdeveloped countries tend
to rely on treating opportunistic infections. In European and North American
countries, a triple drug cocktail of antiretroviral drugs has largely
transformed AIDS from a terminal disease into a chronic, manageable condition.
The need to treat opportunistic infections has fallen away dramatically
and people living with AIDS are able to live virtually normal lives.
The provision of antiretroviral drugs on a wide scale is, in the absence
of a cure, the most effective way of holding back illness and death. But
for poor countries with high infection rates, comprehensive coverage poses
problems: it is far from the simple solution that at first glance it appears
to be. The development of new medicines is complex and expensive, and
largely in the hands of private sector corporations which must make profits
to survive. Although basic AIDS drugs like AZT are available far more
cheaply in South Africa than in Europe and America, the cost is still
out of reach of most infected people. In 1996, it was estimated that using
a combination of three AIDS drugs to treat all those infected in sub-Saharan
Africa who required help would cost between R612bn and 969bn . Moreover,
antiretrovirals do not cure AIDS, they simply delay its progression. So
they are needed throughout the life-span of an HIV-infected person. If
insufficient attention is given to prevention programmes, the number of
infected patients - and therefore the demand for antiretrovirals - will
be continuously increasing. But cost is not the only problem. Even at
substantially reduced costs, most countries with high infection rates
would not obtain optimal benefit because of the lack of basic medical
care and poor infrastructure . AIDS expert Mark Heywood argues that governments
of underdeveloped countries often try to shift responsibility onto pharmaceuticals
by citing high costs, without acknowledging that "social conditions make
compliance with complicated regimen almost impossible in countries where
most people with HIV/AIDS cannot read, do not have enough to eat, nearby
clinics or even clean water" .
Distribution is also a problem. The World Bank estimates that only $12
worth of drugs out of every $100 allocated to Africa actually reaches
the patient . The remainder is lost through bureaucracy, poor planning,
inefficient distribution, theft or corruption.
The drugs crisis in
South Africa
The South African government's response has been, in the words of Justice
Edwin Cameron, an attraction to "the lure of misguided, `quick fix' solutions"
. Wide-spread ridicule was evoked by the disastrous Virodene affair. Of
more long term significance has been the conviction that drug manufacturers
must be compelled to supply drugs more cheaply before South Africa will
supply them to its infected citizens. ANC spokespersons, and former health
minister Dr Zuma in particular, have argued that prices in South Africa
are "exorbitant" and medicines are supplied on an "irrational" basis .
In the words of former Presidential spokesperson Ronnie Mamoepa, "The
problem lies not with the government but with the exorbitant prices companies
charge for the drug. …The onus is on [the pharmaceuticals]" to provide
drugs at a cost the government is prepared to accept" . Flowing from this
perspective has been a policy directed at circumventing established means
of accessing drugs. To this end, the Medicines and Related Substances
Control Amendment Act was piloted through Parliament in 1997. The act
has two major implications:
* Legalisation of parallel importation of medicines and compulsory licensing.
* A radical restructuring of the Medicines Control Council. Parallel imports
and compulsory licensing. The parallel importation provision will allow
the South African government to circumvent patent laws where a drug is
being manufactured more cheaply elsewhere in the world by buying these
drugs rather than the South African-manufactured equivalent. Compulsory
licensing will compel drug manufacturers to licence, under certain circumstances,
drugs which have not been manufactured by a holder of the patent for that
drug. There is a continuing uncertainty as to whether these provisions
contravene South Africa's obligations in terms of various international
trade agreements, and particularly the Trade-related Aspects of Intellectual
Property (Tripps) agreement. These have held up the implementation of
the Act since it was passed in October 1997. A court case brought against
the department by several pharmaceutical companies was suspended in September
1999, pending a review of the legislation by the new minister of health.
Shortly afterwards, an agreement was reached between South Africa and
the United States government, whereby the US government would effectively
turn a blind eye to the provisions. However, this agreement is not final;
objections may well resurface if South Africa should try to implement
the more controversial provisions.
Despite the enormous
energy which went into propelling this act through Parliament, its underlying
assumption - that South Africa's drug prices are the highest in the world
- remains in doubt. While there is unquestionably a significant problem
with private sector drug prices in terms of world averages, evidence suggests
that South African public sector drug prices are comparatively low. The
government buys drugs at heavily discounted prices through the state tender
system.
* A month's supply
of AZT costs R400 in South Africa, in contrast to $400 (R2400) in the
United States.
* Triple therapy for a single patients costs between R24 000 and R36 000
in South Africa; far lower than the World Health Organisation's estimate
of $15 000 (R91 500) a year . ANC speakers during the Parliamentary debate
on the Act rather disingenuously cited a number of studies conducted in
the past as evidence of high drug costs - failing to mention that the
studies dealt exclusively with private sector drug costs. Furthermore,
the Public Protector concluded, in a November 1997 report on Dr Zuma's
claim that drug prices in South Africa were amongst the highest in the
world, that the minister had made "grossly exaggerated and misleading
claims" .
The Medicines Control
Council
There is an enormous world-wide problem with illegal drug trading, and
rigorous controls are essential to avoid putting lives at risk. In South
Africa, this control function is carried out by the Medicines Control
Council (MCC). The council is a body of medical experts, operating as
an autonomous and independent body, which tests new drugs to ensure that
they maintain a consistently high quality. The MCC was highly regarded
internationally. It was officially appointed by the World Health Organisation
as a model drug regulatory authority for training purposes. Many of its
members have participated in international meetings for the development
of policy world-wide. Its reputation as one of the ten top such control
bodies to be found anywhere in the world was at no time during the debate
on the Act disputed by any party. The Act waters down the requirements
for membership of the council, and at the same time greatly increases
ministerial control.
The DP's vision
A cheap, ample drug supply
The DP fully supports
efforts to provide cheaper drugs. But certain caveats must apply: ·
While the health ministry has preoccupied itself with the pharmaceuticals,
it has largely ignored far more significant problems: the poor drug distribution
systems in the public health system, the declining state of public health
care facilities, poor communication, staff demotivation and the inability
of the public health system to cope with large inflows of AIDS patients.
While Dr Zuma has been employing her own energies and those of many others
in a Don Quixote-like battle against pharmaceuticals, the real battles
have been evaded. The energy and resources devoted to this Act could better
have been devoted to more constructive prevention efforts or more constructive
engagement with pharmaceuticals.
Get the MCC back on
track
The DP has deep concerns about the status accorded to the Medicines Control
Council in terms of this Act. The minister will be given a tight rein
over both the composition of the board and its activities, all of which
increases ministerial control and waters down the effectiveness of the
council. The combined effect of these various measures is that the assurance
that the MCC was previously able to give that the quality, safety and
effectiveness of medicines were the only grounds for consideration is
likely to be subject to doubt. Indeed, although the Act granting these
powers has not yet been passed, the enslavement of the MCC has already
begun. Dr Zuma replaced MCC chairperson Peter Folb by Dr Helen Reese in
1997 in what was widely regarded as a fit of pique at the board's failure
to approve the industrial solvent, Virodene. In the words of SAMJ editor
Dr Daniel Ncayiyana, "The timing and the abruptness of the decision to
abolish the MCC conveys the impression of a desperate and vindictive ministry
bent on showing the MCC and the world who is boss" . During Parliamentary
hearings on the Act, Dr Folb highlighted the dangers inherent in watering
down the independence of the board: I have seen the end of the tunnel
that has been described in this draft bill and it is dark. It is a third
world trap. …It does not make any sense to undermine international confidence
in our medicines control with legislation that will take us to the bottom
of the pile. The minister and her department are advised not to arrogate
to themselves control over medicines…. Powers will, in terms of the draft
bill, be devolved to ministerial advisers who cannot match the collective
expertise of an independent body, comprising the best available persons
in the country able to do such work…We demand such a high standard because
for medicines there can be no other way . Control of medicines must be
in safe, independent and incorruptible hands. The MCC must be independent
of the state; particularly in South Africa, where the state purchases
80% of all medicines manufactured in the country. It must also be independent
of all other groups with vested interests. Most importantly, this body
must enforce rigorous quality controls. We propose that the Medicines
and Related Substances Control Amendment Act of 1997 be scrapped to allow
a return to the legislative environment which previously supported such
a body. The South African Medicines and Medical Devices Regulatory Authority
Act, which supports the Medicines Control Act, has been temporarily withdrawn.
When it is reintroduced, we must ensure that it does not tamper in any
way with the strict control of medicines in this country.
Harnessing resources
No other individual or body, or even government, has anywhere close to
the combined resources, expertise and finances of the pharmaceutical companies.
These resources are needed, but unless they are harnessed constructively
they will not last. Pharmaceutical companies have no more or less of an
obligation to do what they can to fight AIDS than any other organisation
or individual; they are just better placed than most to make this contribution.
Policy must aim at working with rather than against them. Within the framework
established by the principles of sustainable exploitation and rigorous
quality control, policy should focus on harnessing international resources
and expertise for South Africa's fight against AIDS more effectively,
through the development of partnerships with research-based industry,
with foreign governments, with drug importers and with all other relevant
bodies. Vast resources are being devoted to AIDS - partly by pharmaceutical
companies, but also by donor organisations, governments, and a multitude
of other sources. The National Institute of Health, a United States-based
organisation doing a great deal of work in AIDS research, has an annual
budget for bio-medical research and research training of $13bn - four
times South Africa's total health budget - and it is only one of many
similar organisations . South Africa has the particular attraction of
being the only sub-Saharan country with adequate laboratories and other
research facilities.
The magnitude of the efforts already being undertaken is suggested, but
by no means covered, by these three examples:
* New Jersey-based Covance, one of the world's
largest contract pharmaceutical development firms, is looking to use South
Africa as a testing ground for new drugs to treat infectious diseases.
Covance said that South Africa was "one of the few regions on the African
continent where the standards of good clinical practice are routinely
followed, offering a regulated environment for clinical testing" .
* Two South African research sites, one based at the Chris
Hani Baragwanath Hospital and the other in Kwazulu-Natal, have been chosen
to take part in the international search for an AIDS vaccine. The award
was granted by the US Government's HIV Vaccine Network Programme which
is sponsoring research sites around the world .
* UNAIDS launched its HIV drug access initiative in
November 1997 to identify strategies to increase access to HIV drugs in
developing countries, including South Africa. Four pharmaceutical companies
are participating in the programme .
Competition for funds
is tough, and the South African government is currently too caught up
in its efforts to forbid private involvement in the AIDS war to take advantage
of the opportunities. But getting it right may open up funds that South
Africa could only dream about up until now. This in turn will give South
Africans infected with HIV/AIDS access to ground-breaking new treatments
and techniques.
Uganda provides an example of how a poor country has been able to exploit
opportunities. President Museveni's declaration of his country's policy
of openness, his early acknowledgement of the AIDS crisis and a rigorous
upholding of high research standards, gave foreign donor agencies the
incentive to unlock Uganda's potential as a research base in East Africa.
The result is that this poor, landlocked country has helped to develop
the most advanced scientific strategies to fight AIDS on the continent.
For example, it was in Uganda that trials for Nevirapine were conducted
. There are certainly legitimate concerns about South Africans being used
as guinea pigs for AIDS interventions which they may never be able to
afford and which might not confront Africa-relevant strains of the virus.
So a priority is the development of guidelines for the acceptance of international
assistance. Scientifically and internationally accepted principles must
apply, and research must be carried out in a way which will provide benefits
to South Africa.
The MRC has developed a protocol regarding drug trials and their conduct
in South Africa. The DP fully supports this, and we would always support
the following principles in such a code:
* All
participants must give their full and informed consent.
* Participants must have
the right to exit at any time. · where possible, there should be no discrimination
regarding trial entrants.
* After completion, participants should have continued
access to successful drugs.
Drug prices are high, and efforts should be made to explore ways to lower
prices - but within the framework of the guiding principles we have specified.
Rather than launching ad hoc attacks on pharmaceuticals, we believe the
government needs to be more constructive and proactive. For example:
South Africa needs to re-evaluate its communications between
donor firms, NGOs and governments to ensure that all drugs coming into
the country, whether via donations or sales, are appropriate to South
Africa's needs and will serve useful purposes.
A concerted effort must be made to improve distribution systems
within South Africa to ensure that drugs actually reach the intended beneficiaries.
There must be sound lines of communication between the government, distributors,
and hospitals and clinics. This will not only benefit people with HIV/AIDS
in the short term, but the long term instilling of confidence in South
Africa's systems can only help to maximise our access to assistance. The
key to this is in creating greater autonomy for individual components
of the health system, to allow for more direct control (for more details
see section on alternatives to hospitals).
The ball is in South Africa's court to take up this cause properly and exploit
the opportunities to the maximum.
5.ACCESS TO CARE
Improving health care management
We must accept that huge demands are going to be made, and are already being made, on the health care system as a result of the need for AIDS-infected people to obtain treatment. Effective opportunistic infection management makes high demands on health systems. It requires treatment by health care staff who are well trained and experienced in HIV care, and facilities which are adequately supplied with resources. The terminally ill have a right to palliative care, but facilities are currently inadequate. Remedying this situation will necessitate a vigorous effort to improve management of the South African health care system.
The essence of the DP's plans to revitalise state health care, explained in greater detail in our general health policy, centres around reducing the centralisation and red tape which is bogging down the system:
- Health care management must be restructured to create a number of independent management units, constructed on the principle of separation of the functions of purchaser and provider, in order to enhance efficiency. Provincial health departments will allocate budgets to local authorities. Local authorities will purchase health care from the provincial health service or from private providers, who will compete with each other for service contracts. This will allow for direct responsibility and control.
- Provincial health services will be established, by legislation, as independent statutory bodies. They will be managed in accordance with business principles, with maximum decentralisation and devolution of authority and responsibility. Savings made or revenue generated will be retained where they are achieved.
- We believe that every effort should be made to establish working partnerships between the public and private sectors which would include the sharing of facilities, equipment and resources in general. There are vast opportunities for expanding health care through public-private partnerships.
In addition to these general measures, we propose specific, localised interventions to improve conditions in targeted clinics where conditions are most dire. This involves tackling a clinic individually and ensuring that it has all the necessary resources for providing effective care, including a water supply, electricity, sufficient staff and sufficient bedding. A principle which must be borne in mind regarding care for AIDS patients at state hospitals is that these patients must not have more rights to health care than other patients. Resources are scarce and not all patients can receive immediate treatment. AIDS patients must not be prioritised over other patients just because they have AIDS; access must be based on who has the most pressing need.
Health care workers
In order to clarify
the situation around treatment for AIDS patients, a guide for the medical
care of patients with HIV/AIDS, which specifies and integrates the rights
of AIDS patients, the rights of other patients and the rights of medical
staff, is required. This will help to prevent abuses on either side. Internationally-accepted
treatment guidelines exist, on which such a guide should be based. It
should be drawn up in consultation with all organisations involved in
treating AIDS patients, including medical staff associations. An aspect
of AIDS care which should be of high priority in such a guide is the enforcement
of the right of health care workers to protect themselves against the
specific risks associated with caring for HIV-positive patients. All hospitals
must be supplied with gloves and protective gear, and health care workers
must have a legislatively enforced right to withhold treatment when these
are not available.
Alternatives
to hospitals
While the state hospital
system needs to be made more efficient, the DP believes that policy on
AIDS care should encourage a move away from the traditional institutional
approach and towards community-based solutions. There are a number of
reasons why we support this:
* The sheer number of infections. In excess of 40% of admissions
to state hospitals in South Africa are HIV-positive. At Johannesburg hospital
the figure is 60% and in Kwazulu-Natal, where the epidemic has hit the
hardest, the figure is far higher. State hospitals simply cannot cope.
* People become disassociated from their families, with
negative social, emotional and practical consequences. * The
unit cost of caring for a person in an institution is generally significantly
higher than home-based forms of care. A re-think of how best to support
and extend community-based care and support for those that are infected
and affected is required. Many NGOs are already moving in this direction.
Home care initiatives have been developed to some degree of sophistication
by, for example, the Church of Scotland Hospital and South Coast Hospice
in Kwazulu-Natal. These centres are already in a position to provide training
in home based care. Others like that at Josini Hospital near Ulundi are
in the developmental phase. Many others in the Durban functional region
have begun to provide care to varying levels .
A number of employers
have recognised the need to keep their work force economically active
as long as possible and have either initiated or subsidise home-based
care. Examples in Kwazulu-Natal include Defy Appliance, Sanachem, Mondi,
Portnet, Alusaf, Illovo Sugar and Eskom. There are still many more that
have no policy in place to address this serious problem and have to be
brought into the fold rather urgently. Public-private partnerships are
required to strengthen and extend these efforts. For example, an initiative
is currently being explored involving the use of facilities at the University
of Cape Town medical school by a private hospital and would be aimed at
benefiting both.
AIDS orphans
Increasing numbers of children are suffering the consequences of AIDS.
Many are infected with the virus through their parents and will probably
die before they turn five. Many millions more will watch their parents
die, and be thrown out into a world which offers them no support and nurturing.
Unless provision is made for these children, a new "lost generation" of
adults, with no skills and no future, is certain. The DP's view of how
the crisis should best be met centres around adapting current systems
of care to make them more appropriate to the circumstances:
- Strengthening the capacity
of families and communities to cope with their problems. Current systems
of caring for orphans will have to change. Many millions more children
will be orphaned over the next years than the system is able to cope
with and current practices, largely based on institutionalisation, will
reach only a very few. Children are becoming more and more dependent
on community support structures like churches, extended family and welfare
organisations. These structures must be strengthened so that they can
cope. Steps required to bring about this change include:
* Most of the work currently done by social workers must be shifted to community volunteers. The professional's role should become one of recruitment, training, monitoring and support of volunteers, and rendering more sophisticated services. This will require changes to the ways social workers are trained, selected and managed.
* Speeding up the processing of disability grants for people living with AIDS so the grants can be used effectively.
* Children with HIV or AIDS should have access to a child support grant, whether or not they are over seven. - Ensuring that the government
protects the most vulnerable children.
Where family or community support structures are inadequate, the government must have back-up measures in place to protect these children by either placing them in care or providing them with the means to help themselves. Measures to do this include:
* Providing financial support for initiatives such as the Child Welfare Society's project to set up child care committees in as many communities as possible. These committees will identify vulnerable children, trace family, identify potential foster parents, supervise placements and channel material support to them.
* Creative foster care options need to be explored. For example, the criteria for acceptance as a foster parent must be broadened, and fostering should, in approved cases, be linked to "employment".
* In terms of the child Care Act, no. 74 of 1983, a child in need of short-term emergency care before a childrens' court enquiry can only be identified by an `authorised officer'. The definition of authorised officer needs to be amended so that persons and structures beyond the state can identify children in need of care and protection.
CONCLUSION
An AIDS policy must, above all else, be malleable. We are in the process
of finding out what will and will not work, and we have to be prepared
to be creative and flexible. Theories will not always work in practice,
or changing conditions might mean that they stop working. New developments
regarding treatment and management of the disease are constantly evolving.
A review of this policy will therefore take place on a continuing basis
to ensure that it continues to meet the best needs of the country's citizens.
Supplied by the Democratic Party
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