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Human Science Research Council & Western Cape Department of Health on Hiv/Aids: briefing - Tue 2 Oct 2001

The Parliamentary Monitoring Group - http://www.pmg.org.za List all minutes for this committee

IMPROVEMENT OF QUALITY OF LIFE AND STATUS OF WOMEN JOINT COMMITTEE 2 October 2001 HUMAN SCIENCE RESEARCH COUNCIL & WESTERN CAPE DEPARTMENT OF HEALTH ON HIV/AIDS: BRIEFING
Chairperson: Ms P Govender
Documents handed out: Opportunities and Challenges in implementing evidence-based prevention and care programmes in developing countries – Dr O Shisana (See Appendix) Public Policy Making Process PowerPoint Version
The Executive Director of the Human Science Research Council stated that research results seldom have an immediate impact on government policy but understanding the complexities in policy making will help in addressing opportunities and challenges of HIV/AIDS in South Africa.
The introduction of anti-retroviral drugs has led to a dramatic decline in mortality of HIV/AIDS related deaths.The transmission of HIV from mother to child could be prevented safely through low cost drugs. Government needs to establish sustainable financing mechanisms to ensure reliable distribution and access of these drugs.
The Western Cape Department of Health expected a dramatic drop in mother to child transmission by the end of this year. It was anticipated that by the end of the year 2004 no child should be born HIV positive in the Western Cape.
MINUTES Briefing by Dr Shisana, Executive Director, Social Aspects of HIV/AIDS and Health, Human Sciences Research Council (HSRC) Dr Shisana, discussed Aids in South Africa. She presented three possible interventions-treatment of sexually transmitted infections to reduce HIV incidence
-use of highly active anti-retroviral therapy
-prevention of mother to child transmission (MTCT) of HIV

Aids was preventable, according to her, as has been the case in democratic societies such as North America and Western Europe where the scourge of Aids has been contained. More than 34 million people are globally infected with HIV/AIDS out of which 67 percent were in developing countries. South Africa has 4.7 million HIV infected people.Half of those people were women while in some places one woman out of three women was HIV/AIDS positive.
In 1999, 1.3 million children were infected with HIV/AIDS out of which about 90 percent were through mother-to-child transmission (MTCT). In the same year, more than 2 million Africans died of AIDS.
Dr Shisana said out of 10.7 million people infected with HIV in the SADC region half of them were South Africans which makes South Africa the leading country with the number of people infected with HIV in the region.

Government could train health workers to be more empathetic towards patients, which was part of service delivery. The government could also step up the testing of HIV/AIDS in women who are "especially vulnerable to the HIV/AIDS epidemic".

Sexually Transmitted Infections
Most women depend on men for their livelihood, she told the committee, which gives them no choice to tell men to use a condom, or not because of their status in the community.The other area of intervention could be to increase the health budget to better combat the disease. She said sores on genitals were the main culprits. She stated that having sexual intercourse involves blood and a sore from a person infected makes the transmission more easier.
Dr Shisana said with the introduction of the antiretroviral (ARV) drug in the United States in 1996, there was a dramatic decline in mortality or HIV/AIDS related deaths. This was the same case in Canada and Western Europe were new Aids cases were declining. However, she pointed out that the cost factor played an important role here in the sense that in the US there was a marked decline in AIDS related deaths among white men while amongst black women, "who come from low income groups", the trend of decline was more slower. So too among black men who were poor and marginalized

Highly Active Anti-Retroviral Therapy (HAART)
Dr Shisana said drug companies in the United States were among the leading Fortune 500 Companies in profit making whose profit increased between 1998-1999 by $4.8 billion, exceeding the profits of companies like the automotive industry, oil companies, security firms and airlines.
These drugs become too costly for developing countries to access these drugs. For instance, she mentioned the high cost of infrastructure of these drugs cost between $20-$187 per unit which is out of reach for Aids patients in developing countries.
Dr Shisana stated there was hope though for developing countries. Before leaving office former US President Bill Clinton's Executive Order that encourages Sub-Saharan countries to use the options in the TRIPS agreement to use private licences to gain access to drugs for the treatment of HIV/AIDS. The Bush Administration has been pressurized by activists to keep that Executive Order but unfortunately many governments are not using that option.
Brazil and Thailand have the technology to produce drugs for HIV/AIDS. Dr Shisana said it would be a good idea for South Africa to emulate their counterparts in Brazil. Government needs to negotiate cheaper prices for diagnostic kits and reagents. Sustainable financing mechanisms have to be established to ensure reliable distribution and access to drugs.

Prevention of Mother to Child transmission (MTCT)
The transmission of HIV from mother to child can be prevented safely through the use of low cost AZT. A study conducted by the Paediatric AIDS Clinical Trial Group shows that the risk of transmission has been reduced by 67.5 percent when zidovudine is given antepartum and intrapartum. However, this remedy is complex and expensive for developing countries to adopt. It was more appropriate for developed countries where women can afford not to breast feed. Implementing interventions meanwhile for developing countries requires family planning (such as the use of condoms to prevent pregnancies, STDs, and HIV, early access to quality anti-natal clinical treatment, trained health workers, counseling, HIV/AIDS testing, and ARV for those mothers who are HIV positive.
Many health workers were overworked, had low moral and some were ill due to HIV/AIDS related illnesses. They needed training in order to "provide further prevention transmission." There was need for government to prioritize intervention by subsiding infants and HIV positive mothers. There was a possibility of drinking contaminated water, which threatens the survival of children. South Africa may want a solution of producing ready-made instant formula which women may be able to use.

Discussion
Ms C September (ANC) asked if the World Health Organisation (WHO) approached the WTO about TRIPS. As the HIV/AIDS issue was highly politicized in this country, how was it being handled in other countries?
Dr Shisana replied that she left the WHO a year ago and was not informed of developments there. HIV/AIDS was politicized everywhere in the world. It started in the United States in the early 1980s when the gay community was ostracized because of the virus. She said debate on the issue was vital to reach a common response.
Ms D Nhlengethwa (ANC) asked if AZT had any side effects?
Dr Shisana answered that there was no drug that had no side effects and that the AZT had the backing of the WHO.
Rev P Moatshe (ANC) asked if South Africa was classified as a developing country or developed country?
Dr Shisana replied that South Africa was a developing country with few certain areas resembling the first world but overwhelmingly third world in the majority of the areas. As such, it was viewed as a middle-income country or an emerging market.
Ms N Twala (ANC) asked for clarification on the Brazil and US saga over TRIPS.
Dr Shisana said the USA took Brazil to the WTO where it argued that Brazil was violating the WTO rules of patent laws and intellectual property by manufacturing HIV/AIDS products in Brazil. For five years the two countries locked horns over this issue but at the end Brazil won.
Ms P Govender (ANC) asked for clarification on the linear approach to policy making.
Dr Shisana responded that when scientific evidence says that this thing works, policy makers have the right to test it by putting it into implementation. Unfortunately in reality this was not the case. Before evidence can be tested it goes through long discourses before it is approved or discarded to the detrimental of the patients involved.
Ms Lamani (ANC) inquired what measures were being taken to train health workers?
Dr Shisana replied that it was unfortunate that HIV/AIDS patients were not well treated in hospitals but the worst scenario was from the private sector, which was notorious for not treating sexually transmitted diseases effectively. The Department of Health has been trying to look at the issue of health workers in general and several issues have been raised especially after the post-Durban Aids conference.
She said social factors that facilitate the spread of HIV/AIDS should be examined. Some of these social factors are issues like polygamy and the culture of multiple partners. Messages like abstinence, faithfulness and condomising have to be examined to study their effectiveness. Lastly, HIV/AIDS awareness should be recognised in the socialization of young people.

Presentation by Dr F Abdullah: Mother to Child Transmission in the Western Cape Ms Z Mazwi and Dr N T Naledi accompanied Dr Abdullah the leader of the delegation. The main focus of Dr Abdullah's presentation was based on Khayelitsha statistics. The population of Khayelitsha was about 325,000 people with 70 percent of the people living in shacks and 40 percent unemployed. The infant mortality rate was between 35-45 per 1 000 life births.
There are no hospitals in Khayelitsha but there are three community health clinics and eight clinics with facilities for child health, TB and STD. About 60 percent of deliveries are done at a community setting.
Mother to Child Tranmission therapy in Khayelitsha started in June 1999. AZT is offered up to 36 weeks while in labour. Formula feed is provided for up to six months.
So far up to 18,788 women have been attended to, a number that Dr Abdullah said was more than the number of women treated in Uganda over the last two years. Out of that number 13,945 (about 74%) accepted the testing and 2,674 (19.2%) were HIV positive. Dr Abdullah said the latter figure was an alarming figure. Of the remaining women, about 11,271 tested negative.
About 791 infants were tested at age nine months and ninety-four (11.9%) tested positive or "indetermined". He said nine out of ten babies in the Western Cape are born negative.

The Western Cape Provincial Health Department found that individual counseling was better than group counseling. Rapid tests were better because they give results in ten minutes. AZT was given for 34-36 weeks and was self-administered.
They were expanding to other areas such as George, Paarl, Worcester, KTC, Guguletu, Langa, Hout Bay and Plettenberg Bay. By June next year they hope to reach 95 percent women and the remaining 5 percent being based in remote areas. Every year there were 70 000 pregnancies in the Western Cape alone.

Effects of the MTCT
Dr Abdullah said they expected a dramatic drop in MTCT therapy by the end of next year and that by the end of the year 2004 a child should not be born HIV positive. It was now easier to implement the MTCT therapy because the Department has its own budget. It has community support and the Western Cape is mostly urban with clean water. Breastfeeding is low in the province.
Discussion
Ms C September (ANC) noted that there was a gross infrastructure inadequacy in Khayelitsha where deliveries are often performed on the floor. Was there a provincial coordinator? What was the implementation programme for the Department?
Ms Mazwi replied that there were deliveries taking place on the floor but the reason for that could be varied. For instance she said deliveries were at times taking place in the car while the patient was on the way to the clinic.
Ms Morule-Maine (ANC) stated that services provided in Khayelitsha were not enough in view of the population there.
Dr Abdullah said they were planning to build another clinic at Site C.
Ms Govender (ANC) asked whether they were monitoring other people from other places coming to make deliveries in Khayelitsha.
Ms Mazwi said it was difficult to monitor them because when coming to make deliveries they give residential addresses in Khayelitsha.
Ms Maloney (ANC) asked if there were follow-ups for babies for formula feeding.
Dr Naledi responded that they provided free formula feeding for six months at local authority clinics in the surrounding areas.

OPPORTUNITIES AND CHALLENGES IN IMPLEMENTING EVIDENCE-BASED PREVENTION AND CARE PROGRAMMES IN DEVELOPING COUNTRIES

Dr. Olive Shisana, Executive Director, Social Aspects of HIV/AIDS and Health, Human Sciences Research Council

The path from generation of evidence to knowledge utilization in policy formulation is not as straightforward as it may appear. It seldom results from a rational process of conducting a study, analysing the findings, preparing policy options and politicians choosing among the given options and then mandating their departments to implement the chosen option. It may result from a political process that involves negotiation, bargaining and accommodating different interests. The process involves interest groups, often with varying agendas. These partners include politicians, members of the executives, scientists and academicians, NGOs, activists, donors, private sector and multilateral organizations. For parliamentarians it is crucial that you understand what the scientific evidence is, so that you can contribute to policy development and also evaluate policies and legislation. '
Understanding the complexities in policy making process will assist in examining opportunities and challenges South Africa faces in applying evidence to address HIV/AIDS--a major public health and development problem in our country.
Three examples of effective and safe interventions are (a) treatment of sexually transmitted infections to reduce HIV incidence, (b) use of HAART to reduce new AIDS cases and prolong life, and (c) use of zidovudine to prevent transmission of HIV from mother to child. HIV/AIDS is now the most serious epidemic facing developing countries, with an estimated 34 million people infected. The majority of these people live in developing countries, particularly Sub-Saharan Africa, where more than 67% of infected people are residing. South Africa is home to 4.7 million HIV positive people. WHO estimates that 250 000 South Africans died from HIV/AIDS-related illnesses in 2000. The National AIDS Foundation estimates that by 2008 half a million South Africans will be dying of HIV/AIDS-related illnesses. Instead of increasing to approach the levels in developed countries, life expectancy of South Africans is expected to decline. Projections based on the Metropolitan Doyle Model indicate that life expectancy will drop as follows:
Sex199920052010 Female524337 Male494338
No other country besides South Africa has such large numbers of people living with HIV/AIDS. South Africa leads the SADC region in being home to so many people living with the HI virus. Of the 10,7 million people estimated to be living with HIV/AIDS in the SADC region in 2000, nearly half are South Africans.
Globally, women comprise a sizeable number, with approximately 15,7 million living with HIV/AIDS. In some high prevalence areas one in three pregnant women are infected with HIV. In South Africa, women have higher infection rates than men.
Globally, about 1.3 million children were infected with HIV in 1999, and 90% of these resulted from transmission of the virus from mother to child (MTCT). HIV/AIDS is reversing key development goals achieved over the last fifty years. Life expectancy and child survival are declining. South Africa is not an exception. In 1999 more than 2 million Africans died from AIDS. With limited resources and impending disaster looming over developing countries, it has become imperative that countries implement evidence-based policies to urgently curb the spread of this epidemic.
Sexually Transmitted Infections as co-Factors in HIV Transmission

There is now ample evidence from both non-randomised and randomised studies based on epidemiological and biological evidence that new HIV infections can be prevented through appropriate management of sexually transmitted infections. A series of studies, involving heterosexuals and men who have sex with men in developed and developing countries, have demonstrated that STI is a significant risk factor in HIV infection. In non-randomised studies the relative risk range from 1.5 to 8.5
In a randomized intervention study in Mwanzaa Tanzania, the researchers found that improved STI treatment reduced HIV incidence by approximately 38% after adjusting for co-factors. However the results from the Rakai randomised controlled study did not show any impact of HIV incidence. The differences in the two randomised controlled studies include the differences in the prevalence of HIV infection and differences in the treatment approaches (syndromic vs. mass treatment).
Biological evidence is solid. The presence of STI increases HIV infectiousness due to the increased viral load in genital secretions. Secondly, the presence of STI increases susceptibility to HIV due to disruption of epithelial barrier and increased cell receptivity to HIV (in vitro data). Finally genital ulcers and other non-ulcerative STIs are associated with increased shedding of HIV.
Highly Active Anti-Retroviral Therapy
Sub-Saharan Africa has seen in the last year more than 2 million of its residents dying prematurely from AIDS. With South Africa accounting for 12% of all African infections, this country must have contributed significantly to these deaths. HIV/AIDS was the leading cause of death in this continent. These deaths occur in spite of availability of highly effective anti-retroviral therapy in developed countries. On the other hand, countries in the north have used the evidence from clinical trials to intervene through highly active antiretroviral therapy to significantly (a) reduce new HIV infections, (b) reduce occurrence of opportunistic infections, (c) new AIDS cases and (d) AIDS deaths. Evidence exists in Uganda and Cote dÍvoire that AIDS patients in developing country settings can also be managed successfully,i.e., they do take their medications regularly and are responding to treatment. Yet, this evidence is still not translated into daily medical care practice in Africa, including South Africa. Botswana is well on its way to providing care for its infected population. The most frequent and legitimate reasons developing countries cite are:
The high cost of ARVs. The latest Report by Public Citizen in the United States show that the 10 most profitable drug companies increased their profits by $4.8 billion, or 20 percent, from 1998 to 1999; and show data revealing that the 1999 profits of major drug companies far exceeded the profits of other Fortune 500 industries such as auto, oil, securities and airlines. The high cost of infrastructure necessary to use these drugs (including cost for testing and monitoring CD4 cell counts, viral load, to monitor adherence to treatment regimen, training, development and implementation of treatment guidelines.
Voluntary Counselling and Testing not routinely available in most facilities