ANC Today Briefing Document - 30 November 2001

HIV/AIDS IN SOUTH AFRICA: CHALLENGES, OBSTACLES AND RESPONSES

1. INTRODUCTION

The following document sets out in brief some of the main obstacles, key lessons and key questions still to be answered in addressing the HIV/Aids epidemic in South Africa. The document by no means aims to address all of the issues relating to HIV/Aids, but rather addresses the most urgent and strategic issues that government needs to consider in ensuring an effective response to the HIV/Aids epidemic in South Africa.

2. GOVERNMENT'S RESPONSE TO HIV/AIDS

Early response to HIV/Aids

Initially the response of the Department of Health was almost exclusively focused on three components or interventions:

• Public awareness
• Promotion of safe sexual practices (condoms), and
• STI management

Even the public awareness focused more on condoms than on the current elements of the ABC strategy (abstinence, faithfulness and condom use). The lack of a coherent HIV/Aids strategy was partly addressed through the establishment of NACOSA in 1993.

A comprehensive review conducted in 1997 of the HIV/Aids programme in government identified some of the main deficiencies of NACOSA, and also highlighted four main lessons:

• The response was too health sector driven, and needed to encompass a more multi-sectoral response;
• The need for visible political leadership to ensure success;
• The need for better coordination within government spheres and between government interventions and those in the private sector;
• The need to strengthen implementation structures.

Response post-1997

The 1997 review highlighted some key issues to address. Government therefore embarked on four strategies. The first important strategy was the creation of the Inter-Ministerial Committee on HIV/Aids (IMC) late in 1997. The second was the launch of the Partnership Against Aids in 1998, which recently celebrated its third birthday. In January 2000 the South African National Aids Council replaced the IMC. These strategies addressed particularly the issues of political leadership, coordination and a multisectoral response.

The fourth important strategy was the launch of the HIV/Aids/STI Strategic Plan for South Africa, 2000-2005. This was an effort to move beyond NACOSA and provide government and society with a comprehensive strategy for action. The strategy focuses on four main areas:

• Prevention,
• treatment, care and support,
• legal and human rights,
• research, monitoring and surveillance.

An important aspect of the Strategic Plan is the focus on care and support. This is the culmination of a realisation in late 1999 that government efforts need to shift more towards care and support. However, prevention activities remain the mainstay of the response. There is a good balance within the strategic plan and subsequent implementation thereof between prevention activities (public awareness, life skills, sexually-transmitted infection (STI) management, condom provision) and care and support activities (home based care, support to children and orphans).

The following presents some of the key responses to the HIV/Aids epidemic within the health sector.

Prevention

The prevention activities of the Department of Health focus on four main areas:

• Barrier methods (male and female condoms),
• STI management,
• life skills and HIV/Aids education,
• TB control and integration with HIV/Aids,
• Prevention of mother-to-child transmission (PMTCT).

The first backbone of the response to HIV/Aids is ensuring that sufficient information is available for healthcare workers to address HIV/Aids, STIs and opportunistic infections effectively. To this end, the launch of the nine HIV/Aids related guidelines in October 2000 was significant. The guidelines launched were:

• Rapid HIV Tests and Testing,
• Recommendations for Managing HIV Infection in Children,
• Management of Occupational Exposure to HIV,
• Prevention of Mother-to-Child HIV Transmission and Management of HIV Positive Pregnant Women,
• Draft National Policy on Testing for HIV,
• Policy Guidelines and Recommendations for Feeding of Infants of HIV Positive Mothers,
• Ethical Considerations for HIV/Aids Clinical and Epidemiological Research,
• Tuberculosis and HIV/Aids,
• Recommendations for the Prevention and Treatment of Opportunistic and HIV Related Diseases in Adults.

This intervention has been followed up with the training of healthcare workers on the guidelines. In the last three months approximately 1,000 healthcare workers have been trained in the guidelines, and this training will continue in 2002.

The issue of healthcare worker training is of particular importance to the health sector, and not just in the context of HIV/Aids, but more generally as well. The increasing HIV/Aids epidemic has made the emphasis on training more urgent, as most healthcare workers in public facilities today were trained at a time when there was limited information on HIV/Aids and its relate opportunistic infections in training curricula.

The Department of Health has always committed itself to the provision of preventive barrier methods. In the 2000/1 financial year the department distributed approximately 250 million free male condoms in the public sector, and this increases in the current financial year to 300 million. In terms of female condoms the department in 2001 expanded the number of sites where females condoms are available from 27 to 114.

Sexually-transmitted infection (STI) management is a very important element of any prevention programme. It has been shown conclusively that the effective management of STIs, using the syndromic management approach, plays a central role in reducing the risk of HIV transmission. The department has committed significant resources to this through making resource materials available to healthcare workers. In addition, 80 percent of public sector clinics now have health workers trained in the syndromic management of STIs. Training continues.

Another important prevention strategy is to ensure that the youth of South Africa has as much information available to enable them to make informed choices regarding their sexuality and sexual behaviour. A crucial element of this approach is the life skills and HIV/Aids education programme in primary and secondary schools. In collaboration with the department of education, health has worked to ensure that a life skills and HIV/Aids education programme is now a compulsory part of the curriculum. The full implementation of life skills in primary and secondary schools is planned for the end of 2003. Current implementation stands at 45 percent in secondary schools (grades 8-9) and 15 percent in primary schools (grades 5-7).

Another element of providing information, education and communication is the mass mobilisation efforts. This includes producing posters and pamphlets, as well as adverts in the media (electronic and print). Another is popularising the Aids help line. This activity has been particularly successful, and has seen calls to the Aids help line increase by over 130 percent in the last three years.

In terms of TB/HIV integration, the focus has been on the establishment of TB/HIV pilot districts in four provinces to implement and evaluate a comprehensive package of HIV/Aids/STI/TB prevention, care and support. Some of the significant achievements in this programme have been:

• Quadrupled the number of people tested for HIV from 1,703 per quarter in the third quarter of 1999 to 4,963 per quarter for the first quarter of 2001 in the TB/HIV pilot districts through providing counseling and rapid HIV testing at primary care level.
• Increased the proportion of people receiving the HIV test results from between 10 percent and 83 percent to over 99 percent.
• Identified 6,398 HIV-positive people and started 1,400 of them on TB preventive therapy and 904 on cotrimoxazole prophylaxis.

This programme will be expanded to all provinces in 2002 using funding provided by the Belgian Development Corporation.

The last programme to touch on is that of prevention of mother-to-child HIV transmission. Following the 13th International Aids Conference held in Durban in July 2001, the department of health interrogated the data presented on the efficacy and safety of using the drug Nevirapine on a mother-to-child HIV transmission intervention. A more comprehensive package of care was developed, including the provision of HIV counseling and testing, breast milk substitutes for women who choose not to breastfeed, multivitamins for the pregnant women to ensure their health status during pregnancy is elevated, the Nevirapine to both mother and infant during birth, and the treatment of any opportunistic infections during and after birth for both mother and infant.

Implementation started in the first of the 18 national sites and its 215 access points (clinics and hospitals) in May of 2001. Since implementation started approximately 20,000 women have presented for antenatal care at these access points, of which approximately 14,000 agreed to be given voluntary and confidential HIV counseling, and approximately 9,500 agreed to HIV testing. Of these women, 36 percent tested positive. To date almost 800 babies have been provided with Nevirapine.

Already the information obtained from the various sites highlighted some of the challenges in implementing such a programme, and the implications for wide-scale rollout. The main challenges relate to:

• The lack of adequate space to ensure confidential HIV counseling and testing,
• Inadequate staffing levels to provide the HIV counseling and testing,
• The need for support groups, especially for women who choose to formula feed,
• The impact of lack of access to water, electricity and transport on the efficacy of the intervention.

Treatment, care and support

The debates around treatment for people with HIV/Aids in South Africa dominate the media at this stage. However, this media "debate" is also characterised by gross misrepresentation. The impression created by the local media, and picked up by the international media, is that individuals who are HIV positive have no access to treatment within the public health care system.

The reality is that government has placed its emphasis in treatment on improving quality of life through the effective treatment and management of opportunistic infections and STIs. This treatment is provided to every person that presents at public health care facilities, irrespective of HIV status.

It is unfortunately true that there are still many negative attitudes among health workers. This is a result of frustration around long hours, perceived low pay, increasing workloads and lack of capacity building. These issues are being addressed through the teaching and training initiatives with the health and education departments. Within the HIV/Aids programme of health, the emphasis of health worker training referred to in the previous section is on the identification and treatment of opportunistic infections and the other eight HIV/Aids-related guidelines. This ensures that health workers are provided with the knowledge to manage these patients optimally.

For people who present to public health care facilities with opportunistic infections, an important element of the public awareness and care package is the opportunity to know their status. The expansion of voluntary HIV counseling and testing (funded from the National Integrated Plan) is an important policy direction for health. There are benefits to knowing one's status, whether positive or negative. For people who are HIV positive, the post-test counseling provides important information on issues such as nutrition and prevention of further transmission to improve the quality of life. For those that are HIV negative, the post-test counseling focuses on those lifestyle choices that will ensure that the person remains HIV negative.

Since this programme started at the end of 2000, 359 voluntary counseling and testing sites are operational of the initial 495 identified by the provinces.

Much of the debate in South Africa currently focuses on the provision of antiretroviral therapy to pregnant women (mono-therapy), survivors of sexual assault (mono-therapy), and people who are AIDS-ill (triple-Therapy). For antiretroviral therapy to be effective, it needs to be used in optimal conditions. This includes access to good nutrition and a healthy lifestyle (exercise), good laboratory support for monitoring CD4 levels and well trained physicians to manage adverse reactions to these drugs.

The main challenges posed by antiretrovirals for the public health system are:

• The documented toxicity and the need for close monitoring, and thus also the infrastructure to do so;
• the development of resistance to antiretroviral drugs and its public health implications if there is a resistant virus;
• the high costs of antiretrovirals (treating only 100,000 individuals for a year at US$2 per day would cost approximately R620 million);
• the fact that these drugs have to be taken for life, and thus the need for strict adherence to the treatment regime. Sub optimal adherence does play a role in the development of resistance; and
• The sense of "complacency" created by antiretroviral drugs and then reverting to dangerous sexual practices, increasing the spread of the virus

In the face of these challenges, it is clear that the public health sector in South Africa is not in a position to roll out triple therapy. Access to antiretrovirals is limited to the private sector, but even in this regard government is not passive. Earlier this year the health department met with the private sector to develop guidelines for the use of antiretrovirals in the private sector

A second important activity is support of Government (Health and Arts, Culture, Science and Technology) for the South African AIDS Vaccine Initiative (SAAVI) that was established in 1999 to develop and test an effective, affordable and locally relevant vaccine for South Africa within the next ten years. Since then good progress has been made. Some of the main achievements are:

• International recognition as an excellent model of how a national vaccine initiative should be established and run (combination of government and private sector collaboration);
• Preparation for the first clinical trial with VEE (Venezuelan Equine Encephalitis) vaccine ongoing (for start in early 2002). This has been expanded from one site to two sites;
• SAAVI investigator (Dr C Williams) awarded the "World Technology Forum" award for biotechnology in London (July 2001) for her VEE vaccine work.
• Nine potential HIV vaccine types being researched and developed by SAAVI, and another four internationally in collaboration with SAAVI scientists. Four of these internal SAAVI vaccines are being fast-tracked so as to start human clinical trials within 24 months. (This is extremely fast by international standards).
• Commitments with international vaccine manufacturing partners in place for in 2002.
• Significant numbers of patents granted for HIV vaccine products.
• Extensive community involvement and mobilization at trial sites.
• Establishment of a primate research facility infrastructure for SAAVI.

Government funding for SAAVI will also increase in the 2002/03 financial year to facilitate the expansion of the SAAVI activities. However, despite the very positive developments, a viable vaccine will not be on the market for probably another 8-10 years, and will not address the tremendous burden on social services in the country of those who are already HIV positive and AIDS-ill.

One of the primary policy drives for the Government in the area of care and support is the establishment of home/community-based care (HBC) in South Africa. Home-based care programmes have 2 benefits:

• It relieves some of the burden on the public health care system by ensuring that people that are terminally ill do not occupy expensive hospital beds for too long, and
• It provides psychosocial support for patients in being surrounded by friends and family in a familiar environment.

The main challenge in the establishment of home-based care within South Africa is to ensure that this is managed correctly and does not constitute an abrogation of the responsibilities of the public health care system.

The Departments of Health and Social Development has thus worked together extensively within the context of the National Integrated Plan to establish HBC, and good progress has been made.

• Implementation has started in six provinces, namely Eastern Cape (Tsolo), Northern Cape (De Aar), North West (Jouberton), Northern Province (Polokwane, Maraba and Mashashane), Mpumalanga (Tonga) and the Free State (Welkom).
• Provincial and local coordinating structures have been established.
• All sites are providing services and social relief (food parcels) to beneficiaries.
• HBC supplies are being provided.
• A total of 21 300 beneficiaries have been identified to receive services from the newly established HBC programmes.
• 1 350 caregivers have been trained on service delivery.
• Provincial HBC coordinators have been appointed in 7 of the 9 provinces.
  

One of the guiding principles of the HIV/AIDS/STI Strategic Plan for South Africa, 2000-2005 is the involvement of people living with HIV/AIDS (PWAs). The Department of Health's PWA Support Programme in 2001 conducted several provincial Drug Literacy Workshops to provide PWAs with information on treatment available in the public sector, issues of side-effects, and the importance of compliance to drug regimens.

In addition the Department of Health has appointed PWAs in 5 national government departments to assist them to drive their response to HIV/AIDS.

There are also some important lessons we have learnt from our response to HIV/AIDS in the last 2 years. The most important lesson is the impact/contribution of issues outside of the scope of the health sector. This refers specifically to social conditions such as poverty, unemployment, and access to basic services (housing, electricity). Also, the role of cultural factors on the spread of HIV in society. There can be no denying that conditions on poverty play an important role both in the transmission of HIV, as well as the impact of being AIDS-ill on the poor.

3. INTERNATIONAL COLLABORATION ON HIV/AIDS

Since 1994 South Africa, and the Department of Health in particular, has played a leading role in the regional and international community. South Africa is currently the chair of the SADC Health Sector Council, as well as the Non-Aligned Movement. In addition South Africa is a very active participant in international forums such as the WHO and UNAIDS. This also included hosting and attending international and important national conferences held in South Africa. Some of the prominent conferences either hosted or attended by HIV/AIDS managers or officials include:

• 13th International AIDS Conference 2000: Durban, South Africa
• Second National Conference for People living with HIV/AIDS: 8 - 10 March 2000: Durban, South Africa
• 2nd Meeting of the Cosponsors of UNAIDS on the International Partnership Against AIDS in Africa: Harare, Zimbabwe
• 9th PCB meeting: 25 - 26 May 2000: Geneva, Switzerland
• Attendance of the African Medical and Research Foundation (AMREF) Inter-Country Consultative Meeting on HIV/AIDS: Kenya
• National Summit on Sex Work, 28-29 November 2000
• WHO Consultation on Re-use of the Female Condom: June 2000: Geneva, Switzerland

Of particular importance was the successful hosting of the 13th International AIDS Conference held in July 2000 in Durban. The Conference presented a very important opportunity to focus on HIV/AIDS in the developing world, as South Africa was the first developing country to host the Conference. It also demonstrated clearly that South Africa is capable of hosting major international events.

Previous International AIDS Conferences were not only hosted in the north, but also focused on the challenges of the developed world. The Durban conference was different, and was a success in terms of the goals set by the government. Most importantly, it had a strong African character as evidenced by the participation of more than 4000 African delegates out of a total of about 12,300. Also striking was a strong African contingent amongst the media representatives who enhanced the prospects of wider coverage of the events within our continent.

South Africa also sent a very strong delegation to the UN General Assembly Special Session on HIV/AIDS (UNGASS) held in June 2001 in New York. The aim of the special session was to secure a global commitment to enhancing coordination and the intensification of national, regional and international efforts to combat the epidemic in a comprehensive manner.

During the statement by South Africa, the Minister of Health, as the Head of the Delegation, focused on the issues that are important to South Africa - namely poverty, underdevelopment and a range of other public health challenges. She further emphasised the need for the response to be rooted in strong preventive programmes, such as life skills programmes, public education, and the provision of barrier methods.

The Special Session also allowed an opportunity for various bilateral discussions between South Africa and other countries, and these discussions are also reported on for information.

South Africa also committed itself to the Declaration of Commitment on HIV/AIDS, entitled "Global Crisis - Global Action". The Declaration of Commitment contains clear goals and timelines and identifies specific actions, through partnerships at the national, regional, international and civil society levels, to ensure that governments accelerate their leadership role, implement prevention strategies, receive assistance to enable governments to offer appropriate care, support and treatment for HIV/AIDS sufferers, address human rights, vulnerable groups and children orphaned by HIV/AIDS, reduce vulnerability for individuals at risk of HIV infection, develop strategies to alleviate the social and economic impact of the pandemic, increase further research and development of HIV vaccines and microbicides, contain the pandemic in situations of conflict or humanitarian interventions and obtain the required resources through international assistance, for example through the establishment of the Global HIV/AIDS and Health Fund (as first raised at the Abuja Summit).

This fund, renamed the Global Funds for AIDS, TB and Malaria will be formally established by mid-December 2001. Here again South Africa has played a crucial role. South Africa is one of the members of the Transitional Working Group that was created to do the initial work on the Global Fund. In the recent Africa consultations on the Fund, South Africa chaired the sub-committee on governance issues. Also, South Africa was one of the drafters of the initial framework for the Global Fund as conceptualised in the Abuja Summit.

4. MAIN OBSTACLES TO AN EFFECTIVE RESPONSE

The four main obstacles addressed in this section are the lack of empirical data, surveillance deficiencies, assumptions regarding HIV tests, and the lack of behaviour change.

Inadequate Empirical Data

AIDS is not a notifiable disease in South Africa, and this negatively affects the ability of Government to gather reliable empirical data. Also, HIV/AIDS causes an immune deficiency, predisposing individuals to a number of opportunistic infections that are presented at health care facilities. In addition the stigma related to HIV/AIDS and the continued practice by financial institutions to penalise people who are HIV positive make people less likely to want to disclose their status. The Government has attempted to address this issue through legal steps, but it does still persist.

There was an attempt in 1999 to make AIDS a notifiable disease, but during parliamentary hearing several human rights lobby groups raised serious reservations regarding such a step, as they felt that the environment in South Africa was not yet conducive to such a step. This matter is now in abeyance.

In the absence of a notification system there is really only one alternative strategy which can be considered for use in South Africa at present (the vital registration programme is still unable to provide this information). This is a reporting system based at selected sentinel sites in each of the nine provinces.

A sentinel site programme can generally provide the type of information that would be obtained through a compulsory notification system. Most countries for instance assess HIV prevalence trends among women attending antenatal clinics using a sentinel site methodology. A national notification system requires more logistical support but has the advantage of being more sensitive in describing peculiar trends in more localised geographic areas.

In addition to collecting and collating information on future episodes of HIV/AIDS associated disease and deaths using a sentinel sites AIDS reporting system, studies have been commissioned to estimate the burden of HIV/AIDS disease and deaths using empirical data as opposed to modelling estimates. In particular a study being conducted by HSRC and Medunsa is making significant progress in investigating:

• Estimated morbidity (types and quantity) attributable to AIDS
• Estimated numbers individuals with AIDS defined illness utilising public health services.
• Understanding the most dominant opportunistic infections and symptoms that individuals with AIDS present at health facilities
• Understanding the demographic profiles of those presenting with AIDS at public facilities.
• Estimated morbidity attributable to AIDS among patients in public health facilities,
• Determine the health services that are most severely affected by HIV/AIDS, estimate and project important health service indicators such a drug utilisation, bed occupancy and average length of stay
• Determine the impact of HIV/AIDS on human resources with a focus on the following: training, staff morale, workload, working hours and absenteeism, and
• Estimate the cost of administering preventive therapy to newborns and pregnant mothers at different levels of care.

Surveillance Inadequacies

To date, South Africa's surveillance data on HIV is based on the annual antenatal sero-prevalence surveys conducted every year (since 1990). These surveys are conducted every October in public health facilities. The weakness of this system is that public sector facilities target mainly people who are African and from lower socio-economic classes. It can therefore be argued that this does not provide as comprehensive picture as required.

To address this obstacle, the Department of Health has placed significant emphasis on improving the methodology for these annual antenatal surveys.

In 1997 the DOH initiated a phase programme to strengthen surveillance of HIV/AIDS. The first phase of the program involved strengthening the methodology of the antenatal survey. The sampling procedure was refined so as to ensure that a full cluster random sample was obtained. Quality control measures were introduced. This has resulted in even more reliable data obtained from a nationally representative sample of antenatal clinics through South Africa. These improvements have resulted in South Africa being hailed by UNAIDS/WHO and other experts in the field, to have one of the best methodologies for HIV prevalence surveillance in the world.

The second phase of the program has entailed developing a more comprehensive "second generation" HIV/AIDS and STD Surveillance programme. The comprehensive programme includes the following components:

• The antenatal survey for HIV prevalence estimates. Assessment of the prevalence of HIV in other sub-population groups e.g. men, non-pregnant women, non-African women will be assessed by conducting a "twin" antenatal survey amongst private sector antenatal attending women. The first private sector survey of women attending antenatal clinics is currently being conducted (November 2001).
• Estimates of new infections (HIV incidence estimates) are be made using recently developed serological testing algorithms for recent sero-conversion (STAHRS) tests. These test are able to detect new or recent infections that occurred in the last 4 to 6 months on historically collected sera. Calibration for the Claude C virus (the test was originally designed for use in clade B environments) has been completed. The test is currently being used to assess, using sera from the 2000 antenatal survey, what proportion of those positive tests were recent infections i.e. women who were infected 4 to 6 months prior to their sera being taken for testing.
• A behavioural surveillance programme has been developed. Surveys will be conducted in the early part of 2002 in collaboration with research and academic units. This behavioural surveillance system will track behavioural change and be an important monitoring tool for programme activities. Baseline data form studies such as the Demographic and Health Survey are under review for strengthening the behavioural sentinel surveillance (BSS).
• Over the last few years a programme to strengthen STI management and surveillance using the syndromic management and microbiological approach has been implemented and shown successful reductions in STD incidence in a three provinces. The program is now being expanded and rolled-out to the rest of South Africa. It is expected to be completed in approximately 18 months. This programme is expected to drastically reduce the incidence of STDs and STIs and provide important surveillance information of the epidemiology of STIs in South Africa. This information will augment information currently available from the antenatal survey and smaller laboratory studies.
• South Africa previously ran a voluntary AIDS reporting system. Under-reporting rates were high and eventually the data ceased to be as useful for planning. Estimates on AIDS cases are derived by models developed by UN agencies, the Department of Health and private sector in South Africa. The Department of Health is currently in the process of establishing sentinel sites for AIDS case reporting. These sites will provide empirical data on AIDS cases. In addition the South African vital registration system has been modified so that HIV/AIDS associated deaths can be recorded in due course.

A number of empirical research projects and modelling exercises are ongoing to assess the impact of HIV/AIDS on the social, economic and health environment. In particular a study by the HSRC and MEDUNSA is conducting empirical research.

HIV Test Assumptions

The third obstacle is the assumptions that form the basis of the response from Government. Our current response assumes that the HIV tests used in the public health care system (ELISA assay and the rapid HIV tests) are reliable, and that they measure what they are supposed to. (An ELISA test is an assay to detect antibodies that are HIV-specific antibodies.)

The issue of the reliability of the HIV tests are one of the questions currently being addressed through the Presidential AIDS Advisory Panel. It is also known that the earlier tests used in the public system showed some cross-reactivity with some of the other antigens. The issue currently being examined by the Presidential AIDS Advisory Panel is whether antibodies detected by the HIV ELISA tests are indeed detecting antibodies specific for HIV or are cross-reacting antibodies. This is phase 2 of the efforts to address the reliability of HIV tests. What has already been addressed is the correlation between an HIV test conducted in South Africa and the same plasma tested by the CDC in the USA.

Behaviour Change

The fourth, and one of the most significant obstacles relates to the human factor. Despite our efforts at providing information, education, and the tools to facilitate behaviour change (such as condoms), there is still no direct correlation between levels of awareness and behaviour change. Up to now there has been relatively insignificant information on the barriers to behaviour change, and these are based more on anecdotal evidence of the effect of issues such as cultural beliefs, access to barrier methods, and general misinformation.

To address this the Department will require ongoing review of behavioural trends in order to maintain a dynamic process of modifying and focusing behavioural strategies and intervention appropriately. Behavioural surveillance programme described above will provide long-term trends on:

• Whether behaviour change is taking place, when behavioural changes is most likely to taking place
• The uptake of behavioural change is specific sub-population groups.
• Which conditions are most enabling for effective behavioural change
• Which programmatic activities are most effective vehicles for behavioural change
• Most important social, cultural and societal determinants of behavioural change
• Impact of behavioural modification of disease trends.

5. KEY QUESTIONS THAT REMAIN IN HIV/AIDS

The last section of this document deals with some of the unanswered questions that remain in HIV/AIDS. Scientists have been grappling with these questions for the last 20 years, and yet there are still some disputes on these issues.
The first relates to he virus itself. The questions to be answered are:

• Does an infective agent exist? If it does, is it a virus? Is this virus then the main cause for the immune-suppression seen in patients who have tested HIV positive?
• Are the tests that we use to detect the virus reliable?
• Do the tests measure HIV?
• What is the level of cross-reactivity of HIV tests with other common antigens?
• What definition should South Africa use for an AIDS diagnosis? The CDC definition used in the developed world, or the Bangui definition used in the developing world?
• What are the reasons for the difference in the main mode of transmission between the developed and the developing countries (homosexual and injecting drug use in the developed world, and heterosexual in the developing world)?

Despite these questions of science, what does seem to be evident is that there is a correlation between a positive HIV tests and a weakening immune system and rapid disease progression.

In the face of international criticism, it remains important for the Government to pursue answers to these questions through the Presidential AIDS Review Panel to ensure that our response is informed by documented evidence that is relevant to the African context.

6. CONCLUSION

Government has responded very positively in the face of a growing HIV/AIDS burden in South African society. This response has been scaled up tremendously in the last 2 years, but challenges remain and more seem to appear on an almost daily basis.

Some of the key lessons from Government interventions in the last 2 years have been the impact of socio-economic factors on HIV/AIDS, and the fact that no one is immune to this infection. However, the poor are hardest hit, and also have the weakest coping systems. People are dying more of starvation than from the actual infection. The need to address HIV/AIDS in a multisectoral approach is thus self-evident. Such a multisectoral response needs to draw on the best skills and resources of Government and civil society. An effective response to HIV/AIDS is also not limited to health interventions, but also of Agriculture (food security), Housing, Local Government (water and electricity), Social Development (grants and care of orphans), and Education (life skills education).

HIV/AIDS needs to be seen as a responsibility of every government department, and not limited to the few that take the lead currently. Every government department at national and provincial level should ensure that it has plans and strategies in place to address HIV/AIDS within its sphere of influence.

The last lesson is that the response to HIV/AIDS needs to be driven from the ground up. Strengthening our district health system and the provision of a comprehensive package of primary health care play an important role in ensuring quality health care to South Africans, irrespective of their HIV status. The general strengthening of health and other social services at community level remain the best defence against a further growth of the HIV/AIDS epidemic in South Africa.