South Africa Redoubles Efforts Against AIDS

South Africa Redoubles Efforts Against AIDS
By CELIA W. DUGGER
Copyright by The New York Times
Published: April 25, 2010
http://www.nytimes.com/2010/04/26/health/policy/26safrica.html?th&emc=th


SOVANE, South Africa — South Africa, trying to overcome years of denial and delay in confronting its monumental AIDS crisis, is now in the midst of a feverish buildup of testing, treatment and prevention that United Nations officials say is the largest and fastest expansion of AIDS services ever attempted by any nation.

President Jacob Zuma's H.I.V. test on April 8 appeared in newspapers across South Africa. He disclosed that his test was negative.

The undertaking will be expensive and difficult to pull off, but in the past month alone the government has enabled 519 health facilities to dispense AIDS medicines, more than it had in all the years combined since South Africa began providing antiretroviral drugs to its people in 2004, South African health officials said.

And on Sunday, President Jacob Zuma, who recently admitted to having unprotected sex with a much younger woman, inaugurated a campaign to test 15 million of the country’s 49 million people for H.I.V. by June 2011. In a speech at a hospital east of Johannesburg, he disclosed that his own fourth test again showed he was negative and he said he made the result public “to eradicate the silence and stigma that accompanies this epidemic.”

To hoots and laughter from the audience, and with a touch of humor, Mr. Zuma said, “I’m sure South Africans know I’m open about my life generally.” A photograph of his personal doctor drawing blood from Mr. Zuma’s arm for an H.I.V. test on April 8 had appeared in newspapers across the country.

To broaden access to services, the government has trained the hundreds of nurses now prescribing AIDS drugs — formerly the province of doctors — and will train thousands more so that each of the country’s 4,333 public clinics can dispense the medicines, a step Health Minister Aaron Motsoaledi called essential to combating “this monster amongst us” in a country short of physicians.

Michel Sidibé, executive director of Unaids, the United Nations AIDS agency, said South Africa’s undertakings offered hope to the continent. “It’s the first time one country has scaled up so quickly, to so many people,” he said.

South Africa, the region’s richest nation and a symbol of democracy, has an estimated 5.7 million H.I.V.-positive citizens, more than any other country.

“In my village, when we want to kill the snake, we don’t hit the tail, but the head,” said Mr. Sidibé, who is from Mali. “The head of this epidemic is South Africa.”

The South African Finance Ministry said it expected that the broadened access to drugs would put a million more people on treatment in the next few years, roughly doubling the current case load. It has budgeted an extra $1 billion for it. Dr. Motsoaledi said that Mr. Zuma reopened the budget to get more money for AIDS when it became clear that costs would be higher.

South Africa’s understaffed public health system and the ballooning cost of treating millions of people for life will pose daunting challenges to the government’s ambitious goals.

The United States has long been South Africa’s principal donor in the fight against AIDS, giving the country $620 million this year. But advocates worry that global donors will not provide enough money to sustain a rapidly growing treatment program.

For now, though, there is optimism among the scientists and advocates who had despaired as the nation dithered on AIDS under its former president, Thabo Mbeki.

“I’ve never known such a gathering of momentum around H.I.V. as in the last month or so,” said Mark Heywood, who directs the AIDS Law Project, based in Johannesburg.

Mr. Mbeki had questioned whether H.I.V. caused AIDS and suggested that anti-retroviral drugs were harmful. Harvard researchers estimated that the government could have prevented the premature deaths of 365,000 people during the last decade if it had provided the drugs to AIDS patients and medicines that help stop pregnant women from infecting their babies.

“If we had acted more than a decade ago, we might not have been in this situation where we are,” Dr. Motsoaledi said. “Obviously, we did lose time.”

Mr. Zuma, in office for almost a year, has broken sharply with the Mbeki record, broadening access to AIDS drugs for H.I.V.-positive pregnant women and babies, as well as for people with tuberculosis. The government is moving toward routinely offering H.I.V. tests to all who come into the public health system, rather than waiting for people to ask for them.

Silindelokuhle Biyela, a widowed nurse who works at a tidy red-brick clinic in this remote village in the rugged hills of KwaZulu Natal Province, is on the front lines of the new push. She has just completed the training that qualifies her to dispense AIDS medicines. No longer will her patients have to go to a hospital 30 miles away for drugs, an $8 round trip that many are too poor to make.

“The nation is dying,” Mrs. Biyela said. “The people are dying. But we are going to try to help them.”

Hundreds of private pharmacies, including the retail chains Clicks, Link and Dis-Chem, will offer free H.I.V. tests for the next year with government-provided kits. More than 2,000 retired nurses, doctors, pharmacists and other health workers have volunteered to help with the drive.

The health minister said the country was racing to reduce H.I.V. infections — now 1,500 a day — before treatment costs swell even further.

South Africa pays far more for some drugs compared with the prices paid by other African countries covered under steeply discounted prices negotiated by the Clinton Foundation, which is now advising Dr. Motsoaledi.

“We must be able to purchase ARVs at the lowest prices, as we are the largest consumers” of anti-retroviral drugs in the world, despite opposition from local pharmaceutical manufacturers, Dr. Motsoaledi told Parliament this month.

The government is also pushing to prevent new infections. Three years after the World Health Organization recommended circumcision as a way to reduce a man’s risk of contracting H.I.V. by more than half, the country’s hardest-hit province, KwaZulu Natal, began a drive this month to circumcise 2.5 million men. President Zuma said Sunday that the approach would be offered across the nation by next year.

“If you really want to get a handle on the epidemic and reduce the incidence of the disease, this is the most powerful thing you can do, along with reducing the number of sexual partners,” said Daniel Halperin, an epidemiologist at Harvard University.

Dr. Motsoaledi, who became health minister in May, said he planned to personally perform many such procedures to remove the foreskin. “I want to do a thousand,” he said.

Hundreds of young men, many in jeans and track suits, heeded the call of Goodwill Zwelithini, the king of the Zulus, and lined up in a clinic and hospital in Nongoma on a recent Saturday to be circumcised. Concerned about the high rates of H.I.V. infection among his people, the king has declared that the tradition of circumcision must be revived.

It died out in the 19th century during the time of King Shaka, who suspended the custom to avoid having young warriors out of commission while they healed from circumcision cuts that sometimes got infected, said Nelson Ntshangase, a lecturer at the School of IsiZulu Studies at the University of KwaZulu Natal.

Members of the king’s own extended family were among those getting circumcised this month, including Sakhile Zulu, 18, a tall, slender 10th grader who addressed more than 100 boys at his school after he had his circumcision two weeks ago. Back for a follow-up visit, he said he had seen a dozen students from his school there that day for the procedure. “The king observed many of the men are dying,” Mr. Zulu said. “He said the custom should be brought back to save the people.”