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Tue August 27, 2013
After Missteps In HIV Care, South Africa Finds Its Way
Originally published on Wed August 28, 2013 2:39 pm
South Africa has more people with HIV than any other country in the world.
Roughly 5.5 million of its 53 million citizens are infected with the virus. In some of the hardest hit parts of the country, one-third of women of childbearing age are HIV positive.
Now, after years of delay and mistakes, South Africa is transforming how it approaches the disease.
The South African government is simplifying AIDS care, cutting treatment costs and providing antiviral drugs to almost 2 million people every day.
The country just rolled out a new treatment regimen, which involves just one pill a day and costs less than $120 a year per person. By comparison, similar treatment in the U.S. costs thousands of dollars a year for each person.
Even AIDS activists, who continue to badger the South African Health Ministry, concede that the country is attacking the disease in new and innovative ways.
The delivery of antiviral drugs through the public health care system has been so successful and saved so many lives that the overall life expectancy in the country has increased by eight years since the crest of South Africa's AIDS crisis in the mid-2000s.
Nearly 350,000 South Africans died of AIDS in 2005. But in 2012, that number dropped by nearly half to about 190,000 deaths, the government reports.
At Johannesburg General Hospital, Dr. Francois Venter, who leads the infectious disease department, says South Africa is finally making significant progress against the AIDS epidemic.
"Just anecdotally, at my hospital 10 years ago, there were people dying on the floor," he says. "It was horrible. You'd step over bodies that you were looking after."
Venter credits the change in large part to the new health minister, Dr. Aaron Motsoaledi. He took over the position in 2009 as part of a Cabinet shuffle after President Thabo Mbeki was forced to resign.
A universal HIV treatment program could have been put in place years earlier, Venter says, if there had been the political will from Mbeki. "In my view, Mbeki and his Cabinet at the time were responsible for a minimum of 330,000 deaths and probably closer to half of a million, if they had had the energy we are seeing from the current government," he says.
Sibongile Tshabalala, 37, counts herself as one of the lives saved by the new HIV treatment program in South Africa.
She was diagnosed with HIV on Oct. 31, 2000. She recalls the exact date without any hesitation, as if it has been burned into the calendar in her mind.
"It was very hard for us back then," Tshabalala says. When you were diagnosed, it was like a death sentence, she says. You knew that you were going to die.
President Mbeki had been publicly questioning whether HIV causes AIDS. His government appeared in no rush to make antiretroviral drugs available, and his minister of health was touting garlic, beet root and lemon peel as a remedy.
When antiretroviral drugs were finally offered in South Africa's public health care system, they were hard to get and caused serious side effects.
Tshabalala says the first AIDS drugs that she took made her nauseous and caused several of her teeth to fall out. The newer medications are far easier to take, she says.
She has also benefited from a new government policy to make HIV services available at local health clinics.
Up until recently, she had to go to a hospital in Soweto to get her monthly prescription filled. Soweto is on the western side of Johannesburg, and Tshabalala lives on the far eastern extremities of the metropolitan area.
"I was waking up early in the morning at 5 o'clock to go there," she says. "I had to wake up early in the morning. By half past five, I must leave the house. By about 7 o'clock, I'd be at hospital."
Now Tshabalala can get her pills at a small clinic that is just a few minutes' walk from her home.
Under the policy, all routine HIV services, including testing and drug treatment, are offered at local health facilities. Nurses are able to prescribe AIDS drugs and even start patients on what will be lifelong treatments.
South Africa has tamed what used to be a terrifying disease, Tshabalala says. "Now people have a choice — to live or not to live," she says.
MELISSA BLOCK, HOST:
This is ALL THINGS CONSIDERED, from NPR News. I'm Melissa Block.
ROBERT SIEGEL, HOST:
And I'm Robert Siegel. Over the last five years, South Africa has transformed its approach to HIV. In grappling with the worst epidemic on the planet, it has gone from a pariah of the AIDS world, to a poster child for treatment. How? Well, it's streamlining AIDS care, cutting treatment costs, and providing anti-AIDS drugs to almost 2 million people every day.
The public program still faces challenges, and HIV continues to spread. But now, even some of its most vocal critics say South Africa is attacking the disease in new and innovative ways. NPR's Jason Beaubien has the story.
JASON BEAUBIEN, BYLINE: The head of infectious diseases at Johannesburg General Hospital, Dr. Francois Venter, has worked on AIDS since the early days of the epidemic.
FRANCOIS VENTER: Just anecdotally, at my hospital 10 years ago, there were people dying on the floor. You know, just horrible - you'd step over bodies which you were looking after.
BEAUBIEN: But recently, he says, things on the HIV wards have gotten much better.
VENTER: Now, I talk to my junior doctors upstairs, and they all whine about how overworked they are and how, you know, terrible things are and these patients are so sick. And I look around the wards and I think, everybody's in a bed; there's an occasional empty bed. You know, you've had two deaths in the last two days - compared to when I was here, it was one, giant mortuary. It really has changed.
BEAUBIEN: The government's HIV treatment program has been so successful that the average life expectancy in South Africa has increased by eight years since 2005. Thirty-seven-year-old Sibongile Tshabalala has been dealing with HIV for more than a decade, and she agrees with Dr. Venter that there's been a fundamental shift around HIV in South Africa.
SIBONGILE TSHABALALA: I was diagnosed 2000 - 31st October, 2000.
BEAUBIEN: When she tested positive 13 years ago, Tshabalala says the disease was terrifying.
TSHABALALA: It was hard then. If you were sick by then, you know that is the death sentence - now, you are going to die, if you are diagnosed with HIV. So it was very hard for us back then.
BEAUBIEN: The South African president at the time, Thabo Mbeki, was publicly questioning whether HIV causes AIDS. Mbeki's government appeared in no rush to make anti-AIDS drugs available; and his minister of health was touting garlic, beet root and lemon peel as a remedy. When anti-retroviral drugs were finally made available in South Africa's public health care system, they were hard to get and caused serious side effects. Now, the government is using a new generation of anti-AIDS medications that Tshabalala says are far easier to take.
(SOUNDBITE OF BACKGROUND CHATTER)
BEAUBIEN: Tshabalala lives in a dusty, arid settlement of simple, concrete homes and sheet metal shacks on the far eastern edge of Johannesburg. Until recently, she had to go to a hospital in Soweto - all the way on the western side of the city - for treatment.
TSHABALALA: I was waking up early in the morning - at about 5 o'clock - to go there for the queues because the queues were too long. So I had to wake up early in the morning. By half past 5, I must leave the house so at about 7 o'clock, I'll be at hospital.
BEAUBIEN: Under a new government policy, all routine HIV services, including testing and drug treatment, are offered at local health facilities. Nurses are now able to prescribe AIDS drugs, and start patients on what will be lifelong treatment. Tshabalala can get her monthly prescriptions filled at a small clinic that's just a few minutes' walk from her home. For her, South Africa has tamed what used to be viewed as an unstoppable killer.
TSHABALALA: Nowadays, people - they have choice, to live or not to live.
BEAUBIEN: And the treatment program gave Tshabalala confidence that as an HIV-positive woman, she could safely have children.
TSHABALALA: After I've been in treatment, I had two children who are negative and healthy. You can look at them; they are behind you.
BEAUBIEN: If you have HIV now, she says, you can still have a normal life - like everybody else. And this is South Africa's success. In a country where 5.5 million people, or almost 20 percent of all adults, are infected with the virus, the government has managed to normalize the disease. HIV treatment has become just another part of the public health care system.
Earlier this year, South Africa rolled out a new drug treatment regimen that some doctors hope could become the standard throughout Africa. The patient takes just on pill, once a day. And the ministry of health managed to slash the cost of this treatment down to less than $120 per patient, per year. Patients in the U.S. - or their insurance companies - still pay thousands of dollars a year for similar treatment.
Lauren Jankelowitz, the head of the Southern African HIV Clinicians Society, says South Africa has entered a new phase of the AIDS epidemic.
LAUREN JANKELOWITZ: We joke about this being sort of the middle age and what's kind of sexy about HIV and middle age. You know, we're just kind of plodding along.
BEAUBIEN: She points out that the biggest challenges now are kind of boring - around logistics and adherence. Health officials need to make sure the drug supply chain functions, and that hundreds of thousands of people take their pills properly every day. The drug-treatment program still only reaches about half the people who need it, but there are plans to expand it.
The one place that South Africa is still really failing, Jankelowitz says, is in cutting new HIV infections.
JANKELOWITZ: We haven't been very successful at prevention. I'm not sure if anyone has, anyone is - if prevention works. You know, there's a whole - I don't know. You know, we've tried a range of different things, which have been unsuccessful.
BEAUBIEN: Each year, roughly 400,000 more South Africans are infected with the virus. At the same time, fewer people are dying from AIDS. Managing this ballooning HIV-positive population is one of the most crucial issues facing the nation; and it appears South Africa has come up with an effective, low-cost way to do it.
Jason Beaubien, NPR News. Transcript provided by NPR, Copyright NPR.