Before the official start of the 2nd South African AIDS Conference, representatives from the United States President’s Emergency Plan for AIDS Relief (PEPFAR) held a satellite conference to review the challenges faced and progress made by the programme’s South African partners during the first year of the plan's implementation.
The five-year US initiative to support HIV/AIDS prevention, treatment and care activities around the world has worked in close collaboration with the South African government from its very inception.
PEPFAR has specific targets to achieve by 2008:
- 2,000,000 people on antiretroviral therapy (South Africa's share of that target: 500,000 people). The PEPFAR approach to the rollout of antiretroviral treatment (ART) is to assist local government strategies and programmes (and avoid setting up parallel programmes), and to partner `as much as possible` with private providers and industry.
- 55% of the PEPFAR is designated to treatment, including procuring antiretroviral drugs. Unfortunately, the reach of the programme is limited by US administration insistence on purchasing only pharmaceuticals that have received US Food and Drug Administration approval. Since few generics have received provisional approval by the FDA, this means that projects have no choice but to purchase expensive name-brand pharmaceuticals and treat fewer patients than they could if they could buy more affordable generic drugs.
- Care for 10 million HIV-infected individuals, AIDS orphans and vulnerable children. Again, a quarter of PEPFAR's total target for care provision is in South Africa. Provision for care includes the diagnosis and treatment of opportunistic infections, particularly TB, and palliative care, as well as services for orphans and vulnerable children. Many of these services will be community-based. Overall, provision for non-antiretroviral care comprises 25% of the PEPFAR budget.
- Prevention of 7 million new infections (one fourth of which will be in South Africa). One of the more controversial aspects of PEPFAR is its prevention component. 20% of PEPFAR's funding will be spent on projects that promote the Abstinence, Be faithful, and Condoms 'when necessary' (ABC) approach to prevention. A third of that funding will target the AB aspect only in youth in the hope being that it might be possible to postpone sexual activity.
Other projects will specifically target cross-border and migrant populations. PEPFAR is relying on non-governmental organisations and faith-based organisations to do the bulk of the prevention work.
How these prevention programmes will measure their success is unclear. There have been many complaints that the approach to prevention had led to decreased access to free condoms and safe sex education (see aidsmap news story).
PEPFAR activities in South Africa
In South Africa, PEPFAR is being implemented in partnership with the South African government and an array of public and private partners. According to Dr Gray Handley, medical attache for the US embassy in South Africa, 89 million dollars was committed to PEPFAR's South African partners in fiscal year 2004 (a rather low figure considering that a quarter of the emergency plan's 2008 targets are in South Africa).
Nevertheless, within the last year approximately 25,000 people in South Africa have enrolled in treatment projects directly supported by Emergency Plan. PEPFAR also supports 23 employees in the South African Government's national and provincial Departments of Health, and has funded the training of over 30,000 service providers.
PEPFAR funding for fiscal year 2005 has increased to $149 million in South Africa.
By September this year, South African partners plan to have provided treatment to prevent mother-to-child transmission to 50,000 women, care for around 110,000 orphans and TB treatment for 40,000 patients.
Government partners
PEPFAR has a major prevention, treatment and research initiative ($50 million over five years) in partnership with the South African National Defence Forces (SANDF).
Colonel Xolani Currie reported on the Phidisa Project, a collaborative effort between the SANDF, the US Department of Defense and the US National Institute of Health, to conduct clinical research in the South African Military. Phidisa was established to determine the impact of HIV upon the military, evaluate management strategies (including antiretroviral therapy), and to build capacity within the South African Military Health Service (SAMHS) to deal with other diseases of critical importance to military force preparedness.
Currently, Phidisa provides antiretroviral treatment to HIV-positive SANDF members and dependents at six selected research locations. The first stage of the project, Phidisa I, was a prospective epidemiological cohort study of HIV and risk-related co-infections in the military. A total of 2771 individuals with HIV have been screened at the project’s six research sites, (three in urban and three in rural settings). Of these, 771 patients qualified for antiretroviral treatment (with less than 200 CD4 cells or symptoms of advanced HIV disease).
Treatment-naive adults were enrolled into Phidisa II, onto one of four treatment arms, based on efavirenz (Sustiva) or lopinavir/ritonavir (Kaletra) plus either AZT/ddI or d4T/3TC.
However, a number of the HIV-positive people screened did not meet Phidisa II's inclusion criteria (for example, a number were treatment-experienced or were dependent children). SANDF therefore sought help from PEPFAR for Phidisa III, which covers the laboratory costs and provides treatment for this group of 176 adult patients and 56 patients under 14 years of age.
Department of Correctional Services (DCS)
Not every PEPFAR project has run as smoothly. Sometimes it can be a logistical challenge just to get the money. Gustav Wilson of South Africa's DCS said, "Systems have to be put in place, and there has to be an agreement in the way funds are to be transferred."
Apparently, the former US ambassador had asked DCS to submit a proposal to PEPFAR; they received a letter confirming an approval for $600,000 last August, and a formal announcement was made on October 22, 2004. Nevertheless, Wilson said DCS only received funds in April and may find it difficult to disburse the funds before the start of the next US government financial year (October 1) which could jeopardise future funding.
Plans also change. "Initially we thought that we would make ART available to offenders but then we were made aware that we would not be able to do this," said Wilson. "Our institutions do not have the pharmacists and dieticians - we just don't have the resources" [required by the Comprehensive Plan before a site offers antiretroviral therapy]. Until DCS can recruit the necessary staff, offenders in need of treatment are referred to the nearest treatment rollout sites (which is another logistical challenge).
In the meantime, the bulk of PEPFAR funding is being spent on the procurement of educational and awareness materials, and awareness and peer-support training for prisoners and staff. DCS is also conducted an HIV prevalence survey of both offenders and staff, which should finally give accurate figures on the burden of infection in the prison system before the end of the year.
Department of Social Development (DSD)
Around one million children have been orphaned by HIV/AIDS in South Africa. Some of these orphans are struggling to survive in a growing number of child-headed households. In many cases, grandparents or other relatives have taken in most of the orphans, which has consequently increased the financial and emotional burden on these families.
The public social services, non-governmental organisations (NGOs) and community-based organisations (CBOs) do not have the capacity for dealing with such a large number of vulnerable children and families, and existing efforts have been unorganised or sometimes poorly implemented on the ground. The government has been working to co-ordinate the efforts of social services or other departments with a stake in child welfare (such as education) with provincial, local government and civil society responses. Meanwhile, DSD is compiling a national database of orphans and vulnerable children.
DSD has also partnered with PEPFAR and a number of NGOs to help increase capacity, especially on the local CBO level, and to increase care and support for children within their local communities. NGOs include Hope Worldwide (HW), Nurturing Orphans and AIDS for Humanity (NOAH), CARE International, Star Fish, Nelson Mandela Children's Fund and Save the Children UK
According to Dr Kylene Khunaka, Chief Director of HIV Services for DSD: "These NGOs have facilitated grants, have helped identify orphans, and assisted those without identification documents get proper documentation and then referred them to social services. They have also scaled up social support networks for orphans and helped their extended families cope with the increased burden of care, by providing counselling and support, delivering food parcels for children before school, and setting up drop-in centres where children are assisted with homework before going home."
For more on PEPFAR’s non-governmental partners in South Africa see the accompanying report.