Download Cabinet`s decision on the Operational Plan for Comprehensive Care

Cabinet's decision on the Operational Plan for Comprehensive Care and
Treatment of people living with HIV and AIDSQuestion & Answers
19 November 2003
What is government's approach to HIV and AIDS?
What are the elements of the comprehensive approach?
What are the main elements of the treatment plan?
At what stage, for patients, will ART be considered?
When is it to be introduced; where; how it will be scaled up?
Why is it being introduced in stages?
Is there a role for traditional medicine?
What is required for a health facility to be accredited?
What will be needed to ensure that all areas are serviced?
How long will it take before people can access antiretrovirals?
Has government made a u-turn?
Why is this step being taken now -in particular why is ART being introduced
now into the public sector?
What will it cost to implement the plan? Is it sustainable?
Won't it take resources from other health care and social service?
Why is the price of drugs important?
What can ART do, and what are its limitations?
How will the ART impact on the comprehensive strategy?
Does the role of partnership change?
Government is taking advantage of new developments to enhance our country's
comprehensive response to HIV and AIDS. It will, as matter of urgency, start implementing a
programme to provide anti-retroviral treatment (ART) in the public health sector. Let us build
on the foundations laid in the past three years through implementation of the five-year
strategic plan.
What is government's approach to HIV and AIDS?
[top]
Ours is a comprehensive strategy based on a partnership of all sectors of society, because
HIV and AIDS represent a challenge to all of us. Success depends on close collaboration and
continuing strengthening of partnership. The Partnership was formalised in October 1998 in a
national launch by then Deputy President Thabo Mbeki, and is now represented by the South
African National Aids Council (SANAC).
What are the elements of the comprehensive approach?
[top]
The comprehensive programme includes prevention, treatment and care, research and
human rights:

Prevention of HIV infection is the bedrock of Government's approach to halt the spread
of HIV and the impact of AIDS, since there is no cure for AIDS. We must ensure as a
nation that the 40 million South Africans who are not infected stay that way.

Ensuring that those who are currently infected with HIV but have not developed AIDS
progress as slowly as possible to this stage, through enhanced efforts in dealing with
opportunistic infections, prophylaxis, improved nutrition and lifestyle choices.

Effective management of those HIV-infected individuals, currently estimated at
400,000 to 500,000, who have moved on to develop AIDS, through appropriate
treatment of AIDS-related conditions (including using antiretroviral therapy in patients
presenting with low CD4 counts, and suitable care where treatment has run its course.

Important in supporting these efforts are:

Social programmes that aim to reduce poverty, improve education and bring about
moral renewal.

Strengthening the immune system, of critical importance for the health of those
infected by HIV.

Promoting a climate of acceptance of all people infected and affected by HIV and
AIDS; intensifying implementation of a policy and legislative framework and community
awareness to promote the rights of all.
What are the main elements of the treatment plan?
[top]
The treatment plan has two goals - to provide comprehensive care and treatment for people
living with HIV and AIDS, and to help strengthen the country's national health system.
The programme responds to the holistic needs of people at all stages of HIV infection and
attempts to slow progression and maintain the person at the highest functional level.
Voluntary counselling and testing (VCT) is a crucial entry point. Once identified as HIVpositive, patients will be assessed for the stage of their illness and referred into appropriate
medical care. The assessment will involve a CD4 count test and the patient's medical history
and status.
HIV-positive patients will enter into a system of care that monitors progress of infection. Care
will focus on slowing progression to full-blown AIDS and maximising health through prompt
diagnosis and treatment of opportunistic infections, periodic medical examinations and CD4
and viral load tests. They will be closely monitored for TB, a common opportunistic infection
associated with HIV.
At what stage, for patients, will ART be considered?
[top]
Patients who are symptomatic and/or with a CD4 count less than 200 will be counselled and
offered the option of antiretroviral therapy. They will be fully informed about the benefits of
restoring immune function and improving the quality of life and about serious side effects that
may result from treatment with these drugs. For those choosing antiretroviral therapy, CD4
and viral load tests will be done as treatment begins.
Patients will be treated at Service Points that have been accredited to provide antiretroviral
treatment and will be treated by health professionals who have been trained and certified.
They will receive psychosocial and nutritional support, as needed.
Community care and support services such as transportation, home-based care, hospice
services, etc., often provided by NGOs and CBOs, will help keep people in care and
encourage their adherence to treatment.
Nutritional support will be provided as part of this comprehensive care and treatment
programme.
When is it to be introduced; where; how it will be scaled up?
[top]
The goal of the programme is to establish at least one accredited service point in every
health district (in each District or Metropolitan Municipality) by the end of the first year of
implementation and within a period of five years to provide all South Africans who requires
comprehensive care and treatment for HIV and AIDS equitable access to the programme
within their local municipal area.
Some areas will be able to start sooner than others.
However we should all be aware that this is a complex programme with many elements
requiring cooperation of various role-players, inside and outside government - the actual pace
of change will depend on how well we all cooperate in implementing the plan.
Why is it being introduced in stages?
[top]
The plan calls for significant additional capacity in the national health system, in particular
strengthening human resource capacity and providing incentives to recruit and retain
thousands of health professionals in historically under-serviced areas. Over the next four and
a half years, over R750 million is proposed for upgrading systems in the healthcare
infrastructure in areas such as drug distribution, patient information systems and monitoring
of reaction to the drugs.
We must ensure the safe and effective use of antiretrovirals and other medicines; the care we
provide must be of the highest quality; and it must be accessible to all South Africans on an
equitable basis.
We will need a system for procuring the necessary drugs at the best price.
We will need to establish facilities - Service Points - of a standard that can provide the whole
range of required interventions: diagnosis, counselling, treatment of opportunistic infections,
other preventive and supportive strategies such as nutrition and nutritional supplements and
traditional and complementary medicines with immune-boosting properties as well as
antiretroviral drugs for the management of AIDS. A service point will be a group or network of
linked health facilities operating through a hospital or clinic in a defined catchment area.
Is there a role for traditional medicine?
[top]
Many people including those living with HIV and AIDS consult traditional health practitioners
and use traditional medicine to meet some of their health needs. We will work together with
these health practitioners to share experiences in the care of people with AIDS and they will
also serve as a critical resource in providing support and assisting patients to adhere to
treatment regimen.
Government is also committed to upscale research into traditional medicines that may in
future render further treatment options.
What is required for a health facility to be accredited?
[top]
The plan establishes standards for accreditation of service points. This will ensure that
comprehensive HIV and AIDS care and treatment of high quality can be delivered. There will
be technical assistance and financial resources to help service points meet the accreditation
requirements, with special attention paid to underserved areas of the country to promote
equitable implementation

The criteria defining the conditions at a service point for high quality care and
treatment include:

A service point project manager

A trained care team on site including clinicians, nurses, and counsellors,

Easy access to trained laboratory, pharmacy and nutritional staff, and links to NGOs
and other service providers

Standards of care according to the National Treatment Policy Guidelines

24-hours a day access to care at the service point, or in the vicinity

A staff recruitment, training and skills development plan for health care workers
responsible for HIV and AIDS care and treatment (including volunteers and lay
counsellors) based on initial needs and projected long-term patient numbers

Consultation, treatment and counselling rooms to assure patient confidentiality

Access to appropriate laboratory services, overseen by the National Health Laboratory
Service;

Adequate specimen preparation protocols

Secure pharmacy storage

Adherence to Drug Dispensing Standard Operating Procedures for Opportunistic
Infection prophylaxis and treatment, and ARVs

Access to patient nutritional status assessment and nutritional support

Links with VCT centres, antenatal clinics, Family Planning clinics, TB clinics, STI
clinics, TB/HIV demonstration districts, and any other patient referral facilities, to
ensure that HIV-positive patients are formally referred to the accredited service point

A PMTCT programme for service points providing antenatal care and a referral system
for sites without antenatal care facilities

Linkages with community resources and other support organisations that complete the
continuum of medical care and support services,

A system to track patients/treatments

A system to maintain medical records and transmit core data to a central data
collection point

24-hours post-exposure prophylaxis (PEP) access, according to the latest national
guidelines

Links with the provincial HIV and AIDS Unit

Participation in Information, Education and Communication activities.
What will be needed to ensure that all areas are serviced?
[top]

Strengthen human resource capacity by recruiting and retaining thousands of
additional health professionals; and implement a training programme for heath
professionals, including traditional health practitioners, as part of the accreditation
process

Upgrade our drug distribution system including secure facilities and training of
personnel who handle and dispense drugs

Strengthen the National Health Laboratory Service, including better coverage and
expansion in specific capabilities to perform the CD4 and viral load tests essential for
high quality HIV and AIDS care and treatment

Improve patient information systems

Strengthen the system which monitors the efficacy of drugs being used as well as any
adverse reaction to the drugs (pharmacovigilance)

Establish a research programme that will focus on practical questions and help us
better understand and improve the provision of comprehensive care and treatment
The programme will need an integrated national structure to manage and coordinate
implementation, incorporated within the existing national health system, and in particular
integrated within the prevention and education programmes.
How long will it take before people can access antiretrovirals?
[top]
Within a year there will be at least one service point in every health district and within five
years access to all who need it in their own municipal area.
Some areas will be able to start sooner than others, and each service point per district may
begin to operate as soon as it is accredited, and as soon as the drugs are available..
Has government made a u-turn?
[top]
In April 2002 after reviewing its approach to HIV and AIDS, Cabinet reaffirmed its
commitment to the Strategic Plan. Noting progress in the implementation of the Strategic
Plan, Cabinet decided on a number of measures to strengthen and reinforce these efforts,
including:

Intensifying efforts to remove systemic constraints on access to ARV drugs such as
cost and infrastructure

Strengthening partnerships, especially via strengthening of SANAC

Continued use of nevirapine in Preventing Mother-To-Child Transmission, and
development of a universal roll-out plan

Providing a protocol for a comprehensive package of care for survivors of sexual
assault, including post-exposure prophylaxis with antiretroviral drugs

Ensuring that no-one is turned away without appropriate treatment and management
of any infection or illness, irrespective of HIV status

Alongside poverty alleviation and nutritional interventions, to encourage investigation
into alternative treatments, particularly supplements and medication for boosting the
immune system
In July 2002, Government established a joint Health/Treasury task team to investigate issues
relating to the financing of an enhanced response to HIV and AIDS, including Anti-retroviral
Treatment.
On 8 August 2003 Cabinet received the team's report, which provided options for introducing
antiretroviral therapy. The Minister of Health was requested to present a detailed operational
plan in this regard.
An Implementation Task Team was set up, made up of South African experts and advisors
working with the Clinton AIDS Foundation. A summary of plan is available on SA Government
Online (http://www.gov.za/)
Why is this step being taken now -in particular why is ART being introduced now into
the public sector? [top]
The possibility of considering sustainable and effective antiretroviral therapy in the public
sector is a natural progression of the implementation of the comprehensive 5-year strategic
plan. A number of positive developments with regard to the constraints on such treatment
made this possible:

Continuing fall in prices because of new opportunities to manufacture some drugs in
South Africa; and successful negotiations with drug companies;

Increased international and local experience in combating HIV and AIDS

Growing appreciation of the role of nutrition in enhancing health and improving the
efficacy of medical treatment, so that people do not rely only on drugs.

The building of a critical mass in our country of scientists and health workers with skills
and understanding of the fight against HIV and AIDS, as a result of the implementation
of our comprehensive strategy over the past few years;

Initial steps towards strengthening our health system in relevant areas, though much
remains to be done in this regard;

More resources in the budget to strengthen the national health system and to pay for
the drugs and testing needed and to improve training and health infrastructure.

A better appreciation of the social dimensions of the pandemic, which allows policies
on health care interventions to be located within a broader social and health context
What will it cost to implement the plan? Is it sustainable?
[top]
The cost of implementing the plan is R296 million for the rest of fiscal year 2003/4, growing to
nearly R4.5 billion in 2007/8.
The budget is based on international tendering as the means of procuring drugs.
Total Programme Budget Estimate (Millions of Rands)
2003/04 2005/06 2004/05 2006/07 2007/08
New Healthcare Staff
21
322
432
662
1027
Laboratory Testing
20*
152
311
520
806
Antiretroviral Drugs
42
369
725
1118
1650
Nutrition
63
343
421
532
656
Other Health System Upgrades
70
171
184
160
160
Programme Management (National & 16
Provincial)
103
128
128
128
Capital Investment
30
75
100
100
0
Research
34
55
55
48
48
Total
296
1590
2358
3268
4474
*Note: Includes R20 Million advance payment to NHLS through March '04.
This enhancement of our response to HIV and AIDS has been designed to be cost-effective
and efficient without compromising quality. To ensure sustainability most of the budget will
come from government. This has been made possible by the sound economic policies
government has pursued, releasing resources for social spending. But where appropriate,
financing of the programme may be supplemented using donor sources.
Won't it take resources from other health care and social service?
[top]
The decision of Cabinet comes with new resources that have been allocated to fund it. It will
not detract from other programmes, whether in the fight against HIV an AIDS or in the
reconstruction and development of our society. In fact the strengthening of the health system
which is required for sustainable ART will bring benefits to health care more generally.
More than half the proposed total expenditure will go toward: strengthening the national
health system; emphasizing prevention; and promoting healthy lifestyles. These funds will not
only allow for delivery of comprehensive care and treatment for those infected with HIV - they
will improve the overall capabilities of the public health system and benefit all.
Why is the price of drugs important?
[top]
Two years ago this programme for comprehensive care and treatment would have been
impossible, amongst other things due to the cost of the medicines and laboratory tests
required. Falling prices internationally and new opportunities to manufacture some drugs in
South Africa; as well as successful negotiations with drug companies made it feasible to
consider such a programme.
The plan provides for a system of drug procurement that will secure drugs at prices well
below today's best international prices. In time South Africa will have its own production
facilities for these drugs.
What can ART do, and what are its limitations?
[top]
Many uncertainties remain and our knowledge of HIV and AIDS continues to evolve rapidly.
But we are better equipped now to ensure that the benefits of ART outweigh the risks, for
patients already in a desperate state of illness that has progressed beyond what can be
managed by other means alone.
There are important facts we should be aware of:

The new elements of the treatment programme will help extend the lives of those who
have reached the stage of AIDS - but antiretrovirals are not a cure

Not everyone who is infected with HIV needs antiretroviral treatment- the majority with
HIV can still live a healthy life, with proper nutrition, treatment of any diseases and a
responsible lifestyle.

Both health workers and patients should adhere to the strict guidelines - antiretrovirals
can have serious bad side effects and can be dangerous if not properly used, and the
treatment involves a life-long daily regimen.
Patients should be able to make an informed choice. Information will be provided to patients,
to explain the benefits, limitations and possible negative effects.
ART also brings great responsibility on health practitioners with regard to ethical conduct in
line with the requirements of the profession, concerning such matters as the rigour of HIV
tests, counselling, management of ARV prescriptions and so on
How will the ART impact on the comprehensive strategy?
[top]
We must not relax our prevention efforts, but rather sustain and intensify them so that we
reduce the level of new infections. The operational plan emphasises that prevention of HIV
infection is the bedrock of Government's comprehensive approach and makes provision for
integrating treatment and care with intensified prevention.
Most people infected with HIV have not reached the stage at which they require antiretroviral
medicines. But they do need access to treatment for opportunistic infections, so provision for
that treatment will be stepped up. No one should be refused treatment simply because of
their HIV status.
Since HIV thrives on a weak immune system, and in turn also weakens this defence system
of the body, proper nutrition for all South Africans and dealing with poverty remain critical in
the fight against HIV and AIDS. These social programmes of government will continue with
even greater intensity.
We will continue and intensify support to families and individuals affected by HIV and AIDS.
Together we must continue to fight discrimination and stigma.
Does the role of partnership change?
[top]
Success in the implementation of ART, as with every other aspect of our comprehensive
strategy will rely on partnership across society.
That includes communication of objective facts about the new elements of treatment and
about the spread of HIV infection and the impact of AIDS and its management. Creating false
expectations or an atmosphere in which society lowers its guard on matters of awareness or
change in lifestyle, or engaging in mutually debilitating contestation about what can be
achieved by when, could undermine not only the treatment programme but set back the hardwon advances made curbing the spread of HIV and reducing the impact of AIDS.
We must intensify every aspect of our comprehensive national programme. To do so we must
strengthen the partnership by joining hands in the war against AIDS
Through this enhanced care and treatment programme, government is adding to the nation's
armoury in the fight against AIDS.
A cooperative relationship among all sectors, particularly in the implementation of this
element of the comprehensive strategy, the spirit of letsema and vuk'uzenzele, a message of
hope and responsibility as well as constructive engagement in the realm of practical work
would ensure that South Africa advances even more decisively in this endeavour, which is
literally a matter of life and death.
Issued by: Government Communications (GCIS) 19 November 2003
STATEMENT OF CABINET ON A PLAN FOR COMPREHENSIVE
TREATMENT AND CARE FOR HIV AND AIDS IN SOUTH AFRICA
[Presented by Minister of Health, Dr Manto Tshabalala-Msimang]
Cabinet today in principle approved the Operational Plan for Comprehensive
Treatment and Care for HIV and AIDS, which it had, on 8 August this year,
requested the Department of Health to prepare. Amongst other things, the
Plan provides for Anti-retroviral Treatment in the public health sector, as part
of the government's comprehensive strategy to combat HIV and AIDS.
The meeting instructed the Department of Health to proceed with
implementation of the Plan.
It is envisaged in the Plan that, within a year, there will be at least one service
point in every health district across the country and, within five years, one
service point in every local municipality. Some areas will be able to start
sooner than others, and the Department of Health will keep the public
informed of the progress of the rollout.
These service points will give citizens access to a continuum of care and
treatment, integrated with the prevention and awareness campaign which
remains the cornerstone of the strategy to defeat HIV and AIDS.
Concretely this far-reaching decision of government will mean:
 Stepping up the prevention campaign so that the 40 million South Africans
not infected stay that way
 A sustained education and community mobilisation programme to
strengthen partnership in the fight against the epidemic
 Expanding programmes aimed at boosting the immune system and
slowing down the effects of HIV infection, including the option of traditional
health treatments for those who use these services
 Improved efforts in treating opportunistic infections for those who are
infected but have not reached the stage at which they require
antiretrovirals
 Intensified support for families affected by HIV and AIDS
 Introduction of antiretroviral treatment for those who need it, as certified by
doctors.
BUILDING CAPACITY
To deliver this kind of care across the country, with equitable access to all, will
require a major effort to upgrade our national healthcare system. This
includes the recruitment of thousands of health professionals and a very large
training programme to ensure that nurses, doctors, laboratory technicians,
counsellors and other health workers have the knowledge and the skills to
ensure safe, ethical and effective use of medicines.
Built into the implementation of this programme will be a massive public
education campaign so that patients will know what is expected of them. This
will include the provision of all the necessary information about benefits as
well as dangers of usage of ARVs, to allow patients to make an informed
choice.
Over half of the total budget that will be spent over the next five years in
implementing this programme will go to upgrading health infrastructure,
emphasising prevention and promoting healthy lifestyles. As such, the
implementation of this plan will benefit the health system as a whole.
Cabinet agreed that the funds allocated for this programme should be "new
money". The programme will and must therefore not detract from other
programmes of health care and provision of social services.
FAVOURABLE CONDITIONS
South Africa has reached this point at which qualitative enhancement of our
response to HIV and AIDS, within the framework of our five-year strategic
plan, is possible due to a number of factors. These include
 A fall in the prices of drugs over the past two years without which this
programme would have been impossible, including new opportunities to
manufacture some of these drugs in South Africa, as well as successful
negotiations with pharmaceutical companies
 New medicines and international and local experience in managing the
utilisation of ARV's and other interventions
 Growing appreciation of the role of nutrition in enhancing people's health
and efficacy of medicines
 The building of a critical mass in our country of health workers and
scientists with skills and understanding of the management of HIV and
AIDS
 The availability of fiscal resources to expand social expenditure in general,
as a consequence of the prudent macro-economic policies pursued by
government.
CENTRALITY OF PREVENTION
Government wishes to reiterate that there is no known cure for AIDS. We
cannot therefore afford, as a nation, to lower our guard. Prevention therefore
remains the cornerstone of our campaign.
The eradication from the body of the HIV virus remains beyond reach. The
mechanisms of HIV infections remain difficult to fathom, and the downhill
plunge of the infected, to severe immune deficiency over the next 2-14 years
is ill understood. The co-factors that are thought to mitigate immune
destruction of healthy CD4+ cells by the minority of infected CD4+ are still
uncharacterised. In the South African context the immune systems is
assaulted by a host of factors related to poverty and deprivation.
The Operational Plan places a high premium on strengthening prevention
efforts and it underlines the critically important messages of prevention and of
changing lifestyles and behaviour. These elements of our Comprehensive
Strategy remain the starting point in managing the epidemic.
At the same time, it should be noted that not everyone who is HIV positive
requires Anti-retroviral Treatment. As such, the plan also provides for
enhanced care for those who are infected but have not as yet progressed to
an advanced stage of AIDS.
At the same time, the challenges of home-based care, the campaign to
combat discrimination against those who are infected and affected remain
critical. So is the task of intensifying efforts to deal broadly with poverty and
poor nutrition.
STRENGTHENING PARTNERSHIPS
Progress in implementing the Plan adopted by government today will depend,
to a significant degree, on intensified mobilisation across society. Besides the
legion of non-governmental and community-based organisations who are
involved in constructive work in this regard, the media is an important partner,
as it has the potential to communicate messages of awareness and hope, and
to keep the nation accurately informed about the campaign against HIV and
AIDS.
A cooperative relationship among all sectors of society, particularly in the
implementation of this element of the comprehensive strategy, the spirit of
letsema and vuk'uzenzele, a message of hope and responsibility as well as
constructive engagement in the realm of practical work will ensure that South
Africa advances even more decisively in this endeavour.
The Comprehensive Plan for Treatment and Care carves out a future for
those infected with HIV, and for those suffering from immune deficiency;
whilst assisting the vast majority of South Africans who are HIV negative to
remain that way. The peculiarly South African nature of the problem demands
South African solutions; solutions contained within this complex and detailed
Comprehensive Plan for Treatment and Care.
Such an ambitious goal - targeting the immense complexity of the human
immune system operating within the environmental milieu of Africa predicates a multifaceted, integrated and intersectoral response in prevention,
treatment and care. The Plan is the final piece completing the jigsaw puzzle of
the National Strategic Plan for HIV and AIDS 2000 - 2005 whose four key
areas of intervention were: prevention, treatment, care and support; research,
monitoring and surveillance; as well as legal and human rights.
CONCLUSION
Cabinet wishes to express its appreciation of the work done by members of
the Task Team - including in particular experts and specialists from inside and
outside the country - whose contribution has helped shape this Plan. We are
confident that, as with our national prevention efforts, this Plan will rank
among the most comprehensive in the world.
Government is once more strengthening the hand of the nation in the fight
against HIV and AIDS, in keeping with its mandate to build a better life for all.
If correctly implemented this Operation Plan provides an excellent opportunity
to complete the treatment sector of the National Strategic Plan for HIV and
AIDS whilst also strengthening prevention. The challenge is immense but not
impossible.
We are confident that, together, bound by a people's contract for a better life,
we shall all continue to make progress in building South Africa into a land our
dreams.
There is hope!
Issued by: Government Communications (GCIS)
19 November 2003