Antiretrovirals give new hope and new life to South Africans

The long-awaited antiretroviral roll-out improves morale; at last there is hope for HIV/AIDS patients.

Much of the inspiration for the province's rollout programme came from MSF, which opened three HIV/AIDS clinics in the impoverished Khayelitsha township in May, 2001. The clinics currently follow up nearly 6000 people with HIV and on April 29 admitted their 1000th patient to antiretroviral treatment amid celebrations. An extra 60-100 people each month are brought into the treatment regimen, which is backed up community educators and counsellors.

The GF Jooste hospital stands as testimony to South Africa's past health-policy failings and offers a glimmer of hope for the future.

Situated a stone's throw from Cape Town's thriving international airport, the hospital serves an estimated 1.5 million people in the city's most violent and impoverished townships. The average age of death of female patients on the 84-bed medical wards is 35, with males just over 40. Some 60% of all patient deaths are HIV-related, often due to tuberculosis complications.

The hospital deals with 6,000-7,000 casualty cases each month ... and many of the sick have to wait more than 24 hours for a free bed. A high local incidence of hypertension and diabetes adds to the problems, according to Vanessa Burch, head of the medical unit.

But a short distance away from the chaotic triage centre, is a quiet, tastefully decorated haven that dispenses antiretroviral drugs to a small but growing number of AIDS patients. The clinic, which opened last December thanks to a grant from the Nelson Mandela Foundation and the South African Medical Association, is currently treating about more than 90 phase IV patients and accepts new admissions by the week.

"This really was the hospital where people used to come to die; it was like a hospice", senior registar Kevin Rebe told The Lancet. "But now 85% will leave alive. We now see patients coming in who are severely unwell and they get better."

"40-50% of all admissions into the medical ward have AIDS. Before we couldn't deal with it; now we can start to try", he said.

Rebe said the advent of antiretroviral treatment led to a massive boost in staff morale, and even prompted some hospital employees to admit their HIV-positive status despite the continuing stigma that usually forced staff to seek treatment where they would not be recognised.

Scenes such as those at GF Jooste are slowly unfolding at hospitals throughout South Africa as the government's rollout programme struggles to its feet. With more than 600 people dying of AIDS each day, the health ministry estimates that about 4,000 people have so far benefited from antiretrovirals. About half of them are in the Western Cape province, which is by far the most advanced.

The Western Cape hopes to reach 6,000-7,000 people within the next year, says antiretroviral coordinator Nevilene Slingers--although she stressed that this is still a drop in the ocean. In the catchment area of GF Jooste alone, about 15 000 people are in urgent need of treatment.

Much of the inspiration for the province's rollout programme came from Médecins Sans Frontières (MSF), which opened three HIV/AIDS clinics in the impoverished Khayelitsha township in May, 2001. The clinics currently follow up nearly 6,000 people with HIV and on April 29 admitted their 1000th patient to antiretroviral treatment amid celebrations. An extra 60-100 people each month are brought into the treatment regimen, which is backed up community educators and counsellors.

WHO last year chose the MSF programme as a model of best practice in the implementation of antiretroviral treatment at primary health level in resource-poor settings.

"We have no magic bullet", said MSF spokeswoman Marta Darder. "We are learning as we go along." Thanks to the organisation's work, increasing numbers of Khayelitsha residents are willing to be tested; mother to child transmission has been slashed; and the three MSF doctors have acquired hero status among those whose lives have been transformed.

"Many people in the government say that poor people are too stupid to undertand how to take the antiretrovirals", commented Bulelwa Nokwe. "We love these drugs. We never forget to take them. This is the most important thing to us. Like air."

Those accepted for therapy must have a CD4 count of less than 200, no alcohol or substance abuse, and a stable domestic environment conducive to compliance with the treatment regimen. Unlike MSF, GF Jooste does not insist that patients tell a family member or partner because of the risk of violence in a society which still hasn't accepted AIDS.

Rebe said he expected a 10% complication rate from antiretroviral treatment because many patients are very sick with tuberculosis, pneumonia, and other HIV-related infections by the time they are admitted. The waiting list for treatment extends for several months--too long for many.

"A lot of people will die while they are on our waiting list before they get access to treatment", said Rebe with a sad shrug.