HIV/AIDS treatment in South Africa proves success in the poorest conditions

©: Sebastian Charles, 2002 Patient following the ART treatment in Khayelitsha, a township near Cape Town, South Africa. MSF initially committed to a five year programme to place 180 patients on antiretroviral therapy in a Cape Town township. However with the recent success in access to generic drugs used in the treatment, MSF has been able to cut the cost of treatment from $4.55 per-patient per-day to just $1.55. As a result, MSF will be increasing its capacity and will be offering ART to some 400 patients.
In Khayelitsha, South Africa, MSF is running an anti-retroviral therapy (ART) treatment programme where the results have been exceptional. Based on the results from the first six months of treatment to 177 patients in the programme, over 85% of the patients have responded with high rates of improvement. A pilot programme for MSF, the patients who are in the ART programme started with an immune response level so low that the results prove the possibility of ART treatment in even the most severe, and seemingly hopeless, situations. The number of people in the programme increases frequently and there are currently 220 people receiving ART care from MSF in Khayelitsha. An anti-retroviral treatment programme treats AIDS patients with drugs intended to reduce the HIV virus levels in their bodies. In tests, the undetectable viral load has climbed to 91%, indicating the HIV infection, although still present, has diminished and the ability of the body's immune system to ward off any attack from opportunistic infections has increased. An indicator for the treatment is the CD4 level of the patients, which measures the normal immune response of the body. The ART programme in Khayelitsha provides a triple cocktail of drugs - mostly generic. Patients visit the clinics every week in the first month and then once a month afterwards. Each time they are assessed by MSF staff and then given treatment. Poverty stricken setting Khayelitsha is a township just outside Cape Town, South Africa, with a population estimated between 400,000 and 500,000. The population is overwhelmingly poverty stricken and the choice of the township by MSF was in itself an opportunity to prove that an ART programme can be undertaken in even the poorest conditions in a primary health care setting. MSF started its project there in 1999. The ART programme started in May 2001. HIV and AIDS is a fact of life in Khayelitsha. Although there are no official figures, MSF estimates, based on HIV/AIDS test already conducted, that approximately 40,000 people have HIV/AIDS in various stages. Of these, only around 7,000 of them are aware of their condition. MSF has established a pilot programme where HIV/AIDS care and treatment is provided free to the community. The organisation has established three dedicated HIV clinics inside the existing public health facilities throughout the township where close to 3,000 HIV patients are treated for opportunistic infections. From these, a limited number have been placed in the ART programme. The present treatment capacity of the MSF project is 400 patients and, to date, 110 people have been included. Patients with HIV/AIDS are accepted into an ART programme based on medical criteria such as their CD4 level (which determines their ability to fight off deadly infections if not treated) and their clinical status, as well as individual traits such as their previous consistency in attending consultations as well as having a supportive home environment. Most AIDS sufferers die when their CD4 rates fall to such low levels that severe opportunistic infections, such as extra-pulmonary TB, cryptococcal meningitis and toxoplasmosis, can take hold and kill the patient. Severe opportunistic diseases are most prominent when CD4 rates fall below 200. An average healthy person has a CD4 rate between 800 and 1,200. Of the patients in Khayelitsha's first ART programme by MSF, the average base line CD4 rate was 48. In truth, these patients were simply victims waiting to die. South Africa has a population of 39.8 million people. Of these, 4.2 million are living with HIV/AIDS Source: UNAIDS2000
Treatment for the worst CD4 levels Around the world, ART programmes generally accept patients when the rates are below 250 (according to the new NNHS recommendations). In the USA, the standards have recently been lowered to allow patients with rates below 350 to be accepted (previously the rate was 500). However in Khayelitsha the numbers of people at either of these levels were so large it was not a feasible criteria for admittance. The organisation chose to take the worst cases as the first choice. A strategy that could have been disastrous for the programme had the patients been too frail to be helped. Admittance to an ART programme is no guarantee of survival. To date, eight people in the MSF programme have died. However, given the low levels of the CD4 in the group, it is likely that 50% of the group would have died within a year without treatment. Instead the results of the first group have proven the feasibility of ART treatment at even the worst stages of HIV/AIDS development. The numbers from the South Africa project are preliminary - based on the first six months of treatment - but the results are still remarkable. On average, the CD4 rates have increased by 128 points per person, bringing everybody to a level close to 200. The success rate in the first session, measured by their undetectable viral load in their blood, is 91%. The difference for the patients means these people are now able to have a more active life. They have had an average weight gain of 8.2 kg and are able to be active members in their community - even take on work. Without treatment, their only choice was to wait to die from an opportunistic disease. Change in the community Providing care has also changed the way HIV/AIDS has been perceived in the community and reinforces the argument that testing must go hand in hand with treatment. "There are some 7,000 people who know they have HIV/AIDS in Khayelitsha," said Dr Goemaere, who leads the MSF Khayelitsha project. "Now there are 22 support groups and different organisations like TAC (Treatment Action Campaign), and awareness programmes in the township." "As long as there was no treatment, people never got tested. The introduction of treatment has been a trigger to get tested. It is a community wide reaction. Before the introduction of the programme, there were less than 500 HIV tests per year. Now more than 14,000 tests are done per year.