Impact of HIV/AIDS on Women and Girls: hearings

Meeting report

JOINT MONITORING COMMITTEE ON THE IMPROVEMENT OF QUALITY OF LIFE AND STATUS OF WOMEN
25 September 2001
GROOTE SCHUUR HOSPITAL AND THE DEPARTMENT OF HEALTH ON RAPE AND HIV AMONGST WOMEN

Chairperson: Ms P Govender (ANC)

Documents handed out;
Department of Health Presentation
Groote Schuur Hospital Presentation

SUMMARY
Delegations from the University of Cape Town working with in conjunction with Groote Schuur Hospital, and the Department of Health, were invited to report on the current position of women and girls in the Republic as far as rape and the spread of HIV/AIDS were related. In addition, the committee were informed of initiatives underway to improve the position of women in these situations.

MINUTES
Groote Schuur Hospital Presentation
Mrs Van Der Spuy introduced the members of the delegation. Professor Dennie ran the rape programme at the hospital and had designed protocol that had been used in the Western Cape and throughout the nation. Professor Bessor dealt specifically with issues relating to HIV, and it was said that he would cover this aspect in the presentation. Professor Coetzee was an obstetrician and would answer any questions posed by the floor. The meeting was then handed over to Professor Dennie.

Professor Dennie explained that she would deal specifically with tertiary health care from the aspect of a gynaecologist. Wider issues relating to the impact of HIV would not be covered because she was aware that the committee had been made aware of these aspects in previous presentations, and the hospital concurred with many of the opinions that had already been given.

From a clinical perspective, HIV had changed the face of the medical practice. This was through the introduction of a whole range of new diseases in women, and the need for the treatment of them. This was a very challenging and complex situation. A large number of women suffered from severe complications as a result of the sexually transmitted diseased (STD’s). This was because they would only present themselves at the hospital at very advanced stages of the disease. Thus in order to save them, it would require highly trained specialists and better medical services. Because Intensive Care Units were overloaded, patients were usually not admitted. As a result, Groote Schuur Hospital was of the opinion that it would be essential to maintain resources in order to provide treatment to those that were seeking it.

The hospital was anticipating an increase in the instances of cervical cancer in HIV infected women. However, this disease is curable with the right treatment. As a result, a policy giving women three free pap smears in a lifetime was to be introduced. However, there might still be need to find a different approach. However, this initiative was very important because this cancer was very common amongst women, and its importance had been severely downsized. Thus as an increase was anticipated due to AIDS, it would be necessary to obtain resources and equipment in order to treat patients. Although HIV was not curable, the hospital felt that the provision of expensive treatment to treat curable diseases such as cervical cancer should be complementary to primary health care.

Professor Dennie then explained that violence and rape against women were very important issues. She referred to a ‘Speak Out’ article that highlighted the occurrence of the crimes, and said that comprehensive controls for rape victims had been developed. Data has now been computerised and is currently under analysis, and out of this data certain factors had been established: -
- the majority of women do not report instances of rape
- only 50% of the victims come to hospital within 24hours of the crime
- over 40% of women that are raped are raped by more than one man
- women are frequently raped on the way to and from work
- rape is usually accompanied by the use of great violence
- 15% of women are sodomised during rape
- approximately 1 in 10 000 are killed during rape
It is therefore be essential to expose rape victims to post exposure anti-retroviral treatment (PEP) after rape as these women were at a high risk of catching the virus. This treatment has been provided for the past 2 and a half years. However, only 20% of the women returned for follow up so she could not comment on the effectiveness of the treatment on a large scale. She added that a large tracking system was being started in order to obtain proper information relating to PEP.

Professor Dennie said that a Provincial Rape Task Team was training personnel to deal with the matter. There is a standardised training manual, which she hoped would be adopted nationally in order to provide holistic care for women that were raped.

She then said that although her presentation had been rather superficial, she hoped that it highlighted the fact that tertiary institutions had an important role to play. She proposed that: -
- anti-retroviral treatment was offered to women
- tertiary institutions were maintained in order to provide treatment
- prioritising the screening of cervical cancer
- adopting policies for rape victims
- initiating a national multidisciplinary approach led by and prioritised by government.

She concluded by saying that in her opinion rape was a ‘national emergency’. It was for this reason that prevention and rigorous treatment of STD’s was necessary, because only then would serious illnesses and consequences be prevented. This needed a mass campaign by government. In addition, well-designed research would be necessary in order to contextualise the needs of the people. She hoped that this would be encouraged and rigorously promoted.

Discussion
Ms Magazi (ANC) wanted clarificationon PEPE.

Professor Dennie explained to her that it was the concept used to explain the situation where a patient exposed to HIV was being given anti-retroviral treatment. A study in France showed that the rate of transmission was lower in women who received the medication in comparison to those who did not receive it. This was because as the virus became accessed to the body, the treatment would prevent it from getting a hold of the body if it was taken within 24hours. She felt that it was important to give the treatment to rape victims. In addition, Groote Schuur Hospital had two documented cases where HIV could only have been acquired during rape. One was a 12year old virgin, whilst the other was a 70year old woman who had not had intercourse for over 20years. Tserved to illustrate the importance of that factor.

Ms Magazi (ANC) asked for clarification regarding the relationship between HIV and cervical cancer, and why only the cancer could be treated.

Professor Dennie explained her that although cervical cancer was treatable, HIV was not. Thus although it could be possible to spend a lot of money treating the cancer, it would not be possible to give anti-retroviral treatment in an attempt to cure aids. She added that this was a complex issue for the hospital, which was well aware of the irony.

Ms Magazi (ANC) wanted to know why medication was given to pregnant women in the Western Cape to cure HIV.

Professor Dennie explained that this medication was given in order to prevent the transmission of the virus to the baby. She said that this was offered to rape victims, but was in no way an indication that there was a cure for the virus in the Western Cape. This is because treating HIV and stopping the transmission of the virus were two completely different things.

Ms Magazi (ANC) asked why HIV was not a notifiable disease like Tuberculosis (TB).

Professor Dennie said that the incidence of TB varied amongst communities.In the worst areas 500/10000people had the disease. However, in 1996 311/1000 were raped in the Western Cape. This indicated that there were more prevalent cases of rape than of TB. However, only TB was treated seriously, and she felt that this approach was incorrect.

Mr Govender (ANC) thanked Professor Dennie for her presentation on behalf of the committee. The presentation was then handed over to Professor Bessor.

Professor Bessor began his presentation by giving some background information. He said that it had been established in an Antenatal Survey carried out in 2000 that 25% of the childbearing women in South Africa were infected with HIV. Graphic representation of this indicated that this situation was worsening every year. He said that screening women who went for Antenatal care produced this information. However, the Western Cape had the lowest prevalence of the virus in South Africa, with a figure currently sitting at 8%. Graphic representation of this showed that Kwa-Zulu Natal, on the other hand, had a figure of 30%. This meant that the Western Cape was at the tip of the iceberg, and that it would be necessary to act now in order to have any impact. This was because the disaster in Kwa-Zulu Natal was difficult to manage as it stood.

Professor Bessor said that HIV was responsible for more deaths in pregnancy than any other medical conditions. This information was provided by a Report on Confidential Enquiries into Maternal Deaths in South Africa conducted in 2000. He highlighted this by referring to a newspaper article on 28 November 2000 which stated that AIDS was now the number one killer of women in pregnancy. Effective interventions would make a difference, and that this was the role that anti-retroviral treatment had to play.

Professor Bessor then mentioned treatments that were known to work against HIV. Without treatment, between 25% to 40% of women would transmit the virus to their babies. ACTG 076 had worked in the USA, dropping transmission rates by 8%. The Thai Regimen had a 9% success rate, whilst Nevirapine in Uganda had a 13% success rate. In addition, an elective Caesarian section combined with AZT treatment would reduce rates by 3%. The non-detectable Viral Load could reduce rates if it was available. He then focused on the elective caesarean sections saying that it would work if used. A meta-analysis study and a European Collaborative Study indicated that a 50% reduction in transmission would occur where the C-Section was conducted before the onset of labour. In addition, a 50% reduction in the subsets of women both treated and untreated with the anti-retroviral therapy was possible. However, he noted that the result of this treatment would be greater infectious morbidity. In addition, the treatment was expensive and exposing the women could actually leave them worse off.

Professor Bessor stated that the alternatives to breastfeeding were another option. It was a fact that there was an accumulation of evidence demonstrating that HIV was transmitted through breast milk. An increased duration of breast-feeding was associated with higher rates of transmission. In addition, breastfeeding from HIV positive mothers had a 14% to 29% risk of infection over 1 to 2 years. The higher rate was associated with sero-conversion of the mother during breastfeeding. It had been reported that exclusive breastfeeding was safe, based on a study conducted in Durban. However, it was important in the context of South Africa to look clearly at what was possible, that is, to find alternatives to formula feeding that were safe. As a result, he could not say that all women should formula feed because they were still in search for the answer and he did not want to mislead the committee.

Professor Bessor said that the unequivocal support of the government with education programs, health promotion activities, and community action would make a difference. Such policies in Uganda cut the rates by a half, and in Thailand the control of HIV rates was now falling. He hoped that the meeting today would steer development in the right direction. The University of Cape Town was working with Groote Schuur Hospital in the context of providing services to HIV infected women. There were activities that had been initiated by National Government. In addition, activities initiated by the Western Cape were of importance. By April 2002, it is expected that there will be 95% coverage of all women seeking antenatal care. This is in comparison to other provinces, which have only just begun such policies. He added that the initiatives by the University of Cape Town were also significant. The Peninsula Maternal and Neonatal System (PMNS) involved an integrated network of Maternity Obstetric Units (MOU’s), district hospitals, and tertiary care centres, such as Groote Schuur Hospital. The triage found that HIV was not a homogenous condition. Criteria for cites of care were established and providers were trained to screen patients. This is because it was realised that HIV was not a single condition. In addition, they tried to create a screening mechanism in order to identify low risk and high-risk patients. This was in an attempt to control morbidity because it was not possible to hospitalise all sick individuals.

Professor Bessor then mentioned the programs that had been initiated in hospitals. These applied to mothers to be. Graduates of the Maternal HIV Clinic at Groote Schuur Hospital returned after delivery to serve as mentors for pregnant women. They provided health education and emotional support. In addition, adherence to anti-retroviral treatment and medical therapy was encouraged. Mentors would benefit form the sustained relationship with the structured medical service. There were also programs to encourage women in the post-exposure Prophylaxis Study. The Bristol-Myers "Secure the Future" funded project was introduced. Voluntary counselling and testing would be offered to women with unknown HIV status after delivery. In addition, anti-retroviral treatment would be offered to the baby starting in 24 hours of life. Transmission from mother to baby would then be evaluated.

There was a program named MIRIAD (Mother Infant Rapid Intervention at Delivery), which involved a CDC/PACTG study. There would be HIV counselling and testing in labour. Anti-retroviral therapy was given to the mother during labour, and there were initiatives for formula feeding. There was an additional program at the University of Western Cape known as MTCT. MCTC Programmes were for HIV infected pregnant women. The programme was taught at UWC in June 2001, at which 35 delegates from 5 provinces representing doctors, district and provincial health managers, nurses and counsellors were present. The focus was on program development and implementation and monitoring and evaluation.

Professor Bessor concluded his presentation by setting out the strategies in progress. They included access to testing and treatment facilities, educating and empowering women, and reducing maternal morbidity. Future strategies included more effective anti-retroviral therapy to reduce transmission to less than 2% as in the USA, keeping mothers healthy after delivery, and supporting families.

Mrs Van Der Spuy added that they had not mentioned preventing AIDS. In the UK 70/1000 teenage pregnancies were of girls up to the age of 19 years; 50% of them aborted their babies. In the USA this figure stands at 50/1000 girls. However, in Holland the figure is 4/1000, and she said that the difference lay in education. The average age of first-time intercourse in Europe was 17 and a half years. This was because of programmes where young people were teaching each other. The concept involved taking medical students to talk to their peers. In her opinion, if STDs were prevented, this would go a long was to preventing HIV. Girls are more vulnerable than boys because boys would sleep with younger girls, whilst girls would sleep with older men. She concluded by mentioning a study that showed that only 15% of women knew when they fell pregnant. This meant that the system was failing somewhere along the line, and thus meant that it would be necessary to equip young people in order to prevent the spread of the virus.

Professor Coetzee added that he had learnt that in order to make a difference, it would be necessary to begin locally. Having done that, it would be possible to identify highrisk individuals who needed the treatment provided on tertiary levels. This had to be combined with a programme of primary to tertiary care. In addition, by considering the health of the family, it would be necessary to care for the mother as well. There had to be continuation of care for the mother otherwise there would be failure in reaching the ultimate goal.

The Chairperson then welcomed the Department of Health. She invited Dr Kamicheti to introduce her team, and she explained that they would be focusing on issues dealing specifically with the question of how South Africa would address the issue of the HIV and its impact on women. They would also indicate how the budget addressed this issue. In addition, the team would suggest how to deal with the scourge of rape.

Presentation By The Department Of Health
Dr Kamicheti, Deputy-Director General: Department of Health introduced her team: Mborechewe and Mr Lekola from the HIV directorate.

Mr Lekola began by reminding the committee that it was the prevalence rate in South Africa that assisted the Department in policy development. It had been discovered that 24.8% of all the women that attended antenatal clinics in 2000 were HIV positive. There was an infection rate between 8% and 36%. To him this was a cause for concern. He outlined the the determinants of the epidemic. These include the history of South Africa in terms of apartheid. The societal dislocation mitigated the increase. Inequity throughout the country perpetuated the increase. Microfactors, such as wealth, income distribution, and culture all had a role to play. The socio-economic factors such as migration, urbanisation and mobility. And lastly women’s rights and their status in the community.

Mr Lekola discussed the impact of the epidemic on the following. The household ;more households are headed by children; loss of income; diverted income to medical expenses; it leads to a burden on families (ie burial etc). Psychosocial impact – it was traumatic for children and for society. Education – the impact on secondary schools led to dropouts; high vulnerability with regards to teachers. Most importantly women – low status in society causes them to be further outcasted; less economic power; survival practices such as ‘survival sex’ (prostitution); carer provider roles (will men be carers?)

Mr Lekola explained that these factors all led to the development of how to address the issues. He said that it was realised that there was a need for a 5year strategic plan, developed in consultation with other stakeholders. The plan looked at prioritising by intervention. This was in terms of prevention, treatment, human rights, monitoring and focusing on the youth. The goals of the 5year plan were to reduce the transmission of HIV especially in youth, and to reduce the impact of the epidemic on society and on families.

Mr Lekola went on to say that as far as prevention was concerned, this required an improvement in the management and control of STD’s. In addition, it would be necessary to promote safer and healthier sexual acts. Mother to child transmission needed to be reduced. There would be provision of treatment in health centres, communities and to children and orphans. He added that this made it necessary to create a supportive social environment, and a legal and policy environment. He ended by saying that there would also be promotion of vaccine development, and the conduction of regular research.

He laid out the strategies for Prevention. The Department was looking to ensuring proper management through training, and ensuring the provision of drugs. The focus would be particularly on women. However, it would be necessary to treat both parties in a relationship. In addition, the provision of female condoms had been initiated, and 342 000 had been distributed to date. Male condoms were also provided and that 250 000 000 had been distributed. It would also be necessary to reach out to other populations.

As far as treatment was concerned, he said that guidelines on infectious diseases had been developed and circulated, and that these had led to proper management. Drug literacy had been provided. In addition, home community based care was to be introduced, and district teams would be established in order to perform this function. He pointed out that 95% of the carers were women and that it would be necessary to involve men in the strategy. The provision of and integrated strategy for children infected by AIDS was being undertaken as a joint strategy with the Department of Social Development. Medical sites had been set up for voluntary counselling, as it would be necessary to move away from the stigmatisation of the disease.

Mr Lekola then explained the initiatives as far as intervention. Violence Against Women campaigns had been started in conjunction with the Department of Social Welfare in 3 provinces, in an attempt to assess whether the plan was viable. There was a special gender unit in the Department of Health. The Department was also dealing with Church groups focusing on care and support.

With regards to research, he said that they were looking into the prevention of transmission from mother to child, the drugs that were in development, and the issue of HIV and TB.

Mr Lekola concluded by mentioning the challenges facing the Department. The National Department HIV Chief Directorate had a budget of R212million. Most of this was for communication strategies. An amount of R7million was put aside for the provision of female condoms. Empowerment of women was sponsored by the Danish government, which had given R100million for 3years. He ended by saying that R14million would deal with childcare.

Discussion
Mrs Pandor (ANC) referred to the first presentation and asked what the limitations of research on the effectiveness of drug treatment were. In addition, she wanted to know if there were any side effects from the drug treatment given to child through mother.

Dr Kamishrati said that unfortunately she had not had the opportunity to look in detail at the presentation made by Groote Schuur Hospital. Thus it would be difficult to comment on the presentation. However, she was able to say that it would be necessary to look at what happened after breastfeeding, as this became a crucial issue.

Many pilot sites had been created. The initial results showed that this issue had to be looked at in further detail later on because many issues arose from the consideration of it.

Mrs Pandor (ANC) wondered whether the Western Cape budget was managing with regards to the drug programme. If indeed it was managing, why was the budget failing on a national scale?

Dr Kamishrati said that it would be useful to ask the Western Cape to provide figures on their budget and its impact. Thus it was difficult at this stage to make any comment.

Mrs Pandor (ANC) wanted to know why HIV was not classed as a notifiable disease such as TB. In addition, she wanted clarification with regards to the position of PEP treatment for rape victims.

Mr Mborechwe said that the Department was making efforts to make HIV a notifiable disease. However, much opposition had been met with from human rights institutions, for instance. As a result, this was a difficult issue and would take time to resolve.

Dr Kamishrati added that this debate was being looked into and further discussion would be conducted around it. As far as PEP, she said that studies had shown that the issue needed to be looked at further.

Mrs Ngwenya (ANC) said she was excited to hear that women would be getting condoms. However, she was disturbed by the fact that more male condoms were distributed, because it was men who did not take the use of condoms seriously. She stated that this situation required speedy action in order to encourage women to use the condoms, and she felt that it was a Department error that female condoms were not introduced firstly, given that women were dictated upon.

Mr Lekola told her that the Department was trying to increase the availability of the female condoms throughout South Africa. Initially piloted the distribution of the condoms, but that they would definitely increase distribution, and also reach the rural areas. He said that the women would be educated and their partners approached.

Dr Kamishrati added that, having started with the pilot programmes, user friendliness was found to be a major problem. Nevertheless, the actual cost of production was also huge. Thus the Department took the decision that there needed to be a roll out. The issues raised had been noted and they would continue looking at further distribution.

Mrs Ngwenya (ANC) asked how speedily the condoms were supplied.

She said she was scared of the budget because it did not mention rollovers. She commented that the Department not forget the needs of the rural community because they also needed a share of this money.

Dr Kamishrati responded by saying that the figures that had been given in the presentation represented only the budget of the National Department of Health. This in no way reflected what was actually spent on HIV and AIDS, because it did not indicate what was spent in every other department, or on treatment and care in hospitals. She reiterated that the figures given represented a very small proportion of the total amount spent.

Mr Mborechwe responded that the Department was doing its utmost to control spending issues. Rollouts would arise from many factors and these were being looked into. However, at this stage he could safely say that there was no roll over in the budget, and that the spending was adequate.

Dr Kamishrati said that it would suffice to say that usually there was a lag time, but once the programmes were rolling, the issue of rollovers would not be a problem.

Ms Botha (DP) wanted to know what percentage of the budget was allocated to HIV, and whether it was sufficient for the national epidemic.

Mrs Botha (DP) mentioned that a previous presentation had suggested that condoms be supplied to schools. She wanted to know the Department position on the matter. In addition, she felt that something had to be done about the sizes of the condoms because they were not sufficient for schoolboys.

Mr Mborechwe said that there had been complaints relating to the sizes of the condoms. Thus there was consideration in this regard, and the issue of smaller sizes was still and idea in the pipeline. However, he added that things were looking towards that direction.

Mrs Botha (DP) asked how the availability levels of the condoms were. She wanted to know what would happen if condoms ran out.

Mr Mborechwe said that it was the duty and responsibility of the individual provinces to supply condoms to public outlets. The matter was entirely upon their shoulders. However, national government would supply provinces with the condoms, and would try to see to it that there were no stock outs.

Mrs Botha (DP) asked what the Department was doing towards education people because it was essential to remove the stigma attached to HIV and AIDS.

Mr Mborechwe said that programmes had been undertaken to provide awareness.

Ms Govender (ANC) said that a key part of the programme was ABC (abstinence, be faithful and condomise). However, she felt that women could not insist on either of those aspects, thus treatment would be of paramount importance.

Dr Kamishrati said that the key message was that prevention was the best strategy. It would be wrong to focus on treatment. This is because it was the responsibility of the Department not to allow ABC to be a barrier for women. Thus any programmes initiated had to address this issue.

Ms Govender (ANC) wanted to know what position the Department had regarding mother to child treatment.

Dr Kamishrati said that this could not be confined to anti-retroviral treatment, and that it was necessary to deal with the effects of the diseases, (for instance, looking at treatment of opportunistic infections such as TB). By strengthening the programme, and separating anti-retroviral treatment itself, the issue of affordability on a large scale would be raised, and the Department would argue that it could not afford such practices. They were awaiting the decision of a current court case dealing with the side effects of anti-retroviral treatment.

Ms Govender (ANC) mentioned the issue of the budget. Amounts given were far below the estimated R2.7billion needed to comprehensively tackle the issue. Costs in relation to treatment were a major issue, and she wanted to know whether the Department was taking this matter seriously.

Dr Kamishrati said that the article in the Weekly Mail that gave this information was a report leaked at the very first draft of research into HIV. Information was not discussed in the Department. In addition, she said that first draft figures were usually rougher that the norm, and that although that figure represented costs for treatment, it was more refined now. Theirs was the basis of ongoing discussion with the Department of Finance, and that until a public announcement was made on it, she would not be able to make any further comment on the budget. She concluded that it would suffice to say that HIV programmes were given the utmost support.

Ms Govender (ANC) said that she wanted a position regarding the current court case in terms of the World Health Organisation and the part it was playing.

Dr Kamishrati replied that she was not totally certain of the question and thus would not attempt to answer it.

Ms Govender (ANC) referred to home based care. In terms of a project that the committee was involved in, the invisible labour of women added to their existing burdens. She wanted to know whether this had been looked at in terms of the implications it had on health and poverty, for instance.

Mr Lekola said that the plight of women had been looked at. It had been recognised that women were actually coming in to report their stories. The Department was trying to provide a stipend to those women, and to equip them with self-help schemes, and to involve them in income generating programmes. In addition, they were currently looking into psychosocial support.

Ms Govender (ANC) thanked the team for the wonderful presentation. She added that she was hopeful that steps were being taken to improve the situation.

The meeting was adjourned.