HIV / AIDS Dual Therapy: Department of Health briefing

Meeting report

Prevention of Mother to Child Transmission (PMTCT) of HIV: Department of Health (DOH) briefing
Dr Nomonde Xundu, Chief Director, HIV/AIDS, stated that she would discuss the introduction of the new PMTCT Policy and Guidelines and the approaches that the Department had used previously with the same programme. The purpose of the meeting was to provide the Committee with information that was requested concerning the progress of the introduction of Dual Therapy for PMTCT.

The policy approach addressed four stages of intervention. It specifically addressed the issue of primary prevention of HIV especially amongst women of childbearing age. This was seen as the most sustainable approach to countering the spread of HIV/AIDS. The second stage included activities that focused on antenatal care. The third stage of intervention looked at activities during labour and delivery and the fourth stage focused on activities related to postnatal care and safe infant feeding.

The Guidelines stressed the importance of early booking of pregnant women, which involved a lot of social mobilisation and would allow them early access to Azidothymidine (AZT) and other antenatal care. Routine HIV testing was part of the health care package that was offered, as well as repeat testing at 34 weeks if the early HIV tests were found to be negative. The Department emphasised a programme called AFASS (Affordable, Feasible, Acceptable, Safe, Sustainable) through counselling on safe infant feeding. This was an area that the DoH struggled to include in policy as it was shrouded in inconclusive scientific evidence. The reality of the South African situation was that most of the women who utilised public health care facilities were those that did not have access to clean water and energy, and could not implement replacement feeding through infant formulas.   

With regard to the Anti-Retroviral (ARV)  aspect of the policy, the Department recommended Dual Therapy, which was an addition of AZT to the currently used single dose of Neviraprine. It was recommended that AZT be started at twenty-eight weeks of pregnancy or soon thereafter and preferably before the onset of labour. The infant would receive single dose Neviraprine plus the AZT for 7 to 28 days after birth, depending on how far the mother was with the treatment before labour. It was important to ensure that the mother and child received Cotrimoxazole, as it was used to manage and reduce the risk of opportunistic infections. The Department would look at nutrition interventions as well as other social security interventions such as registration and referrals for grants.

The Department aimed to present the public with adequate access to CD4 count testing for pregnant HIV positive women. All women who were found to have a CD4 count of 200 and below would be referred to the comprehensive planning and facilities. They would be made a priority and given ARVs as treatment to reduce the risk of transmission.

There were major developments that related to the addition of AZT to Neviraprine and the infant feeding policy. The implications were that there was a longer course of therapy, a more complex health support system was required, and there was an expected improvement in efficacy and a reduction in the risk of resistance development. Challenges included access to the programme, monitoring of the programme, the budget and communication on the protocol to be used.

Considerations for readiness of implementing agents to provide the service included having a facility manager, a trained team on site, adequate physical space, other relevant HIV and AIDS services and reasonable access to laboratory services.

A District-based approach was critical. For the programme to work, it would have to be driven by the district manager. The manager would map the current PMTCT services in each sub district, identify facilities for implementation of the new PMTCT Guideline, establish effective referral systems and support coordination of implementation.

Other factors to be considered were laboratory services, information management and research, communication and social mobilisation, the approach to training and provincial support.

Discussion
Ms C Dudley (ACDP) focused on the referral system. This area experienced many problems because there was a lack of transport. She asked what transport arrangements had been put in place for the system and how the present budget was covering the expenses. Monitoring and evaluation were essential. In terms of the capacity issues that were experienced, she asked if the Department was bringing in personnel such as doctors and nurses.

Ms S Kalyan (DA) wondered how Guidelines could be approved when the necessary infrastructure was not in place.

Dr Xundu stated that the Committee would not find the transport infrastructure and systemic intervention in the document that looked at protocol, even though there was an understanding of those challenges in the district health system. The provinces were the implementing agents and would work closely with district managers. All the issues that related to infrastructure and transport would be addressed as the sub district complexes were developed. Transport would be categorised under Access and Referral Systems. This included details on how the transport system would work. The Department would only know the specifics of the situation once provinces submitted their business plans. In terms of the budget, there were provisions made in relation to those activities.

Mr Thami Mseleku, Director General, DOH, stated that legislative and regulatory tools were needed in order for infrastructure to be developed. In general, policy would be developed and agreed on first, and an assessment would then be done on the extent to which the development of infrastructure was required. One needed to have the regulatory framework decided upon, so that provinces could implement the programme.

On capacity issues, there was a lack of Human Resources (HR). Therefore, all the HR strategies that were being employed to deal with the problem prioritised areas that needed immediate intervention. There was a range of mechanisms that attempted to deal with the challenges of HR capacity, such as improving the remuneration and conditions of employment, recruitment of foreign professionals and increased opportunities for training. The Department also engaged with professionals in the private sector to encourage a partnership so that the Department could ensure that the projects in the private sector were supported.

Mr Mseleku addressed the use of other health professionals and, in particular, nurses. The purpose of this strategy was to ensure that they were given the authority to do diagnosis and prescriptions. This would be accompanied by training. The Nursing Act was amended to include training. 

Ms Kalyan asked how many hospitals and primary health care centres there were in the country that were Comprehensive Care, Management and Treatment of HIV & AIDS (CCMT) hospitals,  and suggested a break down per province. Regarding the budget, outside funding was available for PMTCT. She asked where donor funding fit in and how it was utilised.

Dr Xundu did not know the specifics of the facilities available but said there were at least 380 CCMT facilities nationwide.

The Chairperson asked that the specifics could be given to the Committee at a later stage. 

Dr Xundu informed the Committee that the Department encouraged private and non-profit organisations  that qualified according to set criteria, to provide some services. Some services were supported by different donor agencies and the DOH provided PMTCT elements. Provinces were in the process of monitoring quality, reporting and alignment issues and were working with donor agencies. The Department aimed to ensure that they channelled the additional resources to an identified area of need to minimise overlaps. This was not a “free for all” approach.

Ms M Matsemela (ANC) asked if the structures for the New Strategic Plans on HIV / AIDS were in place for provinces and local municipalities. She asked if the Department could find an efficient way for all the provinces to provide them with business plans for conditional grants on time. She further enquired if the recommended policy guideline provided adequate access to doctors, pharmacy assistants and community health workers.

Dr Xundu responded that the Department was currently in the process of discussing the benefits of the provision for the additional 7% of the conditional grant to ensure the implementation of the programme. The Director-General would receive business plans for this particular guideline by 14 March 2008. This was discussed with the necessary health officials. Dr Xundu was aware that programme managers in the provinces were in the process of preparing business plans. The broader conditional grants business plan included the expanded Dual Therapy programme in PMTCT. 

Regarding the NSP, the Committee was reminded that Section 12 of the NSP spoke about the Government’s responsibility to implement the policies and to maximise the efficacy of the reduction of mother-to-child transmissions. The Department developed and approved this policy so that they could meet the requirements of Section 12 of the strategic plan. Provincial road shows were performed to assess the functionality of the structures and in most cases, the provincial AIDS Councils were found to be functional. Most local municipalities had AIDS Councils.

Mr A Madella (ANC) noted that the presentation did not focus on time frames for the projects. He asked when the programme would be implemented and when people would have access to dual therapy. The Western Cape was already engaged in the process of Dual Therapy. He wanted to know the extent to which the Western Cape’s activities were in line with the National Guidelines. The proposed PMTCT budget seemed a little confusing, as the Western Cape’s allocation was the highest, yet the Province’s HIV levels were the lowest in the country. He asked for clarification on this.

Mr Mseleku stated that the policy was passed and discussions were held with the National Health Council concerning the implementation and business plans in each province. The Department wanted some form of implementation from each province by May. The information on readiness would only be provided to the Committee after the business plans were submitted on 14 March. Therefore, the Department did not yet know the time frames for the programme.

Dr Xundu referred to the proposed PMTCT-MTEF budget in the presentation. She apologised to the Committee for an error made on the 2008/09 column in the table. The 2007/08 columns contained the historical allocation by provinces for their own PMTCT grants. The Western Cape was already in the process of implementing the Dual Therapy; therefore it was more expensive for this province to implement PMTCT. The large allocation was due to the fact that they were already implementing Dual Therapy. The National Department used that formula to apply the MTEF budget but was in the process of reviewing the figures and looking at questions of prevalence, population numbers and systemic requirements. However, the Western Cape, having  already implemented for the past three years, did not need as much for infrastructure as other provinces would. The Department was waiting for the business plans from provinces that would indicate the targets and expected budgets.      

Dr R Rabinowitz (IFP) noted that the reality was a long way away from the ideal. She wondered if the Department really believed that this project would work, given the current health system. She wanted to know what research was used to find the figures on the expected improvement in efficacy. She enquired if there was protocol in South Africa for combining Neviraprine and the different forms of feeding or combining Neviraprine and AZT. The District health systems were supposed to be up and running so that certificates of need could be distributed to people. She asked if the Department could provide the Committee with figures for the number of pregnant women that were being seen by clinics and provided with Neviraprine, as well as the number of infants who were HIV positive and being treated. She also wanted to know why the Department used such a complex feedback system when it added more bureaucratic obstacles.

Dr Rabinowitz informed the Department that she had tried for years to get mobile units to serve the people in Kwazulu-Natal with an AIDS programme. People were still without this service. She wondered how the Department would cope with all these problems.

Ms R Mashigo asked how long the training programmes were, and the level at which these were directed. She also wanted to know if mobile units were to be used in remote areas.

Mr Mseleku stated that one should always be positive about the programme, even though there were challenges. Having challenges did not mean that the policies should not be put in place. Policies were needed to show people how to deal with these issues. The ideal would be to have the information systems in place, but in the meantime the Department would do whatever it could to save a few infants. The evidence showed that the programme could save infants. The Department needed infrastructure to monitor and understand the programme.

Dr Xundu supported Mr Mseleku. If the country managed to implement the comprehensive plan then the health system would be strengthened. The research and evidence that the Department was working on showed that the use of AZT in PMTCT worked. The supporting evidence came from other African and international countries. There were challenges with infant feeding in the context of HIV, specifically in the rural areas. These areas needed intensive support so women would be able to breast-feed exclusively and engage in safe infant feeding. In terms of transmission rates, mixed feeding was the most dangerous.  

Mr Mseleku stated that it was critical for Members to remember that there was a system dictated to by the Constitution that explained the national and provincial responsibilities regarding feedback. If there were a unitary system in the country, the issue of the feedback structure would be averted. The National Department of Health was responsible for the policy as well as monitoring and evaluation, but the actual implementation of the programme was the provinces’ responsibility. It was for this purpose that the feedback structure was developed.

With the issue of mobile units, there was a sustainability issue. At some point, donor funding decreased or went away completely. The Department worked on the premise that the donor funding would go away, as that was the reality. This is why the programme was largely driven and funded by the Government. There was a very critical principle that was used concerning self-reliance.

Ms N Nkabinde (UDM) spoke about pregnant mothers who did not know their HIV status. She asked if testing would become compulsory. She also wanted to know if the therapy could be given to babies whose mothers were not tested as a preventative measure. 

Dr Xundu answered that the Department was not going the route of compulsory testing. They felt that women needed to volunteer to take the test because of the implications of the outcome of the test and the stigma that was attached to it. Babies whose mothers were not tested in advance could not just be given AZT, as this was not a drug without toxicities and complications. The Department was still unsure as to what they were to do about resistance development, but surveillance for resistance management was to be put in place.

Ms Kalyan stated that she was not happy with the DG’s response to why there was a Guideline without the necessary infrastructure in place. She explained that a needs analysis had to be done before the decision was made and a proposal was prepared. A projection of the necessary staff was not performed and yet there was a guideline. This meant that the Department was dependent on the provinces to do all the work. There was also talk of taking nurses away from active duty and training them for seven days. Hospitals were already short-staffed so she wondered what would happen to their other duties when they were sent to training programmes.  She wanted to know why a doctor in Kwazulu-Natal who took the initiative to find outside donor funding and got the medication to dispense Dual therapy was suspended. She also asked why the MEC for Health in Kwazulu-Natal had announced on National radio that AZT was toxic.

Mr Mseleku stated that the needs analysis was a planning exercise and not a policy making exercise. There was a need to change the policy in the country from single dose Neviraprine to Dual Therapy because it was evident that this was the policy that had to be implemented in order to effect better services. The Department aimed to ensure better results in term of the interventions. The policy was declared because it was a necessary policy. Policy making could not be based on planning exercises of other frameworks.

The issue around the doctor who was suspended was discussed. Mr Mseleku stated that the case was dropped. He said that the wrongdoing might not necessarily have been through the initiative that the doctor took, there could have been other issues that were related to it. There were clear principles of discipline in a system. It might have been a good thing for the doctor to do, but there were implications down the line.

Regarding the comments by the MEC in Kwazulu-Natal, Mr Mseleku stated that the comments could have been taken out of context. He pointed out that Dr Xundu had basically confirmed in this meeting that there were issues around the toxicity of the medication. People had the tendency to sensationalise certain issues. They should express their views responsibly. 

Mr Mseleku added that people had to accept that challenges within the Health system were large and continued to grow, due to the burden of the growing number of diseases. It was, however, necessary to look at what was being done with the challenges. The training programme  was a way of transferring skills and knowledge so that people could implement and adhere to certain standards. 

Ms Madumise stated that according to the Department, there was a patient treatment tracking system in place. She asked if this meant that the Department  would be able to locate patients anywhere and monitor if they were taking their medication. She also wanted to know if they would be able to locate thefts during transport of medication. Ms Madumise said that she was worried that small hospitals did not have the capacity to receive some of the services that the Department wanted to give them. She wanted to know how the Treatment Action Campaign (TAC) was used in those services and the comprehensive action plan.

Dr Xundu said that the tracking system was not in place yet, but it was a recommended requirement for provinces. The Department wanted to encourage provinces to strengthen the health system by making sure that it was put in place.

Dr Xundu added that the PMTCT programme was available in small clinics and the services were already being implemented where they were already in place.  

Mr M Sibuyane (IFP) was worried about how all the provinces would implement the policies. He asked how the DOH would ensure that the policies were actually practised. He also wanted to know what the Department was doing about the shortages in transport, nursing and midwifery.

Dr Xundu stated that the Department was not setting up a specialised unit, they were simply enhancing an existing programme and adding certain elements. They aimed to integrate the programme into other related activities, like care for pregnant women and family planning, so that they could use the current system more efficiently. Implementing the policies was about providing good quality services.   

Ms Dudley stated that it was a reality that nothing was working in the provinces. People were being referred but there were no means available to enable them to get to a particular service. It was her opinion that the Committee should make transport a major priority.

Dr Rabinowitz asked how many hospitals there were that were accredited to provide ARVs and how many would provide the Dual Therapy. She also wanted to know how the number compared with the amount the Department wanted to be accredited. She asked how many people were being treated with ARVs. Thirteen indicators were needed as a guideline to put people on to the therapy. She asked how many indicators needed to be present before Dual Therapy could be implemented.

Dr Xundu stated that the Department had a sense of what the current figures were and that they would be posted on the Departmental website in the near future. She stated that there were about 350 000 that were enrolled in the public health sector. In the private sector and Non-Government Organisations, there were about another 100 000 people enrolled on ARVs. However, the Department did not know how many people were still receiving ARVs.

She stated that the indicators were meant to monitor the programme; they were not conditions that were meant to be in place. Also, the plan was not to go the route of accreditation because it was a plan that was to be implemented to the best of the system’s ability. The DoH was adding an element to the current programme. The Department used the approach taken from the comprehensive plan. In the initial introduction of the comprehensive plan, with all of the complex elements, provinces would identify certain facilities that were needed in order to implement. There was a checklist with about thirty items that needed to be in place before the comprehensive plan could be implemented. The Department developed a strengthening plan for the facilities that they would implement. All the services were being implemented in the small clinics so they would not need to be accredited.      

Ms Matsemela wanted a comparison between women that were HIV positive with a CD4 count of 200 and below, and HIV positive women with a CD4 count of above 200.

Dr Xundu stated that the Department was trying to manage the women’s HIV disease and to reduce the risk of transmission. For a CD4 count above 200, the policy recommended that they be considered for dual therapy. CD4 count would be closely monitored. Women with a CD4 count of 200 and below would be made a priority.     

The Chairperson stated that the Committee would use the information provided to assess whether the Department was meeting its targets. The Committee would be the ambassador for the efficient implementation of the programme.

Ms Nthari Matsau, Deputy Director General, DOH, told Members that the Department had taken on a massive challenge in terms of resource requirements. They were driven by the belief that they could lessen the transmission rates.  She appealed to the Committee for support.

The meeting was adjourned.