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A TIME OF CELEBRATION

South Africa breathed an audible sigh
of relief last month when our cabinet
finally agreed to a national
antiretroviral roll out programme.
Apparently and correctly there is a real
sense of urgency to translate this into
numbers of people on treatment as
soon as possible. This is in keeping with
the World Health Organisation's target,

expressed on 1 December this year, of 3
million people on antiretroviral
treatment by 2005. The South African
approval for roll out has been dependent
on the provision of a plan that would
be acceptable to government. Happily
this plan, formulated in record time by

a task force headed up by Or Tony
Mbewu and with substantial input from
the C1inton Foundation experts,

required only a readdressing of
infrastructure support before being pronounced adequate.
Such a national plan, which has been based on WHO
treatment guidelines, means that there will be conformity and
consistency throughout the country and streamlines a number

of logistic issues such as staff training, drug procurement,
laboratory needs and evaluation procedures. This conformity is

ideal as long as the implementation plan is based on perfect
guidelines. We all know, however, that guidelines quickly
become outdated and irrelevant unless they undergo revision

as new data are gathered. However, there is a real danger that
as one plan is adopted the input from a diversity of protocols
and projects will be lost. In South Africa, as we put our energy

into the rollout of a single plan, we should continue to
encourage and fund pilot sites that will test new or different

strategies, such as different drug regimens, adherence

strategies, monitoring schedules, or even treatment strategies
such as intermittent therapy. Logistics such as methods of
drug and data management may also be varied. With adequate

evaluation and assessment. lessons learnt from these pilot
sites should then be used to modify the national programme

appropriately and ensure that our practice does not become
outdated and ineffectual. Critical to the success of the

national programme is an evaluation process that will quickly
identify shortcomings in the programme and enable

modifications to occur. It will also need to respond
dynamically to changes in the epidemic such as changes in

drug sensitivity, population targets, etc. Evaluation should also

be sensitive enough to allow quality assessment from site to
site, again enabling real-time modification and improvement.

An awesome task, but one that must happen and must

succeed.

How appropriate in this time of
celebration that Zackie and TAC have
been nominated for a Nobel prize I We
are immensely proud of this activist

organisation. In contrast. one
remembers how destructive and
obstructive the early US and European
activist community was. They appeared
to be passionately opposed to everyone,
especially the medical community. TAC
has worked with the medical
community towards a common goal of
care and treatment for the HIV-infected.

I guess this has been one good outcome
of a perceived obstruction from
government - it has united activists
and the medical community in a

common mission. TAC, together with
the AIDS LEw Project, has rationally and
cleverly used the excellent laws and

constitution of this country to move
this agenda forward, both in terms of

government policy and in relation to the pharmaceutical
industry. The recent settlement with pharmaceutical

companies on the Competitions LEw in this country is yet
another example of putting good laws to constructive use and

has resulted in benefit to the country as a whole.

Speaking of missions, wasn't it great to be united in music at
the 413664 concert recently held at Greenpoint stadium in

Cape Town] How spectacular to see South Africans really
caring about the plight of the HN-infected, and to see some

of those old (and a few new) rockers giving up time and
energy to make a difference. It wasn't about the quality of the

music, but the quality of feeling.

As we look back on the past year in South Africa, it is as usual
astounding to note the water that has flowed under the
proverbial bridge. I am reminded of a line in a one-person play

that I saw in New York some years ago in which it was said
that more happened in a day in Israel than happened in a year

in Norway' South Africa in its young democracy is a bit like
the former - but to the HN community the fact that

treatment is on the cards is undoubtedly the most exciting.
Roll on 2004, when we will actually see the treatment happen

and lives and communities be changed as a result.

We wish all of our readers a most wonderful holiday season,
and thank the staff at SAMA, Des and the staff at the HIV

Clinicians Society office for all their hard work, and also all the

contributors to the journals this year - we look forward to a
torrent of articles, papers and contributions in the new year!

Keep them coming!

UNDA-GAIL BEKKER
Managing Editor

THE SOUTHERN AFRICAN JOURNAL OF HIV MEDICINE ---------- NOVEMBER 2003 11