ARV ROLLOUT

Helen Schneider, Centre for Hea1lh Policy~ School of Puhli£ Heabh, UnivemLy of che WU'WGteTSTand, Joho.nnesburg

JaDles Mc::Intyre, Perinatal mv Research UniI, Chin Hani Baragwa7UUh Hospi.raJ, Sowew, Gauteng

NOVfMHfR 2003

are implemented in a manner that benefits the health

system as a whole and builds equity. A programme of ARV

access also has to grapple with the challenge of ensuring

that people take drugs several times a day, every day, for

the rest of their lives. Poor adherence rapidly leads to the

emergence of drug resistance and treatment failure at the

individual level. If resistance develops on a wide scale, this

will have broader public health implications. Obligations on

the part of individuals to adhere have to be matched by

obligations on the part of the health system to ensure

continuous access to uninterrupted supplies of drugs,

skilled providers and laboratory support able to maximise

the safety and efficacy of drugs, and a supportive

environment for adherence. Unfortunately, the margin for

learning through failure is narrow.

THf SOUTHfRN AFRICAN JOURNAL OF HIV MfOICINf ----------

This article reflects the outcomes of a Seminar hosted by

the School of Public Health and Perinatal HIV Researdh

Unit, University of the Witwatersrand, 0!1 Friday 1

August 2003.

SUMMARY OF PROCEEDINGS

Challenges were discussed from all these perspectives
during the course of the seminar, with the purpose of

specifically addressing the health systems challenges. The

seminar deliberately did not address two key aspects of the

scaling up procurement: provision of affordable drugs, and
the mobilisation of financial resources for the

implementation of a programme, as these were being

debated in other fora.

SCAlING UP THE USE OF
ANTIRETROVIRAlS IN THE PUBLIC SECTOR:

WHAT ARE THE CHAlLENGES?

On 1 August 2003 the Wits School of Public Health and
Perinatal HIV Research Unit hosted a l-day seminar on the

challenges to scaling up access to antiretroviral therapy
(ARV or ART) in South Africa.

Highly active antiretroviral therapy (HAART, also referred to

as ART or ARVs) makes a dramatic difference to the survival

and health of people living with HIV. At present only about

1 000 public sector users in South Africa have access to

ARVs through a series of small-scale projects across the
country. Greater access to ARVs could change the lives of

millions of people. It could also bring with it large new

investments in the health system that, if properly planned,

could address systemic weaknesses as well as strengthen

less resourced areas. It is imperative that these investments

The meeting was attended by 130 people, representing a

wide variety of backgrounds and including such diverse
role players as people involved in pilot programmes

successfully delivering antiretrovirals in poor communities
(including a neighbouring country) and those involved in

the roll-out of the mother-to-child transmission

prevention [PMTCT) programme and the national

tuberculosis programme, and the implementation of the

Termination of Pregnancy Act



A number of projects have shown that these challenges can
be confronted on a small scale within the public sector,
such that the benefits of ARVs far outweigh the risks

associated with them. South Africa has a health care
infrastructure that has proved that it is capable of
providing chronic disease care, most notably for

tuberculosis. Scaling up access to ARVs through this system
is not outside the bounds of imagination. However, the TB
programme and the implementation of the Termination of

Pregnancy Act and PMTCT programme provide evidence
highlighting the fact that a programme of universal access

to ARVs will require performance from our health system at
a level and scale far higher than at present. It means

addressing key weaknesses, such as the inadequate staffing
and support of primary health care facilities,

demoralisation and flight of health care workers from the

public sector, inequities in access to facilities, drugs and
other forms of infrastructure, and poor relations between

users, communities and the health system. The experience
from neighbouring Botswana is that the challenges to

scaling up lie in two areas: health system capacity

(particularly human resources) on the one hand, and
stigmatisation and inadequate demand for services on the

other. The need for communication and community

mobilisation emerged as a key theme across all

presentations at the seminar.

Ultimately, to be successful, an ARV programme must face

the complexity of transforming relationships - it must
appreciate its role as one of innovation, of 'thinking out of

the box: It can only do so by mobilising all available

expertise and energies across the country, both inside and

outside government. Given its significance, it is imperative

that all South Africans participate in the process of

discussion and debate about how to implement an ARV

programme.

PROPOSED PRINCIPLES FOR SCALING UP

ACCESS TO ARVs

1. A policy on widespread access to ARVs can only succeed

if it fully mobilises the existing health system. It should

form an integral part of the continuum of HIV care through

the public primary health care and hospital system, co-
ordinated by district, provincial and national management

structures. This does not preclude a degree of

'exceptionalism' and vertical programme arrangements,

under very specific conditions; nor does it exclude the

possibility of co-ordinated action between public and

private sectors where this is deemed relevant at local level.

2. An ARV programme integrated into the health system,

however, will not succeed if it is regarded as a simple 'add-

on' to the multiple functions and activities already

performed by the health system. Additional resources must

NOVEMBER 2003 ----------

be provided, particularly in the range and numbers of
skilled personnel at facility level, but also in support
systems. New ways of managing existing resources need to

be developed.

3. The massive additional investment in health systems
brought about by an ARV programme provides a unique

opportunity to strengthen the health system as a whole.
Improvements in systems, such as drug supplies, access to

laboratory services, referral, and staff training and support,
should be structured to strengthen quality and access for
all health conditions. An ARV programme should be seen

as an opportunity to address fundamental problems, such
as the public sector human resource crisis and provider

attitudes and values. It should not be implemented at the

cost of other essential health programmes.

4. An ARV programme should not deepen the inequities in

our health system. Ultimately, it must be judged by whether
it succeeds in reaching the most remote and disadvantaged

areas of the country. This may mean special measures to
build the 'capacity to benefit' from an ARV programme in

disadvantaged areas. This would require investment in

basic systems and infrastructure upon which a continuum

of HIV care, including ARVs, can be built.

5. Existing public health and HIV treatment initiatives in

South Africa provide useful models for the design of an

ARV programme. Experiences with the procedures, systems
and infrastructure of the national TB control programme

can inform an ARV programme. They include

standardisation of treatment, registers, monitoring and

evaluation processes and the particular combination of

vertical support and horizontal implementation. Existing
ARV projects suggest that an ARV programme integrated

into a broader HIV care treatment service can be configured

in the same way as other chronic disease programmes, as

nurse-based follow-up with adequate doctor support

6. Alternatives to the main approach to tuberculosis care,

namely 'directly observed therapy', however, are needed if

the stringent adherence requirements of ARVs are to be
achieved. The evidence from pilot projects is that high

levels of adherence stem from a new kind of contract

between providers and clients. This contract is premised on

very high levels of understanding or treatment literacy on

the part of users. It requires the establishment of explicit

support systems for users and community mobilisation and

advocacy processes that promote the rights of people living

with HIV/AIDS. The responsibility for adherence is given to

the client him/herself, but occurs within a clear framework

of empowerment, a period of treatment preparedness and

the building of trusting relationships with providers. This is

very different to the traditional paternalistic and passive

relationship between health care workers and patients, and

THE SDUTHfRN AFRICAN JOURNAL Of HIV MEDICINE



making the change represents the key innovation challenge
of an ARV programme. Central to this relationship are the

front-line providers, who have to be won over to the
purpose, content and process of an ARV programme.

7. How an ARV programme is implemented is as important
as the whotof the programme. To build the levels and scale
of performance required of an ARV programme

necessitates an innovative approach to implementation.
Task teams developing guidelines and procedures at
national level alone will not achieve the rapid buy-in and

change required at all levels of the system. Political
management, in the sense of actively building common

visions, is as important as technical design. We therefore

propose a set of sub-principles to govern the
implementation process:

• The planning process should be as inclusive as possible.
It is important that the voices of all stakeholders with

insight and an interest in the implementation of an ARV
programme be represented in defining the vision and

principles of the programme. These include line and
programme managers at national, provincial and

local/district levels; clinicians and others involved in

pilot ARV programmes or who have shown that they

can provide good quality HIV care in the public sector;
front-line providers, NGOs and activist groupings

involved in community mobilisation; and researchers
who can support monitoring and evaluation. Donors

and external consultants, while clearly important

stakeholders, should not dominate the process. The

roles and responsibilities of all these role players need

to be discussed and agreed upon.

• The process of implementation needs to be supported
by a rigorous and creative communication strategy

aimed at preparing and ensuring the buy-in of all who

will be implicated in the process of implementation. Its

aim would be to develop a common vision and

understanding, as the foundation for action.

• Top-down planning should be combined with bottom-
up processes that harness local energy and stimulate

initiative. The need for defining clear outcomes and

standardisation must be balanced with flexibility in

programme implementation at local level. It also

requires designing an implementation strategy that

involves constant engagement with the periphery in

iterative processes of learning and problem solving, of

learning by doing.

• District and facility actors are much more likely to take
up the challenge of an ARV programme if they can

witness it being done in other districts and by other

actors. Horizontal processes of interaction will lead to

more effective learning tr.an instructions from the top.

A key aspect of implementation must be to promote

NOVfMBER 2003 ----------

networking between actors already involved in HIV

treatment programmes and those wishing to develop

programmes in their areas.

• An incremental, step-wise process of building capacity
for ARVs needs to be defined. Building blocks such as
the establishment of a good follow-up, 'wellness'
service for people with HIV, evidence of community

mobilisation and support groups, voluntary counselling
and testing and laboratory infrastructure need to be

spelt out Support strategies need to involve not only
training but also mechanisms for developing

infrastructure and systems at facility and district levels.

• While certain aspects of implementation need to be
standardised, local people should be given some choice
and flexibility in the content and pace of

implementation. This includes front-line providers,
users and community members who are the ultimate

implementers of policy. We propose, in the first

instance, a process of voluntary accreditation, in
which facilities and their community and district level

counterparts apply for the right to distribute ARVs. The
onus will rest on them to prove their ability to do so

and will be formally assessed through an accreditation
process where clear criteria are spelt out These districts

could then form learning partnerships with others in

the process of horizontal learning described above.

Obviously, such a process would require co-ordination
and management to ensure that equity is maintained.

• An ARV programme is one necessary and important
component of a wider social response to HIV/AIDS in

South Africa. The HIV epidemic represents both a crisis
and an opportunity for the country - currently in the

midst of profound and dynamic transformation. In this

context, a commitment to scale up the introduction of

ARVs must be viewed alongside a measured and multi-

dimensional approach to HIV - one founded on a
renewed commitment to prevention and to a broader

social response· to the structural conditions that

influenc'e vulnerability to HIV.

FINAL COMMENT

South Africa has the potential to generate a model

approach to the introduction of ARVs that has relevance

and application to the wider sub-Saharan region. As
unprecedented external funds are made available to
support and facilitate this process, effective co-ordination

and providing clear direction around the care components

of the ARV-health systems approach is essential. In this

context, there is a need to balance effective partnerships

and the generation of creative responses on the ground

with a comprehensive vision for the systems required to

sustain such an ambitious intervention in the long term.

THf SOUTHERN AHlICAN JOURNAL Of HIV MfOlCINf