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A CRACK IN THE DAM
WALL

I feel optimistic! I think that there
is at last light at the end of the

tunnel, and ART access for all the
HIV-infected people of South

Africa may just be coming into
view. We have a lot to do! To date,

despite the World Health
Organisation call for expanded

access, the South African public
sector has had very limited

access to antiretroviral agents.
For ART to have an impact on the

South African epidemic, where it

is estimated that 5 million people
may already be infected, it will be

necessary to establish care

structures in the communities
that carry most of the disease

burden. Implementation of a

national HIV treatment

programme is likely to require a
variety of reproducible delivery

models to seNice areas with

different levels of care and

infrastructure. There is an urgent
need to investigate the various

models of ART delivery available

in public sector settings in South

Africa in order to estimate our

national human resource,
training and infrastructure

requirements more accurately.

This operational research is an amazing opportunity to inform

not just ourselves but our continent and the rest of the world.

There is real recognition that while there are lessons to be learnt

from the developed world our situation in the developing world

is different. and we need to find out what is applicable in Africa,

culturally and logistically - time is running out

In order to carry out this type of research it is often necessary

to provide ART to a group of research volunteers or people

recruited onto programmes for a defined period of time.

However, researchers find that drug supply for such research

poses a catch-22 situation. A recent editorial in Science

describes the difficulty that has become central to the ongoing

funding of operational research, about which a debate has been

raging in the USA. Funders have previously not provided the

drugs or the finance to purchase ART. The US National Institute

of Health has recently encouraged research on the best ways to

deliver ART to developing

countries, but it is concerned that

the cost of drugs for such studies
would swamp its research budget
A draft policy from NIAID, the

AIDS division of the Institute,

states that the cost of purchasing
drugs would severely restrict the

Institute's research capacity by
limiting the number, scope,

duration and focus of its
international HIV-related research

activities. The Institute is also

concerned that it would be
unethical to stop treatment when

the trial ends. The editorial in

Science quotes Professor Bruce
Walker from Massachusetts

General Hospital in Boston as

saying that a limited period on

drugs is better than none, that
the NIAIDS policy is less than

visionary, and that it is stifling

research since it is obviously a tall

order to expect the researchers to
come up with the drugs

themselves. The policy has

resulted in long waiting periods

before these projects can be

undertaken, while pharmaceu-

ticals and NGOs are wooed into

supplying drugs.

South Africa has a number of

internationally approved grants, where building infrastructure

and implemen ation costs are paid for but funding for ART

remains outstanding. Most of these projects involve innovative

research that will teach us much abou ART delivery models and

operational issues around drug delivery. Researchers are now

trying a variety of well-worn avenues to obtain drugs so that·

their research can go forward. It was refreshing and

encouraging to hear recently that at least one major funder,

Secure The Future from Bristol Myers Squibb, is calling for

operational research proposals investigating ART provision and

that they will provide treatment Let us hope that others will

overcome the difficulties and follow suit. Obtaining these drugs

and initiating these projects will be instrumental in breaking

down some more of the obstacles to a national ART roll-out in..': .

South Africa.

L1NDA-GAIL BEKKER
Managing Editor

TH!: SOUTHtRN AFRICAN JOURNAL OF HI M!:OICIN!: ------------ MAY 2003 11