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From Despair to Hope: Providing Antiretroviral Therapy in South Africa
A letter from South Africa
June 1, 2001
This article is part of the Summer 2001 issue of the MSF Alert newsletter.
In 1999, Massachusetts native Toby Kasper volunteered in the New York office of Doctors Without Borders/Médecins Sans Frontières (MSF) with the Access to Essential Medicines Campaign while he was working as an HIV treatment educator at Gay Men's Health Crisis. He took up his current post as Access Campaign Coordinator in Cape Town, South Africa, in March 2000. Kasper writes from Khayelitsha, a large township outside of Cape Town, where MSF supports a government program to prevent mother-to-child transmission of HIV and has just launched a pilot antiretroviral treatment program.
As a young American growing up in the 1980's, I considered the repressive South African apartheid regime to be one of the world's great evils. Like many others, I greeted the news of Nelson Mandela's release, and later the advent of a multiracial democracy, with joy. However, it took coming to South Africa as an MSF volunteer for me to understand that the horror of apartheid had not disappeared. A new scourge, AIDS, had appeared in its place.
The first time I went to a township funeral, I was amazed by how normal it seemed to everyone there that the language developed to challenge apartheid was being reused to bury a comrade felled by HIV. The thrill of victory over racial repression has worn off, replaced by the recognition that another struggle is necessary, this one against the devastation being wrought by AIDS. This time, the goal is to create a society in which people living with HIV/AIDS receive the same medical care as do those living in Brazil, Europe, and North America.
MSF's project in South Africa is bringing hope to a dire situation. Our project is small. We work in just one of Cape Town's townships, Khayelitsha (pop. 500,000), where we support a government-run mother-to-child transmission prevention program and have set up clinics that provide care to people with HIV/AIDS. We have recently introduced antiretroviral therapy that, in wealthy nations, has turned AIDS from a death sentence to a chronic disease. The vision of this project is clear: in addition to improving and extending the lives of our patients, we seek to demonstrate that it is possible to provide treatment in a resource-poor setting, and in the process, develop a model that is replicable in similar settings around the world. Our goal is to break down the "medical apartheid" now dividing South Africa.
Our approach has stimulated much debate. The idea that it is possible and necessary to provide treatment for people with HIV/AIDS in a setting such as Khayelitsha is still heretical to some. Pharmaceutical companies try to defend high prices by insisting that even if drugs were free, they could not be used for lack of infrastructure. Some "AIDS experts" say prevention programs are more "cost effective" than funding treatment. And government officials, fearful they will not be able to reach everyone in need overnight, refuse to begin even pilot projects.
We have developed a comprehensive program to address all aspects of the use of antiretroviral therapy. Most importantly, we work to ensure that we have the support of all local stakeholders: provincial health authorities, medical staff at our clinics, the NGOs with whom we work, and most importantly, our patients, most of whom knew little about antiretrovirals before the project began.
Community participation has been a vital component of one of the most difficult aspects of our project, the selection of which patients to place on therapy. We require that each patient considered for therapy meets strict medical criteria. A pool of 1500 people with HIV have already visited our facilities, and competition for the limited number of treatment slots is fierce. Unfortunately, we will only be able to enroll 180 people this year.
Every two weeks, members of the community counselors, nurses, and doctors, as well as people living with HIV, meet to select candidates to be placed on therapy. All candidates are presented anonymously. Not a pleasant task, but one necessitated by limited resources. Faced with this daunting undertaking, the community members have impressively helped the project get off the ground successfully.
Antiretroviral therapy alone will not turn around the HIV/AIDS epidemic in Khayelitsha. Community involvement will. In a culture in which HIV infection is still stigmatized, demonstrating that HIV can be a chronic condition, not a rapid death sentence, can lead to a change in attitude, perception, and behavior, as antiretroviral therapy has already done in countries with widespread access to medicine.
In a country where there has been little incentive to get tested for HIV, we believe the availability of treatment will encourage people to learn their status. As an HIV-positive Khayelitsha woman said when we launched the program, "I believe that the availability of treatment will help people come out and seek help at the clinics. I think that it will encourage people to go for HIV testing simply because now there is help available."
If her hope of treatment becomes reality, this will be our contribution to reducing the horror that HIV/AIDS has visited upon this society.