IN THE HIGH COURT OF SOUTH AFRICA TRANSVAAL PROVINCIAL DIVISION Case No. 21182/01 In the matter between: TREATMENT ACTION CAMPAIGN First Applicant DR HAROON SALOOJEE Second Applicant CHILDREN'S RIGHTS CENTRE Third Applicant and MINISTER OF HEALTH First Respondent MEC FOR HEALTH, EASTERN CAPE Second Respondent MEC FOR HEALTH, FREE STATE Third Respondent MEC FOR HEALTH, GAUTENG Fourth Respondent MEC FOR HEALTH, KWAZULU-NATAL Fifth Respondent MEC FOR HEALTH, MPUMALANGA Sixth Respondent MEC FOR HEALTH, NORTHERN CAPE Seventh Respondent MEC FOR HEALTH, NORTHERN PROVINCE Eighth Respondent MEC FOR HEALTH, NORTH-WEST Ninth Respondent MEC FOR HEALTH, WESTERN CAPE Tenth Respondent _______________________________________________________________ AFFIDAVIT _______________________________________________________________ I, the undersigned HERMANN REUTER do hereby affirm and say: 1. I am a Medical Officer working in Khayelitsha at Nolungile and Michael Mapongwana Day Hospitals. I have worked at these hospitals since April 2000. 2. I qualified as a Medical Doctor from Stellenbosch University in 1991 and have since worked in public Hospitals in Namibia, Gauteng, the Eastern Cape and Western Cape in urban and rural settings. 3. I am a member and volunteer of the Treatment Action Campaign (TAC) and was the Western Cape Provincial Co-ordinator for TAC during 1999. 4. My present work is to provide medical treatment to HIV infected adults and children at a specialised Infectious Disease Clinic. 5. At the moment I have about 800 adults and 50 children (all living with HIV) under my direct care and do about 450 consultations per month. 6. I have also participated in some of the meetings of the Khayelitsha AIDS Task Team (a joint management team of provincial and local government health facilities), have conducted some training workshops for nurses and doctors on management of HIV, and have assisted in some of the monitoring of the MTCT program. 7. I have read the Supporting Affidavit of Dr PN Simelela. I believe that I have the necessary experience and expertise to reply to some of the allegations of Dr Simelela, particularly those about the Khayelitsha MTCT project. 8. It is important to note that although thirty-two percent of my adult patients are directly referred from the existing MTCT program only two out of the fifty children are infants who were infected despite the participation of their mothers on the MTCT program. 9. All the mothers of the other children with HIV did not have access to MTCT, either because they did not give birth in Khayelitsha, or because they gave birth before 1999, when the MTCT program started in Khayelitsha. Of the 50 children with HIV/AIDS, the majority acquired their infection in the last five years. 10. I believe this illustrates clearly how it is possible to dramatically reduce the number of consultations of children with HIV by implementing a MTCT program. 11. I agree with Dr N. Simelela that one needs a phased approach of implementation of a major public health intervention. That is how MTCT is being implemented in the Western Cape. 12. However, in my view and experience, Dr N. Simelela fails to provide the framework for such implementation in her supporting affidavit or anywhere else for that matter. In the Western Cape, a clear framework exists for roll-out and coverage – 50% of women with HIV are already covered and the program will reach 90% by April 2002 and near-complete coverage a year later. 13. Dr Simelela elaborately describes the government program as one of research and training at the pilot sites a. She provides no evidence of a systematic national training plan. b. The 'research' component, described at paragraph 42 is also misleading. The first component of data collection, described by Simelela as Level 1, is not research but a routine management tool. c. Furthermore I notice that although the new sites have only recently started they have already come up with the same "findings" learnt at pilot MTCT sites in Khayelitsha since 1999 – e.g. need for private space for counselling, need for re-arranging priorities of staff. d. I believe the third tier of research involving specialists (e.g. into viral resistance to Nevirapine) could happen at specific research sites even while provinces provide the full MTCT service. Resistance will only be monitored at two of the 18 research sites according to Simelela. 14. I attach a paper by Dr. Saadiq Kariem and Dr. Maylene Shung-King of the University of Cape Town delivered in June 2000 on the "Lessons and Challenges of the Mother-to-child Transmission Program in Khayelitsha, Western Cape, South Africa." Dr. Kariem is the secretary of the African National Congress Health Committee chaired by the First Respondent. At paragraph 7 of the paper, Kariem and Shung-King outline the "challenges of implementation and how these were overcome". ("HR1") Ad Para 29 15. Dr N. Simelela states that the sentence of the WHO MTCT guidelines "the implementation of the ARV drug regimens (including Nevirapine) could be recommended for general implementation" does not take into account operational and implementation issues. She goes on to say that it specifically relates to the efficacy and safety of the drug but later goes on and questions this in paragraph 82 – 116. 16. She also points out that her department cannot provide a VCT service even in selected sites although it was already policy of the government in 1994 as a priority to "Develop STD/HIV counselling and support services at all CHCs by end of 1999" (A National Health Plan for South Africa p85; see also Five year Strategic Plan for STDs and HIV, 2000-2005) 17. In the Western Cape access to MTCT has been seen to have broad acceptability. In Gugulethu 89% and in Paarl 95% of clients accept HIV testing after counselling. You could not wish for a more effective VCT service. Clients agree to HIV testing because they get offered a way to prevent their child from contracting a deadly illness. They understand that, it seems Dr Simelela does not. The high take up of HIV testing shows how MTCT can assist with other priority interventions such as VCT that the HIV/AIDS Directorate has failed to implement so far. 18. As a medical professional it saddens me tremendously to witness distraught mothers after I have informed them that their child is HIV positive and that the child contracted the virus during childbirth. Their usual response is, "but the sisters checked my blood". On my question what tests did they do, the mothers ask, "don't they check for everything?" I have to answer, "No, they check for syphilis, sugar diabetes and your blood group". However, HIV, the most common complication of pregnancy does not get tested. The mothers don't understand, "I even had a PAP smear" or "but why does the government then always publish the statistics of HIV rate at the maternity units?". Ad Paras 37 & 38 19. Scarce resources are given as the reason for implementing "learning sites first". However, Dr Simelela does not outline the Department is going to overcome the problem of scarce resources of providing medical care for HIV infected children, whose HIV infection could have been avoided. Sibongile Mazeka (referred to in the affidavit of Thembisa Constance Mhlongo pp 481-484), who died of AIDS on 11 September 2001, was in hospital 14 times in her last year of life, and two times in ICU – at tremendous cost. Ad Para 43 20. In this paragraph, Dr N. Simelela, lists information that must be collected by the pilot sites. I believe that the collection of this information, whilst necessary, should not hinder implementation. In Khayelitsha, when the MTCT program started there was an HIV prevalence rate of about 16%. It has now risen to 22%. This is frightening. There is no time to first study what the poverty levels are (43.1.2) and what the literacy levels are. Nurses do health education everyday – HIV health education does not require a better knowledge of the literacy levels of our clients. We already knew that the incidence of TB was 0,8%. But these statistics do not change the urgency of addressing the biggest health crises. And, you do not need doctors with special obstetric or paediatric skills (43.2.4.5.). In fact you need no doctors at all to implement MTCT. Yet you do need doctors to treat children with HIV. Ad Para 47 21. Admittedly, there is a lack of staff to implement MTCT. But this is not restricted to MTCT. If you would question any public health services in South Africa you would find a lack of staff. In the past two years in Khayelitsha, we have lost three senior professional nurses, two professional nurses, seven enrolled nurses and two enrolled nurse assistants in the local government clinics alone, but this does not lead to arguments that TB treatment only take place at pilot sites. 22. Dr Simelela alleges at 47.2 that nurses mentioned problems with the confirmatory HIV test. The rapid tests were pioneered in Langa, in a program to integrate HIV and TB management. They used the Abbot Determine test as screening test and the Gaiffar Instant Screen as confirmatory test without any problems. We have taken over the same tests in Khayelitsha and have, without any problems, accurately tested both adults and children. However when the tender board allocated tenders to all our astonishment they tendered for the Smartcheck test. We immediately reported problems with this test and asked for reviewing of the tenderboard decision but our pleas fell on deaf ears. As a result, nurses now resort back to the Elisa testing at three times the cost and which again poses the problems of having to draw blood for the patient and the fear of needle stick injuries. Ad Para 55.2 23. In this paragraph Dr N. Simelela attempts to explain why implementation of MTCT is possible in the Western Cape, but not in the other provinces. She states "that the Western Cape has been able to employ the services of fully paid lay counsellors through funded NGO's". This is misleading and mistaken. The Western Cape government asked Lifeline, an NGO, to supervise the counsellors employed in Khayelitsha and also at the roll-out sites. However their monthly salary of R1500.00 comes from the provincial government's budget. Why is this impossible in the other provinces? There are numerous NGO's including Lifeline that would be prepared to do the same in other provinces. Ad Para 57 24. This paragraph also gives a misrepresentation of the Khayelitsha program and I would like to correct several mistakes made by Simelela. a. Midwifes do not follow up the children until they are six or nine months old. The nurses in the baby-clinics do that. b. Formula feeding has been extended to nine months, as Simelela alleges, but not because of 'malnutrition'. Formula feed has been extended to ensure appropriate nutrition and to give the mothers an incentive to be followed up for nine months until the first HIV test was done on the child. Indeed, mothers were asking for getting the formula milk for longer. It is important to note that exactly the same issue will present itself in areas where mothers are encouraged to exclusively breastfeed for three months, and then switch to formula feeding? In any event, any infant at risk of malnutrition regardless of HIV status are entitled to nutritional supplementation under the national PEM (Protein-Energy-Malnutrition) Scheme. 25. Anecdotally I can report that when visiting Sibongile Mazeka in Conradie Hospital before her death, I walked through the ward and examined the folders of the many malnourished children. All of them were HIV positive. Not a single one was malnourished because of being on the MTCT program. I have not heard of a single HIV negative child that had to be hospitalised for either malnutrition or diarrhoea due to formula feeding on the MTCT program. 26. It is regrettable that Dr. Simelela only visited the Khayelitsha MTCT site for the first time to respond to the court papers. During the most difficult times of the implementation program and when staff ingenuity and commitment was tested, this program did not receive assistance or support from Simelela's program. In my view, this was not a visit to learn but a fault-finding mission. Ad Par 67.2.1 & 80 27. Again Dr N. Simelela chooses to misrepresent the MTCT program of Khayelitsha. The Khayelitsha program was never set up as a research site. It was set up as a pilot site to spearhead a roll-out to other areas as tasked by the previous Health Minister Dr Nkosasana Zuma in 1998. Only in 2000, when it became apparent that the health department was altering its previously professed aims, did we start putting an effort into collecting data to show the success of the program. 28. The Khayelitsha AIDS Task team then discussed whether to do PCR tests (rather than Elisa) on all the babies at six months as this would provide us with quick reliable test results of all babies. We already had quotes of about R200 per test to do this. Yet it was decided to rather emphasise that we are a program that can be replicated everywhere in the country, with out researchers and expensive lab tests, and decided at that stage to switch over to the cheap option of rapid tests, at R 10 per test. These are some of the protocol changes that Dr N. Simelela mentions in 80.2.6. 29. It is true that many mothers have not brought their children for the 18 months HIV test. But this is a challenge to us to ensure that follow-up is improved and it proves that nothing is perfect. Some of the mothers came from other areas and also provinces and if a national program existed, they could be properly followed- up in their areas. 30. The program was not designed to "produce data" but to keep children healthy. The monitoring was developed as a management tool and not to produce scientific data. If however, data is needed on transmission rates, one could extrapolate data from a scientifically selected sample. 31. The 18 month follow-up has nothing to do with the maternal health. We know that we have provided formula milk to the baby and thus taken away a big risk factor for the mother – breastfeeding. We have also set up Infectious disease clinics where we can ensure the well-being of the mother. The point is that any antibody test is only reliably positive at that stage. 32. Looking at the existing data shows an infection rate of 11.9%. This is even better than the expected halving of the presumed infection rate of 30% without the MTCT intervention. Ad para 80.2.7 33. It is unclear what Dr N. Simelela means with, "The rate of HIV infection was sixteen percent (16%). It is much higher in other provinces." I trust she means that an effective MTCT prevention program is even more urgent in worse effected provinces. Ad Para 80.2.8 34. It is also unclear why Dr N. Simelela highlights that "various components of health service infrastructure are still fragmented by authority and level" without suggesting a programme of integration. 35. One of the most important indirect benefits of the MTCT program in Khayelitsha was much improved management at district level. Before MTCT the different facilities were run by PAWC (province) or COT (local government) or Groote Schuur. A sister-in-charge of COT could hardly set a foot into a PAWC facility without causing a major uproar. Now they have meetings together every two weeks and have just developed a joint comprehensive Strategic Plan to combat HIV. This will ultimately lead to a more or less smooth amalgamation of services into the metropole – thanks to the MTCT program which by its nature included adult curative, TB, maternity, sick baby and healthy baby services. 36. In addition, there are now 18 registered support groups for people with HIV/AIDS. Many of the peer educators in the community are women who have participated in the MTCT prevention program. They together with others have created a greater climate of openness in relation to HIV/AIDS. CONCLUSION 37. I note Dr N. Simelela's affidavit with great concern. I believe that it is essential for senior health officials to accept the recommendations of international science and public health policies for resource strained countries and focus on primary health care, with special emphasis on maternal health care, of which an effective nation- wide MTCT program would form a corner stone. Please move beyond politics and accept that it is time for implementing programs and not promote confusion to hide poor service delivery. __________________ DR. HERMANN REUTER DEPONENT SIGNED AND AFFIRMED TO BEFORE ME IN THE PRESCRIBED MANNER AT CAPE TOWN ON THIS DAY OF NOVEMBER 2001, THE DEPONENT HAVING STATED THAT HE HAS NO OBJECTION TO TAKING THE AFFIRMATION AND THAT HE REGARDS THE AFFIRMATION AS BINDING ON HIS CONSCIENCE COMMISSIONER OF OATHS 1