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TAC and partners tell SA government to provide leadership on HIV/AIDS ahead of crucial UN High Level meeting

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Treatment Action Campaign (TAC), Médecins Sans Frontières/Doctors Without Borders (MSF), World AIDS Campaign (WAC), the AIDS and Rights Alliance for Southern Africa (ARASA), and SECTION27 last week issued a joint letter to the South African government, including President Jacob Zuma, calling on the country to provide critical leadership in ensuring increased access to HIV services ahead of a crucial United Nations High Level meeting on HIV/AIDS.

Treatment Action Campaign (TAC), Médecins Sans Frontières/Doctors Without Borders (MSF), World AIDS Campaign (WAC), the AIDS and Rights Alliance for Southern Africa (ARASA), and SECTION27 last week issued a joint letter to the South African government, including President Jacob Zuma, calling on the country to provide critical leadership in ensuring increased access to HIV services ahead of a crucial United Nations High Level meeting on HIV/AIDS.
 
Next month’s UN meeting in New York (June 8-10) will pave the way for the next decade of the international HIV/AIDS response. The meeting comes at a time when the world has seen both unprecedented scientific gains proving the benefits of anti-retroviral therapy (ART) and mounting threats to HIV programmes through persistent funding cuts.
 
UN Member States are already shying away from committing to treatment targets despite the fact that UN Secretary General Ban Ki-moon has called for at least 13 million people to be placed on treatment by 2015 – a target that amounts to less than universal access, which the world committed to in 2006. In their May 20 letter, MSF and partners call on South Africa to lobby for this target to be set at 15 million.
 
South Africa is central to this UN meeting because of its leadership role within Africa and the extent of the epidemic within the country. As of 2009, 5.6 million South Africans were HIV positive, more than any other country in the world. While South Africa has made significant strides in scaling up access to services, currently only 37% of people eligible for ART under World Health Organisation (WHO) guidelines receive it.
 
MSF and its partners call on South Africa to set ambitious and measurable domestic targets that will increase access to services motivate fellow UN Member States to set global targets that can ultimately reverse the course of the HIV epidemic. The requests to the South African government include:

  • Place at least 3 million people on ART by 2015;
  • Because tuberculosis (TB) is the number one killer of people living with HIV, ensure that at least 80% of public sector facilities provide integrated TB and HIV services. These services must include ART.
  • Immediately and fully implement WHO treatment guidelines for earlier ART initiation at CD4 350. Currently South Africa’s treatment protocol allows for initiation at CD4 200 except for pregnant women and people co-infected with TB, who can be initiated at CD4 350. South Africa has not instituted new WHO protocol despite being a recent recipient of the Global Fund to Fight HIV/AIDS, TB and Malaria, and the fact that treating people earlier has been shown to save lives and reduce illness in people living with HIV. Importantly, an increasing amount of scientific data shows that ART also makes people less infectious. A recent study (HPTN 052) showed that ART use in heterosexual couples where one partner was HIV positive and the other HIV negative reduced infection rates by a staggering 96%. Other Southern Africa countries with less resources have already implemented or are in the process of implementing new WHO treatment guidelines;
  • Implement innovative treatment and care strategies such as out-of-facility community distribution of pre-packaged ART to stable patients in order to optimise limited health resources and promote better patient outcomes;
  • Put in place the policy framework to fully take advantage of flexibilities as allowed under international law to increase access to affordable, effective medicines; and
  • Actively support innovative financing mechanisms on both a national and international scale that provide long-term, predictable and robust funding for HIV and other health programmes.

Below is the letter TAC and partners submmited to the South African Government

20 May 2011
 
Dear President Jacob Zuma, Deputy President Kgalema Motlanthe, Minister of Health Aaron Motsoaledi, Director General for Health Precious Matsotso, and the South African National AIDS Council,
 
We write to you today as representatives from the Treatment Action Campaign, SECTION27 incorporating the AIDS Law Project, Médecins Sans Frontières/Doctors Without Borders (MSF), World AIDS Campaign, and the AIDS and Rights Alliance for Southern Africa.

Considering the upcoming United Nations General Assembly High Level Meeting on HIV/AIDS, taking place from 8-10 June 2011 in New York, we are writing to share our perspectives on the urgent need for Member States to set ambitious, measurable treatment targets, coupled with enabling policies and practices.
 
It has been a decade since the UN General Assembly Special Session on HIV/AIDS in 2001, and in that decade we have seen critical advances in HIV treatment, prevention and care. Taking forward the lessons learned, combined with new science, we know anti-retroviral therapy (ART) saves lives, reduces illness, and prevents new infections. The HIV response has also catapulted the world forward towards achieving the Millennium Development Goals (MDGs) by strengthening health systems, expanding access to care, and putting downward pressure on maternal and child mortality.

The upcoming June meeting will set the stage for the continued fight against HIV/AIDS in the next decade. It is essential that we learn from the successes and failures of the past to pave the way for a future that sees a continued decline in HIV related deaths, HIV related illnesses, and new HIV infections.
 
The world can only go forward in combating the HIV/AIDS epidemic if ambitious and measurable targets are made at the June meeting. Strong language, while essential, is not enough, as it does not provide clear guidance or a strong framework for increasing access to services, treatment, and care. We therefore call on the South African government to take the lead in setting and committing to national targets, which will not only stimulate scale-up on a national level but will also provide leadership within the UN, encouraging fellow Member States to set targets on an international scale. While we recognise that South Africa will set its revised national targets in the new HIV and AIDS and STI Strategic Plan for South Africa (NSP) for 2012-2016, this will not be released in time for the June meeting and cannot be used to demonstrate South Africa’s renewed ambitious targets. We therefore call on the South African government to commit to certain targets in the lead up to and as part of the High Level meeting, in line with and encouraging international commitments made by UN Member States. These targets can also help to guide the NSP process.

We call on the South African government to commit to:

  • Place at least 3 million people on ART by 2015;
  • Ensure that at least 80% of public sector facilities provide integrated TB/HIV services, including ART;
  • Immediately and fully implement World Health Organisation (WHO) treatment guidelines for ART initiation at CD4 350;
  • Utilise innovative treatment and care strategies such as out-of-facility distribution of pre-packaged ART to optimise limited health resources and promote better patient outcomes;

Put in place the policy framework to fully take advantage of TRIPS flexibilities as allowed under international law to increase access to affordable, effective medicines; andGiven the global funding retreat, actively support innovative financing mechanisms on both a national and international scale that provide long-term, predictable and robust funding for HIV and other health programmes.

Supporting these goals and targets will help South Africa to continue to act as a leader in the fight against HIV/AIDS, providing much needed political will for the next decade.

The need for treatment

Treat people now
 
We know that providing ART saves lives, prevents illness, and also prevents HIV from spreading. Globally, HIV related deaths decreased by 19% between 2004 and 2009, as ART access increased. ART also reduces illness by strengthening immune systems: for example, the therapy reduces risk of tuberculosis (TB) by 67%, and reduces the risk of death from TB by up to 95%. Important new evidence also shows that ART can reduce HIV transmission by over 96% in serodiscordant couples, proving that treatment is prevention. Importantly, because of downward trends on mortality, illness and hospitalisation, universal access to ART is cost effective in the medium to long-term.
 
Today, 10 million people are currently in need of ART. Ahead of the 2011 High-Level Meeting on HIV, UN Secretary-General Ban Ki-moon has called for Member States to support the scale up of HIV treatment to at least 13 million people by 2015 and a further reduction of HIV horizontal transmission by 50%. Noting that 13 million by 2015 falls short of treating 80% of those in need, South Africa should lead the call for this target to be increased to 15 million by 2015.

While South Africa has made major inroads in placing those who need it on treatment, only 37% of those eligible under new WHO guidelines are receiving ART. South Africa must reaffirm its commitment to providing ART to at least 3 million people by 2015 as outlined in the approved Round 10 Global Fund proposal. South Africa reaffirming this treatment target before and during the High Level meeting will be an integral step in encouraging other actors and the international community as a whole to set an ambitious treatment target.
 
In order for treatment targets to be reached, the national and provincial health departments should annually determine absolute treatment targets for each public sector facility based on the population of its catchment area and HIV prevalence. This data should be released publicly and monitored by the Department of Health.
 
We additionally call on the government to facilitate this increase in treatment coverage with 80% domestic funds.  The commitment of the South African government to take greater fiscal ownership of its treatment needs is an important step towards the long-term sustainability of treatment programmes.

Treat people better
 
The benefits of ART have an even larger impact when treatment is started earlier, as reflected in WHO treatment guidelines, which recommend initiation at CD4 350. Data from MSF’s project in Lesotho has shown that starting patients on ART earlier (between CD4 levels 200 and 350 as compared to below 200) led to a 68% decrease in deaths, 39% decrease in patients lost to follow up, and a 27% reduction in illness. Mounting scientific evidence showing that placing people on treatment earlier dramatically reduces their infectivity proves that providing ART before people become very sick not only has benefits HIV positive individuals, but communities as a whole. Importantly, providing ART earlier will help to alter the course of the epidemic by reducing incidence.
 
However, South Africa has still not fully implemented the new WHO guidelines. This is in spite of the fact that many poorer countries in the region have instituted ART initiation at CD4 350. We call on the South African government to fully adopt WHO treatment guidelines into national policy, including providing treatment for infants under 24 months of age, through a non-phased approach by the end of 2011.
 
Better programmes for better outcomes
 
Make ART access easier for patients and for health care workers

In order to facilitate expanded coverage and optimised care, South Africa must institute innovative health care strategies. As such, the country should support long-term ‘out of health facility’ strategies for distributing pre-packed ART in order to help alleviate overwhelmed health facilities. We call on the South African government to set a target of 30% of stable ART patients to receive their treatment out of facility.
 
MSF has already piloted out of facility programmes that have proven effective. In Mozambique, for example, patients who are stable on ART have formed community ART groups, in which a member of the group collects medication for other members monthly. As such, each member must only visit the facility every six months. These groups have maintained excellent adherence and care outcomes and decreased facility reported workload by fourfold. MSF has also instituted adherence support groups in Khayelitsha, which support ART stable patients. These are run by lay health care workers who dispense pre-packed ART. The groups meet every two months, during which time patients receive educational talks, are asked about the development of adverse events, are provided with their medication and referred to the health facility when necessary. These and other models can help pave the way for alleviating clinic workload while simultaneously improving patient adherence and care.

Integrate TB and HIV services
 
Given that tuberculosis is the leading cause of death among people living with HIV, South Africa must continue its strong commitment and leadership with regards to TB/HIV integration on a local, provincial, and national level. We call on the government to scale out comprehensive integrated TB/HIV services including ART to 80% of public sector facilities including at primary health care level. Integration will be an important step in reducing the number of TB deaths in people living with HIV by 50% by 2015. In order to facilitate this process the TB and HIV departments need to be integrated at the national and provincial health departments.
 
More people can only be placed on treatment if the government makes use of new technologies that facilitate intensified case findings. Given South Africa’s rollout of Xpert/Rif, the government must ensure that 80% of public sector facilities have access to molecular testing by 2015.

Promote services for those most vulnerable
 
Furthermore, there is a need to recognise populations most vulnerable to HIV, including men who have sex with men, women, children, youth, sex workers, migrant populations, and people with disabilities, in order to ensure that their legal rights are protected and programmes tailored to meet their needs. Women currently bear the greatest brunt of the HIV epidemic. Within South Africa, over half of people living with HIV are women: almost one in three women aged 25-29 is infected with the virus. HIV prevalence among women of childbearing age impacts both individuals’ well being as well as the vulnerability of South Africa’s children: nationally, the transmission rate of HIV from mother to child was a staggering 11% in 2009. South Africa must therefore commit to scaling up services targeted to women and children, including increased access to PMTCT and the creation of and accessibility to pediatric-friendly diagnostics, treatment and care.

Increase access to medicines
 
South Africa must support an enabling policy environment that not only eliminates barriers to accessing affordable medicines so that people can receive the best possible care, but that also supports adaptation and innovation that puts patients’ needs first. South Africa must immediately take advantage of flexibilities and public health safe guards permitted under international trade law. We ask for the Department of Health to take the lead in putting this matter on the policy agenda.
 
Furthermore, we call on the government to amend the 1997 Medicines Act to allow for the use of medicines registered by a stringent international health authority, such as the FDA, EMA, or WHO pre-qualified drugs, within South Africa’s public programmes pending registration by the Medicines Control Council. We are currently gravely concerned that generic ARV fixed-dose combinations (FDCs), such as an FDC including tenofovir, efavirenz, and 3TC, are not reaching patients because of the long queue for registration.

More funding needed for greater access
 
We need long-term, robust financing now

The global response to the HIV/AIDS epidemic is at a critical crossroads.  While we have seen unprecedented global financing and global commitment, both political leadership and funding are dwindling, potentially reversing the incredible gains made in the past ten years. South Africa, as both an African and international leader, must commit to scaling up the HIV response on a national level, while working with other UN member states to make sure that a regional and global scale up is also seen.
 
South Africa must recognise and address the impact of PEPFAR’s recent change in policy. PEPFAR has recently moved “away from emergency to sustainable response by focusing on country ownership”. Instead of focusing on implementing programmes, PEPFAR now provides technical assistance and capacity building. This policy change has resulted in large numbers of patients being transferred from PEPFAR funded clinics to public sector facilities. The capacity of these facilities is not adequately strengthened in order to absorb the increase in patients. This has grave implications for the continuity and quality of care provided to patients in addition to the increased workload on health care workers managing their care in under resourced conditions.
 
While South Africa may not be losing net financing from PEPFAR, this change represents a retreat in funding priorities and specifically a retreat away from financing life saving ART programmes. We call on the South African government to monitor and publicly note how this shift in funding affects patient care, workload for health workers, and strain on the health system. Additionally, we call on the government to work with PEPFAR as well as independently to ensure that public sector facilities are adequately resourced and equipped to absorb transfer patients so as to ensure continuity and quality in care. While we understand that South Africa and other countries rely on donor funds for HIV and other programmes, we encourage governments to call for funding to be allocated based on national priorities rather than set by donor mandates.

We need long-term, robust financing for the future
 
Given the threats to global HIV funding, there is a need to explore and support innovative financing mechanisms that will provide long-term, robust, and predictable financing. One such potential mechanism is a Financial Transaction Tax (FTT). South Africa, as part of the G20 and the only African nation in the group, should add its voice to the global call for an FTT as lead by France and Germany and supported by a variety of civil society groups across the globe. South Africa should also lead by insisting that a specified portion of the monies raised go towards health and that this call does not obviate donor states current funding responsibilities, such as funding the Global Fund. 

South Africa must act as a leader in the UN High Level meeting
 
Global leaders, including South Africa, have an important opportunity to ensure that we do not miss the chance to build on the successes achieved over the last decade and combine these with the promising new scientific developments to begin to turn around the HIV epidemic. We urge you to realise the opportunities presented and pursue ambitious goals and outcomes in the political declaration at the upcoming UN High Level Meeting on HIV/AIDS, which will likely serve as a blueprint for the coming decade of the global AIDS response.

Should you need further information, please do not hesitate to contact us.

Yours sincerely,
 
Treatment Action Campaign
SECTION27
Médecins Sans Frontières /Doctors Without Borders (MSF)
World AIDS Campaign
AIDS and Rights Alliance of Southern Africa