Three New Initiatives to Take the Fight Against AIDS to the Next Level

In a demonstrated effort to take the fight against AIDS to the next level, on World AIDS Day, 1 December 2009, the Western Cape Department of Health is announcing the intention to actively pursue three initiatives. The Western Cape regards the three bold initiatives outlined in here, together with the existing strategies, essential to taking the fight against AIDS to the next level.

Routine HIV testing:
The Western Cape Department of Health wishes to routinely offer HIV testing to all public health facilities in the Western Cape as a standard of care in each facility and is encouraging the private sector to adopt a similar approach. While the conventional Voluntary Counselling and Testing (VCT) to date has required pretest counselling, the World Health Organisation (WHO) recommends "routine" testing rather than "voluntary" testing in a generalised epidemic where the prevalence of a disease is greater than 1%.

In the Western Cape the prevalence is currently between 1,8% and 31%, which necessitates the move to offer HIV testing to all adults, adolescents in health facilities and in addition children in pediatric facilities. Research has indicated that people with knowledge of being HIV positive are more likely to alter behaviour than those ignorant of their HIV status and thus the move to ensure that everyone has the opportunity to know their status.

Says Western Cape Minister of Health, Theuns Botha: "There is no plan to make HIV testing compulsory, but as stated above the emphasis for HIV testing has shifted from conventional voluntary HIV counselling and testing (VCT) to ROUTINE OFFER of HIV testing and the patient therefore has the right to "opt-out" i.e. decline the test that has been offered."

The conventional VCT protocol used in most public health clinics only screens a fraction of the patients served and subsequently, every day thousands of vulnerable patients flow through our health care system without being offered HIV testing.

A new framework for HIV testing and counselling will be introduced in the Western Cape that aims to create ample opportunities for all residents of the Province to learn their HIV status and then access the care and support they need.

The ACTS (Advise, Consent, Test, and Support) approach offers a system for implementing routinely offered HIV testing and counselling in clinical settings by streamlining the traditional VCT counselling approach and tasking nurses and doctors with the integration of testing and counselling for HIV as a routine standard of care. By reducing the conventional pre-test counselling session, the ACTS approach will increase lay counsellors' productivity and will enable nurses to integrate testing and counselling, as they do for many other diseases, into the clinical services they provide. The time saved can be more effectively used in important post-test counselling interventions.

Earlier initiation of treatment:
The Western Cape Department of Health intends, dependent on the availability of adequate funding, to commence treatment of patients with AIDS when the CD4 count falls below 350 as against the current practice of only beginning treatment when the count has dropped below 200.

With a treatment cut-off or a CD4 count of 350 it is estimated that an additional 50,000 patients would require treatment as a once-off and thereafter an additional 20,000 per year. However, since not all such individuals will present to health facilities requesting treatment, it is estimated that this change in policy would see between 6,000 and 20,000 additional patients on antiretroviral drugs in the Western Cape at an estimated cost of R16 million.

In addition to the altered threshold for commencing with antiretroviral treatment (ART) in adults, it is proposed that treatment with ARV's is commenced in all children under the age of one year who test HIV positive, irrespective of the CD4 count as research has shown that early treatment dramatically improves the outlook for these children.

The rationale behind this step is that earlier ART reduces the complications associated with AIDS, which are particularly prevalent in patients who have reached the late stage of the disease. Currently, despite the cut-off of a CD4 count of 200, many patients present with CD4 counts below this level. For this reason it is imperative the health system as a whole be strengthened to enable earlier access to treatment by all those who are HIV-positive and require treatment.

While the additional funding required for this initiative is not immediately available, the Western Cape will be motivating for additional funds from the national government as well as looking for other sources of funding outside government.

Triple therapy for the prevention of mother to child transmission (PMTCT):
The Western Cape has achieved great success with the implementation of PMTCT and research has indicated that currently infant mortality in the Western Cape is approaching levels seen before the advent of the HIV-epidemic. This has been achieved through the provision of two anti-retroviral drugs to the mother and baby during pregnancy and at delivery of the baby. The current levels of transmission in the Western Cape are at around 4% which is the lowest in the country.

To take the next step and reduce this rate even further with the aim of eradicating pediatric AIDS it is necessary, on the advice of researchers in this field and supported by recommendations of the WHO, to introduce a regime in the PMTCT program that will include three anti-retroviral drugs. Once again this will require additional resources for which the Western Cape will motivate nationally, but it is regarded as an essential and vital next step to reduce the number of children infected with the HI-virus.

Conclusion:
The Western Cape on World AIDS Day 2009 calls upon all organisations in the public, private and the non-profit sectors to unite in efforts to reduce the number of unnecessary and preventable deaths from AIDS and to begin to significantly reduce the prevalence of AIDS in our communities.

Theuns Botha MPP
Western Cape Minister for Health