A Dialogue on ART Delivery

A dialogue on the delivery of antiretroviral treatment in resource-limited settings, held at Maropeng, Cradle of Humankind, Gauteng, South Africa, September 2006 A DIALOGUE ON ART MODELS

Foreword by Nelson Mandela In 2003, I launched the Siyaphila La HIV and AIDS treatment programme in Lusikisiki, in the Eastern Cape, a joint project between Médecins Sans Frontières (MSF) and my Foundation.

The project has been a shining example of how an antiretroviral (ARV) treatment programme can be implemented successfully, even in a rural area with few resources.

Today, the project is a useful touchstone in talking about how to achieve the universal delivery of ARV drugs. If we can learn from the lessons of Lusikisiki and other similar projects, it can help us in our long-term fight against HIV and AIDS. Through the communication and sharing that dialogue allows, we will be able to save more lives.

We are now at a point where the project has been handed over to the provinicial Department of Health, to continue to run as a successful model for ARV rollout.

We salute the community of Lusikisiki for its active support and participation in this campaign against HIV and AIDS, as well the valuable contribution of the health professionals and government officials who have participated in this initiative.

The success of the Siyaphila La project shows that we are breaking down the stigma surrounding the disease, and creating a supportive environment in which HIV-positive patients can speak openly about their status.

This project shows that the fight against HIV and AIDS can only be won if it is led by the communities affected by the disease, and if government and civil society unite with one another in partnership against the pandemic.

Treatment plans cannot be separated from prevention, care, and support efforts. Through community mobilisation, the availability of ARV treatment can promote greater awareness about the disease, encourage voluntary counselling and testing for HIV among all sexually active people, and enhance home-based care and support.

The name Siyaphila La is an appropriate one. It means “We Are Alive”. Let us continue to work together, to send that message to communities across South Africa and around the world.

I thank you.

N R Mandela

Photograph: Matthew Willman

NELSON MANDELA FOUNDATION A DIALOGUE ON ART MODELS Contents

WELCOME PRESENTATIONS Introduction 2 On the Frontier in Lusikisiki 6

Fighting HIV/AIDS Head On by Dr Nthatho Motlana 3  Delivering a Rural Model 12  Phambili nge-ARVs 13 The Participants 4 Forming Successful Partnerships 14

Supporting ART in Rural Health Facilities 17

The Business of Treatment 21

Task-Shifting in Thyolo 23

Treatment: A View from Government 27

 Questions and Answers 30

DIALOGUE Emerging Themes and Challenges 36

 Model of Care 36  Accreditation and Policy 36  Partnerships 37  Human Resources 38  Task-Shifting 39

From Ideas to Action 40

 Models of HIV Care 40  Steps Towards Getting Your Facility Accredited 41  Integration into Chronic Care PHC Model 42  Involving General Practioners in HIV Clinical Management 44  Expansion of ART for Children in Deep Rural Areas 45  Engaging Volunteers/Community Workers 46  Community Involvement in ART 47  Support Groups: Adherence and Maintenance 48  Empowering Health Workers in Rural Areas to Reach More Clients 49 ROUNDING OFF  Counsellors to Do Pricking 50 Reflecting on the Process 55  Nurses Prescribing ARVs 51  Proactive Testing 52 MSF and NMF 56  A Dialogue on African Traditional Practices 53  The Dialogue Process and the NMF 54 Participants’ Contact Details 57

NELSON MANDELA FOUNDATION A DIALOGUE ON ART MODELS Introduction The Nelson Mandela Foundation convened a dialogue on September 26 and 27 2006, at Maropeng, Cradle of Humankind, in Gauteng. This brought key stakeholders together to share lessons on models of delivery of antiretroviral treatment (ART) in resource-limited settings in South Africa. Delivery of antiretrovirals is a complex issue which demands a multistakeholder approach.

Often we bring people together to listen to experts, ask a few questions and make some comments. The general feeling then is that we have involved them and we call it a dialogue. But we believe that a shift needs to occur which requires the involvement of stakeholders from all parts of the system: business, government and civil society, because complex challenges such as these require a diversity of views.

This dialogue process also marked the end of a successful four-year project run in partnership with the Eastern Cape Department of Health, Médecins Sans Frontières (MSF) and the Nelson Mandela Foundation (NMF), providing antiretroviral therapy to people in Lusikisiki in the Eastern Cape. MSF and NMF handed over the project in its entirety to the Eastern Cape Department of Health on October 12 2006.

The provision of ART is possible in resource-limited settings, as has been proven over and over again; this is no longer up for debate. There is also demonstrable will all around to achieve this, and this needs to be celebrated.

Critical issues such as task shifting, accreditation, nurses prescribing ARVs, human resources, and community involvement, among others, were raised and debated during this dialogue. Concrete suggestions were tabled on what really works.

The dialogue process provided an opportunity for clarifying policy issues. It is our wish that the resulting dialogue outputs are taken up and addressed at the relevant levels through further dialogue and/or other relevant means.

There is a clear need for dialogue, but most importantly, the need exists for an organisation that can convene this dialogue – something the NMF is uniquely placed to offer.

Dr Mothomang Diaho Nelson Mandela Foundation

Contact the Nelson Mandela Foundation

Naomi Warren Dr Mothomang Diaho Tel: (011) 853 2621 Tel: (011) 853 2623 Fax: (011) 728 1111 Fax: (011) 728 1111 [email protected] [email protected]

www.nelsonmandela.org

NELSON MANDELA FOUNDATION A DIALOGUE ON ART MODELS Fighting HIV and AIDS Head On Dr Nthato Motlana

ood morning everybody. I‘ve been as- Gsociated with the Nel- son Mandela Foundation from its very inception. I was privileged to be Man- dela’s personal physician, privileged to travel the world with him, and was part of a stage in our nation when there was so much controversy about how we handled this AIDS epidemic.

I recall one president, Ugandan to do something or say something, Mandela was one of the best fund- President Yoweri Museveni, com- that’s when I have to repeat, you all raisers in the world, and we would ing to South Africa at State House in know that Madiba really took the go to Pakistan and Madiba would say Pretoria and the kind of discussions bull, as we say, by the horns, and he to the president of Pakistan: “You, some of us had with him. I visited ran a campaign that really addressed Mr President of Pakistan, your GDP Uganda several times to talk about the question of HIV and AIDS. is so and so and so and so. From you what they were doing and I regret, When the Mandela Foundation we need 10-million American dollars. as you all know, that our government was formed, we focused on three And then the president would be tak- didn’t quite understand what AIDS areas. We said Mandela is a peace- en aback and go “um-oh-um-oh”. But was all about. maker, so the one area would be Madiba would say: “Just call your fi- Mr Mandela himself, God bless peacemaking: reconciliation through- nance minister to sign the cheque.” his soul, he’s not a physician, he was out the world. Secondly, Mandela was And so we could raise funds, and a lawyer. He didn’t quite understand very keen on seeing that something is we raised funds. At that time it was and I would sit with him and say, done about our schools, so we had for the ANC, of course, but later, af- “Madiba, what do we do about this a schools or education programme. ter that, we could raise funds for the damn epidemic?” And it was quite And thirdly, HIV and AIDS. Foundation. But, you know, the ac- clear that he didn’t quite get it. Our programme was really a lit- tual programming on the ground I mean, he was not opposed as tle uninformed. My one attitude, as was not as it should have been and some people became opposed to the a former GP in Soweto, was to say to I thought we should not be involved campaign against AIDS, but even our the Foundation, “It’s not for us to en- in the actual projects on the ground. wonderful Madiba, I repeat, he didn’t gage in actual programmes; let us be The Foundation is too small to actu- quite get it. the kind of think tank that would raise ally be engaged; but, I repeat, when But when he realised the need funds all over the world.” I mean, Mandela realised the need to take on the struggle against HIV and AIDS, the Foundation wanted to be there, ABOUT THE SPEAKER to be counted as an organisation that Dr Nthato Motlana was born in the village of Marapyane near Tshwane, in 1925, would address this problem head on. but moved to Johannesburg at the age of 10, and lived in Sophiatown. Motlana has And when we went to Lusikisiki, I a long history with the African National Congress (ANC). As a student at Fort was there when Mr Mandela, together Hare University in the 1940s, he became the secretary of the ANC Youth League. with Médecins Sans Frontières, called He later studied medicine at the University of the Witwatersrand. in the first patient, who needed antiret- Motlana established South Africa’s first privately owned black hospital, Lesedi Clinic rovirals. ... Oh what a wonderful day! in Soweto, and the first black-owned company to be listed on the Johannesburg I’m sorry that I have to go back to Stock Exchange, New African Investment Limited. Formerly Mandela’s physician, he Lusikisiki this time, to wind down is now the deputy chairperson of the Nelson Mandela Foundation and a trustee. a programme that I think has done very well.

NELSON MANDELA FOUNDATION A DIALOGUE ON ART MODELS: THE PARTICIPANTS

Dr Kuku Appiah Daniel Berman Roeleen Booi Marta Darder Dr Mothomang Diaho Right to Care Médecins Sans Frontières Free State DoH Médecins Sans Frontières Nelson Mandela Foundation

Nathan Ford Dr Victor Fredlund Dr Bernhard Gaede Dr Eric Goemaere Dr Ashraf Grimwood Médecins Sans Frontières Mseleni Rural Practitioner RuDASA Médecins Sans Frontières ARK

Sheila Hokwana Guillaume Jouquet Dr David Kalombo Nomzi Khonkwane Marianne Knuth Eastern Cape DoH Médecins Sans Frontières National DoH Médecins Sans Frontières Facilitator

Pumla Kobus Dr Doris Macharia Nomalanga Makwedini Brad Mears Nombulelo Mofokeng Tshepang Trust ICAP Eastern Cape DoH SABCOHA Quakeni LSA

NELSON MANDELA FOUNDATION A DIALOGUE ON ART MODELS: THE PARTICIPANTS

Dr Mosa Moshabela Dr Eula Mothibi Dr Nthato Motlana Dr Stanley Muwonge Tembekile Ntlangulela RADAR Facilitator/Western Cape DoH Nelson Mandela Foundation Mokopane Hospital Qaukeni LSA

Akona Ntsaluba Nondumiso Ntsikeni Dr Lesley Pitt Thuli Qali Dr Hermann Reuter TAC Lusikisiki Siyakhanyisa Valley Trust Church of Scotland Hospital Médecins Sans Frontières

Tandiwe Sapepa Dr Helen Schneider Helen Struthers Dr Ebrahim Variava Bavuyise Vimbani Quakeni LSA Centre for Health Policy Perinatal HIV Research Unit Klerksdorp Tshepong Hospital HAACO

Dr Marga Vintges Naomi Warren Lynne Wilkinson Tandi Xozwa Dr Rony Zachariah Family Physician Nelson Mandela Foundation Madwaleni Hospital Mthatha Hospital Médecins Sans Frontières

NELSON MANDELA FOUNDATION A DIALOGUE ON ART MODELS

On the Frontier in Lusikisiki Médecins Sans Frontières Lusikisiki Project Co- ordinator Dr Hermann Reuter presents a model for universal ARV access in a deep rural area South Africa ’m going to present to you the Lusikisiki primary health-

Lusikisiki care ARV model, which we believe is able to produce uni- Eastern Cape Iversal access to ARVs in a rural site like Lusikisiki. MSF first came to the Western Cape and started ARVs in a township scenario and it was said, “But you know it’s easier in an urban Lusikisiki area, can you do this in a deep rural area?” • Population: 150 000 • Hospitals: 1 We went to visit Tembi Ntlangulela, said, for the primary health-care pro- • Rural Clinics: 12 local service area manager in Qaukeni, gramme, we need to decentralise. • HIV prevalence: 30% at and the first thing she says is: “This is In the middle of the district there’s antenatal clinics deep, deep rural.” a hospital and then around it are the • Situated: in the Eastern Cape Two of the 10 poorest municipali- roads going to the rural clinics: there Province, South Africa. The area ties in South Africa are Mbizana and are 12 of them. contains two of the country’s Qaukeni, which is our area. In that The challenges that we faced, poorest municipalities, Mbizana area we’ve got a 280-bed hospital and apart from the geographical distanc- and Qaukeni HIV prevalence of about 30% at the es, were that the laboratory services antenatal care clinics. Immediately, I didn’t extend to the clinics. There was

NELSON MANDELA FOUNDATION VCT done at ANC consultation March – August 2003 VCT done at ANC consultation March – August 2006

ANC consultations VCT done % tested ANC consultations VCT done % tested 400 600

500 89% 99% 300 99% 400 85% 80% 81% 200 300

200 31% 30% 28% 100 22% 21% 25% 100 Patients increase + staff constant Number of pregnant women and tests 0 Number of pregnant women and tests 0 =rising workload MAR APR MAY JUN JUL AUG MAR APR MAY JUN JUL AUG Decentralisation - better enrolment 2003 2006 Clinic ARV enrolment Hospital ARV enrolment Patients per month Nurse : Patient ratio 250 240 30 000 29 000 Cumulative Enrollment in HIV Care and Treatment at Patients Initiating ART St. Patrick’s Hospital + 4PHCs 200 27 000 47 ICAP Supported Sites, Eastern Cape May 05 – June 06 25 000 43 HIV Care ART Total Hospital PHCs 150 700 20 000 642 15 999 16 000 15 000 600 100 91 15 000 Number of patients 500 75 68 59 50 10 000 400 9 608 29 10 000 336 8 300 306 0 5 000 A DIALOGUE ON ART MODELS Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 2004 2004 2004 2004 2005 2005 2005 2005 2006 Number of patients 200 poor drug supply to the clinics, there able to provide, because we see a very PMTCT 6127 were no HIV services at the clinics at 5000low rate there. It is because the com- 2004 2005 2006 all, there was a shortage of staff andNumber of patients munity health workers were asked When the prevention of mother-to-child 100 the clinics had not seen a doctor for to work for four hours, because 2they 022 transmission (PMTCT) programme in more than five years. had asked906 for an increase in their sti- Lusikisiki was implemented in 2003, 0 In Qaukeni, as a whole, there are pends. It wasn’t coming, so they were the women were asked to go for VCT APR JUN AUG OCT DEC FEB APR- 24 05 05 05 05 05 06 JUN five doctors per 100 000 population, told,0 “Work four hours”. In August, after their antenatal care visits. So usu- 06 OCT-DEC JAN-MAR APR-JUN JUL-SEP OCT-DEC JAN-MAR APR-JUN which is 1/14th of the South African they were2004 asked2005 to work2005 for eight2005 ally the2005 nurses 2006saw the women2006 in the average. This is fewer doctors than hours again and we tested 1 700 peo- morning and then said in the afternoon, the Zimbabwean average, than the ple in August this year. if you want to test, you can. We tested RESULTS (3) Moving Foward - Policy dependent Democratic Republic of Congo average and the Sierra Leone average. But VCT STATS Patients Initiating ART Holy Cross Hospital + 3PHCs ART: New inclusions / month Quarterly enrolment at clinics we are expected to implement the May 05 – June 06 (2 main hospital sites) same ARV model as Pretoria. VCT - health seeking behaviour ART Inclusions VCT Health-Seeking Behaviour Total Hospital PHCs 250 VCT, Lusikisiki, March 2003 August 2006, 12 clinics 240 Testing – Task shifting to medical assistants, nurses & PLWAs no. people tested no. people tested HIV+ % HIV+ 500 497 Firstly, to get people on to ARVs, “Partial” task shifting to Three health centres 2000 they need to be tested. We started Nurse CHW Nurse/ CHW 4h 8h medical assistants 200 1800 45% CHW initiating Voluntary Counselling and Nurse 400 500 ARV initiation done by Testing (VCT) at clinic level. 1600 doctors instead of nurses 40% I’m hoping to give an honest re- 1400 35% flection of how I perceive the VCT 400 1200 300 150 services in Lusikisiki. 30% 260 1000 In 2003, we did about 900 tests 237 300 per month (see Figure 1). During that 800 200

time it was MSF that taught the nurses 600 Number of patients 100 200 91 to do the testing and the nurses were 400 doing the testing. In the second year, 200 100 we asked the counsellors to do test- 100 0 ing as well and the testing increased 50 Jul Jul Jul Jul Oct Oct Oct Feb Feb Feb Apr Apr Apr Apr Jun Jan Jun Jan Jun Jan Jun Sep Sep Sep Aug Nov Dec Aug Nov Dec Aug Nov Dec Aug Mar Mar Mar OCT-DEC JAN-MAR APR-JUN JUL-SEP OCT-DEC JAN-MAR APR-JUN May May May May to about 1 200 per month. 0 0 2004 2005 2005 2005 2005 2006 2006 2003 2004 2005 2006 APR JUN AUG OCT DEC FEB APR- 2004 2005 2006 2006 At a TB conference in May 2005, Mar 05 05 05 05 05 05 JUN (JUN) when we were told that counsellors Figure 1. VCT, Lusikisiki, March 2003 – August 2006, 12 clinics. 06 were not allowed to do the prick- Achieving Sustaining Universal Access ing, but that it should be done by the The number of people tested fluctuates depending on the health nurses, this is where we see a dip. We services1400 provided. Meanwhile, an expected percentage decrease in were concerned that if the nurses got people testing HIV-positive occurs as more people use VCT services. the pricking added to their work load 1200 that it would impact negatively. 1000 Potential At the clinics, where there were Rx gap enough nurses, the nurses were actu- 800 Optional vs Opt-Out ally doing the pricking. At the outside VCT doneVCT at doneANC atconsultation ANC consultation March –March August – August 2003 2003 VCT doneVCT at done ANC at consultation ANC consultation March March – August – August 2006 2006 clinics, the nurses are also supposed ANC consultations600ANC consultationsVCT doneVCT% donetested% tested ANC consultationsANC consultationsVCT doneVCT% done tested% tested to do the testing, but if the counsellors 400 400 600 600 400 New Stage 4 (need for ARVs) see that patients need to be tested, and Enrolment actual500 500 89% 89% 99% 99% 300 300 Scenario 1 – intended trajectory the nurse doesn’t have time, some- Scenario 2 – failure to increase enrolment85% 99% 99% 200 400 400 85%80% 80% times the counsellor will also do the Scenario 3 – enrolment stagnates81% 81% 200 200New Stage IV and new patients started on ARVs 300 300 pricking and that is represented where 0 200 200 31% 31% we did about 1 300 tests per month. 30%200330% 2004 200528% 28%2006 2007 2008 2009 2010 100 10022% 22% Then, suddenly, in 2006, we saw a 21% 21% 25% 25% 100 100 PatientsPatients increase increase + staff + staff constant constant Number of pregnant women and tests Number of pregnant women and tests severe drop in VCT of about 900 tests Number of pregnant women and tests 0 0 Number of pregnant women and tests 0 0 =rising=rising workload workload MAR APRMAR MAYAPR JUNMAY JULJUN AUGJUL AUG MAR MARAPR MAYAPR MAYJUN JUNJUL JULAUG AUG DecentralisationDecentralisation - better - better enrolment enrolment per month. I’m taking a lot of time 2003 2003 2006 2006 for this because often people say an Clinic ClinicARV enrolment ARV enrolment HospitalHospital ARV enrolmentARV enrolment PatientsPatients per monthper month Figure 2. VCT done at ANC consultation, Figure 3. VCT done at ANC consultation, NurseNurse : Patient : Patient ratio ratio 250 250 activist organisation or a community- March – August 2003. March – August 2006. 240 240 30 00030 000 based organisation should ask people 29 000 29 000 PatientsPatients Initiating Initiating ART St. ART Patrick’s St. Patrick’s Hospital Hospital + 4PHCs + 4PHCs 200 27 000 to come for testing. And I want to In 2003Cumulative, Cumulativewomen Enrollment Enrollmentwere in HIV asked Carein HIV andto Care goTreatment and Treatment atIn 2006 at , women first have an opt- 200 27 000 May 05 – June 06 47 47 ICAP SupportedICAP Supported Sites, Eastern Sites, Eastern Cape Cape May 05 – June 06 25 00025 000 show that the testing rate doesn’t de- for VCT after an antenatal care visit. out VCT session before they see a 43 43 HIV Care ART pend on the community’s willingness Average testingHIV rate: Care 24%.ART nurse. Average testingTotal rate:Total 89%.Hospital Hospital PHCs PHCs 150 150 700 700 20 00020 000 to test, but on the services that we are 15 999 642 642 15 999 16 000 16 000 600 100 91 15 000 15 000 600 100 91 15 00015 000 Number of patients Number of patients 75 68 500 500 75 68 NELSON MANDELA FOUNDATION 59 59 50 50 10 000 400 10 000 9 608 400 29 10 000 10 000 9 608 336 29 336 8 300 306 80 5 000 300 306 0 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 5 000 Q1 2004Q2 2004Q3 2004Q4 2004Q1 2005Q2 2005Q3 2005Q4 2005Q1 2006

Number of patients 2004 2004 2004 2004 2005 2005 2005 2005 2006

Number of patients 200 6127 6127 200 5000 2004 2005 2006 5000 Number of patients 2004 2005 2006 Number of patients 100 100 2 022 2 022 906 0 906 0 APR JUN AUG OCT DEC FEB APR- 24 APR 05JUN 05AUG 05OCT 05DEC 05FEB 06APR- JUN 24 0 05 05 05 05 05 06 JUN 06 0 OCT-DEC JAN-MAR APR-JUN JUL-SEP OCT-DEC JAN-MAR APR-JUN 06 OCT-DEC JAN-MAR2004 APR-JUN2005 JUL-SEP2005 OCT-DEC2005 JAN-MAR2005 APR-JUN2006 2006 2004 2005 2005 2005 2005 2006 2006 RESULTSRESULTS (3) (3) MovingMoving Foward Foward - Policy - Policy dependent dependent Patients Initiating ART Holy Cross Hospital + 3PHCs ART: New inclusions / month Quarterly enrolment at clinics Patients Initiating ART Holy Cross Hospital + 3PHCs ART: New (2inclusions main hospital /sites) month Quarterly enrolment at clinics May 05 – June 06 (2 main hospital sites) VCT - health seeking behaviour May 05 – June 06 ART Inclusions VCT - health seeking behaviour Total Hospital PHCs ART Inclusions 250 VCT, Lusikisiki, March 2003 – August 2006, 12 clinics Total Hospital PHCs 250 240 VCT, Lusikisiki, March 2003 – August 2006, 12 clinics Task shifting to medical assistants, nurses & PLWAs 240 500 497 Task shifting to medical assistants, nurses & PLWAs no. people tested no. people tested HIV+ % HIV+ 500 no. people tested no. people tested HIV+ % HIV+ 497 “Partial” task shifting to Three health centres 2000 “Partial” medicaltask shifting assistants to Three health centres 200 2000 Nurse CHW Nurse/ CHW 4h 8h Nurse1800 45% CHW Nurse/ CHWCHW 4h 8h medical assistants 200 Nurse 400 1800 45% CHW 500 ARV initiation done by Nurse 400 1600 500 ARVdoctors initiation instead done ofby nurses 1600 40% doctors instead of nurses 40%1400 35% 1400 35% 300 400 150 1200 400 1200 30% 300 260 150 1000 30% 260 237 1000 300 800 200 237 300 800

600 200 Number of patients 100 200 91 600 400 Number of patients 100 200 91 400 200 100 100 100 200 0 100 50 Jul Jul Jul Jul Oct Oct Oct Feb Feb Feb Apr Apr Apr Apr Jun Jan Jun Jan Jun Jan Jun Sep Sep Sep Aug Nov Dec Aug Nov Dec Aug Nov Dec Aug Mar Mar 0 Mar OCT-DEC JAN-MAR APR-JUN JUL-SEP OCT-DEC JAN-MAR APR-JUN May May May May 0 50 Jul Jul Jul Jul 2004 2005 2005 2005 2005 2006 2006 Oct Oct Oct 0 Feb Feb Feb Apr Apr Apr Apr Jun Jan Jun Jan Jun Jan Jun Sep Sep Sep Aug Nov Dec Aug Nov Dec Aug Nov Dec Aug Mar Mar Mar OCT-DEC JAN-MAR APR-JUN JUL-SEP OCT-DEC JAN-MAR APR-JUN May May May 2003 2004 2005 May 2006 APR JUN AUG OCT DEC FEB APR- 2004 2005 2006 2006 Mar 0 05 05 05 05 05 05 JUN 0 2004 2005 2005 2005 2005 2006 2006 2003 2004 2005 2006 APR JUN AUG OCT DEC FEB APR- 2004 2005 2006 2006 (JUN) Mar 06 05 05 05 05 05 05 JUN (JUN) Achieving Sustaining Universal Access 06 Achieving1400 Sustaining Universal Access 1400 1200 1200 1000 Potential 1000 Potential Rx gap 800 Rx gap 800 600 600 New Stage 4 (need for ARVs) 400 Enrolment actual New Stage 4 (needScenario for ARVs) 1 – intended trajectory 400 Enrolment actualScenario 2 – failure to increase enrolment 200 Scenario 1 – intendedScenario trajectory 3 – enrolment stagnates

New Stage IV and new patients started on ARVs Scenario 2 – failure to increase enrolment 200 Scenario 3 – enrolment stagnates 0 New Stage IV and new patients started on ARVs 2003 2004 2005 2006 2007 2008 2009 2010 0 2003 2004 2005 2006 2007 2008 2009 2010 A DIALOGUE ON ART MODELS

an average 24% of women, and then the just counted the last 100 results, con- our TB patients, because the TB and baby had to be tested at 12 months, and secutive results that came back – there the HIV programmes are done by the we didn’t know, we couldn’t give any was a transmission rate of 12% at each same nurse, because there’s only one outcomes reports at all (see Figure 2). one of those two busiest clinics, which professional nurse. VCT done at ANC consultation March – August 2003 VCT done at ANC consultation March – August 2006 In 2006, we’ve now got an opt- is more or less what one expects with At Gateway Clinic in town we’ve out strategy where the woman starts the Nevirapine-only intervention. If got a special room for TB patients with VCT before she gets seen by we had an AZT-based intervention it and we’ve got a special container ANC consultations VCT done ANC consultations VCT done % tested % tested the nurse. When she gets seen by the could probably come below 6-7%. for HIV patients. Our testing rate of 400 600 nurse, the nurse already knows her TB patients is 29%; this is the differ- HIV status, can do a CD4 count and Integrating HIV ence of having two separate rooms can get her onto ARVs if she needs for TB and HIV. And of those TB pa- 500 89% 99% them. By changing the management and TB Care tients that test, 66% test HIV-positive, 300 99% 400 85% 80% of the clinic we’ve now got a testing We are happy to be able to give ARVs showing the huge importance of do- 81% rate of 89% throughout the 12 clinics at the clinic level because TB is a ing those testings. 200 300 of Lusikisiki (see Figure 3). clinic-based programme. TB and HIV We’ve also introduced dry need to be integrated and so giving Decentralised 200 blood spot blood testing and do- ARVs at clinic level is an ideal op- 31% ing Polymerase Chain Reaction tests portunity to integrate TB and HIV ARV Provision 100 30% 28% 22% (PCRs) at six weeks on the babies and, programmes. At the clinics outside With an ARV decentralised model, 21% 25% 100 looking at the two busiest clinics, I’ve Lusikisiki, we managed to test 75% of the first advantage in terms of- out comes is Patients the enrolment. increase The graph + staff constant

Number of pregnant women and tests 0 Number of pregnant women and tests 0 ENROLMENT (see Figure 4) represents the enrol- MAR APR MAY JUN JUL AUG MAR APR MAY JUN JUL AUG =rising workload Decentralisation - better enrolment ment per quarter, so in the first four 2003 2006 months at the hospital, eight patients Clinic ARV enrolment Hospital ARV enrolment Patients per month were recruited. At the clinics, 59 were recruited, because the clinicNurse started: Patient ratio 250 240 three months before the hospital. So, basically,30 000 at the end of quarter one, the hospital recruited eight patients. 29 000 Cumulative Enrollment in HIV Care and Treatment at Patients Initiating ART St. Patrick’s Hospital + 4PHCs 200 And then the hospital and27 000 the clinic were more or less working 47 ICAP Supported Sites, Eastern Cape May 05 – June 06 25 000 at a parallel pace of recruiting 43 new HIV Care ART Total Hospital PHCs 150 patients, quarter by quarter. But 700 then after20 000 the first year the hospital reached a plateau and basically car- 642 15 999 ried on recruiting the16 000 same amount of 15 000 600 100 91 people month15 000 by month. Whereas, at

Number of patients the clinics, after a slight dip, it start- 500 75 68 ed shooting up. The space for faster 59 50 enrolment10 000 is shown by the faster re- 400 cruitment at clinic level. One of the 9 608 29 10 000 336 reasons is that at clinics – we’ve got 8 300 306 0 12 clinics5 000 – each one of them has to Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 recruit about eight people per month. 2004 Figure2004 4. Decentralised2004 clinics2004 are enrolling2005 far greater2005 numbers2005 than the2005 hospital.2006 Number of patients That means you can distribute your 6127 200 Figure 4. Clinic ARV enrolment is currently outstripping hospital ARV enrolment. work load over many more people 5000 than at the hospital,2004 where you’ve2005 got 2006 Number of patients 100 an ARV-specific clinic, where you’ve 2 022 got limited staff. 0 Clinical Outcomes: Clinics and Hospital 906 APR JUN AUG OCT DEC FEB APR- 24 05 05 05 05 05 06 JUN CLINICS HOSPITAL 0 06 Comparing Clinical OCT-DEC JAN-MAR APR-JUN JUL-SEP OCT-DEC JAN-MAR APR-JUN 2004 2005 2005 2005 2005 2006 2006 Patients 595 430 Outcomes Still on ARVs 483 (81%) 289 (68%) This table (See Table 1) shows the Deaths 100 (17%)RESULTS (3)58 (13%) clinical outcomesMoving of the first Foward about - Policy dependent Lost to follow-up 13 (2%) 83 (19%) 1000 patients starting ARVs. These Patients Initiating ART Holy Cross Hospital + 3PHCs ART: New inclusions / month Quarterly enrolment at clinics CD4 > 200 87% 75% patients were chosen because they May 05 June 06 (2 main hospital sites) started in the first 18 months and – VL undetectable 90% 78% VCT - health seeking behaviour ART Inclusions all of them have now completed 12 Total Hospital PHCs Table 1. Outcomes of patients who completed 12 months of ARVs. 250 VCT, Lusikisiki, March 2003 August 2006, 12 clinics months of treatment. At the clinics, it 240 – Task shifting to medical assistants, nurses & PLWAs no. people tested no. people tested HIV+ % HIV+ 500 497 NELSON MANDELA FOUNDATION “Partial” task shifting to Three health centres 2000 Nurse CHW Nurse/ CHW 4h 8h medical assistants 200 1800 45% CHW Nurse 400 500 ARV initiation done by 1600 doctors instead of nurses 40% 1400 35% 400 1200 300 150 30% 260 1000 237 300 800 200

600 Number of patients 100 200 91 400 200 100 100 0 50 Jul Jul Jul Jul Oct Oct Oct Feb Feb Feb Apr Apr Apr Apr Jun Jan Jun Jan Jun Jan Jun Sep Sep Sep Aug Nov Dec Aug Nov Dec Aug Nov Dec Aug Mar Mar Mar OCT-DEC JAN-MAR APR-JUN JUL-SEP OCT-DEC JAN-MAR APR-JUN May May May May 0 0 2004 2005 2005 2005 2005 2006 2006 2003 2004 2005 2006 APR JUN AUG OCT DEC FEB APR- 2004 2005 2006 2006 Mar 05 05 05 05 05 05 JUN 06 (JUN) Achieving Sustaining Universal Access 1400

1200

1000 Potential Rx gap 800

600

Decentralised ARV provision through TB and HIV services can be primary health care results in greater integrated successfully. 1enrolment figures. 2

Task-shifting spreads the work load High community participation between doctors, nurses, support staff results in destigmatisation and better 3and the community. 4adherence rates. was 595 patients; at the hospital, 430 At the clinics we had 100 deaths. ed deaths could have been higher at patients. Of the clinic patients, 483 are At the hospital we had 58 deaths re- the hospital, but we haven’t got those still on treatment at the clinic, which corded. At the clinics we had 2% of exact figures. After 12 months, 87% of represents 81%. At the hospital, it’s patients who were lost to follow-up. clinic patients had a CD4 count above 68%. I have included the patients that At the hospital we had 19% lost to 200 and 75% of hospital-treated pa- were transferred out and that are still follow-up and we know that a lot of tients had a CD4 count of above 200. In on treatment, and they represented these patients actually passed away, terms of detectable viral load, the best 6% at the clinics and hospital. but it wasn’t recorded. So the record- indication of adherence: at the clinics

NELSON MANDELA FOUNDATION VCT done at ANC consultation March – August 2003 VCT done at ANC consultation March – August 2006

ANC consultations VCT done % tested ANC consultations VCT done % tested 400 600 A DIALOGUE ON ART MODELS 500 89% 99% 300 90% had an undetectable viral load, their ARVs at the support group are constant at about 50% vacancy level, 85% 99% 400 80% compared to 78% at hospital level. happier if they don’t have to pay for our workload started at 29 patients 81% 200 300 So for me, that is quite convinc- transport money – the main constraint per nurse per day in 2004 and is now ing data of the superior quality of the of having to go to a hospital-based 47, compared to an Eastern Cape av- 200 31% clinic-based programme. I also be- system. erage of 26, taken from the Health 30% 28% 100 22% 21% 25% 100 lieve that the patients dancing with Systems Trust statistics, and the SA Patients increase + staff constant Small Decision: average of 25.5 patients per nurse (see Number of pregnant women and tests 0 Number of pregnant women and tests 0 WORKLOAD=rising workload Figure 5). MAR APR MAY JUN JUL AUG MAR APR MAY JUN JUL AUG Decentralisation - better enrolment Huge Impact 2003 2006 Clinic ARV enrolment Hospital ARV enrolment Patients per month Obviously there is a huge belief in Task-Shifting and Nurse : Patient ratio the community that the hospital is 250 240 better equipped, has got doctors and Down-Referral 30 000 29 000 that it is better. But in Lusikisiki we So to deal with the backlog, or the Cumulative Enrollment in HIV Care and Treatment at Patients Initiating ART St. Patrick’s Hospital + 4PHCs 200 27 000 were getting support for the clin- shortage of staff, we have to do 47 ICAP Supported Sites, Eastern Cape May 05 – June 06 25 000 ics because of the cheaper access to task-shifting. There are no doctors per- 43 HIV Care ART Total Hospital PHCs 150 them and their immediacy for the manently at the clinics, so the nurses 700 20 000 patients. Then came the directive that have to do the initiation, the counsellor 642 only doctors are supposed to initiate has to do the preparation, community 15 999 16 000 15 000 600 100 91 15 000 people on ARVs and suddenly the health workers have to be trained as Number of patients patients said, “Well, then we might as assistant pharmacists and the com- 500 75 68 59 well have to go to the hospital if we munity has to be involved to help the 50 10 000 400 have to wait at the clinic.” So a small clinic to develop the services to bring 9 608 29 10 000 336 8 decision can make a huge impact on the sick patients to the clinic, and to 300 306 0 5 000 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 the image of the programme. educate people about adherence. 2004 2004 2004 2004 2005 2005 2005 2005 2006 6127 Number of patients 200 Our main constraint at clinics is There’s a big issue in the

5000 2004 2005 2006 that the patient number increased Department of Health about down- Number of patients 100 from 16 000 seen per month to 29 000 referral and I appreciate it because it Figure 5. Patients increase + staff constant = 2 022 seen per month this year. starts recognising the role that clinics 906 0 workload rising. APR JUN AUG OCT DEC FEB APR- With the nurse numbers staying can play, but I think we need to look 24 05 05 05 05 05 06 JUN 0 06 OCT-DEC JAN-MAR APR-JUN JUL-SEP OCT-DEC JAN-MAR APR-JUN 2004 2005 2005 2005 2005 2006 2006 RESULTS (3) Moving Foward - Policy dependent Patients Initiating ART Holy Cross Hospital + 3PHCs ART: New inclusions / month Quarterly enrolment at clinics May 05 – June 06 (2 main hospital sites) VCT - health seeking behaviour ART Inclusions Total Hospital PHCs 250 VCT, Lusikisiki, March 2003 August 2006, 12 clinics 240 – Task shifting to medical assistants, nurses & PLWAs no. people tested no. people tested HIV+ % HIV+ 500 497 “Partial” task shifting to Three health centres 2000 Nurse CHW Nurse/ CHW 4h 8h medical assistants 200 1800 45% CHW Nurse 400 500 ARV initiation done by 1600 doctors instead of nurses 40% 1400 35% 400 1200 300 150 30% 260 1000 237 300 800 200

1200

1000 Potential Rx gap 800

600

New Stage 4 (need for ARVs) 400 Enrolment actual Scenario 1 – intended trajectory Scenario 2 – failure to increase enrolment 200 Scenario 3 – enrolment stagnates New Stage IV and new patients started on ARVs 0 LONG WAIT: Patients queue for health services at a district clinic in Lusikisiki. 2003 2004 2005 2006 2007 2008 2009 2010 10 NELSON MANDELA FOUNDATION VCT done at ANC consultation March – August 2003 VCT done at ANC consultation March – August 2006

ANC consultations VCT done % tested ANC consultations VCT done % tested 400 600

500 89% 99% 300 99% 400 85% 80% 81% 200 300

200 31% 30% 28% 100 22% 21% 25% 100 Patients increase + staff constant Number of pregnant women and tests 0 Number of pregnant women and tests 0 =rising workload MAR APR MAY JUN JUL AUG MAR APR MAY JUN JUL AUG Decentralisation - better enrolment 2003 2006 Clinic ARV enrolment Hospital ARV enrolment Patients per month Nurse : Patient ratio 250 240 30 000 29 000 Cumulative Enrollment in HIV Care and Treatment at Patients Initiating ART St. Patrick’s Hospital + 4PHCs 200 27 000 47 ICAP Supported Sites, Eastern Cape May 05 – June 06 25 000 43 HIV Care ART Total Hospital PHCs 150 700 20 000 642 15 999 16 000 15 000 600 100 91 15 000 Number of patients VCT done at ANC consultation March – August 2003 VCT done at ANC consultation March – August 2006 500 75 68 VCT done at ANC consultation March – August 2003 VCT done at ANC consultation March – August 2006 50 59 ANC consultations VCT done % tested ANC consultations VCT done % tested 10 000 400 400 ANC consultations VCT done % tested 600 ANC consultations VCT done % tested 9 608 29 10 000 336 400 600 8 500 300 306 0 5 000 89% 99% Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 300 500 89% 85% 99% 99% 2004 2004 2004 2004 2005 2005 2005 2005 2006 300 400 80% Number of patients 81% 99% 6127 200 400 85% 80% 200 300 81% 5000 2004 2005 2006 200 300 Number of patients 200 100 31% 30% 28% 100 22% 200 2 022 21%31% 25% 100 30% 28% 100 906 0 22% 21% 25% APR JUN AUG OCT DEC FEB APR- 100 Patients increase + staff constant 05 05 05 05 05 06 JUN Number of pregnant women and tests 0 Number of pregnant women and tests 0 0 24 MAR APR MAY JUN JUL AUG MAR APR MAY JUN JUL AUG Patients increase=rising +workload staff constant 06 Number of pregnant women and tests 0 Number of pregnant women and tests 0 Decentralisation - better enrolment OCT-DEC JAN-MAR APR-JUN JUL-SEP OCT-DEC JAN-MAR APR-JUN 2003 2006 =rising workload 2004 2005 2005 2005 2005 2006 2006 MAR APR MAY JUN JUL AUG MAR APR MAY JUN JUL AUG DecentralisationClinic ARV enrolment - betterHospital enrolment ARV enrolment 2003 2006 Patients per month Clinic ARV enrolment Hospital ARV enrolment PatientsNurse per : Patient month ratio 250 RESULTS (3) Moving Foward - Policy dependent 240 Nurse : Patient ratio 250 240 30 000 Patients Initiating ART Holy Cross Hospital + 3PHCs ART: New inclusions / month Quarterly enrolment at clinics 29 000 Patients Initiating ART St. Patrick’s Hospital + 4PHCs 200 30 000 (2 main hospital sites) Cumulative Enrollment in HIV Care and Treatment at 27 000 29 000 May 05 – June 06 May 05 – June 06 47 ART Inclusions CumulativeICAP Enrollment Supported in HIV Sites, Care Eastern and Treatment Cape at Patients Initiating ART St. Patrick’s Hospital + 4PHCs 200 25 000 27 000 VCT - health seeking behaviour May 05 – June 06 43 47 Total Hospital PHCs 250 ICAP SupportedHIV Care Sites, EasternART Cape Total Hospital PHCs 25 000 VCT, Lusikisiki, March 2003 August 2006, 12 clinics 240 150 43 – Task shifting to medical assistants, nurses & PLWAs HIV Care ART 700 Total Hospital PHCs 20 000 150 no. people tested no. people tested HIV+ % HIV+ 500 497 15 999 700 642 20 000 16 000 “Partial” task shifting to Three health centres 15 000 600 642 100 91 2000 15 999 15 000 16 000 Nurse CHW Nurse/ CHW 4h 8h medical assistants 200 15 000 600 100Number of patients 91 1800 45% CHW 500 75 68 15 000 Nurse 400

Number of patients 500 ARV initiation done by 59 50 75 68 1600 doctors instead of nurses 500 10 000 40% 400 50 59 1400 10 000 9 608 10 000 29 35% 400 336 300 400 150 8 1200 10 000 9 608 300 306 0 5 000 29 336 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 30% 260 8 300 306 0 2004 2004 2004 2004 2005 2005 2005 2005 2006 5 000 1000 Number of patients 237 6127 200 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 300 2004 2004 2004 2004 2005 2005 2005 2005 2006 A DIALOGUE 800ON ART MODELS Number of patients 200 5000 6127 200 2004 2005 2006 Number of patients 100 600 Number of patients 100 5000 2004 2005 2006 200 91 Number of patients 2 022 100 THE FUTURE 400 0 906 2 022 APR JUN AUG OCT DEC FEB APR- 200 100 24 0 05 05 05 05 05 06 JUN 100 0906 APR JUN AUG OCT DEC FEB APR- 06 0 24 OCT-DEC JAN-MAR APR-JUN JUL-SEP OCT-DEC JAN-MAR APR-JUN 05 05 05 05 05 06 JUN 50 Jul Jul Jul Moving Forward Depends Projections For Achieving and Jul Oct Oct 2004 2005 2005 2005 2005 2006 2006 Oct Feb Feb Feb Apr Apr Apr Apr Jun Jan Jun Jan Jun Jan 0 Jun Sep Sep Sep Aug Nov Dec Aug Nov Dec Aug Nov Dec Aug Mar Mar 06 Mar OCT-DEC JAN-MAR APR-JUN JUL-SEP OCT-DEC JAN-MAR APR-JUN May May May May OCT-DEC JAN-MAR APR-JUN JUL-SEP OCT-DEC JAN-MAR APR-JUN 0 0 2004 2005 2005 2005 2005 2006 2006 2004 2005 2005 2005 2005 2006 2006 on Policy Sustaining2003 Universal2004 Access 2005 2006 APR JUN AUG OCT DEC FEB APR- 2004 2005 2006 2006 RESULTS (3) Moving Foward - Policy dependent Mar 05 05 05 05 05 05 JUN (JUN) Moving Foward - Policy dependent 06 Patients Initiating ART Holy Cross Hospital + 3PHCs ART: NewRESULTS inclusions (3) / month Quarterly enrolment at clinics (2 main hospital sites) Patients Initiating ARTMay Holy 05 –Cross June Hospital 06 + 3PHCs ART: New inclusions / month Quarterly enrolment at clinics Achieving Sustaining Universal Access VCT - health seeking behaviour May 05 June 06 (2 main hospitalART Inclusions sites) Total – Hospital PHCs 250 1400 VCT,VCT Lusikisiki, - health March seeking 2003 – Augustbehaviour 2006, 12 clinics ART Inclusions 240 Total Hospital PHCs Task shifting to medical assistants, nurses & PLWAs 250 VCT, Lusikisiki, March 2003 August 2006, 12 clinics 500 497 240 no. people tested no. people– tested HIV+ % HIV+ Task shifting to medical assistants, nurses & PLWAs 1200 500 “Partial” task shifting to Three health centres 2000 no. people tested no. people tested HIV+ % HIV+ 497 medical assistants 200 Nurse CHW Nurse/ CHW 4h 8h “Partial” task shifting to 1800 45% CHW Three health centres 1000 Potential 2000 Nurse 400 Nurse CHW Nurse/ CHW 4h 8h medical500 assistants 200 ARV initiation done by 1800 1600 45% CHW doctors instead of nurses Rx gap 40% Nurse 400 1400 500 ARV initiation done by 800 1600 35% doctors instead of nurses 40% 300 400 150 1400 1200 35% 30% 260 1000 300 400 150 600 1200 30% 237 300 800 260 1000 200 237 New Stage 4 (need for ARVs) 300 400 Enrolment actual 800 600 Number of patients 100 200 200 91 Scenario 1 – intended trajectory 400 Scenario 2 – failure to increase enrolment 600 Number of patients 100 200 100 200 91 Scenario 3 – enrolment stagnates 400 200 100 New Stage IV and new patients started on ARVs 0 100 200 50 0 Jul Jul Jul Jul Oct Oct Oct 100 Feb Feb Feb Apr Apr Apr Apr Jun Jan Jun Jan Jun Jan Jun Sep Sep Sep Aug Nov Dec Aug Nov Dec Aug Nov Dec Aug Mar Mar Mar OCT-DEC JAN-MAR APR-JUN JUL-SEP OCT-DEC JAN-MAR APR-JUN May May May 0 May 2003 2004 2005 2006 2007 2008 2009 2010 2003 2004 2005 2006 0 0 50 2004 2005 2005 2005 2005 2006 2006 Jul Jul Jul Jul APR JUN AUG OCT DEC FEB APR- Oct Oct Oct Feb Feb Feb Apr Apr Apr Apr Jun Jan Jun Jan Jun Jan Jun Sep Sep Sep Aug Nov Dec Aug Nov Dec Aug Nov Dec Aug 2006 Mar Mar Mar 2004 2005 2006 OCT-DEC JAN-MAR APR-JUN JUL-SEP OCT-DEC JAN-MAR APR-JUN Mar May May May May 0 05 05 05 05 05 05 JUN 0 (JUN) Figure2004 6. Enrolment2005 figures2005 dropped2005 after2005 nurses were2006 stopped2006 from 2003 2004 2005 2006 APR JUN AUG OCT DEC FEB APR- 06 2004 2005 2006 2006 Figure 7. Three enrolment scenarios using the ASSA model. Mar 05 05 05 05 05 05 JUN (JUN) initiating ARVs in early 2006. Achieving Sustaining Universal Access 06 1400 Achieving Sustaining Universal Access 1400 1200 at clinic-initiated ARVs. The mere we saw in the last quarter, we must 1200 Looking forward 1000 Potential fact that people have to start in the make sure that it doesn’t continue go- Rx gap 1000 Potential 800 hospital is a bottleneck and it doesn’t This graph (see Figure 7) relates to ing down, because the treatment gap Rx gap 800 help with adherence, because as soon the previous graph and shows not is going to increase unless we manage 600 as the hospital doctor wants to down- how many people are on ARVs, to carry on recruiting more patients 600 New Stage 4 (need for ARVs) 400 Enrolment actual refer a patient, there’s a breach of but how many people get initiated every month. New StageScenario 4 (need 1 – intended for ARVs) trajectory 400 Scenario 2 – failure to increase enrolment 200 Enrolment actual contract. Or the patient gets used to month by month. So, initially we So I believe there are a few policy ScenarioScenario 1 – intended 3 – enrolment trajectory stagnates New Stage IV and new patients started on ARVs Scenario 2 – failure to increase enrolment 200 a system and suddenly you want to initiated few people. Now we are ini- issues that are central to the success 0 Scenario 3 – enrolment stagnates New Stage IV and new patients started on ARVs 2003 2004 2005 2006 2007 2008 2009 2010 expel them from that system. So we tiating about the need that exists in of sustainability of Lusikisiki: decen- 0 2003 2004 2005 2006 2007 2008 2009 2010 need to start at clinic level immedi- our community. tralised ARV initiation, task shifting ately with initiation. The need is modelled with the (especially nurses to initiate ARVs), This is what happened (see Actuarial Society of South Africa community health workers to do HIV Figure 6). That arrow points at the (ASSA) model as having to recruit testing and more staff for primary time when we were told in Lusikisiki in Lusikisiki about 1 000 patients per health-care level. nurses were not allowed to initiate year. If you continue with the present ARVs anymore, and then the next rate we might make our aim of uni- quarter our ARV intake dropped. versal access, but with this dip that

ABOUT THE SPEAKER

Dr Hermann Reuter is the co-ordinator of the Médecins Sans Frontières (MSF) HIV programme in Lusikisiki, Eastern Cape. Reuter was born in Namibia, but grew up in South Africa. He studied medicine at Stellenbosch University and has worked as a doctor in South Africa, Namibia and Botswana. In 1999, he joined the Treatment Action Campaign as a provincial co-ordinator for the Western Cape. In 2000, he joined MSF and worked on the MSF Khayelitsha project, the first NGO project to provide ARVs in South Africa. Seeing the need for a rural model of care for HIV and AIDS patients, Reuter proposed, and co-ordinated, the MSF project in Lusikisiki. After officially handing over the project to the Department of Health in October 2006, Reuter plans to take a holiday along the east coast of Africa before deciding on future work.

NELSON MANDELA FOUNDATION 11 A DIALOGUE ON ART MODELS Delivering a Rural Model

r Hermann Reuter has lived and breathed Dthe rural Eastern Cape area of Lusikisiki for four years, since he founded the Médecins Sans Frontières project there.

Before Lusikisiki, Reuter was involved with the groundbreaking MSF Khayelitsha project, the first NGO- run ARV project at a government facility in South Africa, established in 2001 at a time when public-sector ARV treatment was still illegal. Despite the tremendous success of the Khayalietsha programme REASON TO CELEBRATE: The MSF’s ARV delivery project was handed over to the Eastern – it was chosen by the World Health Cape Department of Health in October 2006. Organisation as a model of best practice in 2003 – something nagged away from the Eastern Cape Department of Four years on, Reuter says the at Reuter’s mind. Health’s Nomalanga Makwedini. “We change in the community’s spirit is He told his colleagues at MSF that agreed to have a verbal agreement,” immeasurable. a separate model needed to be de- he says. By October 2003, Reuter had a “Many people saw HIV as some- veloped for rural districts. “Seventy written confirmation from the govern- thing coming from the ancestors, percent of people in SA make use ment to start ARV treatment. “It was poisoning, or bewitchment. By pro- of rural clinics and it is a different about two lines,” he recalls. viding treatment, people can see ball game,” he argued. The model Reuter says the model of care his there is an answer to this, so it isn’t would be based on a decentralised team developed over four years is not bewitchment. ... approach, where primarily nurses, complex. “I don’t think those are dif- “In Lusikisiki there are no secrets. instead of doctors, would manage the ficult things,” he remarks. “There’s If you get carried out of your house programme. nothing extremely difficult in what on a stretcher to a car and the car At first some of his colleagues we did. What is different is that we takes you out to hospital, the whole were not convinced. “They said MSF had the independence to do what we community knows about it. If you is not here to provide know is right, without come back on your two feet walking, services in the country; waiting for government and say, ‘I was saved by ARVs,’ that we are here to have a “In Lusikisiki policy changes each time. is powerful.” demonstration model.” there are no However, to keep the He’s confident that the programme But Reuter argued that a programme sustainable will continue to be a success long af- rural model was signifi- secrets.” and to role it out to other ter MSF’s departure. “At the moment cantly different, and the areas, policy changes are I’m bored in Lusikisiki,” says Reuter. lessons could be taken to urgently needed.” “These last two months I didn’t see other countries on the continent. He also attributes some of the suc- [ART] patients. Because I wanted to Reuter eventually won MSF cess to the lessons learned from other show to the patients that the services backing, but it wasn’t until Nelson MSF projects. go on even if I’m not there.” Mandela visited the Khayelitsha “As an international NGO, you “I’m bored in the office, writ- project that political will met the come with that experience. You can ing reports. It’s not fun for me,” he NGO’s commitment. Mandela said, come to Lusikisiki and say, ‘I have chuckles. “This is great, but can’t you do some- experience of 10 countries.’ I have Reuter is planning to take three thing like this in the Eastern Cape?” only visited one of the other projects, months’ leave and cross more bor- recalls Reuter. “MSF said, ‘That is ex- but we can read about them; we hear ders. “I’m going to Ethiopia ... I’m actly what we are thinking about, will about the debates. There is tremen- driving up to Malawi and Kenya and you fund it?’ And he said, ‘yes’.” dous knowledge to help you find seeing the countries. I want to take a MSF then received a commitment your way.” break and then work in Ethiopia.”

12 NELSON MANDELA FOUNDATION A DIALOGUE ON ART MODELS

Phambili nge-ARVs! The story of Lusikisiki’s first ARV recipient

am Akhona Ntsaluba. I come from Cala, but I stay by Nelson Mandela himself. I was in a rural area called Lusikisiki, in the Eastern Cape. I was so happy to see him taking a political lead on ARVs and believing that Idiagnosed HIV-positive in 2002. In hospital, I was advised ARVs can save people’s lives. that I should be sterilised, because I was told that all my chil- In my room, I kept a poster dren would be HIV-positive. I didn’t know anything then. of Mandela as a reminder to take my ARVs. I took him as my ARV I was also supposed to have an oper- Lusikisiki. The doctor was concerned supporter. ation for piles, but I couldn’t do both that I would be going back to an area The last time I did my CD4 count, because I wasn’t well enough. I was where ARVs were not available, but I it was 860 and my viral load was sterilised and stayed in hospital for a went anyway. undetectable. I am few days, then went home. In 2003, I joined healthy and I am tak- The sores on my private parts I’d the Treatment Action “On December ing AZT, 3TC and had came back and this time they Campaign (TAC) in Nevirapine. I have were bad. I told my aunt. She took Lusikisiki and luck- 10 2003, I took gained weight since me to the hospital and afterwards ily enough, MSF was my first pill, 2003. took me to her house. She took care there, working very I thank MSF in of me till I got better. closely with the TAC. which was given Lusikisiki for saving I want to thank the Ntsaluba, In my work for people’s lives in a Ndungane, and Mthyali families, the TAC, I was edu- to me by Nelson rural area. We will al- because they all took care of me. My cating people about ways remember your mother and father have also been VCT, CD4, PEP, TB, Mandela.” good work. very supportive. rape and ARVs. One We need more At the end of 2002, I went to the day, I decided to do people like Madiba, Médecins Sans Frontières (MSF) a CD4 count; the result was 151. I was TAC and MSF, to fight the struggle of clinic in Khayelitsha, Cape Town, scared to start ARVs. HIV and AIDS in South Africa. which my aunt’s friend introduced But on December 10 2003, I took Phambili nge-ARVs! (Forward with me to. I told them that I was living in my first pill, which was given to me ARVs!)

NELSON MANDELA FOUNDATION 13 A DIALOGUE ON ART MODELS Forming Successful Partnerships

Right to Care Clinical Director Dr Kuku Appiah

y name is Kuku Appiah. I’m from an Morganisation called Right to Care. It’s a non-governmental, non-profit organisation that was formed in 2001, but has been operational since 2002 and our aim is to increase the access of people to safe, affordable and effective ARV therapy.

Our sources of funding are mainly from grants from the United States government through the President’s Emergency Plan for AIDS Relief (PEPFAR) programme, and we also have a private income that we earn. Most of the work that we do is through partnerships, through the formation of successful partnerships with the government, with other NGOs and community-based organisations and with the private sector. And one of our specific aims would be to target people who – for one or another reason – haven’t got access to antiretrovirals. grammes – such as VCT, training and service delivery and our philosophy We work in the urban, peri-ur- the use of doctors, who are treatment is that no one method is going to fit ban and in the rural setting and I’ll experts, and mobilisation and also our for a specific community or a specific explain to you further how we do data management and research – as group of people. that. We would regard ourselves as a supportive operations to achieve our We want to be very flexible in the well-established organisation. We are outcomes. Through this, we strive to way that ARVs are distributed to currently the largest in-country re- provide a comprehensive service to our different groups of people, because cipients of PEPFAR funding and we target populations. people’s needs are different and peo- support six NGO treatment sites. We ple are different in their geographic also support workplace and indigent Five Methods location. patient programmes. We have partnerships and We use the provision of ARVs as our We currently have developed five memoranda of understanding with focus target and use other support pro- methods of delivery of ARVs and the Northern Cape government,

14 NELSON MANDELA FOUNDATION A DIALOGUE ON ART MODELS the Gauteng government and the Mpumalanga government.

Successful Partnerships Currently our most successful activity is in the partnership we have with the Gauteng government at Helen Joseph Hospital, where we have used a significant amount of funding to build a state-of-the-art, purpose-built ARV clinic with all the space required for counsellors and for patient education, with the pharmacy as per requirements. We’ve also used our funding to recruit doctors, nurses and fund NGOs to do counselling in this clinic, and we would like to view that clinic as a demonstration model. We do have major constraints in STATE OF THE ART: Thembalethu Clinic at Helen Joseph Hospital is the largest ARV delivery that clinic. It is currently bursting at site in Gauteng. INSET: The counselling rooms are clearly marked. the seams after two years of being in operation. There are 6 000 patients on private sector. We have a programme employ in the clinic are all tasked to treatment and no specific plans for that we run with a financial services work in this clinic for a period of time the down-referral – so that’s a good company where employers pay for and then to move – say for six months and a bad story at the same time. their ARVs and we also fund private – out to the other rollout sites within We have partnerships with NGOs. practitioners to see patients in differ- our network. Our model is that we wouldn’t go ent communities. So all the doctors have an un- to a community and set up a clinic derstanding that they will not be de novo, we would want to find out Helen Joseph Hospital permanently based at a specific site from communities what is being but would be required to rotate and done there and seek to support doc- Our clinic at Helen Joseph Hospital provide services to different sites. tors who are working or health-care has over 6 000 patients on ARVs and In terms of the salary of the doc- workers who are working in clinics this photo (see above) is of the pa- tors, we are trying to keep our salaries that have already been established in tient-waiting area. The bottom two very closely aligned to government the community. doors are counsellors’ rooms, so it’s salaries so that we don’t create some We are not very prescriptive in demonstrated that ARVs can be suc- sort of inequity. But then we do find the way that those clinics are run. cessfully delivered in this sort of it’s much easier for us to recruit We would try to set specific targets environment with a big label put people than it would be for the gov- in terms of patients treated or receiv- outside saying “Rollout Clinic”, and ernment at the same or similar salary ing care in order to meet our donors’ people haven’t got any problems with scales. wishes, but in terms of the day-to-day accessing care. running of the clinics and the way But what also challenges us, is White River that the funds that what to do, because we give to the clin- all the patients This is one of our clinics that we sup- ics are used, we are “There are 6 000 who are receiving port in White River in Mpumalanga. not very prescrip- treatment here will This is a well-established clinic under tive in that sense, patients on continue to receive Dr Margie Hardman, who’s a shining because we un- treatment and no treatment, and how light in the ARV care and provision derstand that we do we move these arena, and we just support it with cannot know every specific plans for patients or down- funds to be able to purchase drugs. community and be refer patients, so The aim for their clinic is to be able to prescribe the down-referral that other patients accredited to the government pro- how many times a can pass through gramme, and to continue providing clinic should oper- – so that’s a good the bottleneck? their care with the support of the ate or other such and a bad story at government in terms of the provision things. Doctors of drugs and lab services. They run We have part- the same time.” a very comprehensive service, with nerships with the The doctors that we home-based care provision, hospice

NELSON MANDELA FOUNDATION 15 A DIALOGUE ON ART MODELS

services and a lot of training and sup- to remote communities that don’t port groups running from this site. have established health-care systems and it seems to be fairly successful. Wynberg The 1 000 patients on ARVs are the patients who are funded by their This is our own clinic that we estab- employers. lished in Wynberg, next to Alexandra township. It’s in an industrial area. Thusong We employ staff there, provide their medication and pay for the laborato- The Thusong programme is a ry services to provide care for people programme where we ask gen- that live in Alexandra township. eral practitioners to see a specified DELIVERY IN ACTION: Right to Care number of patients, say 50 patients, offers mobile treatment and care to farm Mobile Delivery of ART who attend their rooms, who don’t communities in Mpumalanga. have medical aid and don’t have ac- And that’s one of our mobile vehicles cess to ARVs currently through one able to access treatment, say through (see photograph on right). One of our of the rollout sites, and we then pay the government site or through a modes of delivery in Mpumalanga is for the service and pay for the medi- medical aid, we would ask those to use this mobile vehicle to access cation and the laboratory services. patients to transfer to that site and farm communities which are quite ru- We’ve got over 700 patients let this opportunity be available to ral and a lot of these large farms have receiving treatment through this pro- people who cannot currently access small clinics – it’s commercial farms gramme and as soon as patients are treatment. that have clinics on their sites – but no health-care workers at all. ABOUT THE SPEAKER So we provide VCT to these different sites. The normal pattern would Dr Kuku Appiah is clinical director of Right to Care, and has been with the NGO be that the van would go to a site with since 2002. She studied medicine at the University of Zimbabwe and subsequently a nurse and a doctor once a week and studied to become a specialist physician at the University of the Witwatersrand. we initially provide VCT and, as peo- Appiah saw her first HIV patient as a medical student in 1986. At Right to Care ple feel more comfortable, we are able she co-ordinates programmes around clinical decision-making, ARV provision, to provide ARVs to people using this VCT and training. Before joining the NGO, she ran her own private practice in mode. This is more like a demonstra- Krugersdorp. tion of the viability of providing ARV

16 NELSON MANDELA FOUNDATION A DIALOGUE ON ART MODELS Supporting ART in Rural Health Facilities Dr Doris Macharia, International Centre for AIDS Care and Treatment Programs

hen we started activities as the WInternational Cen- tre for AIDS Care and Treat- ment Programs, a programme built out of Mailman’s School of Public Health, Columbia University, New York, we came to the Eastern Cape and I remember distinctly meeting Mrs Nomalanga Makwedini, from the Eastern Cape De- partment of Health (EC DoH). There was a great need to go to rural areas in the Eastern Cape. I met Thembi Ntlan- gulela (EC DoH) and also Dr Hermann Reuter from Mé- decins Sans Frontières (MSF) and we discussed how we would support rural communities there.

The sites that were identified for us to begin supporting were in the Qaukeni and Mbizana areas. There was St the problem and that the government through the implementation of a fam- Patrick’s Hospital, with its identified was going to supply them, so we were ily-centred service, and this is our clinics, and Holy Cross Hospital. just going to support ARV services. core vision. When we came to the But, of course, this soon turned out to Eastern Cape, the things we identi- A ‘Different Programme’ be something else because obviously fied were: the need has been great. • Infrastructure development, wheth- This was a different programme for I will talk around activities that er it’s renovations or putting up new us, as a university, because, just like we support in the rural areas of the clinic structures; with most other universities, we Eastern Cape. I would also like to • Lab and pharmacy support; largely provide technical assistance mention what else we are doing in • On-site clinical mentoring and and research programmes, and we other parts of the Eastern Cape, in the training; were funded distinctly for ARV serv- more urban and peri-urban facilities. • HIV adherence support through ices and ARV drugs. Our approach to implementation the implementation of some in- Of course, when we came to the has really been to provide a compre- novative strategies, such as peer province we realised drugs were not hensive care and treatment service education programmes; and

NELSON MANDELA FOUNDATION 17 A DIALOGUE ON ART MODELS

• Patient medical record and data encouraging. And we have demon- have all these funds from PEPFAR, collection management. strated similar results in Holy Cross we cannot do it alone. So we had to So this has been our approach. As Hospital, which is in Flagstaff. look for local partners to address the you can see, it’s as comprehensive as Holy Cross Hospital has about human resources issue. possible, but it doesn’t mean we get 50% of the overall patients recruited There was just a great need to it right at all times. We try as best as in that particular area, and three of support clinics (and initially the possible with the funds we have to try the PHCs which have been identified hospitals) with doctors, nurses, com- and see how best to provide all these with Holy Cross have also recruited munity health workers and some services in the areas where we are. approximately 200 patients. pharmacy staff. Most of this is done in We can see from this graph (Figure partnership with the Foundation for Successes 3) that PHCs are able to get quickly re- Professional Development (FPD). This cruited into ART management. When is a new partnership and, hopefully, Some of our successes have been the programme started at the end of in the next two weeks, we’re going to rapid enrolment, the supporting and May 2005, it was hospital-based. And have the four doctors, four profession- promoting of the down-referral of then by around September/October, al nurses and two enrolled nurses and ART services to the primary health like in Holy Cross, the primary these other local partners, who we are clinics (PHCs), the development of lo- health-care facilities were recruited as working with, to be able to meet the cal partnerships, building the capacityVCT done at ANCpart consultation of the Marchtreatment – August service2003 point.VCT done at ANCneed consultation for local March staffing – August 2006outside. of clinicians to manage patients, HIV ANC consultationsWe canVCT done see% thetested PHCs are really ANC consultations VCT done % tested information systems and the creation400 taking off and it is likely that we 600are CapacityVCT done at ANC consultation Building March – August 2003 VCT done at ANC consultation March – August 2006 500 ANC consultations VCT done % tested ANC consultations VCT done % tested of clinical space. (hopefully) going to have similar 89% 99% 300 400 99% 600 So, in terms of enrolment this is findings to what MSF has400 demon- In terms85% of80% capacity building we’ve 500 81% 89% 99% the accumulative enrolment of 200 HIV strated in Lusikisiki. 300 worked300 mainly with local partners 99% 400 85% 80% 81% into chronic care and also ART for all 200 such as the FPD to conduct basic HIV 31% 200 300 100 30% 28% the sites that ICAP is supporting (see 22% 21% training. We’ve also identified local 25% 100 200 Local Partnerships 31% 100 30% 28% Figure 1). By the end of June this year, pediatricians22% based21% in25% East London Patients increase + staff constant Number of pregnant women and tests 0 Number of pregnant women and tests 0 100 =rising workload we were supporting about 16 000 peo-MAR InAPR termsMAY JUNof theJUL developmentAUG of local MARandAPR atMAY StellenboschJUN JUL AUG University to Decentralisation - better enrolment Patients increase + staff constant 2003 Number of pregnant women and tests 0 2006 Number of pregnant women and tests 0 =rising workload ple in HIV. That is, those patients who partnerships, one thing we realised facilitateMAR APR pediatricMAY JUN HIVJUL AUG training for MAR APR MAY JUN JUL AUGClinic ARV enrolment Hospital ARV enrolment DecentralisationPatients - better per month enrolment 2003 2006 Clinic ARV enrolmentNurse : PatientHospital ratio ARV enrolment Patients per month are coming into the clinic get their when we came in is that even if we health-care workers. 250 240 Nurse : Patient ratio 250 CD4 count and get cotramoxazole. 30 000 240 29 000 30 000 Cumulative Enrollment in HIV Care and Treatment at Patients Initiating ART St. Patrick’s Hospital + 4PHCs 200 27 000 29 000 And about 6 000 or so are on ART, in 47 ENROLMENT Cumulative EnrollmentMay 05in HIV– June Care 06 and Treatment at Patients Initiating ART St. Patrick’s Hospital + 4PHCs 200 27 000 ICAP Supported Sites, Eastern Cape 25 000 47 all the facilities that we are working ICAP Supported Sites, Eastern Cape May 05 – June 06 43 25 000 VCT done at ANC consultation March – August 2003 VCT done at ANC consultation March – August 2006 43 HIV Care ART Total Hospital PHCs 150 HIV Care ART Total Hospital PHCs 150 in, in the Eastern Cape. 700 20 000 ANC consultations VCT done % tested ANC consultations VCT done % tested 700 20 000 642 About 16 000 people have enrolled15 999 642 16 000 400 600 15 999 16 000 600 100 91 15 000 15 000 600 100 91 15 000 15 000 Number of patients in HIV care, and over 6 000 people Number of patients 500 Primary Health Care 89% 99% 500 500 75 68 75 68 300 in ART, at ICAP-supported99% sites in 59 50 59 85% 50 10 000 400 80% 400 10 000 81% 400 9 608 29 Turning our attention to Mbizana10 000 the Eastern9 608 Cape (see Figure 1). 10 000 336 29 200 300 336 8 300 8 306 0 5 000 300 306 0 Q1 5 000Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 and Flagstaff. The graph (see Figure Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 2004 2004 2004 2004 2005 2005 2005 2005 2006 200 Number of patients 200 2004 2004 2004 2004 2005 2005 2005 2005 2006 31% Number of patients 6127 100 2) 30% shows patients 28% who are initiating The number of patients initiating6127 at 200 22% 5000 2004 2005 2006 21% 25% 100 Number of patients 5000 100 2004 2005 2006 treatment at St Patrick’s HospitalNumber of patients in PHCs now rivals that of hospitals 100 2 022 Patients increase + staff constant Number of pregnant women and tests 0 Number of pregnant women and tests 0 906 0 Mbizana, which is a very poor rural (See Figures2 022 2 and 3). APR JUN AUG OCT=risingDEC workloadFEB APR- MAR APR MAY JUN JUL AUG MAR APR MAY JUN JUL AUG 0 24 Decentralisation - better enrolment 05 05 05 05 05 06 JUN 906 0 APR JUN AUG OCT DEC FEB APR- 06 2003 2006 OCT-DEC JAN-MAR APR-JUN JUL-SEP OCT-DEC JAN-MAR APR-JUN community. By the end of June 2006,24 052004 052005 052005 2005Clinic05 ARV200505 enrolment200606 2006JUNHospital ARV enrolment 0 06 Patients per month OCT-DEC JAN-MAR APR-JUN JUL-SEP OCT-DEC JAN-MAR APR-JUN there were an estimated 600 patients 2004 2005 2005 2005 2005 2006 2006 Nurse : Patient ratio Moving Foward - Policy dependent 250 RESULTS (3) Figure 1. Cumulative enrolment in HIV care and 240 on treatment. We can see in this Patients Initiating ART Holy Cross Hospital + 3PHCs ART: NewMoving inclusions Foward / month - Policy dependent Quarterly enrolment at clinics treatment at ICAP-supported sites, Eastern Cape. 30 000 RESULTS (3) (2 main hospital sites) May 05 – June 06 29 000 graph that 52% of patients were being Patients Initiating ART St. Patrick’s Hospital + 4PHCs Patients Initiating200VCT ART - health Holy seeking Cross Hospitalbehaviour + 3PHCs ART: New inclusions / month ART Inclusions Quarterly enrolment at clinics Cumulative Enrollment in HIV Care and Treatment at Total Hospital 27 000 PHCs 250 May 05 – June 06 VCT, Lusikisiki,May March05 – June2003 August 06 2006, 12 clinics (2 main hospital sites)47 240 ICAP Supported Sites, Eastern Cape – 25 000 Task shifting to medical assistants, nurses & PLWAs managed at PHCs. A lesson we have ART43 Inclusions VCT - health seeking behaviour no. people tested no. people tested HIV+ % HIV+ 500 497 HIV Care ART Total Hospital PHCs 250 VCT, Lusikisiki, MarchTotal 2003 August Hospital2006, 12 clinics PHCs 150 “Partial” task shifting to Three health centres 240 learned working in the same district – 2000 medical assistants 200 700 Nurse CHW Nurse/ CHW 4h 8h 20 000Task shifting to medical assistants, nurses & PLWAs 1800 45% CHW 500 Nurse 497 400 as Hermann’s group is that the hos- no. people tested no. people tested HIV+ % HIV+ 642 500 ARV initiation done by 15 999 1600 “Partial” task16 000 shifting to Three health centres doctors instead of nurses 2000 40% 15 000 Nurse 600 CHW Nurse/ CHW 4h 8h 1400 100 35% 91 medical assistants 200 pital enrolment is not as efficient1800 as 45% CHW 300 15 000 400 150 Nurse 4001200 Number of patients 30% 500 ARV initiation done by 1600 500 75 68 260 that of the PHCs. And this is prima- 1000 237 doctors instead of nurses 40% 50 59 300 1400 35% 800 200 10 000 300 400 150 rily because there are more primary1200 400 600 Number of patients 100 29 10 000 9 608 30% 260 200 91 1000 336 400 8 237 health-care facilities involved in pa- 300 306 200 0 100 3005 000 800 200 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 100 0 2004 2004 2004 2004 2005 2005 2005 2005 2006 Number of patients 600 Number of patients 50 Jul Jul Jul Jul 100 Oct Oct Oct Feb Feb Feb Apr Apr Apr Apr Jun Jan Jun Jan Jun Jan tient recruitment. Jun Sep Sep Sep Aug Nov Dec Aug Nov Dec Aug Nov Dec Aug Mar Mar Mar OCT-DEC JAN-MAR APR-JUN JUL-SEP OCT-DEC JAN-MAR APR-JUN May May May 6127 200 May 200 91 400 0 0 2004 2005 2005 2005 2005 2006 2006 2003 2004 2005 2006 APR JUN AUG OCT DEC FEB APR- 2004 2005 2006 2006 5000 For example, in St Patrick’s we 100 Mar 05 05 05 200405 05 200505 JUN2006 Number of patients 200 (JUN) 100 100 06 0 have about2 022 four PHCs that are in- Achieving Sustaining Universal Access 50 Jul Jul Jul Jul Oct Oct Oct Feb Feb Feb Apr Apr Apr Apr Jun Jan Jun Jan Jun Jan Jun Sep Sep Sep Aug Nov Dec Aug Nov Dec Aug Nov Dec Aug Mar Mar Mar OCT-DEC JAN-MAR APR-JUN JUL-SEP OCT-DEC JAN-MAR APR-JUN May May May May 906 0 0 1400 0 2004 2005 2005 2005 2005 2006 2006 volved, thereby relieving the burden 2003 APR 2004JUN AUG OCT2005 DEC 2006FEB APR- APR JUN AUG OCT DEC FEB APR- 2004 2005 2006 2006 05 05 05 05 05 Mar 06 JUN 24 051200 05 05 05 05 05 JUN 0 06 06 (JUN) OCT-DECofJAN-MAR havingAPR-JUN oneJUL-SEP PHCOCT-DEC managingJAN-MAR APR-JUN all the 2004 2005 2005 2005 2005 2006 2006 FigureAchieving 2. Patients Sustaining initiating Universal ART at AccessSt Patrick’s Figure 3. Patients1000 initiating ART at Holy CrossPotential Hospital 300 patients. Each PHC is managing Rx gap 1400 Hospital and four PHCs. May 2005 – June 2006. and three 800PHCs. May 2005 – JuneRESULTS 2006. (3) Moving Foward - Policy dependent 600 about 100 patients, some 50 and oth-1200 Patients Initiating ART Holy Cross Hospital + 3PHCs ART: New inclusions / month Quarterly enrolment at clinics 400 New Stage(2 4 main(need for ARVs) hospital sites) 1000 May 05 – JunePotential 06 Enrolment actual ers much less, and this has been quite Scenario 1 – intended trajectory VCT - health seeking behaviour Rx gap Scenario 2 – failure toART increase Inclusions enrolment Total Hospital PHCs 200 Scenario 3 – enrolment stagnates 250 VCT, Lusikisiki, March 2003 – August 2006, 12 clinics 800 New Stage IV and new patients started on ARVs 240 0 Task shifting to medical assistants, nurses & PLWAs no.18 people tested no. people tested HIV+ % HIV+ 600 500 497 NELSON2003 MANDELA2004 2005 2006 2007FOUNDATION2008 2009 2010 “Partial” task shifting to Three health centres 2000 New Stage 4 (need for ARVs) Nurse CHW Nurse/ CHW 4h 8h 400 Enrolment actual medical assistants 200 1800 45% CHW Scenario 1 – intended trajectory Nurse 400 Scenario 2 – failure to increase enrolment 200 500 ARV initiation done by 1600 Scenario 3 – enrolment stagnates doctors instead of nurses 40% New Stage IV and new patients started on ARVs 1400 35% 0 400 1200 2003 3002004 2005 2006 2007 2008 2009 2010 150 30% 260 1000 237 300 800 200

1200

1000 Potential Rx gap 800

600

In addition, we have month- ing where ARV site co-ordinators are how it will be used in rural areas, but ly clinical mentoring activities in able to come and learn how they can it needs to get to that level, especially collaboration with Stellenbosch be better managers, how they can im- where we have facilities that have University, through their Ukwanda prove their own reporting skills. about 1 000 or so patients on treat- rural initiative, where experts and ment. The paper-based system may local consultants e.g. neurologists, Information Systems not necessarily be the best way to dermatologists, etc, come and spend capture data. about three to four days in Mbizana, In 2004/5 we were able to participate Mzimkhulu and Flagstaff to pro- in the development and implementa- Infrastructure vide clinical support to nurses and tion of a paper-based system. We were doctors. able to work with the Department of The infrastructure: when we came, This has been quite interesting Health to come up with pre-ART and we did not fully realise the extent of and has proved to be a good way of ART registers, which have been pret- need for clinical space. To this end, providing support by working with ty good in terms of being able to just we have been able to support the in- local institutions. capture very simple data elements at stallation of prefabricated buildings, And finally, we have also- col the hospital and clinic level. some of considerable size in some laborated with MSF to conduct We have a total of 22 data staff and of the health facilities where we are HIV training for medical doctors in that tells you how much work is be- working. Qaukeni. ing done. This is one of the strategies Unfortunately, due to funding re- we are using to task-shift. Hopefully strictions, we are unable to continue Project Management in the future we will have a compu- supporting the installation of clinical terised ART module. We don’t know space. Training I also want to mention the last area ABOUT THE SPEAKER is capacity building: project manage- Dr Doris Macharia is the country programme director (SA) for the International ment training. This really was not Center for AIDS Care and Treatment Programs (ICAP), Mailman School of Public what we thought we were coming in Heath, Columbia University. to do, but this was a need and an is- Macharia oversees the development and implementation of HIV care and sue that came up time and time again treatment programmes in the rural, peri-urban and urban communities in the from where we are working. We re- Eastern Cape and KwaZulu/Natal. Prior to joining ICAP in 2004, she worked with alised that we had to support putting the US Centers for Disease Control and Prevention in Kenya. together project management train-

NELSON MANDELA FOUNDATION 19 A DIALOGUE ON ART MODELS

Enabling Factors One of the enabling factors has been the fact that there are existing national and provincial guidelines. I think these act as a good base and I think it is important for me to say that. The other is the close collaboration with the Department of Health, both at local level, and at provincial level. I think that has been really good for us, to be able to respond to some of the needs that are local, and also obviously at provincial level. And then the fact that there are at least some indicators, which have enabled the development of a simple patient information system for the capturing of data, and then the ongoing mentorship and supervision that’s focused on clinical staff, and the development of a service continuum, that is a multidisciplinary team with programmes with programmes such to absorb the programme and then a the integration of HIV services. Finally as TB and PMTCT. This is something more robust data-collection system: there is need for continuous evalua- we need to get on with very quick- that is needed. tion and employing quality assurance ly as this is an area where we are After all or most of these identi- methods. likely to see a reduction in pediatric fied issues have been addressed, and HIV infections and also enrol more after we integrate HIV-related serv- From Possibilities to eligible TB/HIV co-infected into the ices, we need to start thinking about programme. the next opportunity that needs to Probabilities One, of course, be addressed, so as to ICAP intends to build on the is task-shifting, as improve HIV services. programme implementation opportu- we’ve all been talking “I keep saying We need to start think- nities that we have already identified. about: working with the only ing about operational One is integration of HIV care registered nurses to research to answer ques- prescribe and dis- thing that’s tions regarding our ENABLING Factors pense ARVs, ensuring programme implemen- the peer educators are sustainable is tation. These questions • Existing national and provincial HIV able to counsel and need to be answered in plan provides overall guidance. test, and then making HIV itself.” scientific ways so that • Close collaboration with ECDoH, more use of the data we are able to know CDC and implementing partners. collectors to assist the what really works. • HIV indicators available to enable professional nurse in recording the development of simple patient clinical encounter so that the nurse is Challenges and information systems for data not over-burdened. (You know, she’s capturing. testing, she’s counselling, she’s doing Questions • Ongoing mentorship, supervision the BPs, she’s now also filling in the I was asked: what are some of the and focused training of clinical staff registers.) I think we can easily shift challenges and questions? One is, on HIV/AIDS issues with the intent that task to people who are prob- how do we ensure programmes are to develop local expertise that will ably affordable and available, but, sustainable and how do we measure sustain programmes over time. of course, clear scopes of work are sustainability? • Development of a service continu- needed so that there’s no clash, and This has really been difficult and I um that focuses on multiple entry people don’t feel that their jobs are keep saying the only thing that’s sus- points into care. being taken over. tainable is HIV itself. We have to do I was told this morning that there something. • Continuous evaluation and em- is nothing like pharmacy auxiliary And then what strategies can be ploying quality assurance methods workers, but, you know, training of adopted to decrease staff attrition to improve programme (including pharmacy auxiliary staff as pharmacy and to attract more health providers? the feedback of enrolled patients). assistants, basic training and post- Some we’ve already mentioned, but • Task-shifting. basic training, so that they are able is that all?

20 NELSON MANDELA FOUNDATION A DIALOGUE ON ART MODELS The Business of Treatment South African Business Coalition on HIV/AIDS CEO Brad Mears

hank you for allowing me the opportunity to discuss in a lot of treatment programmes, for where we are with regards to a private-sector contribu- example, is that there’s been relatively tion to treatment. My presentation won’t rotate around low uptakes of voluntary counselling T and testing (VCT) and consequently treatment in the funded arena, i.e. through medical aids and low uptakes of treatment. the like, because I think that is quite a different topic and maybe it’s an issue that needs to be treated and discussed through Challenges policy development. One of the boundaries that we need An Overview But when information started to work hard on in the private sector coming out, through projects such as – and perhaps this is where we can But I’ll give you a macro overview of the Médecins Sans Frontières project work much closer with civil society where the private sector’s come from itself down in the Western Cape, the – is the breaking down of the barriers in respect to treating workers in the private sector started realising that caused by stigma. workplace, and then gradually start- it did have a role to play in treat- In a recent survey conducted by ing to extend its programme out into ing workers through self-funded the South African Business Coalition the communities. I think that perhaps programmes. on HIV/AIDS (SABCOHA), stigma one of the biggest successes that has was noted as being the biggest im- been achieved in the private sector is Breaking the Mould pediment to successful workplace realising that you can treat patients in programmes and the biggest impedi- the private-sector environment. And so Anglo American broke the ment to the uptake of VCT and ARVs If we look back to where we were mould, so to speak, and decided to in the workplace. in perhaps 2003 or just before then, start treating workers. But there also needs to be a tack- the private sector didn’t see the treat- But there is a very, very long way ling of the policy framework within ment of workers as its domain; it saw to go. We are now starting to look which the private sector operates the treatment of workers as prima- retrospectively at a lot of the pri- with government. rily a public health-care question and vate-sector programmes and we are something for government to pick up realising that there’s a lot that still Enabling Change on. There was also quite a lot of scep- needs to be done. We’ve realised that ticism within the private sector itself, workplaces are hallmarked by a lack In looking at the enabling factors in saying that treatment should be the of trust, poor communication and in- respect to workplace programmes, role of government and that the pri- sensitivity to the needs of workers, we’ve discovered that trust is an vate sector shouldn’t treat. and so what we’ve started to witness absolute keypin around which the

NELSON MANDELA FOUNDATION 21 A DIALOGUE ON ART MODELS successes of workplace pro- ernment so that we can provide grammes rotate. these facilities to the community The other area that is a ma- at large. jor enabling factor is the issue of leadership. In those compa- Possibilities nies and sectors where we find high levels of proactive lead- Where are the possibilities? Well, ership, from company CEOs, we need to explore the area of trade union leaders, and com- public-private partnerships. I munity leaders, we find that think that whilst the issue of the programmes are much, public-private partnerships may much stronger. Where you exist at a policy level, we haven’t find an ambivalent approach got enough experience on how being taken by leadership in these should start taking place at the private sector, the pro- a practical level. grammes are consequently We need to start extending much weaker. our workplace programmes into the far-flung areas of South Sustainability Africa and this has only become possible recently with, for exam- One of the things that the pri- ple, the changes in the Tax Act, vate sector has been criticised “We need to explore which has affected quite nega- for recently is the issue of tively the company’s ability to commitment. How long is the the area of public-private be able to provide self-funded private sector going to be com- treatment programmes. mitted to treating workers for? partnerships.” In respect of the private I think this is one of the areas sector getting involved in treat- where we need to start devel- ment, it needs to view the area of oping policy and not in isolation, but ing and treatment programme is receiving funding from funds such as policy in relation to government. indeed one of these initiatives. It’s an the Global Fund and the President’s A benchmark has been set by initiative that exists in concept at the Emergency Plan for AIDS Relief South African Breweries, which will moment, but an example of where (PEPFAR) as something that is in its provide treatment to the worker, to the private sector can play a contribu- interests. the spouse, to the children, indefinite- tory role in supplementing public Business has by and large done it ly after employment. So if the person health-care infrastructure and indeed on its own up until now and it needs gets retrenched, no matter when they funded initiatives like MSF. to be partnering with other NGOs are retrenched, they will receive treat- There are several large resources and CBOs. We need to use foreign ment indefinitely. companies in Mpumalanga, such funding far more extensively and we as Eskom, Sasol, Xstrata, Isizwe need an overhaul of the legal frame- Lessons Learned and several other resources compa- work to make it much more enabling nies, that have extensive treatment for employers to test, to make sure, Some of the learning that we are discov- programmes on site and have the for example, that employees are guar- ering as far as private-sector initiatives capacity and the resources on site to anteed access to treatment. are concerned is that there needs to be treat their workers. And finally, we need to move the persistent and consistent messaging, The proposal is to extend these fa- engagement between business and in terms of your programme. There is cilities for the community to be able government from engagement at a sometimes conflict between the mes- to access. One of the restraining fac- national level, down to provincial sages sent out within the company tors is the inability for us to structure level, so that we can make sure that environment and what’s being sent a partnership with provincial gov- these partnerships start taking shape. out in the community. One of the areas, one of the steps that we took to try and harmonise that inconsistency, ABOUT THE SPEAKER was for SABCOHA to partner with the Brad Mears is the CEO of SABCOHA and has worked at the Durban Chamber Khomanani programme. of Commerce and Industry since 2001, where he manages the HIV and AIDS As I’ve already mentioned, the programme. Mears graduated with a law and history degree from the University private sector needs to start extend- of Natal (now the University of Kwazulu-Natal), and also holds a post-graduate ing its treatment programmes to diploma in industrial relations from the same university. His vision is to get people spouses and children and then into in the business sector to understand that HIV poses a threat to the future of the community. South Africa’s economy, but that much can be done to overcome the epidemic. The Mpumalanga Highveld test-

22 NELSON MANDELA FOUNDATION A DIALOGUE ON ART MODELS

Task-Shifting in Thyolo A Treatment Case Study from Malawi Dr Rony Zachariah, Médecins Sans Frontières

was asked by the organisers to give an international perspective of the Médecins Sans Frontières (MSF) experience in terms of task-shifting, but I’m afraid to say I’ve changed Malawi I that slightly because I thought it would be more relevant to try to speak about a context similar to one you are working in. Southern Thyolo Africa So I decided to choose a sub- about 90 000 AIDS-related deaths Saharan African country, a country each year. HIV and AIDS and TB in which there’s a high prevalence of thus constitute a major burden on the HIV and AIDS, a country in which we health services. have an intervention that is rural, a country where we have major human Human Resource Crisis resources problems and a country and a setting where we are trying to However, the health services face a achieve universal access. major shortage of health staff. Over Malawi in Numbers So it’s my pleasure to present to you, 50% of all the health staff positions “Task-shifting in HIV and AIDS care in the Ministry of Health are unfilled. Population of in a resource-limited rural district: Fifteen out of 29 districts have less 10-million Malawi some successes and lessons learned than 1.5 nurses per health facility, from Thyolo District in Malawi”. and when it comes to doctors, there 930 000 HIV-infected Malawi is a small country in sub- are 10 districts with no Ministry of people (9%) Saharan Africa, with about 10-million Health doctor and four districts with HIV and AIDS inhabitants; roughly one million or no doctors at all. The government of 90 000 deaths per year one out of every 10 is HIV-infected. Malawi declared in early 2004 that The country registers about 25 000 they are faced with a major human TB cases per cases of TB each year, eight out of resource crisis and the secretary of 25 000 year (77% HIV+) every 10 of them are HIV-positive. health actually declared towards the Seventy percent of all the hospital ad- end of 2004 that the health services missions are HIV-positive and there had collapsed.

NELSON MANDELA FOUNDATION 23 A DIALOGUE ON ART MODELS

If you look at the staffing per them as close as possible to the 100 000 population for 2004 and communities, close to the rural if you compare Malawi with a communities, especially when number of other sub-Saharan they are distant. African countries, you will see The community has been that Malawi is the worst, with key in all this and we set up 1.1 doctors and 26 nurses per dialogues with pre-existing 100 000 population. What is community support groups very clear from this is that if you early in the process, some of want to roll out HIV and AIDS whom were already providing care and ART interventions, religious and social support. you cannot rely on doctors and Volunteers from these groups nurses to deliver them: what were recruited and trained; we you need to do is shift tasks, set up formal links between down to the communities. them, health units and volun- It is against that backdrop teers and there are carbon copy that I’m going to take you to referral books that allow trac- Thyolo District in Southern ing of patients. The community Malawi. Thyolo is one of the volunteers are involved with a largest districts in the country, number of other activities, in- with 500 000 people, and where “The secretary of health cluding symptomatic treatment the situation is no different. of diarrhoea, fever and oral But despite the human re- in Malawi actually declared thrush, adherence counselling, source challenges, we decided support of family care-givers to embark on an ambitious task towards the end of 2004 at home, referral of patients – with the Ministry of Health who have drug reactions and – in trying to provide universal that the health services risk signs to community nurs- access for the entire popula- es, cough screening for TB, tion of HIV-positive people that had collapsed.” and various forms of social need ART by the end of 2007. mobilisation. The objective of this presentation is, tered patients would be screened by The core of the community work therefore, to highlight some of the a nurse and would be allocated into is based on the volunteer, who takes successes and lessons learned in task- one of three tracks – a slow track, a care of about 8-12 patients. Trained shifting to achieve universal ART medium track and a fast track. volunteers receive a home-based care access in Thyolo. How did we go You will notice that the human re- kit, in which you have very basic, ma- about it? source cadre in the different tracks, as terial: oral re-hydration salts, TB sol well as the tasks that are allocated to tablets, paracetamol, aspirin, anti-ma- The Thyolo Approach: each of these tracks, are different, and larials, co-trimoxazole, condoms and this permitted us to shift tasks, from a hygiene products, to name the main Testing and Tracking doctor to the medical assistant, to the part. The first challenge was to ensure that nurse and to the PLWA counsellor. we tested enough people and we The doctor in Malawi is mostly absent Have Motorbike, knew who we needed to treat. We and the clinical officers are mainly in- did this by expanding our Voluntary volved with supervision and support, Can Nurse Counselling and Testing (VCT) serv- and no longer with direct clinic care. A nurse on a motorbike moves ices, from three nurse-run sites, to We had to also scale up ART counsel- around and supervises 50 volun- 17 sites run by trained People Living ling and we followed a similar track teers; we have seven nurses in total. With AIDS (PLWA) counsellors. system for within the health facilities. The logistics are pretty important, There was then the need to ensure For groups and individual counsel- our volunteers have bicycles and the that our HIV and AIDS clinics were ling, we decided we should try to get nurses have motorbikes of two types able to meet up with the case load. We thus needed to drastically improve the efficiency of the delivery systems, particularly for ART. And Staff per 100 000 population to be able to do that, we needed to change the profile of our clinics, from Cadre South Africa Botswana Ghana Zambia Tanzania Malawi a one-track, doctor-centred approach Doctors 69.2 28.7 9.0 6.9 2.3 1.1 to a multiple flow-track system, that Nurses 388 241 64 113 37 26 involved different cadres. In practice, WHO, 2004 what this meant was that all regis-

24 NELSON MANDELA FOUNDATION VCT done at ANC consultation March – August 2003 VCT done at ANC consultation March – August 2006

ANC consultations VCT done % tested ANC consultations VCT done % tested 400 600

500 89% 99% 300 99% 400 85% 80% 81% 200 300

5000 2004 2005 2006 Number of patients 100 2 022 0 906 APR JUN AUG OCT DEC FEB APR- 24 05 05 05 05 05 06 JUN 0 06 A DIALOGUE ON ART MODELS OCT-DEC JAN-MAR APR-JUN JUL-SEP OCT-DEC JAN-MAR APR-JUN 2004 2005 2005 2005 2005 2006 2006 because the terrain is some- RESULTS ARVs; we have an average times very difficult. RESULTS (3) ART initiation per monthMoving of Foward - Policy dependent 500, as of June 2006 and actu- Patients Initiating ART Holy Cross Hospital + 3PHCs ART: New inclusions / month The Results ART Inclusions (p/m) ally we will reach this target Quarterly enrolment at clinics May 05 – June 06 (2 main hospital sites) by July or August 2007 – in VCT - health seeking behaviour What are some of the re- ART Inclusions fact, four months before the Total Hospital PHCs 250 VCT, Lusikisiki, March 2003 – August 2006, 12 clinics sults? From January 2004 target we had set for our- 240 to June 2006, we had tested Task shifting to medical assistants, nurses & PLWAs selves. I think the important 500 497 no. people tested no. people tested HIV+ % HIV+ a total of 73 484 people in message I would like to de- “Partial” task shifting to Three health centres 2000 Nurse CHW Nurse/ CHW 4h 8h Thyolo. About three-quar- medical assistants liver is that if we had200 not 1800 45% CHW ters of all that testing in the moved to task-shifting, and Nurse 400 500 ARV initiation done by 1600 district was done by trained we had stayed on our doc- doctors instead of nurses 40% 1400 35% PLWA counsellors: this is tor-based system, as in 2004, 400 1200 300 the impact of task-shifting we would have achieved150 this 30% 260 1000 (see Table 1). target only by 2013. 237 Since 2004, we’ve gone 300 800 200 from a maximum capacity of

600 Number of patients Active Case- 100 about 900 tests per month, to 200 91 400 an average of over 3 750 HIV Finding Delivers 200 100 tests per month. At this rate, 100 Far More Cases 0 we will be able to detect the 50 Jul Jul Jul Jul Oct Oct Oct Feb Feb Feb Apr Apr Apr Apr Jun Jan Jun Jan Jun Jan Jun Sep Sep Sep Aug Nov Dec Aug Nov Dec Aug Nov Dec Aug Mar Mar Mar OCT-DEC JAN-MAR APR-JUN JUL-SEP OCT-DEC JAN-MAR APR-JUN May May May May 0 entire 50 000 people who are 0 The community is involved2004 2005 2005 2005 2005 2006 2006 2003 2004 2005 2006 APR JUN AUG OCT DEC FEB APR- 2004 2005 2006 2006 Mar HIV-positive in the district with a number of other tasks 05 05 05 05 05 05 JUN (JUN) 06 by the end of 2007. that we’ve shifted to them, Task-shifting, therefore, Figure 1. ART new inclusions per month (two main hospital sites). and one of them is active Achieving Sustaining Universal Access Task-shifting increased ART capacity by five times. increased our counselling TB case finding. In every 1400 and treatment capacity by household where there is a 1200 at least four times. If you HIV Testing TB patient or an HIV-posi- look at the consultations tive individual, volunteers 1000 Potential per month, the picture is People actually screen for a chronic Rx gap similar. In 2004, there were cough, defined as a cough 800 HIV-tested 73 484 about 1 500 consultations, HIV-positive 24 214 that someone has had for 600 using a doctor-based clini- over three weeks. Tested by a PLWA counsellor 64 461 (>85%) cal officer system. There were 806 individu- 400 New Stage 4 (need for ARVs) Table 1. Over three quarters of all counselling and testing in the district Enrolment actual Through shifting consult- als referred with a chronic Scenario 1 – intended trajectory is done by PLWA counsellors. (Jan 2004 – Jun 2006) Scenario 2 – failure to increase enrolment ing to medical assistants, cough; 161 or 20% of them 200 Scenario 3 – enrolment stagnates

New Stage IV and new patients started on ARVs nurses and PLWAs, we were found with smear- 0 went up to over 4 250 con- ART Outcomes positive tuberculosis. Now if 2003 2004 2005 2006 2007 2008 2009 2010 sultations, and we’ve been you assume that the average able to decentralise to three Community Care No C. Care household size in Thyolo is health centres. Placed on ART 895 739 five, this translates into an

If you look at the ART in- Alive and on ART 856 (96%) 560 (76%) P <0.001 annual TB incidence rate, clusion rates per month (see among the households with Died 31 (3.5%) 115 (15.5%) P <0.001 Figure 1), you’ll see a major a cough, of 1 997 per 100 000, Lost to follow-up 1 (0.1%) 39 (5.2%) P <0.001 difference. In 2004, we had as against the reported TB a maximum capacity of 110 Stopped 7 (0.8%) 25 (3.3%) P <0.001 incidence in Malawi, using inclusions per month and Table 2. Comparing ART outcomes among patients living in areas a passive case-finding strat- with and without community support (Dec 2004). our doctors were saying we egy, of 265 per 100 000. were completely overload- There are two important ed. We did the task-shifting The Power of messages here: cough-screen- and track system, including medical ing gives you a very high yield of assistants, nurses and PLWAs in the Task-Shifting smear-positive TB and this screening two same hospital sites, without in- So we have achieved a five-time in- is done by community volunteers, creasing the staff, and we were able to crease in the capacity, in the district, and second, an active case-finding move up to 350 inclusions per month, without increasing our doctors or strategy will deliver eight times more 3.5 times the previous number. We’ve nurses, but by task-shifting. We will infectious TB cases than a passive now been able to decentralise to three achieve universal ART access at this case-finding strategy. of the main health centres, to nurse- rate, by December 2007. Our target The community makes an average based inclusions, and, as of June 2006, was 10 000 people by the end of 2007; of 422 referrals per month; a great deal we have 500 inclusions per month. by June 2006 we had 4 302 people on of them are actually to HIV testing,

NELSON MANDELA FOUNDATION 25 A DIALOGUE ON ART MODELS therefore, they actually are a provider a few, considering our constraints. for ARV. One in five patients referred We need to be innovative and those to community nurses or to health fa- of us who are policy-makers and cilities had problems with starting or decision-makers must be courageous with side-effects to ART, or compli- enough to challenge and adapt some cated opportunistic infections. So the of our established practices, rules and presence of these volunteers helped regulations. Often, a good deal of us to detect these problems early. these are to do with professional turf- Over a two-year period, between protection, rather than patient safety January 2003 and December 2004, we and patient interest and quality. had placed a total of 1 634 individuals At the end of the day, I think we on antiretroviral treatment (see Table should be judged by what we have 2). Of these, 895 came from areas with done to make a difference to the lives community support, and 739 came of thousands of people who need our from areas without community sup- help and how we have adapted our port. We decided to compare the ART health services to meet their needs. outcomes among patie nts living in DOING IT FOR THEMSELVES: Anala and I will leave you with the words areas with and without community Patricia are orphans who have gone on to of an HIV-positive patient we met in support. There was a significant dif- start their own tailoring workshops in the early 2006 in one of the remote com- Thyolo District in Malawi. They have now ference in standardised outcomes munities of Thyolo, and who was in started to support others. when it comes to those still alive and stage four. He actually told us what on ART (96%), as against 76% in areas exactly we needed to do with the without community care. Similarly, in Thyolo. Then there are various forms health service in Thyolo: areas with community support, there of vocational training for children “I underwent counselling in the was only one patient lost to follow- and orphans over 12 years of age. community and was told by the com- up, as against 39 lost to follow-up in munity nurse that I will still have areas without community care. And if Ambitious to present for another repeat ses- you assume that all patients who are sion, which must be done at Thyolo lost to follow-up are likely to die, you We have been told several times Hospital. I left at 3:30 am on foot and are actually speaking of a five-fold that some of these activities are very arrived there after about four hours of difference in death rates, between ar- ambitious, even within MSF, but hard walking. I waited in the group eas with community care and areas maybe that’s exactly what we want, counselling room until 12 noon and as without community care. because at the end of the day, it brings I was very hungry and thirsty, left for back human dignity and it brings the market to find something small to Community Support Key back hope for the future of many chil- eat and drink. On return, I was told dren like them. that the session was over and I must in ARV Outcomes In summary, what we have learnt now return one week later. If you look at the relative risks, it only from our experience in Thyolo, is that “I had to walk back home for an- confirms the significant difference in if we want to achieve universal ac- other four hours without anything. I terms of ARV outcomes in areas with cess, we need to develop a structured must now walk back twice to Thyolo community care. Thus, community public health ART scale-up model. Hospital, once for a group counselling support is associated with significant- We need to keep it simple, we must session and then again for individual ly better ARV outcomes. There is also be inclusive of all the stakeholders counselling, before I can hope to get a social and economic dimension and and we must use lower cadres and ARV. The nurse tells me, this is all to one must not forget the potential of the the community. make sure I am committed to taking community, especially in rural areas, The choice was pragmatic. We ART, but I already know very well and the contributions they can make. were compelled to act in the best in- that I need antiretroviral treatment We have 25 farms run completely terest of the good for many, instead and I’m ready to take it, but it just by community associations today, of trying to offer the best services for seem so hard to get.” but which were supported initially by us and which produce different agri- ABOUT THE SPEAKER cultural crops, and they’ve also gone into rabbit farming and fish farming. Dr Rony Zachariah is operational research co-ordinator at Médecins Sans The produce of all these agricultural Frontières (MSF), where he evaluates and documents the work done by the interna- products go to destitute HIV and tional organisation. Originally from Luxembourg, Zachariah has worked extensively AIDS and TB patients. There over 900 in Africa, as a doctor and a researcher. He is currently based at MSF headquarters in orphans, mostly under five years of Brussels, Belgium. He studied public health and completed his PHD in Tuberculosis. age, from single-member households, He has obtained qualifications from the University of Maiduguri in Nigeria, London who benefit from pre-school care, to- School of Hygiene and Tropical Medicine, and the University of London. day run by the teachers’ association of

26 NELSON MANDELA FOUNDATION A DIALOGUE ON ART MODELS Treatment: A View from Government Comprehensive Plan Project Manager Dr David Kalombo, National Department of Health

et me give you an overview of the Comprehensive Plan you read it, you will understand why on HIV/AIDS and then I’ll touch on some of the issues we are saying so. And so in early 2004, we started Lwhich were raised during the discussion in the morning, this process of accreditation, and the and if there are questions, we can discuss them. first accredited facilities began providing ART. Between 2000 and 2005, we devel- tation. These were initially led by the At the beginning of every year, oped the strategic plan, which had national Department of Health, and we work with our counterparts in four main pillars: prevention; treat- involved officials from the depart- the provinces, and we develop busi- ment, care and support; legal and ment responding to the call from ness plans. Why are we developing human rights; and research, monitor- provinces. The provinces initially business plans? Just to ensure that ing and surveillance. identified 32 facilities, for the national the provinces do receive necessary During the first two or three years, department to go and assess the read- resources, especially financial -re there were a lot of activities or inter- iness of, in terms of them providing sources, based on the activities which ventions in terms of prevention, care comprehensive care. they have planned or are going to be and management, and legal rights. implementing in the course of the There were still outstanding issues Operational Plan financial year. So we assist our- pro about treatment and it was important vincial counterparts; we discuss their that we had an operational plan and I believe every one of you is familiar needs and their activities. So we agree a comprehensive approach. And so, with that tool of accreditation which to the business plan, then on a month- the government worked with various has been revised recently. Maybe just ly basis we transfer funds to them. stakeholders in the country, to put to- to come back to the operational plan, In terms of accreditation, the prov- gether the comprehensive plan. I expect everyone in this room has inces will do the first assessment of The two pillars of the compre- read that operational plan, because the facility and ensure that the facil- hensive plan are indeed to provide indeed what we are all talking about ity is ready, based on the requirement quality care to people infected with is the implementation of that plan and in the tool. Then the national offic- HIV and AIDS and to ensure that the there’s no way that we as managers ers will go just to certify. This is has estimated 40-million people who are can implement a plan which we’ve been the process up to now. Why are uninfected, remain uninfected. At the never read. So it makes it difficult we doing that? Because we want to same time, we are aiming at strength- for you to understand certain activi- strengthen the health-care system, ening the health-care system. ties clearly if you have never read the because we want to make sure that Since the adoption of the opera- plan. I think our president has said when a patient is seen, he or she is tional plan on 19 November 2003, we that this is one of the best operational being taken care of in a continuum of have engaged in activities of accredi- plans in the world. Indeed it is, and if care and is being given quality care.

NELSON MANDELA FOUNDATION 27 A DIALOGUE ON ART MODELS

For you to provide quality care, you ment. We will then calculate how of service providers who are going to need to make sure that there are ac- much the patient cost will be for the be targeting all interest groups Then tivities or interventions in place. year, and then allocate the budget. we also need to make sure that the So this is a process, but the target of communities are informed and we Human Resources are Key government is mainly to ensure that can mobilise them, so that they can there’s accessibility to the treatment contribute to the implementation of At the same time we’re also assessing for our patients, and we are doing it the comprehensive plan. We have the current services which have been progressively. disseminated more than 10-million offered to patients and making sure In the first year we set ourselves information, education and commu- that there’s enough staff and capacity the target of having at least one serv- nication materials across the board. in terms of human resources. ice point per district, and we have We need to ensure that staff has 53 districts. On March 30 2006, for Prevention been trained, there’s enough space, instance, I did an accreditation in there’s adequate monitoring systems, Kuruman. We have a lot of activities in terms of there’s equipment and the lab system We were struggling to get that prevention. I mentioned the PMTCT works well, there’s enough storage for facility started. There were just no programme. The Promoting Effective the ARVs, there are human resources doctors, but we managed at last to ac- Perinatal Care (PEPC) programme in terms of the doctors, pharmacists, credit it. and the Voluntary Counselling and dieticians, lay counsellors, social For the second-year target, we said Testing (VCT) programme are also workers and data-capturers – I will in- we needed to have moved into the are in place. We feel that prevention sist in data-capturing, sub-district. is the cornerstone of the comprehen- because that’s very, The first target was sive plan, because we don’t have a very critical. “We are trying that at least 30% of sub- cure and there’s no treatment without The reason we’re districts should have prevention. This is the World Health doing all this, is be- to ensure that accredited facilities. Organisation’s Year of Prevention, cause we want to do Last year, it was and we are working on an accelerated things differently. We we provide up to 40%. Indeed prevention strategy. have serious issues quality care and we had to review our The second important pillar is nu- about the Prevention target because we trition-related interventions. This is of Mother-to-Child that patients were doing well. At critical. I’ve had discussions with many Transmission (PMTCT) the end of March this colleagues here who are partners with programme. have access. year, we had 62% of us in this. We do have partners; some The reason we sub-districts having of them have started this provision of are insisting that the Our target is at least one service ART before the comprehensive plan, facility should have point. The current where the focus is mainly on ARVs. a data-capturer is also universal target has now been But we think it’s unfair if you just look to leave the nurse access.” moved from 60% at the aspect of ARVs and you don’t focusing on the nurs- to 75%. To date, we look at the other needs of the patients, ing care. Last year, have 72% of sub-dis- which are very critical. we spent R2.5-million just to do the tricts having at least one service point. It is important that all the patients training of data-capturers, but still we We want to ensure that patients eve- should be assessed for nutrition inter- do have challenges in some facilities rywhere have access to quality care. vention. All patients, wherever they where the data is actually missing, are, and regardless of them qualifying and there’s no way you can manage Interventions for ARVs or not, should be assessed any programme if you don’t have and should be provided with nutri- data. I will now talk briefly about the tion interventions. Looking at the So we are trying to do things dif- interventions. The first one is preven- needs and the level of poverty, I think ferently and to ensure that at the same tion, or maybe I’ll start with social it’s critical. time we provide quality care and that mobilisation. I think we had a lot of Before you provide ART, make patients have access, because our tar- activities through Khomanani. Our sure that those patients are assessed get is also universal access. colleague from the South African and they can be provided with nu- And talking about universal Business Coalition on HIV and AIDS trition interventions, which is also access, we usually say we’re not (SABCOHA) did mention what essential in terms of prevention. I looking at the number of patients on Khomanani has been doing. We have think we have provided nutritional treatment. We’re saying the number all seen the Khomanani media cam- intervention to more that 700 000 pa- of patients is estimated for business paign, which has used TV, radio, tients across the provinces. development. So if a province wants print and billboards. Another intervention as far as national to provide funding, of course It ended at the end of June, but the operational plan is concerned, it needs to have an estimated number we’re working on a new tender, just to is traditional medicine. We feel it’s of patients they intent to put on treat- ensure that we have a diverse number important that we understand and

28 NELSON MANDELA FOUNDATION A DIALOGUE ON ART MODELS assist traditional medicine in terms CD4 count machines. We had three vi- financial resources. of the research, which we’re current- ral load machines; now we have 12. We Ninety percent of the programmes ly doing with the Medical Research didn’t even have Polymerase Chain or projects are funded by government. Council (MRC). Reaction (PCR) testing machines and If we can recall all the expenditure Money and funding has been pro- now we have seven, to make sure that which we have spent in all govern- vided to the MRC, to look at the level we keep the turn-around time of a test ment programmes or departments, of efficacy of some plants. We also en- below six days. it’s more than R11-billion. The budg- gage with traditional healers, in their et last year for the component of registration and training. Single Information System the ART within the comprehensive plan was R1.1-billion. This year it is Traditional Medicines We’re planning to have a single pa- R1.5-billion tient information system, though Let me just finish with the chal- There’s the Traditional Medicine Act unfortunately this hasn’t really taken lenges, the biggest of which is which came into place in 2004, and off as we expected. We started a pilot human resources. According to a very soon we’re expecting to have a of this process in Witbank, and up to statement issued by the World Health Traditional Medicines Council. The now it hasn’t been expanded to most Organisation at the end of 2005, Africa council will assist us to make sure provinces. needs about 2-million health-care that we continue training and will as- This means we’re still relying on workers. We, as an African country, sist with other activities for traditional the paper-based system, which some- are also facing that challenge. We practitioners, so that they understand times makes it quite difficult to get in can have many facilities accredited, the provision of ARVs. data in time. but we do not have enough doctors, We know that 90% of our patients The last important intervention pharmacists, dieticians, and we have do consult traditional practitioners which I really need to talk about is space shortages. and often they’ve consulted them be- the pharmaco-vigilance centres. We Most of our hospitals are over- fore coming to us. know that if you use ARVs, you may whelmed, so we need to down-refer Staff appointments are another in- develop side-effects. So it is important patients. Indeed, we have revised the tervention. In this process, what we for us to ensure the safety of drugs. tool of accreditation, so that we have did, we appointed senior officials to There’s one at Medunsa, and one at at least begun to down-refer stable manage this programme at a national University of Free State and there’s patients to clinics. level, as well as at the provincial level. this spontaneous reporting which is We’re also expecting that we will In terms of procuring drugs, we done in Cape Town. get the nurse-initiated treatment at are engaged with seven pharmaceuti- We have now established three the end of the day, so that we can im- cal services, and R3-billion has been centres and we will increase to five prove the uptake of patients. put aside just to ensure the availabil- centres and continue in other prov- But we can only do that if we ity of drugs. That has been going well inces for the focused surveilance. make sure that there’s capacity at the and to date we have enough stock in There are so many things to talk clinics and this is the process which most of our facilities. about. Let me just finish with the- fi we’re embarking on. We need to have The lab services have been im- nancial resources. Because we want capacity in the clinics and once that is proved. We started with 10 CD4 count this programme to be sustainable, we established, then we can responsibly machines, and we now we have 42 have made sure that there are enough down-refer patients to those clinics. ABOUT THE SPEAKER Dr David Kalombo is the project manager of the South African national Department of Health’s Comprehensive HIV and AIDS Care, Management and Treatment Plan. Kalombo grew up in the Democratic Republic of Congo and has worked as a medical doctor for 16 years. After coming to South Africa in 1991, Kalombo completed his internship at Groote Schuur Hospita in Cape Town in 1993, and worked at a number of hospitals thereafter, including Sebokeng Hospital, Johannesburg Hospital, Hillbrow Hospital, South Rand Hospital, Edenvale Hospital and Dr George Mukhari Hospital in Garankuwa. Kalombo has an MBA from the Milpark Business School. He joined the national Department of Health in 2004. “There’s no way you will manage a programme like the Comprehensive Plan without communication,” he says. “You need to communicate to get buy-in, to improve the way you are doing things. Communication helps to clarify the issues.” He says of ARV delivery, “It’s a combined effort and it doesn’t help to point fingers. We need the involvement of everyone. We either all win or we all lose.”

NELSON MANDELA FOUNDATION 29 A DIALOGUE ON ART MODELS Questions & Answers Dr Marga Vintges

I do agree that the plan, the comprehensive plan, is a huge challenge and I’m very happy with “ the way it is being implemented at the moment. I really do want to ask you to say something about the rural areas now, because we are here for the rural areas. So we’re talking about the guidelines: are they maybe too high for rural areas? Do you not aim, with your accreditation, to create mini-hospitals out there? They don’t have to be mini-hospitals, out there in the rural areas, to roll out ARVs. You don’t need a fancy building, you don’t need a dietician, you don’t need a doctor in every clinic. ... It shouldn’t be a mini-hospital to do proper quality service out there. ” Dr David Kalombo

It would be nice to read the guidelines; maybe then you can pose a question. If you read the “ revised accreditation tool, you will understand that there are minimum requirements for both hospitals and clinics. The plan has to be implemented in a primary health clinic. Why did we start implementing the programme in the hospitals? It is because of the capacity and the demand. The guidelines are actually made or produced by many national experts and some are present in this room. As a group we decided that those minimum requirements need to be in place before the facility or the service point is accredited. You need to have qualified and skilled people to provide quality services. There’s no other way. You need to have consulting space and a laboratory system. Nutritional intervention is of paramount importance. It is all about team work and people that are ready to make a difference. ”

30 NELSON MANDELA FOUNDATION A DIALOGUE ON ART MODELS

Doris Macharia

Looking towards the next couple of years, how do you see accreditation being done differ- “ ently? Because, right now, I think it’s national. ... Is this really sustainable and is there a way of empowering providers at a local level to be able to look at the services they have and almost accredit themselves, so to speak? Your thoughts on that. ”

Dr David Kalombo

We do not have capacity at the national office to reach all places to conduct the accreditation “ process. The responsibility of accreditation is given to provincial officials. They decide which facility they are going to accredit and then they do the assessment and develop strengthening plans, and once the facility is ready, the national office is invited to certify the site. So there is no way in which the national office can delay the accreditation process. ” Dr Kuku Appiah

This may be more of a philosophical question, but, as good as the comprehensive plan is, how “ does it hope to actually provide treatment for all the people that will need it, in say, 10 years’ time? Are we saying that the ARV treatment is going to be hospital-based, doctor or nurse- based provision? Are we saying that drugs will always be dispensed from a chemist? Are we saying that we’ll be able to provide treatment for the number of people that actually need treatment by running clinics that operate from eight to four, Mondays to Thursdays? What kind of major shifts in thought process or in working practices are we going to have to embrace in order to actually deliver this kind of health intervention to the number of people that we’re supposed to be delivering it to?

Kuku Appiah Kuku Right to Care to Right ” Dr David Kalombo

I mentioned the revision of the accreditation tool, which will then lead to a nurse-initiated “ treatment at the CHC (Community Health Centre) and PHC level where there is capacity. So this is where we need to go because we do not have doctors. We have to manage the migration of staff. We have put systems in place to manage scarce skills and provided a rural allowance for people going to remote areas but we acknowledge we still have challenges around that. One critical thing is that we are not going to compromise the quality of care of patients in the clinics. The continuum of care will be at all levels, supported by an effective referral system, and for that we need the collaboration of all stakeholders, including communities. We cannot do it alone. ” NELSON MANDELA FOUNDATION 31 A DIALOGUE ON ART MODELS

Dr Ebrahim Variava

My question is about NGOs that provide ARVs. It’s going to be very difficult for these organi- “ sations to continually provide ARVs on a long-term basis. I’m not too certain if there’s any sort of programme to incorporate those patients within the state and support those programmes that are ongoing, on the one hand. On the other, various NGOs may use slightly different regimens in terms of treatment. Some employee organisations are using different treatment regimens. When they come in to the state there are clearly problems with therapy. Are there any plans to sort out these problems in the near future? ” Dr David Kalombo

There’s an NGO, funded by the Elizabeth Glaser Paediatric Foundation, Thembanabantu, in “ KZN, with which we agreed to go into partnership with. We will be providing the drugs and they will continue with the provision of services. We requested them to support the feeder clinics to allow us to reach more patients. When guidelines are developed they are made available to all stakeholders, in the public and private sector. This is so that there is no confusion among service providers. It is done in the best interest of the patients. Unfortunately some private-sector partners choose to use different protocols which makes it difficult for patients when they are subsequently referred to the state facilities. ” Sheila Hokwana

I think the MSF in Lusikisiki is a case that we can copy, because when MSF was about to leave, “ they informed us in good time to say, we will be leaving and therefore we will need the government to take over the programme or the project. And therefore there have been constant discussions and activities done so that the exit of MSF doesn’t leave patients in the lurch, but patients are managed within the health-care system. I think that is one lesson that we can learn from the NGOs that are operating in our area, so that we communicate with them in good time, so that we know their activities and understand what would become of the patients when the NGO actually leaves. ” 32 NELSON MANDELA FOUNDATION A DIALOGUE ON ART MODELS Dr Eric Goemaere

My question is about universal access. You answered that, in fact, government perspective was “ more in terms of accreditation of the point of care at district level and you said, ‘and now we move to sub-district level and we might achieve 75% of sub-district level’. I wonder if we are not simply in a problem of terminology here, a semantic problem. ... Can you please tell us how do you define the feeder clinic concept, what does it mean and whether or not they will become accredited if their referral facility is accredited? ” Dr David Kalombo

When we are talking about the districts and sub-districts it is in terms of the geographic con- “ sideration. The accreditation of facilities can be done to a single hospital, clinic or a service point. A facility can work alone or have the services spread among feeder clinics, e.g. the readi- ness of patients can be done at one clinic and the actual initiation of ART done at another. The feeder clinics can be used as a down-referral facility for stable patients if there are adequate human and financial resources. ” Dr Hermann Reuter

My question is linked to Eric Goemaere’s question. Your answer was that in some sites the “ accreditation is linked to the budget; you don’t know how much to budget for. Is the accreditation process linked to budgets or is it linked to medical criteria? ” Dr David Kalombo

The accreditation is based on the needs. The need will determine what budget will be allo- “ cated in order to achieve patients’ quality care. ”

NELSON MANDELA FOUNDATION 33 A DIALOGUE ON ART MODELS

Dr Lesley Pitt

The question I wanted to ask was around this issue of the multidisciplinary team and the inclu- “ sion of traditional healers, which I think is a very good idea. I think it goes a lot further than that. I just want to ask from a community perspective, what is going to happen to the caregivers in the community, the community health worker and so on? How are they going to be involved in the plan? Are they going to be funded through the government, are they going to be included in the supply of drugs to the community? How are they going to be used, along with your traditional healers? ” Dr David Kalombo

There are structures in government that deal with care givers and community health-care “ workers, their support is essential in the implementation of the programmes. The supply of drugs will continue to be done by qualified professionals. Traditional healers are members of a multidisciplinary team and will continue to provide the support to patients in their communities. ” Tandi Xozwa

Do we have a future plan, when you talk of human resources – like nurse-patient ratio, doc- “ tor-patient or pharmacist ratio – to address the gradually increasing workload of all the staff members, and then to prevent the burn-out? Because those people are still human beings and at the same time they need to be taken care of. ” Dr David Kalombo

We now have an HR plan and are working on a workload study this year. And this plan and “ the study will address the issues. ” Daniel Berman

The issue came up this morning about the fact that some foreign doctors get a job offer, not “ within an NGO, but directly with the Department of Health. They get a job offer and they’re willing to work in local terms but it takes eight months, a year, sometimes never, or people give up; most people give up before they get there. And I’m wondering what your department is doing to change that? I know it’s not your direct responsibility, but if you’re responsible for implementing the plan and there’s a huge lack of doctors and open posts, it seems like there might be some connection. ” Dr David Kalombo

As in the last question, the HR plan will address the issues. The Health Professions’ Council of “ South Africa is ultimately responsible for the registration of foreign doctors. ”

34 NELSON MANDELA FOUNDATION A DIALOGUE ON ART MODELS Dr Mosa Moshabela

We know very well that the plan, one of its goals is to strengthen the district health system. “ And you’ve mentioned that you’ve appointed co-ordinators in the facilities and at a provincial level. But when it comes to clinics, clinics do not work with the facilities, I’m talking hospitals now, and provincial co-ordinators will not be able to manage the districts. So are their plans also to appoint ART managers at a district level in the near future? ” Nomalanga Makwedini

The current problem – I’m going to relate this to how we’re dealing with this issue in the “ Eastern Cape – we find that most of our clinics do not have 100% staff, even hospitals for that matter. Most of them, they are 70% or 60% staffed, so, with such a situation, where we have a gross shortage of human resources, you are unable to say, your current staffing norms, are they meeting the demand or not? So that becomes a very critical issue because you don’t want it to create posts. Let’s say you have a clinic that is supposed to have five registered nurses, currently you’ve got two, why do you create two more, when you have not filled the other three? That is a big question that is coming from ORD. ... Unless we have already filled all the posts, then we’re able to say, the nurses or the health workers cannot cope. So this has got to be looked at differently. There are lots of non-nursing or non-clinical duties that are done by nurses. We should be having the data capturers to do data-capturing. We might be saying that they are over-worked because, currently, we’re making them do work that should be done by another category of worker. If then we start filling up the posts of data capturers, clerks and all of those people, then we’ll be able to alleviate most of the burden from the nurses. We need to employ pharmacy assistants to do their job of dispensing rather than having nurses running between examining a client and then again having to dispense the drugs. In the Eastern Cape, in the district, we have got what you might call ART managers. We don’t call them that in our province, though we say treatment care and support manager, because we don’t want to verticalise the programme, that you’ve got only a manager to manage ARVs. What about those who need just chronic care? They are still HIV-positive, but they need to be followed up; they are not yet at the stage to receive ARVs, but you want to constantly monitor those clients. Like it was mentioned, some of your clients can boost their nutritional status. Do anything, but those people need to be under your care, so we don’t label those managers as ART managers. ” Dr Marga Vintges

We are here together with quite crème de la crème people working in rural areas and they all “ have credits. Is there a question maybe that you have for us, something that we can help you with? ” Dr David Kalombo

All I can say is that the department appreciates the efforts of every stakeholder. We have been “ saying that there is no way that we can manage this programme alone. So if anyone says we’re failing, we’re all failing. So it is not about people pointing fingers at each other, but it is about engaging with one another on issues which we can solve. And we appreciate the involvement, the participation of the stakeholders, and please talk to us. There were issues of us not being accessible. I think we are accessible to those who really want to talk us, as we are all grappling with the same issues. ”

NELSON MANDELA FOUNDATION 35 A DIALOGUE ON ART MODELS Emerging Themes

MODEL OF CARE PARTNERSHIPS

Dr Ashraf Grimwood the clinic teams in adherence moni- DR MOSA MOSHABELA lationships on the ground but it just be an answer to the issue of part- toring, follow up, reporting back doesn’t happen. If it does happen, it nerships, but a lot of government A Rural Model on patients, and psycho-social After this talk I’m not going to be takes a very long time. officials, especially on the ground, assessments. popular, especially from our friends seem to be disempowered in terms The discussion has been quite dif- in government; they’ll excuse me. I’m of decision-making. People keep tak- ficult. We started off by trying to Training going to sound very much like the ing you from pillar to post, time and define where this model should be. TAC (Treatment Action Campaign). again, over months and over years, And we decided it should really be And there was a suggestion to over- We started off by asking the ques- without arriving at a final conclusion, rural – because this is the focus of come some of the problems of the tion: who are the partners? And or an answer, or a decision. And, as a this discussion – and not urban, peri- shortages. A clinical officer or a there’s a lot of partners, including all result, programmes delay, patients urban or informal, otherwise we’d nurse who might be trained through the non-governmental organisations, wait for a long time and they die. be here for the whole day. And we distance learning, but with the focus the non-profit organisations, the ac- Now, a lot of other people have finally agreed to a model for- ahy being on mentorship, where they be- ademic institutions, the people living embarked on the grey area syn- pothetical area, deep rural, requiring come clinical officers. But, then they with HIV and AIDS, and other com- drome, whereby people just come in a mobile team of mentors, of a doc- are tied into a three-year contract munity structures that exist in terms and start working without any agree- tor, a couple of nurses, depending on plus with the province where they’ll of providing health care. ments. This is not ideal, but it has the area, and lay counselling, who be working, to continue to provide Marianne Knuth: Are there worked for people and I’d like to find would be responsible for maybe five that service. They don’t have a haem- any questions from your group? Working with out from Médecins Sans Frontières or six clinics. orrhage of skilled staff as you’ve had Any questions that are still alive (MSF) if they know anything about with the PMTCT-trained nurses. and unanswered? Government that? But at the end of the day, peo- Capacity The course obviously will be ac- ple might end up working and try to credited. Also, with community care Issues around sustainability, the We also agreed that government is work on a proper model that after a The whole idea would be to develop workers, supported by the expanded training content and recruitment of the major stakeholder in health care couple of months or years they are the capacity of the clinic, ensuring public works programme, begin the community supporters. Who’s going in this country and that’s a fact. And, able to present to government, to that the staff are able to continue creation of a career path for commu- to be responsible for the orientation therefore, especially when it comes say, “Is this acceptable to you, can with a very good quality service. Not nity workers who are trained up on and the management of the mobile to sustainability, we need to work in we now go on to some kind of agree- to forget, though, that there will also adherence. There is a suggestion as teams? line with government. ment?” But the problem is, it takes a be the development of community to where these career paths could go, There needs to be some sort of Now the problem is, how do we lot of effort, a lot of energy and some preparedness, community mobilisa- either to nursing, counselling or adher- conductor of this orchestra. And then get to work with government? We people on the way, they quit before tion, through the use of community ence support. The idea would be that again the issue around task-shifting, realise that in terms of working with they can even provide the service care workers or community adher- the trained nurses would ultimately be issues around testing; who’d do the government, we need to develop that they are supposed to provide. ence workers, trained up to support initiating therapy as your officers. testing? clear service level agreements, right from the start. If we’re going to be Trust and Commitment Solutions? partners, we both have to have an agreement and bring forth what Some of the key things that we find Solutions we don’t have. We’ve got ACCREDITATION AND POLICY we’re able to provide and what the are issues involving trust. A lot of a lot more questions and I think it expectations are. And that’s a major times it doesn’t exist; we don’t know goes back to the question of “how”? Dr Stanley Muwonge mandate and there are mana- barrier to get through right from the where this comes from, but that’s How do we get government to be gerial issues that may present start. what we find. much more open and willing to form We’ve had a very hot discussion problems. What normally people find is that The second thing is commitment. partnerships? about accreditation and policy issues, The way forward is that when they deal with top-level of- We find that the issue of commitment And these issues that we’ve men- you can imagine. I’ve summarised it the national policy needs to ficials, say national, things are easy. is questioned, even after service lev- tioned – commitment, leadership, as follows. be communicated clearly to all But the moment you go to provin- el agreements have been signed. At trust, competence – are the things What we decided, or what we stakeholders and that will help cial, things become very difficult. times you find that it’s only one part- that we’re asking for from govern- agreed on rather, is that there is a hold both national and provincial The moment you go to district, and ner who’s committed to activities or ment. Also, the model should be in national policy that is clear, it is fa- accountable. even facility, it becomes even more to the agreement. context; the partnership should be cilitatory and it is flexible. We agreed Now the hanging question is: difficult. And we also realise that it’s Another issue: it’s the issue of context because you cannot use the that implementation is a provincial how? very important to establish good re- leadership. We think that this will same models for everyone.

36 NELSON MANDELA FOUNDATION A DIALOGUE ON ART MODELS and Challenges

PARTNERSHIPS

DR MOSA MOSHABELA lationships on the ground but it just be an answer to the issue of part- doesn’t happen. If it does happen, it nerships, but a lot of government After this talk I’m not going to be takes a very long time. officials, especially on the ground, popular, especially from our friends seem to be disempowered in terms in government; they’ll excuse me. I’m of decision-making. People keep tak- going to sound very much like the ing you from pillar to post, time and TAC (Treatment Action Campaign). again, over months and over years, We started off by asking the ques- without arriving at a final conclusion, tion: who are the partners? And or an answer, or a decision. And, as a there’s a lot of partners, including all result, programmes delay, patients the non-governmental organisations, wait for a long time and they die. the non-profit organisations, the ac- Now, a lot of other people have ademic institutions, the people living embarked on the grey area syn- with HIV and AIDS, and other com- drome, whereby people just come in munity structures that exist in terms and start working without any agree- of providing health care. ments. This is not ideal, but it has worked for people and I’d like to find Working with out from Médecins Sans Frontières “A lot of (MSF) if they know anything about Government that? But at the end of the day, peo- government officials, ple might end up working and try to We also agreed that government is especially on the work on a proper model that after a the major stakeholder in health care couple of months or years they are in this country and that’s a fact. And, ground, seem to be able to present to government, to therefore, especially when it comes say, “Is this acceptable to you, can to sustainability, we need to work in disempowered we now go on to some kind of agree- line with government. ment?” But the problem is, it takes a Now the problem is, how do we in terms of lot of effort, a lot of energy and some get to work with government? We people on the way, they quit before realise that in terms of working with decision-making.” they can even provide the service government, we need to develop that they are supposed to provide. clear service level agreements, right from the start. If we’re going to be Trust and Commitment Solutions? partners, we both have to have an agreement and bring forth what Some of the key things that we find Solutions we don’t have. We’ve got we’re able to provide and what the are issues involving trust. A lot of a lot more questions and I think it expectations are. And that’s a major times it doesn’t exist; we don’t know goes back to the question of “how”? barrier to get through right from the where this comes from, but that’s How do we get government to be start. what we find. much more open and willing to form What normally people find is that The second thing is commitment. partnerships? when they deal with top-level of- We find that the issue of commitment And these issues that we’ve men- ficials, say national, things are easy. is questioned, even after service lev- tioned – commitment, leadership, But the moment you go to provin- el agreements have been signed. At trust, competence – are the things cial, things become very difficult. times you find that it’s only one part- that we’re asking for from govern- The moment you go to district, and ner who’s committed to activities or ment. Also, the model should be in even facility, it becomes even more to the agreement. context; the partnership should be difficult. And we also realise that it’s Another issue: it’s the issue of context because you cannot use the very important to establish good re- leadership. We think that this will same models for everyone.

NELSON MANDELA FOUNDATION 37 A DIALOGUE ON ART MODELS

HUMAN RESOURCES TASK-SHIFTING Lynne ics. And we discussed the potential So if you get a higher-level post, Task Identification Categorising Staff Task Inventory Wilkinson of government providing a rental when you qualify for a lower-level allowance so that staff were not re- one, that you are either obliged to Dr Helen Schneider: We Dr Ebrahim Variava: I think Dr Helen Schneider: What we We had the rather quired to live in the hospital in order work for three or five years in that looked, first of all, at the life course one of the issues we looked at as thought is needed is a full inventory difficult topic of to qualify for free accommodation. setting. of illness and identified points along well, was at a clinic level what sort of of all the tasks that can be shifted and human resources. ... The community could potentially On-site training. The other point that life course. From, you know, the staff you’ve got, and we tried to cat- then to say, well what specifically is We discussed the build accommodation, which could that we identified as a problem was point of voluntary counselling and egorise your staff. the organisational or institutional im- obvious problems then be rented, providing a benefit to that staff are often removed from the testing, case finding for opportun- We know that some clinics have pediment to changing that? Where’s of getting people the health-care worker, as well as the facility at all times for various sets istic infections, diagnosis, initiation primary care-trained nurses, profes- the decision being made around to work in the community. of training, often leaving the facility of treatment, maintenance, etc. We sional nurses, enrolled nurses and that? And we need to find that out deep rural areas. Grade rural pay. The third idea with very few staff at any one time. identified, right along that - spec enroled nurse assistants (ENAs), as the next step before we can make that we had, which we’ve spoken And, really, trying to focus on creat- trum, a whole lot of tasks that can each with specific functions. All proposals for shifting tasks. about before, is potentially grad- ing practical training at the sites and be shifted from professional workers clinics don’t have that level of staff, ing the rural allowance so that for the provinces to come up with to patients, from professional work- but also related or linked to the clin- Context Environment people benefit more from a deep ru- some ideas about a team, essentially ers to lay workers, from doctors to ics, you’ve got a whole host of other ral setting and people who live in a of mentors or teachers, that come nurses, pharmacists to pharmacy as- NGOs working for the Department of Marta Darder: Basically, we A large point that is often missed is semi-urban area are not getting the and actually teach at the site with the sistants. There’s a whole spectrum Health. The home-based care group- didn’t have enough time. It’s not that providing a nice team, a moti- same rural allowance. team. It will also allow more practi- and quite a few of them have already ings that have been sponsored by the enough time if you are looking at vating environment for a new nurse, Use clinic committees. The last cal training and less theory. been covered. Department of Health, are function- all the tasks that can be shifted and doctor, social worker or dietician, re- issue that we spoke about specifical- ing fairly independently. what are the players and it’s so con- ally adds to people wanting to stay ly was, for instance, the conditions at Issues Outstanding Structure We are looking at these cadres text-based at the moment. in rural areas, even when the condi- the clinics: the access roads, the lack of health-care workers and trying to The solutions are being invented tions are not optimal. of electricity, the lack of water. And And we had a whole lot of further is- Then we looked at the structure of focus on what they should be doing. by people who are struggling with we were saying that one of the solu- sues which we didn’t get to. One of the health service and all the people The DOT supporters, the issues on the Infrastructure tions there is to make use of the clinic those was our problem of working in it and looked at it from a struc- for instance, should not ground and they committees, which most of our clin- with the HR admin function within tural point of view. What you could only just function on come out with From the perspective of actually try- ics have. And try and motivate them government, which often causes a send down the line, as it were, what DOT support; it’s basi- whatever possibili- ing to deal with the infrastructure to demand improvement of services vast delay in employment of staff. you could shift. cally taking in the TB ties they can. problems, we identified that it’s not so at their clinics in order that they are The other issue which we didn’t The underlying conclusion is that programme and trying Basically we’ve much... well it is the accommodation able to recruit and retain staff. tackle was our need for further coun- a huge amount of task-shifting is to co-ordinate it. They been learning from and the roads, but it’s also the lack They have a lot more power than sellors behind the community and possible if you’ve got a coherent sys- should also be assisting each other about of supporting services that creates we often believe they do and if we the appropriate way to fund such tem with all the different elements with VCT and adher- how we found dif- problems for people living in rural ar- assist them and support them in a system. in place and, in particular, to have ence counselling. Your ferent solutions to eas for a long time. For instance, the lobbying for that im- the connections between them. So support groups should the same problems lack of availability of schools, or of provement, potentially that you’ve got, for example, a good be linked to the vari- by “doing”, and churches of the specific religion that it would happen. relationship between a district hospi- ous home-based care based on wherever the person may belong to. Prevent urban mi- tal and a district management team groupings. we were. gration. There were and clinics, then you can do a huge We looked at all the But as for the Solutions a few other issues we amount of task-shifting. If you’ve other issues related to principal role of this discussed. One of them got, for example, well-functioning the entire programme group, which was to We came up with a couple of poten- was also our problem regional training centres at a region- and, I think, it will be better clarified actually make some kind of tentative tial solutions to these problems. of giving people high- al level, then you can train all these when we try to add much more meat terms of reference for the different Incentives. The first was -gov er-level posts and then people coherently at a local and dis- on to the flow diagram we came up groups or different layers, we didn’t ernment potentially paying health the problem that results trict level. with at some point. get there. professionals incentives to allow when they then move their children to go to good boarding to an urban area keep- schools. Because a lot of people move ing the high-level post. away from the deep rural areas once And we suggested their children reach a school-going that if people are of- age. But if they were actually supple- fered a higher-level mented in providing schooling for post, and this relates their children, potentially this prob- to all health-care pro- lem would go away. fessionals, including Rental allowance. The second doctors, social workers, problem is obviously the accom- dieticians and nurses, modation problems, which we have then they are tied into a TO THE POINT: Nomalanga Makwedini, from the Eastern Cape both at the hospitals and at the clin- fixed-term contract. Department of Health, discussing the human resources issue.

38 NELSON MANDELA FOUNDATION A DIALOGUE ON ART MODELS

TASK-SHIFTING Task Identification Categorising Staff Task Inventory Dr Helen Schneider: We Dr Ebrahim Variava: I think Dr Helen Schneider: What we looked, first of all, at the life course one of the issues we looked at as thought is needed is a full inventory of illness and identified points along well, was at a clinic level what sort of of all the tasks that can be shifted and that life course. From, you know, the staff you’ve got, and we tried to cat- then to say, well what specifically is point of voluntary counselling and egorise your staff. the organisational or institutional im- testing, case finding for opportun- We know that some clinics have pediment to changing that? Where’s istic infections, diagnosis, initiation primary care-trained nurses, profes- the decision being made around of treatment, maintenance, etc. We sional nurses, enrolled nurses and that? And we need to find that out identified, right along that - spec enroled nurse assistants (ENAs), as the next step before we can make trum, a whole lot of tasks that can each with specific functions. All proposals for shifting tasks. be shifted from professional workers clinics don’t have that level of staff, to patients, from professional work- but also related or linked to the clin- Context ers to lay workers, from doctors to ics, you’ve got a whole host of other nurses, pharmacists to pharmacy as- NGOs working for the Department of Marta Darder: Basically, we sistants. There’s a whole spectrum Health. The home-based care group- didn’t have enough time. It’s not and quite a few of them have already ings that have been sponsored by the enough time if you are looking at been covered. Department of Health, are function- all the tasks that can be shifted and ing fairly independently. what are the players and it’s so con- Structure We are looking at these cadres text-based at the moment. of health-care workers and trying to The solutions are being invented Then we looked at the structure of focus on what they should be doing. by people who are struggling with the health service and all the people The DOT supporters, the issues on the in it and looked at it from a struc- for instance, should not ground and they tural point of view. What you could only just function on come out with send down the line, as it were, what DOT support; it’s basi- whatever possibili- you could shift. cally taking in the TB ties they can. The underlying conclusion is that programme and trying Basically we’ve a huge amount of task-shifting is to co-ordinate it. They been learning from possible if you’ve got a coherent sys- should also be assisting each other about tem with all the different elements with VCT and adher- how we found dif- in place and, in particular, to have ence counselling. Your ferent solutions to the connections between them. So support groups should the same problems that you’ve got, for example, a good be linked to the vari- by “doing”, and relationship between a district hospi- ous home-based care based on wherever tal and a district management team groupings. we were. and clinics, then you can do a huge We looked at all the But as for the amount of task-shifting. If you’ve other issues related to Dr Helen Schneider principal role of this got, for example, well-functioning the entire programme group, which was to regional training centres at a region- and, I think, it will be better clarified actually make some kind of tentative al level, then you can train all these when we try to add much more meat terms of reference for the different people coherently at a local and dis- on to the flow diagram we came up groups or different layers, we didn’t trict level. with at some point. get there.

Dr Mothomang Diaho

I get a sense that a lot of issues were raised today. And some of them we started grappling with, “ for instance the five issues that were raised. But I think in my reflection tonight, I’d like to come back tomorrow so that when we pass this document around, the recommendations that we made are very specific in certain areas. I think listening to the presentations, there are certain areas where I got a sense that within the next year or two certain things can definitely be done. And I think tomorrow I would like to see that stated clearly: what can be done. And then also state in another section what we propose is something that needs to be looked at as parallel to what it is that we are proposing, so that it’s a much tighter recommendation for policy-makers, ourselves and other partners. I think it needs to come out very clearly. NELSON MANDELA FOUNDATION ” 39 A DIALOGUE ON ART MODELS

GROUP OUTPUT From Ideas to Action Strategies and recommendations for HIV and AIDS care in resource-limited settings 1. Space 3. Policies and National GROUP OUTPUT Treatment Guidelines You need: You need to be in possession of Models of HIV Care • A consulting room and a counselling these guidelines: dispense on site or a pharmacist room. assistant supported by a district Group Representative: Roeleen Booi • A waste management system (box- • Written confidentiality policy. pharmacist. es for needles and red plastic bags • Written universal infection precau- for medical waste) and the company tion policies. 6. HIV & AIDS Introduction • How to recognise and manage side- used by the district to collect the • National ARV treatment guidelines effects and adverse drug reactions. waste. (blue book for children, orange Service Point These models of care employ a decen- • A cellphone or landline for patient book for adult, green book for man- You need: tralised approach to the provision of Identified resources include: communication. agement of side effects). comprehensive HIV care and treatment • www.msf.org • Contraceptive guidelines. • Access to care, treatment and services. • Pulsa+ (proposed for Free State) • Antenatal guidelines. support. 2. Basic HIV and AIDS • VCT guidelines. • A 24-hour service, if not a referral They include: 2. Mentorship of doctors, nurses • PMTCT guidelines. system (hospital), for nursing care and lay health counsellors is need- Services • TB management guidelines. and doctor care. 1. A mobile multidisciplinary team that ed to improve HIV management You need to deliver or have easy • STI guidelines. • Access to expert consultation. is stationed at the accredited hospi- skills at PHC level. access to the following services: • PEP guidelines. • An identified hospital you can refer tal and travels on a regular basis to • Nutritional guidelines. patients to. the primary health clinic (PHC) to The main gap identified in the success- staff and, in the long term, budget- • Family planning. • Appropriate trained staff managing initiate patients on ART. ful implementation of the above models ing for this position at PHC level. • Antenatal services. If you don’t have these, they are freely HIV and AIDS at the service point. 2. A multidisciplinary team available at of HIV care was nursing mentorship or • VCT. available at your district office or refer- the PHC level to initiate ART. preceptorship. 3. Additional auxiliary staff at PHC • IMCI/EPI. ral hospital. 3. A multidisciplinary team at the ac- – “Task-Shifting” • PMTCT. 7. Staff credited hospital to initiate ART and • An HIV clinical preceptorship train- • TB management. 4. Laboratory Capacity down-refer patients to a PHC to ing programme for registered nurses • Lay health counsellors are needed • STI. You need the following staff. If you don’t continue treatment. needs to be established. The end to conduct pre- and post-test HIV • PEP (can refer to nearest service You need: have them, you have to have a plan to re- product of this preceptorship pro- counselling; including performing provider). cruit them and a plan to train them for One or a combination of these three gramme is registered nurses with the actual rapid HIV test and for • Nutritional support (can be done by • Someone trained to draw blood. HIV and AIDS: models is operational at each ART ac- skills needed to mentor other less clerical duties. the district). • A protocol to store and transport credited service point (consisting of a experienced nurses at PHC level in • Data capturers – required for data • Social worker (can be done by the specimens. • Professional nurse. hospital and feeder clinics). HIV management, including ART. collecting and assisting in compiling district). • Access to CD4 testing. • Staff nurse. • A job description or scope of work reports on HIV indicators. • Enrolled nurse. Criteria For Success will need to be developed. 5. Pharmacy Capacity: • Dietician/nutritionist. • Resources identified for this task • Pharmacist assistant. For the decentralisation to be successful include NGOs, nursing colleges/ You need: • Social worker. the following are needed: universities, regional training cen- • Lay counsellor. tres and the skills development unit • A clinical nurse practitioner or • Admin clerk. 1. Clear protocols for HIV manage- of HR in the DoH. a professional nurse licensed to • Data capturer. ment should be available at PHCs. • Policy issues regarding these newly skilled nurses will therefore need to Some of the important areas that the be urgently addressed. Some of the protocols should address are: issues that will need further deliber- ation are: remunerating the nurses • When to initiate ART. graduating from the preceptorship • When to refer patients on ART for programme, official recognition of DECENTRALISED DELIVERY: New further management. the existence of this new cadre of models of care need to be developed.

40 NELSON MANDELA FOUNDATION A DIALOGUE ON ART MODELS

GROUP OUTPUT Steps Towards Getting Your Facility Accredited Group Representative: Dr Ebrahim Variava

1. Space 3. Policies and National Treatment Guidelines You need: You need to be in possession of • A consulting room and a counselling these guidelines: dispense on site or a pharmacist room. assistant supported by a district • A waste management system (box- • Written confidentiality policy. pharmacist. es for needles and red plastic bags • Written universal infection precau- for medical waste) and the company tion policies. 6. HIV & AIDS used by the district to collect the • National ARV treatment guidelines waste. (blue book for children, orange Service Point • A cellphone or landline for patient book for adult, green book for man- You need: communication. agement of side effects). • Contraceptive guidelines. • Access to care, treatment and • Antenatal guidelines. support. 2. Basic HIV and AIDS • VCT guidelines. • A 24-hour service, if not a referral • PMTCT guidelines. system (hospital), for nursing care Services • TB management guidelines. and doctor care. You need to deliver or have easy • STI guidelines. • Access to expert consultation. access to the following services: • PEP guidelines. • An identified hospital you can refer • Nutritional guidelines. patients to. • Family planning. • Appropriate trained staff managing • Antenatal services. If you don’t have these, they are freely HIV and AIDS at the service point. • VCT. available at your district office or refer- • IMCI/EPI. ral hospital. • PMTCT. 7. Staff • TB management. 4. Laboratory Capacity • STI. You need the following staff. If you don’t • PEP (can refer to nearest service You need: have them, you have to have a plan to re- provider). cruit them and a plan to train them for • Nutritional support (can be done by • Someone trained to draw blood. HIV and AIDS: the district). • A protocol to store and transport • Social worker (can be done by the specimens. • Professional nurse. district). • Access to CD4 testing. • Staff nurse. • Enrolled nurse. 5. Pharmacy Capacity: • Dietician/nutritionist. • Pharmacist assistant. You need: • Social worker. • Lay counsellor. • A clinical nurse practitioner or • Admin clerk. a professional nurse licensed to • Data capturer.

Dr Ebrahim Variava

I think it’s actually very easy to get accreditation going. Almost all clinics probably can “ prepare for accreditation quite quickly and quite easily and I would suggest that they go through this list, see what they have and then submit it through the provinces and see if they can get accredited. It’s probably a worthwhile exercise to do. NELSON MANDELA FOUNDATION ”41 A DIALOGUE ON ART MODELS

GROUP OUTPUT Integration Into Chronic Care PHC Model Group Representative: Dr Victor Fredlund

Introduction cough screening and then appropriate tests – blood pressure or blood sugar, Integrating ARV medicine into the pri- previous lab results and institutionally mary health-care model of continuing held files to be obtained, etc. care is a logical step. Patients have many Those just needing medicines are similar requirements to other chronic then fast-tracked to counselling and care patients. The clinic setup should then dispensing, if on ARVs. At specified added but we should be careful not have all the elements required and the review periods or with complications, to swamp activities. flow of patients through the different patients to go via counselling to clinician • Patient record is an interesting is- elements should be directed and moni- (either a nurse or doctor according to sue. Patient-held is good but needs tored by a triage nurse. This could be an programme). organisation. For example, one A4 enrolled nurse. Visits to other segments are ar- page fitted into pocket with tabu- ranged periodically or if the need arises. lated drugs on one side and results Elements Needed TB patients could well benefit from ad- on back. herence counselling and dietary advice, • Triage nurse as may hypertensives! Analysis of data should be done as • Records We need to import some of the ARV survey sampling rather than blan- • Counsellors programme models into other chronic ket collections? • Procedures room care programmes. • Nurse clinician Three Points to Take • Doctor clinician Other considerations: • Dispensing Forward • Social worker • Vary the rooms that are used? • Dietician This may help so that stigma does • Engaging HAST nurses for triaging. • Data capturer not get attached to entering certain • Training counsellors on issues of rooms. adherence in TB, hypertension and The role of the staff nurse (or staff • Adherence training could be diabetes. nurse team, depending on numbers) extended to TB patients. Same • Looking at patient records that give triage is crucial. All patients are given the counsellors. Additional skills can be rapid overview.

Dr Eula Mothibi

There is that move to try and multi-skill these counsellors, so that they’re doing everything. “ When they go into the home, they don’t just say “No I’m HIV, I’m coming to check your tablets”. The one person is able to do diabetic testing and talk about hypertension adherence. So there is that recognition from national DoH, granted, that these people need to be multi- skilled in those ways and there is a module, which probably hasn’t been rectified, on how to train them. But I think all those things will be coming; people are thinking about those issues. ” Dr Hermann Reuter

I think one needs to think about the danger of then giving them everything to do and I “ don’t think that’s what task-shifting means. Task-shifting means identifying a very specific job that somebody can do. Obviously if that person, at some stage, acquires the knowledge to do more than the HIV work, then they can also be trained to do diabetic work and to do hypertension work and so on. But I think the initial shift is towards a very specific job description. But, obviously, as that person visits the house, they will hear about other illnesses and come back with more questions and then we should train them more comprehensively. 42 NELSON MANDELA FOUNDATION” A DIALOGUE ON ART MODELS

Dr Doris Macharia

I was in this group. It’s not only the counsellors and I think Victor’s mentioned that. It’s “ just looking at the flow of patients and seeing what you have. Even if it’s a staff nurse or an enrolled nurse assistant (ENA), you know, what more can they do? So that it’s not like: “Oh, I’m only here for the HIV thing,” you know? ” Dr Marga Vintges

I’m very interested in your ideas about the file, the record-keeping system ... We have already “ developed a special file and a special patient booklet for HIV patients. A file with, you know, the lab results and everything that you use at your ARV site. Now I’m thinking, is this the right way? Should we have a general file system in which you can also monitor diabetes and hypertension? It taps into this whole idea about vertical and horizontal, of course. Should we wait for an integrated file to be developed or should we not start with ARV being a bit vertical, because it’s a new thing for everybody? Once you get established, and you get used to everything, and you know you’re comfortable with ARV in your clinic, then go for the integration? ” Dr Victor Fredlund

I think the flow sheet is an addition to a patient-held record system. In our experience “ in Mseleni, we actually developed a patient-held record that looks the same for everyone but is capable of containing the information for ARVs as it can contain the information for hypertensive medicines and for anything else. So it has a results page, it has a treatment page and then it gives you the same thing. But the motivation to make that happen came partly because of the ARV programme. Which meant that all the patients got it, not only 10% that are on ARVs, or 2% that are on ARVs. You can’t see from outside which patient it is, you see, it’s the same book for everyone, which may be an advantage. ”

NELSON MANDELA FOUNDATION 43 A DIALOGUE ON ART MODELS

GROUP OUTPUT GROUP OUTPUT Involving General Practitioners in HIV Clinical Management Group Representative: Pumla Kobus 1. Incorporate other 2. Increase recruitment Introduction public-sector dependant patients recommendations by for testing and from their rooms at no cost to the paediatric discussion treatment There are approximately 10 000 GPs in patient. private practice in South Africa and of groups those over 6 000 are trained in HIV clini- This would help to address: • Availability of promotion materi- cal management. • Review guidelines to increase family als posters to educate at primary Through these GPs, there is a po- • The infrastructural problems care at primary health-care level. health clinics. Management of Childhood Illnesses tential to demonstrate and develop the faced by public-sector medical • Have a proactive outreach for pae- • Education at immunisation clinics, (IMCI). capacity of the private sector to provide facilities. diatric support. antenatal care clinics, and pension • Education within adult support the much needed human resource and • The issue of stigma, because • Simplify paediatric treatment to points for grandparent caregivers. groups to test their babies/children. infrastructural support for comprehen- patients would be seen in a look at weight bands. • Do not only educate at high schools • Co-stickers system on files (PMTCT sive care delivery for people living with private setting that promotes • Promote simplification of doses but also at primary schools. mothers and HIV-positive adults) for and exposed to HIV and AIDS. privacy, confidentiality and individu- patient managers and counsellors – move to tablets early. • Accelerate dry blood spot use (PCR) following up on tested children. The aim is to align the distribution of alised quality of care. on the ground, working in conjunc- by antenatal care (ANC) nurses. • To include relevant information on medical practitioners, of whom approxi- tion with the doctors. • On-site training while waiting for Road to Health Card as a part for mately 70% are in the private sector, to Logistics formal training, including Integrated screening. the distribution of patients, where only 16% of the South African public have Logistics for offering medical treat- Project Management medical insurance, with a significant ment at GP rooms are around number of them not fully covered for laboratory testing and drug delivery. The Tshepang Trust provides project access to ARVs for a full calendar year. management of the GPs, offering services These doctors are available as an • For laboratory testing, the National on a sessional basis. For example, drawing immediate medical resource in the Pathology Group (a partnership of up rosters for doctors, providing registers clinical management of HIV and are in private laboratories) is in partner- where they sign in for hours worked, re- areas where patients are located, pro- ship with the Tshepang Trust and muneration, etc. The trust also provides a viding easy access to care, privacy and doctors send lab tests through these comprehensive disease management pro- confidentiality. laboratories and the trust manages gramme through its patient managers. The following are lessons learned the costs. from the Tshepang Trust (an NMF- • For patient access to drugs, drugs Additional Inputs funded project). are delivered patient-ready to the GP’s rooms and patients collect The group had these additional inputs: Two Approaches to their medication from there. Involve GPs • There was concern that all public Monitoring and patients might want to go to GPs 1. Sessional and hence overload the system. A Evaluation possible solution to this potential GPs involved on a sessional basis in pub- Tshepang provides a monitoring challenge would be charging a small lic-sector facilities, i.e. hospitals, clinics and evaluation programme that is fee to patients wanting to go to GPs and health-care centres within the com- responsible for: instead of the public ARV sites. munities where potential patients are, in • For sustainability, everybody agrees order to alleviate the burden of treat- • Patient registration and referral to that the government needs to as- ment at public ARV sites and reduce doctors. sume ultimate responsibility for waiting periods for patients before they • Recording of patient clinical maintaining initiatives aimed at as- can be seen by practitioners. information. sisting with the HIV epidemic. To this • Reviewing of scripts and monitoring effect, policy issues surrounding the 2. Private GP Model of patients on treatment. national treasury agreeing to state • Reporting. drugs being delivered to doctors’ This is a model where GPs are seeing • Adherence monitoring through rooms needs to be researched.

44 NELSON MANDELA FOUNDATION A DIALOGUE ON ART MODELS

GROUP OUTPUT Expansion of ART for Children in Deep Rural Areas Group Representative: Tandi Xozwa

1. Incorporate other 2. Increase recruitment recommendations by for testing and paediatric discussion treatment groups • Availability of promotion materi- • Review guidelines to increase family als posters to educate at primary care at primary health-care level. health clinics. Management of Childhood Illnesses • Have a proactive outreach for pae- • Education at immunisation clinics, (IMCI). diatric support. antenatal care clinics, and pension • Education within adult support • Simplify paediatric treatment to points for grandparent caregivers. groups to test their babies/children. look at weight bands. • Do not only educate at high schools • Co-stickers system on files (PMTCT • Promote simplification of doses but also at primary schools. mothers and HIV-positive adults) for – move to tablets early. • Accelerate dry blood spot use (PCR) following up on tested children. by antenatal care (ANC) nurses. • To include relevant information on • On-site training while waiting for Road to Health Card as a part for formal training, including Integrated screening.

Dr Victor Fredlund

Did you think about the inclusion on the Road to Health Card of the PCR result, as a “ standard block? Because, I think, a lot of things that happen on the Road to Health Card are good. If we had a PCR result six weeks under the immunisations, immediately we’ll be jogged to test. ” Dr Bernhard Gaede

I think maybe to even extend that ... to have the mother’s HIV result, from antenatal, on the “ Road to Health Card. Because they’ve done six weeks. That means that the PCR gets done. I think that’s what is really the big gap, and that ABC, secret code, Second World War system, just doesn’t work. ”

NELSON MANDELA FOUNDATION 45 A DIALOGUE ON ART MODELS

GROUP OUTPUT GROUP OUTPUT Engaging Volunteers/ Community Workers Group Representative: Dr Mothomang Diaho Who is the Community? and real decision-making. Introduction • Support groups’ enthusiasm has Initially, the discussion revolved around Support Groups Work rubbed off on nursing staff in some “who is the community” and that the The magnitude of the epidemic calls clinics and added positively to staff way the community is defined often From a number of examples that were for unity of purpose and demands that morale. influences how the local population is shared, the involvement of support we work together and reach beyond • It is easier to engage existing vol- community-based nutrition, etc. being engaged. The total population con- groups seemed to have greater impact. the facilities to engage communities. unteer groups in the community or • We need to promote wellness as stitutes the community; however, only a The groups were used for the dis- service demanding service and thereby Community-based volunteers are the in- create new support groups through part of the training, small number of people are active in the semination of information regarding the having a greater say in the improvement terface between the community and the the clinic if none exist. • Support groups should meet during participation in projects. disease process as well of the service. health facility. Successful and innovative • Being involved with a support group clinic time to provide assistance to as the service delivery. As the support programmes have engaged community- gives one status in the community. both patients and clinic staff. Formal Structures In a number of exam- groups become more based volunteers as demonstrated by the • Training should be a combination of ples that were shared, established, in one MSF adherence counsellors (HAACO). Incentives in-house and training subcontracted Traditionally, the standard approach has this led to a demand example that was out to accredited institutions or been to approach the “official” bodies for better service shared, the support Guiding Principles • Government and NGOs have now individuals. and stakeholders of the community – the from the health-care groups started to be provided some stipends to the vol- • Need to provide counselling and traditional leaders, municipal councillors, services – including a more involved in the There has been an explosion of these unteer groups. debriefing sessions with support church leaders, leaders of organisations demand for ARVs at existing community community-based support groups over • Some have opened their own bank groups, at least twice a year. or the members of hospital boards or the clinic or hospital structures, such as time. It is imperative that we have clear accounts as a result. • Provide recognition for excelling clinic committees. In practice, this ap- and demand for im- the Nkosis’ Councils, guiding principles in working with them. • The MSF adherence counsellors get members. proach yields little in the way of real proved treatment for to address a number There is a lot of duplication of their a stipend paid at the government • Consider innovative ways of sustain- change in the community and few peo- opportunistic infec- of issues related to functions on the ground as a result. scale. ing motivated members. ple on the ground get involved or get tions (such as herpes). domestic violence The group shared some of their experi- • Should consider planning their ca- • Consider members of support information regarding what is going on. The support groups continued to share and rape. The support groups there- ences and observations in working with reers within this context. groups being considered for higher The “formal democratic” structures the information with new patients and fore started to be transformational in volunteers. • Identify leaders/champions in the positions when task shifting. have limited impact on involvement in play an important role in motivation a wider context than the group itself group and provide further support • Build in a mentoring system to sup- actual change in the community and and monitoring adherence. The process and have greater standing and stature in • Members of support groups must to them. port the groups. there is often a veneer of participation results in the “users” or “clients” of the the community. The process of commu- come from the community. • Include PLWHA in the groups. • Set up a monitoring and evaluation nity mobilisation therefore has a greater • They must be sensitive to local • We should consider other non-fi- system for support groups. impact than a more passive process of community experiences and have nancial incentives. • The innovation that has emerged sharing information within the formal a willingness to work with existing from HIV support groups needs to structures. community-based organisations. Training and be shared with other programmes • Community members also join such as the TB programme. Recommendations these groups in the hope that they Accreditation will get jobs. • Develop a clear strategy to develop Conclusion • Community mobilisation, especially • In rural communities, though, volunteer capacity. of HIV-positive people in their fight there are very few choices in “job” • Ideally, if training is involved, it needs No one individual, organisation or gov- for health. selection. to be carried out in the community. ernment can respond to the epidemic in • Health promotion budgets from the • Participation by volunteers, if done • Training must focus on basic issues its entirety. The epidemic is evolving and Department of Health to be used well, such as decision-making in clinic of HIV and AIDS treatment literacy, demands that we constantly look at our to support local support groups in communities, empowers individuals. treatment preparedness, adherence, approaches and act accordingly. their organisation and community mobilisation. • The health promotion process to be a “bottom-up” process (com- Dr Mothomang Diaho munities telling the Department of Health what their demands for In the areas that we work, we’re going to engage some of these recommendations. A lot of service are) rather than a passive “ people work with volunteers and community workers where they come from. top-down approach. This is in line with the WHO Ottawa Declaration ” on Health Promotion.

46 NELSON MANDELA FOUNDATION A DIALOGUE ON ART MODELS

GROUP OUTPUT Community Involvement in ART Group Representative: Dr Hermann Reuter

Who is the Community? and real decision-making. Initially, the discussion revolved around Support Groups Work “who is the community” and that the way the community is defined often From a number of examples that were influences how the local population is shared, the involvement of support being engaged. The total population con- groups seemed to have greater impact. stitutes the community; however, only a The groups were used for the dis- service demanding service and thereby small number of people are active in the semination of information regarding the having a greater say in the improvement participation in projects. disease process as well of the service. as the service delivery. As the support Formal Structures In a number of exam- “The support groups become more ples that were shared, established, in one Traditionally, the standard approach has this led to a demand groups therefore example that was been to approach the “official” bodies for better service started to be shared, the support and stakeholders of the community – the from the health-care groups started to be traditional leaders, municipal councillors, services – including a transformational more involved in the church leaders, leaders of organisations demand for ARVs at existing community or the members of hospital boards or the clinic or hospital in a wider structures, such as clinic committees. In practice, this ap- and demand for im- the Nkosis’ Councils, proach yields little in the way of real proved treatment for context.” to address a number change in the community and few peo- opportunistic infec- of issues related to ple on the ground get involved or get tions (such as herpes). domestic violence information regarding what is going on. The support groups continued to share and rape. The support groups there- The “formal democratic” structures the information with new patients and fore started to be transformational in have limited impact on involvement in play an important role in motivation a wider context than the group itself actual change in the community and and monitoring adherence. The process and have greater standing and stature in there is often a veneer of participation results in the “users” or “clients” of the the community. The process of community mobilisation therefore has a greater impact than a more passive process of sharing information within the formal structures. Recommendations

• Community mobilisation, especially of HIV-positive people in their fight for health. • Health promotion budgets from the Department of Health to be used to support local support groups in their organisation and community mobilisation. • The health promotion process to be a “bottom-up” process (communities telling the Department of Health what their demands for service are) rather than a passive top-down approach. This is in line with the WHO Ottawa Declaration STRENGTH IN NUMBERS: Community workers are integral in the fight against HIV and AIDS. on Health Promotion.

NELSON MANDELA FOUNDATION 47 A DIALOGUE ON ART MODELS

GROUP OUTPUT GROUP OUTPUT Support Groups: Adherence and Maintenance Group Representatives: Nondumiso Ntsikeni and Akona Ntsaluba Training officers, data capturers and community health workers) to allow Challenges • Training of all health workers in pri- task-shifting. mary health care in all aspects of • Proper delegation of duties and • No space or accommodation for HIV and AIDS care and management, time allocation. support group meetings. with primary health services is not come for our projects, for us to so that clients are not referred to • Partnerships can assist to reduce • No food for support group meet- there. continue with ongoing counselling certain specialist nurses and doc- the workload, and sharing responsi- ings. We are forced to meet for a • We are not part of decision- and visiting the needy. tors, but are able to access care in bilities can increase output. very short period of time before making committees for our voices all health facilities. people get hungry. to be heard. Solutions • Rotation of health workers, so that Community Support • We do not have transport for • Stigma attached to HIV-positive all health workers are able to put outreach to the outskirts of the people within government depart- • Department of Health and the their training into practice in all ar- • Use of local people as treatment • Allow a bottom-up approach to in- municipalities, even if we are invited ments makes task-shifting difficult. municipalities must see to it that eas of health care and not just be supporters and these must be at- fluence policy change. So that the to funerals for destigmatisation. • Even if we are registered as an NPO, support groups have space in all the confined to one area. tached to NGOs and local clinics for health workers who are at ground • Lack of recognition by govern- we are not given a chance to do ca- ARV sites. • Training of professional nurses to proper utilisation and monitoring. level play a part in shaping the ment departments, especially the tering for HIV and AIDS campaigns. • Department of Health must take a initiate treatment. • Use of support groups at local lev- health-care system. Department of Health. Integration The funding can be a source of in- leading role in all clinics in Lusikisiki • Availability of protocols and manu- el to channel patients to available and Qumbu Health Centre and als in all facilities. health services. Support groups are Other other support groups. • Mentorship. also helpful in monitoring adherence • Workshops and capacity-building to treatment. • Speed up accreditation of rural by the departments. Task-Shifting facilities. • Transport dedicated to support Policy-Making • HIV and AIDS must be part of a groups to help where there is an • Employment of lower categories one-stop, supermarket approach. outreach (e.g. campaigns). of health workers (staff nurses, • A change of national policies. For ex- • Mobile clinics and NGOs must be • Support group members to be nursing assistants, administration ample, reopening nursing colleges. supported. employed in each and every department and to be offered incentives. • Incentives should be offered for lay counsellors from support groups, who increase VCT and ARV uptake. • Support groups to be funded by the Department of Health. • Call for proposals must be distributed to all the support groups. • All AIDS forums to have a support group representative so that local HIV and AIDS issues can be addressed.

Dr Hermann Reuter I think there’s very much a revitalisation of primary health care going on and I think it’s “ important to include in that floor plan of those clinics, space for support groups. ” 48 NELSON MANDELA FOUNDATION A DIALOGUE ON ART MODELS

GROUP OUTPUT Empowering Health Workers in Rural Areas to Reach More Clients Group Representative: Sheila Hokwana

Training officers, data capturers and community health workers) to allow • Training of all health workers in pri- task-shifting. mary health care in all aspects of • Proper delegation of duties and HIV and AIDS care and management, time allocation. so that clients are not referred to • Partnerships can assist to reduce certain specialist nurses and doc- the workload, and sharing responsi- tors, but are able to access care in bilities can increase output. all health facilities. • Rotation of health workers, so that Community Support all health workers are able to put their training into practice in all ar- • Use of local people as treatment • Allow a bottom-up approach to in- eas of health care and not just be supporters and these must be at- fluence policy change. So that the confined to one area. tached to NGOs and local clinics for health workers who are at ground • Training of professional nurses to proper utilisation and monitoring. level play a part in shaping the initiate treatment. • Use of support groups at local lev- health-care system. • Availability of protocols and manu- el to channel patients to available als in all facilities. health services. Support groups are Other • Mentorship. also helpful in monitoring adherence to treatment. • Speed up accreditation of rural Task-Shifting facilities. Policy-Making • HIV and AIDS must be part of a • Employment of lower categories one-stop, supermarket approach. of health workers (staff nurses, • A change of national policies. For ex- • Mobile clinics and NGOs must be nursing assistants, administration ample, reopening nursing colleges. supported.

NELSON MANDELA FOUNDATION 49 A DIALOGUE ON ART MODELS

GROUP OUTPUT GROUP OUTPUT Counsellors to Do “Pricking” Group Representative: Bavuyise Vimbani

Introduction Possible Solution Introduction The existing Section 38A of the Nursing Act does not specify a Schedule limit that Pricking is part of comprehensive • Allow counsellors to do pricking Participants in the meeting acknowl- nurses can prescribe (4). Nevertheless, HIV care: because they are trained to do it. edged confusion created by mixed the format of the permit makes mention • A nurse will draw blood for an ELISA messages around the issue of whether of various “protocols”, which include 1. Diagnose HIV. test if the results are discordant. nurses are entitled to prescribe ARVs only up to Schedule 4 medicines. In re- 2. Entry point to PMTCT, HIV care • This model has been tested in or not. This would limit their ability to source-constrained settings Schedule have immediately provoked. and ARVs. Lusikisiki and other sites with good initiate patients on ARV and perform the 5 drugs have also been included, par- 3. Preventative strategy. outcomes. involved in the proccess. routine follow-ups. The consequences of ticularly with psychiatric services. In 5. The decision of whether a nurse • The quality is ensured by doing • As a matter of interest, patients this confusion in rural sites is dramatic addition, Section 38 of the Nursing Act can start patients on ARVs or not Challenges screening and confirmatory tests, with diabetes prick themselves, but given the nearly exclusive availability of confers capacities to the South African should be a clinical one depend- and working under a professional are not trained. nurses in the rural primary health-care Nursing Council (SANC) to review the ent on the nurse’s training and 1. Shortage of professional nurses to nurse. • More people can be reached for services. This group tried to clarify the list of drugs that nurses can prescribe. experience. do pricking. VCT. legal, regulatory and political framework At the moment, the Nursing Act 2. Some people are not tested because Supporting Reasons • Nurses can have more time to as- that may affect this question. is under review as it is in conflict with In rural settings, where doctors are testing is restricted to nurses. sess patients for medical problems. the Medicines Act, thus there is no legal not available, nurses should be able to 3. A high workload on the nurses. • Pricking is included in the VCT train- Conclusions answer to this issue, which should be fol- initiate patients on ART. Nevertheless, it Counselling is done by counsellors ing curriculum. Conclusion lowed up with the SANC and the South would be clinically advisable if severely but there is no-one to test, so test- • Pricking will build trust between the 1. ARVs are Schedule 4 drugs, but African Pharmacy Council. ill patients or patients that are very ing should be shifted to counsellors. client and a counsellor. It is safe and effective to allow counsel- government requires them to be immuno-compromised are initiated • Pricking is safe because a vein is not lors to perform VCT, including testing. handled as Schedule 5 in terms of 3. The South African National by a doctor. The ARV site manager or storage conditions. Treatment Guidelines do not in- medical officer should decide on this. clude any restriction for nurses Once Section 56 of the Nursing Act is ARVs are Schedule 4 drugs (1), similar prescribing ARVs. promulgated, nurses’ competence can to other antivirals and to antibiotics. be recognised by registration in a spe- Sheila Hokwana Nevertheless, government requires more The National Treatment Guidelines state cific category. management control over them and re- that treatment initiation should be done Ok, I just want to maybe correct something. I think it’s a misconception of some regarding quests sites to handle them as Schedule by a multidisciplinary team. It doesn’t Acknowledgements “ pricking and policy. The issue that pricking cannot be done by any other person rather than 5 drugs (2). According to Section 30 of specify either that it has to be a doctor, a professional, is not a provincial policy but a national policy. So if other provinces are doing the Regulations of the Medicines and or the composition of the team. Thanks to Prof Andy Gray (Nelson it, they are doing it because they have found a way around the policy, but there has been Related Substances Act (3), registers Mandela School of Medicine, UKZN) for no leniency in that policy as far as I know. So if we need to change that, we have to target a must be kept for Schedule 5 drugs, 4. Nurses working in the public sec- comments on this report. national policy. which must be stored separately, usually tor are allowed to dispense ARVs. under lock-and-key to restrict access. References: ” Therefore, “handling conditions” do not Dispensing regulations are common to Dr Marga Vintges refer to what health professional should all drugs and not specific to ARV medica- 1. Schedules to Act 90 of May 2003, prescribe or dispense, but only to con- tion. According to the current dispensing http://www.mccza.com. I don’t understand why you don’t work out of the box and let patients prick themselves. Then trol over stock management. regulations (5), only practitioners (nurs- 2. Operational Plan for Comprehensive “ you aren’t bothered by rules and regulations. Why not? It’s easy; you are not disobeying the In addition, Regulations of the es and doctors) licensed by the Director HIV/AIDS Care, Management and law. Medicines Act can only be applied to General are allowed to dispense drugs. Treatment, November 2003, http:// substances that are actually listed in The DG issues a licence upon an www.hst.org.za. ” the Schedule. Any arrangement to store applicant’s completion of certain re- 3. General Regulations made in terms of Dr Mosa Moshabela and account for ARVs as if they were quirements, including accredited training. the Medicines and Related Substances Schedule 5 medicines is therefore an in- A circular from the Director General Act, 1965 (Act No. 101 Of 1965), Initially, nurses were supposed to do everything, but counsellors were brought in to alleviate ternal decision of the DoH only, and has issued just before the regulations were 2003. http://www.mccza.com. “ the stresses on the nurses. Then, nurses had to do the pricking so that they could be able to no legal bearing on who may prescribe enforced in June 2005 exempted nurses 4. See Nursing Act. supervise counsellors and because they were doing everything under pressure. But the plan or dispense such medicines. working in the public sector from having 5. Section 18 on General Regulations was also for these people, over time, as the counsellors get used to doing this, just basically to undertake such training and allowed made in terms of the Medicines and to supervise them and see they can do it and to be sure. And over time the plan is for them 2. Professional nurses usually pre- them to continue dispensing to avoid the Related Substances Act, 1965 (Act to take it over. That’s how it’s supposed to be and that’s the paradigm shift we should actually scribe Schedule 4 drugs. collapse of the public services that en- No. 101 Of 1965), 2003. http://www. follow. ” forcement of such a requirement would mccza.com. 50 NELSON MANDELA FOUNDATION A DIALOGUE ON ART MODELS

GROUP OUTPUT Nurses Prescribing ARVs Group Representative: Marta Darder

Introduction The existing Section 38A of the Nursing Act does not specify a Schedule limit that Participants in the meeting acknowl- nurses can prescribe (4). Nevertheless, edged confusion created by mixed the format of the permit makes mention messages around the issue of whether of various “protocols”, which include nurses are entitled to prescribe ARVs only up to Schedule 4 medicines. In re- or not. This would limit their ability to source-constrained settings Schedule have immediately provoked. initiate patients on ARV and perform the 5 drugs have also been included, par- routine follow-ups. The consequences of ticularly with psychiatric services. In 5. The decision of whether a nurse this confusion in rural sites is dramatic addition, Section 38 of the Nursing Act can start patients on ARVs or not given the nearly exclusive availability of confers capacities to the South African should be a clinical one depend- nurses in the rural primary health-care Nursing Council (SANC) to review the ent on the nurse’s training and services. This group tried to clarify the list of drugs that nurses can prescribe. experience. legal, regulatory and political framework At the moment, the Nursing Act that may affect this question. is under review as it is in conflict with In rural settings, where doctors are the Medicines Act, thus there is no legal not available, nurses should be able to Conclusions answer to this issue, which should be fol- initiate patients on ART. Nevertheless, it lowed up with the SANC and the South would be clinically advisable if severely 1. ARVs are Schedule 4 drugs, but African Pharmacy Council. ill patients or patients that are very government requires them to be immuno-compromised are initiated handled as Schedule 5 in terms of 3. The South African National by a doctor. The ARV site manager or storage conditions. Treatment Guidelines do not in- medical officer should decide on this. clude any restriction for nurses Once Section 56 of the Nursing Act is ARVs are Schedule 4 drugs (1), similar prescribing ARVs. promulgated, nurses’ competence can to other antivirals and to antibiotics. be recognised by registration in a spe- Nevertheless, government requires more The National Treatment Guidelines state cific category. management control over them and re- that treatment initiation should be done quests sites to handle them as Schedule by a multidisciplinary team. It doesn’t Acknowledgements 5 drugs (2). According to Section 30 of specify either that it has to be a doctor, the Regulations of the Medicines and or the composition of the team. Thanks to Prof Andy Gray (Nelson Related Substances Act (3), registers Mandela School of Medicine, UKZN) for must be kept for Schedule 5 drugs, 4. Nurses working in the public sec- comments on this report. which must be stored separately, usually tor are allowed to dispense ARVs. under lock-and-key to restrict access. References: Therefore, “handling conditions” do not Dispensing regulations are common to refer to what health professional should all drugs and not specific to ARV medica- 1. Schedules to Act 90 of May 2003, prescribe or dispense, but only to con- tion. According to the current dispensing http://www.mccza.com. trol over stock management. regulations (5), only practitioners (nurs- 2. Operational Plan for Comprehensive In addition, Regulations of the es and doctors) licensed by the Director HIV/AIDS Care, Management and Medicines Act can only be applied to General are allowed to dispense drugs. Treatment, November 2003, http:// substances that are actually listed in The DG issues a licence upon an www.hst.org.za. the Schedule. Any arrangement to store applicant’s completion of certain re- 3. General Regulations made in terms of and account for ARVs as if they were quirements, including accredited training. the Medicines and Related Substances Schedule 5 medicines is therefore an in- A circular from the Director General Act, 1965 (Act No. 101 Of 1965), ternal decision of the DoH only, and has issued just before the regulations were 2003. http://www.mccza.com. no legal bearing on who may prescribe enforced in June 2005 exempted nurses 4. See Nursing Act. or dispense such medicines. working in the public sector from having 5. Section 18 on General Regulations to undertake such training and allowed made in terms of the Medicines and 2. Professional nurses usually pre- them to continue dispensing to avoid the Related Substances Act, 1965 (Act scribe Schedule 4 drugs. collapse of the public services that en- No. 101 Of 1965), 2003. http://www. forcement of such a requirement would mccza.com.

NELSON MANDELA FOUNDATION 51 A DIALOGUE ON ART MODELS

GROUP OUTPUT GROUP OUTPUT Proactive Testing Group Representative: Dr Victor Fredlund

Introduction we are offering this to workers and advertise it to all government We developed ideas for getting well departments. Introduction dent, by showing that traditional healers people to test and getting professionals • Lack of confidentiality is a hindrance. can be put to good use in health issues into a treatment programme. • Department of Education, Free State, This dialogue was initially intended for requiring a massive national response has outsourced, but few come. a discussion around African traditional like HIV and AIDS in South Africa. Motivation • Use private practitioners? medicines in the face of antiretroviral mobilisation for testing and treatment, treatment, but ended up including heal- Dialogue Required counselling, advocacy, committees, etc. • You need a motivation to test; Precipating Events for ers and cultural beliefs by default, due to an event that precipitates testing. the inseparable nature of these issues. We all agreed that there is a need for Principles Hence, many only test once they Testing The dialogue table included two a dialogue with traditional healers. The are sick. • Put testing into employment and job elling around schools. An example medical practitioners currently actively questions are: Can we involve them? Do First, we need to learn to recognise and • Tested at blood donation, marriage applications. This would be placing motto: “Good Teachers Test!” working with traditional healers, and they want to be involved? How do we in- embrace them, and then listen and un- preparation, insurance, visa, etc. the issue before staff each time they • Set a date in the calendar to be one who conducted research on tradi- volve them? At what scale do we involve derstand them. They will withhold their • We need to emphasise the positives promote or move employment. known as a Testing Day. tional healers. The other three members them? What do we hope to achieve? Is contributions if they sense any untoward of testing to people. • They would be asked to provide • Encourage development of role have an interest in traditional practices. this type of dialogue sustainable? attitudes. We need to stop being so pre- • For professionals, we need to say evidence that they had been for models who test. The debate was a little biased in that it Traditional healers have a massive scriptive, and our negative attitudes will counselling but not • Precircumcision testing. comprised members who largely regard power of influence. The national gov- not help us at all. Good relationships and that they had had traditional practice positively (mainly be- ernment is working on formalising the partnerships are built on trust, mutual- a blood test or the Way Forward cause it’s here to stay, common in rural traditional health-care system. With ism and positive regard. We have to be results of it. This areas and a lot of people utilise it), and these two facts in mind, it sounds rea- open-minded and receptive, and this can would mean that it The three main points that need to be lacked strong opposing views. sonable to initiate the dialogue. be achieved by conquering our fear of could not be used taken forward are: We also know that most of the ques- the unknown. as a discriminatory Background tions and concerns we have will not For a long time we dismissed the test. • Get all staff associations to promote be addressed until we get on with the African traditional medicines while we • Churches should the logic of “knowing one’s status There is a clear division between tradi- dialogue. Those who have worked with knew little about them and their illness- propose that peo- and getting necessary management tional and Western health-care systems. traditional healers believe that they want explanation models, but this approach has ple who are going and treatment”. The traditional system has its own to be recognised and involved, but not to to stop. We have created a barrier, and to marry must test. • Discuss with public service the con- weaknesses (toxicity, drug interactions), be ridiculed and robbed of their African now we have the responsibility to break • Testing tents to be cept of a testing requirement at as does the western system, perhaps to science. it down. As the government is working on set up at paypoints employment. a lesser extent). a top-down approach, we have to initiate for child care. Other • Look for creative models for work- Both groups have positive aspects Sensitivity a consultative, bottom-up approach, and ideas would be a place and community event testing attached to them, and it is believed that the two will eventually merge. mobile unit trav- opportunities. they can potentially learn from each The answer to the question of “how” I cannot help but share what Dr PATIENCE: Lining up at a clinic in Lusikisiki. other. It is clear that the two systems remains with someone interested and Bernhard Gaede had to say to a group impact on each other negatively and neutral. This is a sensitive matter that of traditional healers he was addressing maybe positively under certain circum- needs to be approached with absolute in attempting to explain the problem of Dr Lesley Pitt stances. Often, it is a situation where you care. We believe it can be done, and a drug interactions. He asked them how are working with someone in absentia, breakthrough can lead to answers to they would feel if a patient combined The only other one that I thought of was the use of GPs for teachers so ... they wouldn’t have and you cannot hold them accountable many questions we have. It will bring an different traditional medicines from dif- “ to go though the usual channels at clinics and be exposed to long queues and loss of confiden- or negotiate with them in any way. Both understanding that will take our nation ferent healers and took them at the tiality and that sort of thing. groups have one goal and purpose in forward democratically. The programme same time, and they all expressed strong mind, to provide health services to the can have two-way information-sharing disapproval. And that’s all it took for ” same society. sessions, educational activities, practical them to appreciate why antiretroviral sessions, and so forth. treatment cannot be combined with tra- Dr Hermann Reuter Partnerships We can define the different types of ditional medicines. relationships that can exist between the Likewise, it will be important to ad- For many women, getting pregnant is a stimulus to get tested. All the men in Lusikisiki, before Having said that, we realise that the no- two systems. We can request tradition- dress certain socio-cultural practices “ they get circumcised, get a pre-circumcision medical check-up. If that could include an HIV tion of “together we stand and divided al healers to take an active role in the that may be fuelling the epidemic, with test, it would get a large number of men tested. we fall” comes into play. The national TB fight against HIV and other conditions. the traditional healers, community lead- ” programme has set a very good prece- They can play a major role in community ers and the community at large. 52 NELSON MANDELA FOUNDATION A DIALOGUE ON ART MODELS

GROUP OUTPUT A Dialogue on African Traditional Practices Group Representative: Dr Mosa Moshabela

Introduction dent, by showing that traditional healers can be put to good use in health issues This dialogue was initially intended for requiring a massive national response a discussion around African traditional like HIV and AIDS in South Africa. medicines in the face of antiretroviral mobilisation for testing and treatment, treatment, but ended up including heal- Dialogue Required counselling, advocacy, committees, etc. ers and cultural beliefs by default, due to the inseparable nature of these issues. We all agreed that there is a need for Principles The dialogue table included two a dialogue with traditional healers. The medical practitioners currently actively questions are: Can we involve them? Do First, we need to learn to recognise and working with traditional healers, and they want to be involved? How do we in- embrace them, and then listen and un- one who conducted research on tradi- volve them? At what scale do we involve derstand them. They will withhold their tional healers. The other three members them? What do we hope to achieve? Is contributions if they sense any untoward have an interest in traditional practices. this type of dialogue sustainable? attitudes. We need to stop being so pre- The debate was a little biased in that it Traditional healers have a massive scriptive, and our negative attitudes will comprised members who largely regard power of influence. The national gov- not help us at all. Good relationships and traditional practice positively (mainly be- ernment is working on formalising the partnerships are built on trust, mutual- cause it’s here to stay, common in rural traditional health-care system. With ism and positive regard. We have to be areas and a lot of people utilise it), and these two facts in mind, it sounds rea- open-minded and receptive, and this can lacked strong opposing views. sonable to initiate the dialogue. be achieved by conquering our fear of We also know that most of the ques- the unknown. Background tions and concerns we have will not For a long time we dismissed the be addressed until we get on with the African traditional medicines while we There is a clear division between tradi- dialogue. Those who have worked with knew little about them and their illness- tional and Western health-care systems. traditional healers believe that they want explanation models, but this approach has The traditional system has its own to be recognised and involved, but not to to stop. We have created a barrier, and weaknesses (toxicity, drug interactions), be ridiculed and robbed of their African now we have the responsibility to break as does the western system, perhaps to science. it down. As the government is working on a lesser extent). a top-down approach, we have to initiate Both groups have positive aspects Sensitivity a consultative, bottom-up approach, and attached to them, and it is believed that the two will eventually merge. they can potentially learn from each The answer to the question of “how” I cannot help but share what Dr other. It is clear that the two systems remains with someone interested and Bernhard Gaede had to say to a group impact on each other negatively and neutral. This is a sensitive matter that of traditional healers he was addressing maybe positively under certain circum- needs to be approached with absolute in attempting to explain the problem of stances. Often, it is a situation where you care. We believe it can be done, and a drug interactions. He asked them how are working with someone in absentia, breakthrough can lead to answers to they would feel if a patient combined and you cannot hold them accountable many questions we have. It will bring an different traditional medicines from dif- or negotiate with them in any way. Both understanding that will take our nation ferent healers and took them at the groups have one goal and purpose in forward democratically. The programme same time, and they all expressed strong mind, to provide health services to the can have two-way information-sharing disapproval. And that’s all it took for same society. sessions, educational activities, practical them to appreciate why antiretroviral sessions, and so forth. treatment cannot be combined with tra- Partnerships We can define the different types of ditional medicines. relationships that can exist between the Likewise, it will be important to ad- Having said that, we realise that the no- two systems. We can request tradition- dress certain socio-cultural practices tion of “together we stand and divided al healers to take an active role in the that may be fuelling the epidemic, with we fall” comes into play. The national TB fight against HIV and other conditions. the traditional healers, community lead- programme has set a very good prece- They can play a major role in community ers and the community at large.

NELSON MANDELA FOUNDATION 53 A DIALOGUE ON ART MODELS

GROUP OUTPUT The Dialogue Process and the NMF Group Representative: Helen Struthers

Introduction The key challenges to dialogue are: Mothomang Diaho from the Nelson Mandela Foundation gave a brief back- • To bring more voices in, not just the ground to this discussion. NGOs, government or the private She noted that the NMF is redefining sector into the conversation. its focus as a centre of memory, and pro- • To create trust among all key moting dialogue on social issues. Living stakeholders. the legacy means more than just the Since other dialogue processes are implementation of programmes, but to The group found that the important ongoing, it is necessary to determine achieve the founder’s vision for a fairer issues to be considered in the short how the NMF dialogue process will dif- and more just and humane society. term in HIV and AIDS are: fer from the others, and where the focus The intention is to draw on the rich should be. traditions of transformative dialogue, • Define who the key stakeholders problem-solving and social renewal are – government, funders, etc. Principles should include: that have made possible South Africa’s • Ownership of HIV and AIDS. remarkable transition, over a short pe- • Move away from an expert-based • Concrete outcomes. riod of time, from apartheid to an era approach, move out of comfort • Solutions rather than confrontation. of democracy and human rights. In that zones, and talk to other people who • All key stakeholders. sense, the process could be seen as have no stake in the issue. • NGOs and others should evaluate one of re-energising a constellation of • Define the goal or end-point of the outcome rather than government. forces that has already achieved radical dialogue. • Forum to communicate issues. systems change – in this case, to achieve • What is the big picture? the transformation of South Africa into a • Task shifting. In Summary world-class leader in the struggle against HIV and AIDS. In the case of HIV and AIDS the end- There is a need for dialogue to con- There is no other way to look at point could be universal and equitable tinue with all stakeholders beyond ART, complex issues other than to have a access to care. It was felt that govern- but to have a broader perspective. multistakeholder approach. Through dia- ment is a key stakeholder in the dialogue The Comprehensive Plan for HIV and logue, the Foundation intends to bring process, although this may not be the AIDS Care, Management and Treatment about deep conversations among all rel- case in all dialogue. Government is per- (CCMT) programme has brought new evant system actors to develop a greater ceived as being defensive rather than energy and resources into the system. level of understanding and awareness open to discussion around its position There is a groundswell of activity and about the problems they face and each by some key stakeholders. this needs to be capitalised on. person’s role in a larger system of It was felt that the dialogue should It is essential that we build on other interactions. be around the whole health system rath- dialogue processes that are in progress. er than a narrow focus on ART models. The big group discussion added that the The system actors are able to: Gaps in the health-care system were im- dialogue needs specific objectives. It is a portant to identify. tool, but not an end in itself. It is impor- • Generate new alliances, collabora- It was noted that, with the current tant to create spaces where anger and tions, and solutions that go beyond challenges in the health system, it “can- frustration can be vented prior to mov- traditional approaches. not just be business as usual”. ing into dialogue.

Daniel Berman

A dialogue itself doesn’t really necessarily have any value unless there’s a framework of “ objectives. Like we are dialoguing because we want to achieve something or affect change, or whatever. I guess it’s more of a suggestion: the Foundation needs to decide what change you guys are after. Maybe you already have and it’s just my ignorance. Dialogue ... is a tool but it’s not an end in itself. 54 NELSON MANDELA FOUNDATION” A DIALOGUE ON ART MODELS Reflecting on the Process

Eula Mothibi

It was very different, the methodology used, but it lended itself to what happened. People “ opened up, spoke their minds and there was a lot of interaction. What I learnt the most was from others. I hope for those people struggling, they managed to get light and are able to change what they practice and change processes. ” Kuku Appiah

The methodology used to have this meeting has felt uncomfortable at times; it’s not the “ normal way. ... But people seem to be a lot more involved and awake in the process than might have been if we had followed the more conventional ways of having this type of meeting. So I think it’s been a bit difficult but I think it’s interesting to explore other ways of meeting and dialoguing. ” Marga Vintges

Opportunities like this, for me, being rural and alone, are extremely important to think ... and “ to drink other people’s ideas. We need to do this more often and maybe have a weblist. ” Lynne Wilkinson

I know one of the catalysts for this meeting was MSF moving out of Lusikisiki. And I just “ want to say from our side, as a rural site, thank-you very much for everything we learnt from you. Because without you we would have really had to start from the beginning and you gave us insight as to where to go and I think it made the world of difference to our site. ” Marianne Knuth

It feels like it’s gone well. It’s been productive and has brought out new ideas and insights. ... I “ feel we could have created more time for story-telling though. ” Tandiwe Xozwa

I just want to thank you, the organisers and the facilitators, just for recognising the people “ from the deep rural areas. ... I’m just excited with the information and things which I’ve learnt from each of you. ” Mothomang Diaho

I came to listen, I learnt a lot. Never underestimate what a small group of individuals can do “ to change the world. ” NELSON MANDELA FOUNDATION 55 A DIALOGUE ON ART MODELS Médecins Sans Frontières

Médecins Sans Frontières (MSF) and ensuring that they have access was created in 1971 by a small to ARVs that is well supported and group of French doctors. During managed. The project has seen a the Nigerian Civil War, the steady increase in HIV-testing in Nigerian military had formed a the area, as well as high levels of blockade around the newly in- adherence among those on ART. dependent south-eastern region, Despite withdrawing from Biafra. It was here that these French Lusikisiki, MSF is committed to doctors first went to provide ur- continue engaging in HIV/AIDS gently needed medical help. and TB activities in South Africa, MSF is now an international hu- as it has done for the last seven manitarian organisation that provides programme to include one of South years. emergency medical assistance in over Africa’s poorest communities, In addition, MSF is getting ready 70 countries worldwide. Lusikisiki, in the Eastern Cape. The to consolidate the presence in South The beginning of MSF’s involve- Siyaphila La ART programme was Africa by starting a new partner sec- ment in South Africa’s HIV and AIDS launched by Nelson Mandela who tion in the country. The new section pandemic was in May 2001 when administered the first pills to an HIV- will participate in the international three hospitals in Khayelitsha, Cape positive woman. Siyaphila La means, MSF movement – currently con- Town – Michael Mapongwana, Site “We are living here” in Xhosa. stituted by 19 sections in different B and Nolungile – started providing Siyaphila La is recognised by the countries around the world – and will antiretroviral therapy (ART) to HIV- Eastern Cape provincial government be deeply rooted in MSF’s principles positive people. The therapy took as an official programme to initiate and values. place in HIV and AIDS dedicated ART in the province. To drive this process, a new team clinics run by MSF. MSF has achieved much in is being recruited. The new office In 2003, with the Nelson Mandela Lusikisiki, especially in terms of will be based in Johannesburg and is Foundation, MSF expanded its helping people to undertake HIV tests expected to open in November 2006. Nelson Mandela Foundation

The Nelson Mandela Foundation legacy charities will express, in (NMF) was established in 1999 tangible terms, the key aspects of to meet the immediate need of Mr Mandela’s legacy. its Founder for a personal office The NMF has, in its seven years on his retirement as President of existence, also made program- of South Africa. This role re- matic interventions in areas of mains integral to the NMF, but concern to the Founder. These following Mr Mandela’s retire- include: ment announcement in 2004, the • HIV/AIDS and health matters Foundation is in the process of – initiatives include the 46664 converting its core function to that campaign. of a “Centre of Memory” capturing resources, and facilitation of relat- • Rural schooling – initiatives in perpetuity the life and times of the ed dialogues at Mandela House. include the establishment of Founder. The creation of a unique facility the Unit for Rural Schooling The Centre of Memory, which will for researchers working on the life and Development based at the become operational in the course of and times of the Founder. University of Fort Hare, and the 2007, has four main aims as endorsed The work of the Centre of Memory ‘Emerging Voices’ project. by its Board of Trustees: will complement that of the sister • Dialogue forums aimed at en- • The collection and curation at organisations, the Nelson Mandela hancing understanding of social Mandela House of Mr Mandela’s Children’s Fund (NMCF) and the development challenges and personal and other related Mandela Rhodes Foundation (MRF). finding appropriate strategies for archives. The NMF will focus on memory and meeting them. • The provision of an electronic por- dialogue, and also reflect the focus of These important interventions are tal to global resources on the life the NMCF (children and youth), and currently undergoing structural re- and times of the Founder. the MRF (leadership and capacity view so as to fit into the new Centre of • Provision of public access to these building). Together the three Mandela Memory model of the NMF.

56 NELSON MANDELA FOUNDATION PARTICIPANTS’ CONTACT DETAILS

Name Organisation E-mail Tel Fax Dr Kuku Appiah Clinical Director, Right to Care [email protected] 011 276 8850 011 276 8885 Daniel Berman MSF South Africa [email protected] 082 852 1885 021 361 7051 Roeleen Booi HIV & AIDS Directorate, Free State DoH [email protected] 083 294 6683 051 408 1959 051 408 1604 Marta Darder Director, MSF South Africa [email protected] 082 332 9714 Dr Mothomang Diaho HIV/AIDS Dialogue Manager [email protected] 011 853 2623 011 728 1111 Nathan Ford MSF Thailand c/o [email protected] Dr Victor Fredlund Mseleni Hospital, KwaZulu-Natal DoH [email protected] 035 574 1004 035 574 1826 Dr Bernhard Gaede Chief Medical Officer, Emmaus Hospital [email protected] 082 736 6054 086 675 5123 Chairperson, Rural Doctors’ Association of Southern Africa (RuDASA) Dr Eric Goemaere Head of Mission, MSF South Africa [email protected] 021 3645490 021 3617051 Dr Ashraf Grimwood Executive Director, Absolute Return for [email protected] 021 447 0822 021 361 7051 Kids (ARK) Sheila Hokwana HIV & AIDS Directorate, Eastern Cape DoH [email protected] 083 378 0390 040 609 3660 Dr Vincent Jausseus MSF Brussels c/o [email protected] Guillame Jouquet MSF Lusikisiki [email protected] 039 253 1611 039 253 1373 Dr David Kalombo Project Manager: Comprehensive Plan, [email protected] 012 312 0127 012 312 3199 National DoH Nomzi Khonkwane MSF Lusikisiki 039 253 1611 039 257 1373 Marianne Knuth Facilitator, Kafunda Learning Village [email protected] 09 2634 575494 Pumla Kobus Head Project Management, Tshepang Trust [email protected] 011 339 8996 011 339 8998 Dr Doris Macharia Country Program Director (SA), [email protected] 082 555 2207 043 721 1301 International Center for AIDS Care and Treatment Programs (ICAP) Nomalanga Makwedini HIV & AIDS Directorate, Eastern Cape DoH [email protected] 040 609 3957 040 609 3660 Brad Mears CEO, South African Business Coalition on [email protected] 011 880 4821 011 880 6084 HIV/AIDS Nombulelo Mofokeng Qaukeni LSA 073 545 9541 039 253 1519 Dr Mosa Moshabela Rural AIDS & Development Action [email protected] 083 494 3089 013 795 5082 Research Programme (RADAR) Dr Eula Mothibi Co-ordinating Clinician, HIV/TB [email protected] 021 483 9927 021 448 6157 Directorate, Western Cape DoH 082 897 3028 Dr Nthato Motlana Deputy Chairperson and Trustee, NMF [email protected] 011 728 1000 011 728 1111 Dr Stanley Muwonge District Family Physician [email protected] 082 670 3904 086 689 8343 Tembi Ntlangulela Qaukeni LSA [email protected] 083 487 3848 039 253 1519 Akona Ntsaluba TAC Eastern Cape 039 253 1951 039 253 1373 Nondumiso Ntsikeni Siyakhanyisa [email protected] 047 553 0072 047 553 0072 083 618 3952 Dr Les Pitt Valley Trust, Underberg [email protected] 033 701 1024 082 575 3560 Thuli Qali Church of Scotland Hospital, KwaZulu- 033 493 0004 033 493 0977 Natal DoH 083 640 9188 Dr Herman Reuter MSF Lusikisiki [email protected] 043 721 1305 039 253 1373 Tandiwe Sapepa Qaukeni LSA 039 253 1541 039 253 1579 Dr Helen Schneider Centre for Health Policy, Wits [email protected] 011 242 9905 011 720 0010 Dr Helen Struthers Director, Perinatal HIV Research Unit, Wits [email protected] 083 308 6662 011 989 9762 Dr Ebrahim Variava Principal Specialist and Head Of Internal [email protected] 084 507 5640 018 465 5160 Medicine, Klerksdorp Tshepong Hospital Bavuyise Vimbani HIV/AIDS Adherence Counsellors’ [email protected] 039 253 1618 039 253 1373 Organisation (HAACO), Lusikisiki Dr Marga Vintges Family Physician, University of Limpopo [email protected] 072 283 6297 Naomi Warren HIV/AIDS Programme Assistant, NMF naomiw@nelsonmandela,org 011 853 2621 011 728 1111 Lynne Wilkinson Madwaleni Hospital [email protected] 083 254 8821 Tandi Xozwa Mthatha Hospital Complex 073 309 8570 047 502 4968 Dr Rony Zachariah MSF Brussels c/o [email protected]

NELSON MANDELA FOUNDATION 57 Reporting, layout and design by Flow Communications. Tel. 011 440 2232; www.flowsa.com