Meeting the Challenge of HIV/AIDS in South Africa: Treatment Access and Retention

Francois Venter HIV Management Cluster, Reproductive Health and HIV Research Unit, University of the Witwatersrand
Robin Wood Desmond Tutu HIV Centre, University of Cape Town
Laurie Garrett Council on Foreign Relations



This session was part of the CFR roundtable, Meeting the Challenge of HIV/AIDS in South Africa, made possible by the generous support of MSD.


MS GARRETT:  Thank you.  Great discussion and really helpful presentations.  About an hour, hour and a half ago James said the problem with the maternal health programmes is we're not capturing them in.  And here we're hearing about inter-generational sex and certainly this whole idea that these girls have cabinets with the Minister of Transportation and the Minister of Communication and so on is - has got to be a target.  So let me ask the question; what are the statutory rape laws?  What are the paedophilia laws?  If a 30-year old man has sex with a 15-year girl is that illegal?  And what's going on with the parents if their daughters are having cabinets and they must know these guys?  They may even be the same age as the parents.  What about targeting that as an intervention, targeting statutory rape, paedophilia?  And then I guess the last is the whole issue of status and peer pressure among the girls.  I mean, if you have a cell phone studded with glitter that you can show off and you can have unlimited calls because you have a guy that will pay for your unlimited calls, you're a higher status with all your girlfriends.  Is there not some way to just target exactly those status issues so that the incentive for the behaviour is somehow decreased.

MR VENTER:  I think, I mean, the data you're telling us from Olive is very exciting.  All I say is that it's incumbent on the behaviour scientists to explain it very carefully as best they can and I know it's hard, but I think what we're stuck with in Uganda at the moment is that prevalence is going up, or incidence is going up it appears, and we don't really know what the intervention was 25 years ago and it depends - it's very much of arguments about history rather than arguments about science which is like the multiple and current partnership people will weigh in and say it was this that did the trick and then the Christian fundamentalists will say it was because there was more family structures that were respected, and I think what's going to be is that we need to understand what were the interventions that we think probably were the ones that worked and then obviously there's going to have to be debate within that, but I'd hate to be in the situation where five years down the line we suddenly see the incidences starting to go up again in this group and we don't really - and then we have this argument about what it was that was the original driver of the epidemic, so I think it's going to be important to describe and to get some sort of consensus around it as we go forward.

MS GARRETT:  A quick two-finger intervention as we say at the council.  On the incidence issue for Uganda, I agree completely and also I would add the Castro district of San Francisco in the 1980s.  The question is to what degree does death burden play a role and do we draw conclusions about strategies of prevention and falsely congratulate a set of alleged strategies when indeed it was death burdened, generational devastation that was key and they you're going to see a resurgence as the next sexually active generation comes on board.

MS REES:  Thank you.  I apologise for being late.  I came from overseas.  Just on what's being said so far, I mean, I think just to say that I think a lot of these discussions where we're already trying to have behind the scenes.  There's a lot of us who've been talking about how to look at this and particularly surveillance and this question of incidence and with the SANAC research sector one of the things that we're wanting to convene - we've got a proposal in for funding - is indeed a meeting to look at actually how do we look at incidence because I agree with Salim that we do know a lot already about our epidemic.  The second thing is that under SANAC there is the ‘know your epidemic' exercise is going on so we will have the formal ‘you and AIDS; know your epidemic' data, but I think probably that's going to be a sort of - it's going to improve our knowledge, but I don't think it's going to drastically I suspect change what we already know.  I think, just in terms of what Olive said, it'll be interesting to see that data.  I'm just reflecting that the antenatal data in the younger age group in 2008, the prevalence in that younger age group went up slightly again, so it'll be interesting to see how one explains that, but I suppose my point is, apart from I think what you very clearly said and I'm sure James said on PMTCT, is what goes into the prevention strategy in a resource-limited setting and this has been to'ing and fro'ing in the Department of Health recently because there's been a plan that's been written about; what does the department actually do to implement, and it's very easy to go back to same old, same old, but I'm just reminding us that there was a review of adolescent interventions where they looked at 28 well-exercised interventions, randomised controlled studies, only three of which had HIV as an outcome; the rest all had behavioural - self-supported behaviour and various other things and outcomes, and of those 28 studies they had a 102 indicators of behaviour and only just over half of the studies showed an impact on behaviour; 42 indicators showed no impact; 8 indicators got worse and the three studies that looked at HIV showed no impact whatsoever.  So I think that one of the biggest challenges that we've got is to actually start to say what works because otherwise what we're going to do is we're going to keep pouring things into schools programmes that we've got no evidence work and we're going to take the very limited resources we've got and keep putting them where we think they should be, so I think that one of the challenges we got is to really say what's evidence based.  Circumcision's easy, PMTCT's easy, it's clear-cut.  It's this other thing about how do you impact on adolescent particularly adolescent behaviour, on male behaviour, on female behaviour when you've got a generalised epidemic.  And that's I think our gap, so I think that that's the challenge for us to really come up with something (indistinct).

MR BRINK:  Thanks very much for fantastic a presentation and thank you Salim for highlighting so vividly the vulnerability of young women and girls to HIV infection.  I'm not an academic.  I have huge respect for the academics and I listen, but not being an academic I'm free to make some sweeping statements sometimes without all the evidence and so I want to make a sweeping statement and it's simply this; that when it comes to sex and the rights of young women and girls in this country they have none; they have none.  It's not only in this country; it's in many countries, if not most countries around the world.  When you come to men and to boys and you look at the respect that they show for the sexual rights of women and girls; it's abysmal and there simply has to be a fundamental change to the way our society works.  All the HIV epidemic has - it's just exposed what has been going on for centuries, millennia probably.  That's the change that has to happen and it has to happen with young people.  We have to have comprehensive sexuality education for adolescents.  We have to get that in place now urgently.  We have to have a curriculum which is agreed that this is what needs to be taught.  I know we have a curriculum for Maths and English and Science and Biology; where's the curriculum for sexuality behaviour?  We know those things; that has to be documented and it has to be implemented in schools and we need people to teach that curriculum who are expert, who have been trained and know how to do it.  It's no good to give this to the sports teacher and say oh, when you're bored in the mornings you can go and teach sex.  It's not like that.  But if we don't do that we are never really going to change this huge incidence in HIV infection in young women and girls and it's no good saying they must take the measures to prevent themselves getting infected.  It's actually the men that are going to have to change.

MR BESSER:  So there's quite a lot of excitement around this.  Salim would get the first two fingers and then Helen on this.  Mitch, if you don't mind - and then Olive.

MR KARIM:  I just wanted to just take up and respond to both Brian and Helen.  I think, you know, knowing the epidemic is critical and I think we're making great strides on that.  The challenge now is what is the evidence that we can change that?  I mean, knowing what the problem is and then having the evidence to say you can really turn that around.  You go with evidence and you can reduce HIV; not evidence that I can get somebody to use, you know, one and a half condoms instead of one, but I think that is a big challenge, but unfortunately while we wait for that evidence we've got to do something about the epidemic and there we have to use what is probably going to be a combination of best guess, a combination of anecdotes, a combination of observational data and so on, and we need to understand and we need to have some consensus because the, sort of, the world of data that James had is matched by the dearth of data, you know, we've got on HIV prevention, so when you don't have data it's a matter of opinion, you know.  My opinion is that's what the problem is and that's what you should do; your opinion is that.  It's just a matter who speaks the loudest that opinion is carried, so I think we need to find a way as a group and part of this process that Helen was talking about, is to take the available evidence, understanding its shortcomings, work with it and collate that with knowledge, understanding and try and produce some way to move forward in the absence of that kind of solid evidence base that we really need.

MS BEKKER:  Ja, and remembering that sort of five-year piece.  Maybe part of that is so and we've gone through a few of these exercises in a number of forums; what are the five top priorities we would do in a targeted group like an adolescent young woman in South Africa, so you know, maybe even here today we can rehash some - at least think of the methodology of how we'll reach consensus on that.  Helen?

MS REES:  Well, I have looked at the data quite intensively as I'm sure many of us have and you're quite right Salim, it's difficult.  That's why I said that these studies that show well, what works and what doesn't, but then just a response to you Brian; I mean, one of the problems is if you take something like Stepping Stones; and excellently executed study in the Eastern Cape where they had sexuality interventions for men - for young men and young women, intense interventions, regularly followed-up, followed-up and they had HIV and herpes as a marker and self-reported behaviour.  The young men did report much better gender sensitive behaviour, less abuse, less forced sex and many of them had previously reported being - participating in rape, and a number of indicators for the young men.  The young women's behaviour in some indications got worse, that they are having more partners and more transactional sex, and overall there was no impact on HIV.  Now, that's the problem that we've got to grapple with.  It's great sexuality education, a great intervention.  It did have an impact on men generally, but nothing, but Salim, I totally agree with you.  Even if that were the case we're not going to stop doing schools programmes.  We can't stop doing this.  I think that what we need though is the social movement behind this.  It's no good having these little islands of trying to do intense intervention; we need a social movement that says actually gender-based violence is not okay.  It has to be a fundamental change in the way we look at things because trying to focus young people in school when the rest of the outside world doesn't say that is not going to work, so I think that - but just to say that on the incidence the other thing that we have talked about with Olive as the SANAC research sector we've been talking again about having a really big think tank around the prevention data so that we can really get everyone.  We've done this once; we did this last year, but I think this time with the Department of Health being so closely interacting we should really do this again and priorities this.

MS SHISANA:  Ja.  Just a very quick one.  I just want to say that one of the things we're not looking at it's really the family.  If we're going to make a difference in terms of interventions we've got to go to the family.  The qualitative data that we have is beginning to tell is that these young girls are told by their family that it's okay to have a sugar daddy because he's supporting us and in some cases when a sugar daddy stops the relationship some of the family members go back and say I'm going to report it to the police that you've been sleeping with this young girl and then the man comes back and continues to give them the food, so we have some qualitative in-depth data that tell us the dynamics of what is happening in the family.  And finally I just want to say on two quick things; the pregnant women data that you're talking about; pregnant women are different from women who are not pregnant and therefore we cannot generalise on those two.  We cannot treat them the same way; they're very different.  And finally Salim, I just want to say that the method that Tim Harley is using, he's basically taking the prevalence data from the population base survey from one year to the other and using a mathematical model to be able to estimate incidence.  The method was even discussed at the last Bangkok surveillance meeting which we attended and scientists there were very much comfortable with it.  That's why we asked him to come and help us in South Africa to look at this particular incidence data.  Thank you.

MS BEKKER:  Mitch, we've... [intervention]

MR BESSER:  A very quick thought.  As we look at behaviour change and we look at evidence-based strategies and develop coherent strategies for how do we make - proliferate these, I think we need the leadership to say what's the five and 10-year plan?  How do we take these to scale?  If we find something that works how do we make other people aware?  And you know, the one-offs are wonderful, but you know, where are we going to house these behaviour change strategies and who's going to drive them and how do we take them to an entire nation and how do we tailor them to the micro-cultures that exist within the country?

MS BEKKER:  Thank you.  Nonhlanhla, Helga, Alan and (indistinct) we'll cross back to this side.  Nonhlanhla.

DR SIMELELA:  Thank you.  I think my point was going to be based on the factors that were raised by Gita, all those combination factors, and we know that for a fact that they are all housed - they all end up within a certain community.  You need a certain leadership that is within that community and I think in your slides you also highlighted that if you look at SANAC and you are saying it's placed at a level where it can drive most of the combination of all of them together it applies within the communities as well.  We know who will drive that within our own communities and that's the element that I think every time we stop short of reaching and putting all the factors to those leadership; not putting one factor and leaving another; saying this is the combination, this is what we are looking at, can we drive this combination in all areas; in all areas evidently while you are looking for the (indistinct).  I think that's one area that if we go out and do it in the next five years/ten years it makes a difference.

MS HOLST:  I have a couple of controversial points and I'm maybe shot down for them, so I apologise in advance.  The first one, Brian spoke about very passionately and it is setting standards of moral and values standards for our nation and for our families and that starts, yes, at schools helps, but truly it has to be modelled by ourselves and by our politicians and by our leaders and who are the fathers in our society and I think we can each ask ourselves those questions on a personal note and how do we role model what behaviour it is that we expect the young people to follow.  That's the first point.  The link to that is the media that we have and the television programmes which are beamed out into rural areas across the country.  What messages are they giving; instant gratification, live for now, tomorrow I might die, multiple partners, etcetera.  Those are the messages that comes through the media.  Is that what we want to promote and we have the ability to influence that if we choose to.  Then this is possibly controversial; years and years ago low iodine levels in land, in soil, was discovered to lead to - be the result of people having goitres.  Is there something in are soil, in different sections, which can reduce people's immunity and make them more susceptible to transmission?  Question one that I've seen around is selenium.  Maybe it's true; maybe it's not true.  Is that worth exploring somewhere on a scientific level?  Third point; you're incidence will be reduced if you get all HIV positive people that need to be on antiretrovirals.  Their viral loads of low; they can't transmit or they transmit much, much less.  It's another prevention strategy.  And my last point; 2010's with us shortly.  Durban is gearing up towards lots and lots of brothels.  Is HIV, the gift of HIV through brothels the gift we want to give to the world?  I close.


MR WHITESIDE:  Well, I have to say I don't know where those brothels are and I think that that's the one issue that we might over-hype a little bit, Helga, to be quite honest is the question of our football fans coming here and I do think we need to we need to be a bit cautious around that.  On the soil one the major cause of death in Lesotho among patients who are HAART according to MSF data is hypothyroidism so you may have a point and there may be things that we need to be looking at innovatively in terms of - and that was information that was presented in Swaziland at the meeting I was at recently.  I think it's also important as we've sat here and we've talked about the dismay and the despair in our nation and it's there; let's be clear on that.  To recognise that that is not just a cause of HIV, but it is caused by HIV in our nation.  As Olive says if you're going to funerals every weekend because of HIV where are the incentives to change your behaviours?  And you know, when we started working in this more years ago than I care to remember, looking at HIV, we talked about how it might have an impact on the collective psyche of the nation and we've forgotten those early studies and those early questions around what HIV means in our society so I do think, and God help for saying this because I'm an economist, that we do need that moral regeneration in our society.  We need to find ways that we can face this reality and that's why I think this meeting is particularly important because as I look at our person years of experience and the fact that we faced a setting where we couldn't do things because of the national framework; now it's receptive; now we've got to go out there and be champions in a way that we haven't been.  My country, the one I work in most closely is, is Swaziland and they're doing some really impressive things.  The billboard outside Manzini bus station which says:

"Do you abuse your children or allow it in your society?"

The one at the university that says - shows a girl going over to a Mercedes Benz or a BMW and there's an older man in there and it says:

"How would you feel if it was your daughter?"

MS BEKKER:  [Inaudible - speaking without microphone].

UNIDENTIFIED MALE SPEAKER:  Just a couple of things I'd like to raise.  The incubators of HIV - I don't think we have been looking at that sufficiently, especially situations where men who have sex with many in our prisons, in our mines, in our military as well as in our male intense industries, the issue around migration; a major issue.  We certainly need to look at that quite honestly and see what are we missing.  I mean, the male-on-male rape that Rachel Dukes looked at; quite significant in this country.  We're not addressing that.  And then (indistinct) model about treatment as prevention alluded to earlier on.  I mean, we need to be really proactive in trying to get as many - this is an infection and, you know, we have to treat it, so let's look at it quite honestly from an economics perspective.  We treat everybody who is infected, get the cost down, you know.  A lot of us won't be needing to be sitting around this table today, so I just put that.

MS BEKKER:  [Inaudible - speaking without microphone].

UNIDENTIFIED MALE SPEAKER:  Well, this is really anecdotal, but is something that has I guess struck me really profoundly particularly in the last couple of years and thinking about prevention and I was led to this through just asking basic questions as to why do so many of our HIV-positive patients end up still getting pregnant, end up still having unprotected sex, end up not telling their partners their status, etcetera?  And it's rampant.  I mean, it's anecdotally.  And my question became do people really not care?  Do they really not give a damn about infecting other people or is there something else at play?  And the magnitude of it makes me suspect that there's something else at play and as I start to ask these questions I think one thing that started - I think became quite clear to me is that I think we ignore the impact of traditional medicine to our detriment in terms of we're focussed on understanding our epidemic, but I don't think we're focussing on understanding our people and where they really go for care and who their primary care system really is and which messages really resonate and take dominance when you actually have decisions to make or you're faced with hard situations.  As far as I've explored this as best as I can including from forums like, met with people who are educated, highest level of education, ultimate public health ninjas down to the level of, you know, someone in a rural village, the reality is there is really isn't an explanatory model of disease in South Africa that is actually germ-based for the most part.  I think a small segment of the population actually believes diseases are caused by germs, these things called viruses that actually transmit from one person to another.  The dominant explanatory model of disease that I've encountered is one that's based on ancestors, based on spirits, based on, you know, curses, intentions, etcetera.  You get sick because somebody did something to you or you were out of alignment with what the ancestors want or their desires and there's a whole set of interventions that are aligned with this.  And I think almost - I'd say the majority of the population subscribes to this in one way or another and if you look at the services offered by a traditional healer that you'll find on windscreen every time you stop somewhere it's very comprehensive.  It covers everything from getting a promotion at work, making your penis larger, making you last longer in sex, finding your lost lover, you know, all of those kinds of things which is very in touch to me, and by the way it has the person's cell phone number on it as well for you to call them day and night, weekends, etcetera.  And when I compare that to what we offer in our system and the classic allopathic , you know, medical system there's a huge disjoint and I mean, this is somewhat anonymised, but even when I look at my employees and my senior management team and when they get deep with me and explain what they did before the job interview at Broad Reach and the number of people who then said yes you know, we bathed in chicken blood before the interview and therefore I got the job and, you know, it worked, and these are senior managers at Broad Reach Health Care.  So why do we think that when we come with these interventions like, you know, wear a condom, that people really believe that; really, and will really do that, or as me having bathed in something or wearing a particular amulet just as protective against HIV as some of these other interventions we suggest?  So my suggestion is maybe we need to understand a little bit better how to appropriately message our people and maybe some of that understanding can come from learning some of the things that, I guess, represent more of the dominant model that people are used to and how they hear the messages.  Maybe we can adopt some of that; not saying that those messages are necessarily right as they stand, but I think the way in which it's delivered, the spirit in which it's delivered, the part of the brain that those messages access I think we should benefit from that and I think it would be very useful therefore to get much more input from traditional healers and people who actually interface in that way with our population because otherwise I do feel we're missing some very fundamental things.  Thank you.

UNIDENTIFIED FEMALE SPEAKER:  It's perfect to follow on from what Ernest just said because I just want to make a comment in general for this meeting and specifically for this discussion.  We see a lot of shifts going on on the global donor side.  Certainly South Africa in the near term is not going to be able to execute any of the ambitious programmes that you're talking about without external donor support both from PEPFAR, USA ID, the US government generally, but from multiple other sources as well, DFID, Global Fund and so on.  One of the big shifts that is occurring is - and I think it is a positive one - is greater attention to the prevention agenda and a realisation that we can't treat our way out of this pandemic and that treatment is an obligation and represents the moral high ground, the proper thing to do, the right thing to do, the absolute necessity, but without prevention nobody can afford the long-term treatment strategy and you're going to see - I can guarantee you over the next year coming out of the United Nation's system a far greater emphasis on incidence as a target.  So what will this mean, and I hope that as we go on with this meeting we can delve into this a bit; when external funders and external policy makers are trying to support prevention, but prevention as we heard is about moral values and it touches on issues that are absolutely at the core and fabric of this society and of how individuals identify with themselves, with their communities and so on, then the danger of course is that the external provider is seen as meddling in the core values, the core morality, the core culture of the communities and nations in which they try to be helpful.  So the closer - the more we move external funding into the prevention arena the more politically and culturally dangerous it becomes and it's absolutely essential that the programmes for preventions therefore are seen as generated by, led by and executed by the government itself, the people themselves and not by NGOs from the outside; external funders and so on, so this is a very tricky terrain that we're going into and it's I think absolutely essential that this gets passed out and I hope in this meeting we'll get a little more into kind of going head-on into it.

MR PILLAY:  This is a very short intervention.  I think the two points I want to make; one is that you know, we can depress ourselves enormously by talking about health workers who are screwed up and communities that are screwed up and all of us who are screwed up; the fact is that the majority of people in the country are not HIV-positive and the question is why aren't they?  And I don't think we're paying as much attention to why people are negative as we are paying to why people get positive - why people are positive, which of course we must do.  So my plea would be to look at what's going right as much as what's going wrong because a lot is going right.  I mean, it's not all doom and gloom.  There are lots of health workers who do good work and maybe to understand why in the context of shitty working conditions they still do good work; shitty bosses; they still do good work.  The second point I want to make is that my sense is that, you know, unless we start community conversations about life in communities and build from the ground up all the chatting that we might do amongst ourselves at the national level in forums like this might not make any difference, so the question is, you know, how to localise these conversations in communities who - because communities are worried about these things too, you know; high levels of crime, high infection rates, poor service delivery and, you know, we're seeing the consequences of that in protests around the country.  So the question is, you know, how do you mobilise the energy at community level?  Have these conversations in a way that kind of are constructive and come up with community interventions that we can also understand and research from a behavioural point of view, a social point of view, you know, those kinds of points of views.  Now., what we've done in the department, as Helen hinted to, we're trying to get a small group of people to look at what the evidence is on the prevention side and we've come up with a draft, but even within that very small group -Salim, you're absolutely right; there were various opinions and we took a long time, and that's why Helen says we're still kicking it around in the department, just to try and get consensus amongst the very small group of prevention.  Now, we'll be quite happy to share that draft.  It's still a draft because it's a five-year draft operational plan on the prevention that we've put together largely focussing on the biomedical side of it because that's the competence of the Department of Health, but we hint too all these other things; the social, the structural, the economic, etcetera, etcetera, but clearly that's not the main purpose of the Department of Health, so we need to engage through SANAC with all of the other partners to kind of look at what can be done.  My last point Linda-Gail is we've got a big menu.  We don't have as much resources.  The question is how do we prioritise?  What are the key things that we need to be doing in the next five years?  I know we don't have much evidence, but we have some evidence of what works, so let us focus on those things that we know work.  Let's start a longer term programme on the most structural issues, but I agree we need to start it, but we need to ensure that the people who's supposed to be driving that are indeed driving it, whether it's politicians at local level, whatever, whatever.  Thanks.

MS BEKKER:  I think I'm going to have to wrap it up simply because we've come to the end of the time and I think Peter was particularly challenging for this panel to be sort of squeezed into one hour, but I think perhaps just to say that I think we've raised - touched on pretty much all of the areas and perhaps it will still unfold as the day goes, but what I've heard is that we are going to have to prioritise, but we may have to do it smarter in terms of not only knowing our epidemic, but also knowing the individuals to whom those interventions are targeted, you know, that there are these bigger, broader things that are going to have to happen as we go, but I agree we're going to have to, you know, quickly on our best guess whilst also putting in better ways to measure what we're doing, we're going to have to intervene with our best guess interventions and I think it is encouraging that these bits of information are now for the first time sort of being pulled together so that we can really try to get the list, the shopping list as it were, together.  I thank both speakers.  You've done a great job in bringing a big field together and thanks everyone who's contributed to the discussion.

MR NAVARIO:  Thanks Linda-Gail and thanks to the panel and then to everyone else.  It was a great discussion.  It's now time for tea so we'll take a 15-minute break and we'll come back and rejoin the conversation on the subject of treatment.



MR VENTER: the complete failure of the public health approach in South Africa to deal with the HIV treatment programme.  You've got a disease - I've put there at the bottom - that it's common, preventable and treatable and I do not understand why - and it kills almost 50% of South Africans - why it is not a public health priority for both the public health medical schools as well as for the public health departments and the public health specialists is way beyond me.  I go consistently to ARV treatment guideline meetings, to PMTCT meetings and there's one or two people usually from UCT, from the Public Health Department.  You know, and I do think that a lot of what we're dealing with in the treatment and the failures of the treatments scale-up are largely due to the lack of public health leadership.  And the next thing is that we have to engage with is debate around when to start therapy around CD4 counts are a bit moot when the average CD4 count is a little bit - is somewhere between 80 and 100 and that's a reality that the treatment programmes across Africa and across developed and developing countries have had to deal with is the fact that people generally come in when they're sick and it's a reality that we actually have to start engaging with and talking about honestly rather than - I thinks sometimes the when to start therapy debate has got very, very academic when actually the reality of when to start is like when to start during (indistinct) infection is the real when to start debate.  But certainly in our programme it varies.  I have yet to see a single ARV programme in Africa with a starting CD4 count of above 140 and most of them are at somewhere in the region of 80 and 100.  The other thing is that this data from Cape Town shows this incredibly high mortality while you're stuffing around waiting for antiretrovirals and I think that again it's been shown above 200, it's been shown below 200 is the most profound, but the fact is that we spend a huge amount of time preparing our patients for antiretrovirals during which time many off them are carried off by TB and (indistinct) infections.  And a lot of the focus from researchers have been to try and decrease the mortality in the immediate area after initiation of antiretrovirals, which to be quite honest is a condition, I think is quite hard to decrease that mortality.  But here is something we can actually impact on and it's certainly in this study that came from Namibia, from the implementer's meeting, showed a 60% reduction in mortality simply with a nurse-run accelerated programme.  So there's simple things we could be doing to try and decrease the mortality and improve the uptake.  This paper came out a few days ago which relooked at the infamous quote of Mbeki being responsible for 330 000 deaths, but I think the aspect of how public health has got perverted in terms of the approaches by political interventions that allow it to continue within the political and then the problematic atmosphere is still something we feel in particular at the provincial level at the moment is still the dissidence , the denialism, the we're not going to do something different for AIDS from everything else; that I think, you know, has come at which at the national level thankfully is almost completely gone, but is still there within many of the people who are actually executing programmes.  We know that antiretrovirals work and I'm not going to bore this audience with how well they work, but you know, for any chronic illness, for 90% of them to be alive in five years is pretty good going.  This data unfortunately I didn't manage to - I wasn't able to work out how to update the Excel spreadsheets with the more current data, but it pretty much shows that there's a steady increase in the proportion of people who are AIDS sick accessing care.  The problem with it is that the NSP target for 80% in 2011 will not be attained at the current scale of increase and if you look at that arrow there - in the realm at the moment - I crunched the numbers a couple of days ago again and it looks like about 45% of those who need care are actually initiating on antiretrovirals.  That doesn't mean it's not the same thing as being on antiretrovirals five years later that are initiated, so we have almost - just over half of what Botswana claims to be doing in terms of access to care.  Important to this is the absolute numbers of the scales.  James talked about the scale of what we're trying to do in the PMTCT and in terms of - if you look at just one problem there those are the absolute numbers.  Now, Gauteng and KZN are your two biggest provinces accounting for almost 50% of the population.  You can see that by 100 000 people in each one of those provinces did not access antiretrovirals.  Now, the natural outcome of that is death and in this country it's death in a hospital, so there's a 100 000 people who died in hospital of usually an acute (indistinct) illness, at least 25/30% of TB/.  And those were avoidable admissions, avoidable deaths.  And if you crunch numbers like this about 500 000 new - and I tend to round down the numbers that the various models has used, but it's a useful number, it's about 500 000 people die each of AIDS, okay.  There's a backlog of about - sorry, yes, it doesn't add the two - so that's 280 000 people die and about 220 000 people access antiretrovirals each year, so it's not - so, those 280 000 people die in hospital each year.  Just very back of the cigarette pack, box, modelling just suggest that every single time that you put someone on antiretrovirals you avert very conservatively at least one hospitalisation.  Now, we've put about 30 000 people on the antiretrovirals in the Hillbrow area.  When I say to the hospital people, you know, we stopped 30 000 hospital admissions over the last five or six years they're suddenly your best friends and it's something that does need to be emphasised again and again is that averted hospitalisation is for one programmatically a very good thing, but it's also an incredibly strong cost driver of the expense of the - this paper that Laurie was talking about is a paper from Cape Town looking for AIDS data demonstrating that in the initiation zone the majority of the expense is driven by the hospital costs and I can tell you in the state sector that's almost certainly the same case although the bar is much lower for hospitalisation.  I went to this test and treat modelling meeting as well and they said that they felt it depends when your CD for how good your retention and care programme is, but between two and nine days the hospitalisation was averted per person on antiretrovirals.  Now, Johannesburg hospitalisation comes in at about a 1 000/1 200 rand a day, so you can imagine how, you know, people who end up sick and then putting them on antiretrovirals is a huge cost burden to the state, an unnecessary cost burden.  They also modelled, interestingly enough, the test and treat thing for South Africa and it pretty much said that if you avert even these two days it's pretty much cost saving over 10 to 15 years in South Africa because of the cost of our healthcare staff while in Kenya it was cost neutral.  So but can we achieve scale-up?  Well, just to use our programme as an example we, in the inner city, we think we're getting somewhere between 70 and 80% coverage of people who need it which is what the NSP target is.  Our CD4 count is barely budged over the last five or six years that we've been running the programme.  It's still, of the latest data I had, was 106 and that's despite a dramatic increase in testing and Olive's data suggests, and I'm not sure if I'm misquoting it, but my reading of it was that a quarter of all South Africans came to be tested for HIV in 2008.  Now, if that's true, and if you ask me, even if one-eighth has said they were tested, that's a lot.  People are still not accessing care.  They're still coming in when they're very, very sick which suggests to me that your HIV testing programmes are not working and the secondary effects of know your status, stopping transmission and all that is going to have to be very strongly motivated because from a treatment perspective these community-based programmes don't appear, to me, to be working particularly well, and this is from our own programme where we have - as I said we've escalated HIV testing six or seven fold in a variety of community situations.  So here we did manage to get to 80% and we modelled the community and we worked out we needed about 500 people and it took years and I think this is the thing Robin was asking me; what's the answer to the question which is can you get to 80%?  You need very focussed analysis of the programme at a district level to work out where the blockages are and then you have to intervene there and then - and what we did in the Hillbrow area was we intervened at several areas, so we looked for the low-lying fruit and the PMTCT programme, the TB programme; we started testing within the hospital, we expedited treatment; we did a whole lot of things and eventually we got to 80%.  That was work with a whole lot of pretty bright programme implementers applying themselves and I think that again - and the nice this is we had the denominator.  We knew how many people had AIDS.  It's sort of changed now with the huge Zimbabwean influx into the area, but I think what was fascinating though is that it didn't up paediatric numbers; they didn't budge.  We have poured the same resources into paediatrics and we have not seen the improvement in the numbers initiated.  We saw it with adults, but not with paediatrics and I'll come back to it in a second.  James talked about the famous cascade and the PMTCT cascade has prompted all of us to start looking at the cascade within treatment.  I mean, the same cascade operates in adult and in paediatrics at every single step.  The minute you move - you bring somebody the day after or the week after, the minute you send them to another facility half of them are gone from the system and it's remarkably consistent across every single programme that I've seen the analysis.  You can dramatically decrease it by phoning the patients if you intervene correctly, but the reality is that that 50% loss to follow-up has to be built into your planning process and we haven't done that well enough.  I don't think there has been even the hint of target setting at the provincial level.  Provinces have just been given money and told to go off and spend it on what they think is okay and I'm maybe being a little bit provocative here, but the thing about it is that I've yet to see a province come up and say our province is responsible to putting so many people on treatment and it's been left up to the provinces to simply spend the money in a way that they think without being held accountable to the number of people there.  I remember the numbers that they came up with in 2004 and 2005; they just sucked out of their thumb.  I remember I think Mapumalanga had a target of 2 000 and they reported proudly to the Department of Health that they'd proudly hit their target, you know, when they account for a massive hectic part of the epidemic.  And I really do think this target we're busy providing with PEPFAR support, providing a calculator for districts, where you can work backwards and at a clinic level identify how many HIV tests you need to do; how many CD4 counts, how many successful referrals, how many people need to be initiated with ARVs so that you can have X number of patients happy and on the antiretrovirals in five years time and I think that is hopefully the kind of thinking that needs to go forward; is to start using target setting.  Okay, in paediatrics I honestly think that children are a difference.  It's taken me a long time to come to this conclusion, but it really is; they're damn hard to diagnose and they are much harder to treat and the consequences in the long-term for the society are huge and I honestly think that PMTCT has to be made a proper priority.  I think it's been sort of nice to have and the (indistinct) being there, but it really hasn't happened.  They also suffer the most at the hands of the healthcare - of a weak healthcare system.  In terms of (indistinct) shifting, as I said earlier I think that we've made up a whole of this stuff.  I think that other countries have done it with far less staff than we have and paradoxically being relatively well-staffed compared to other African countries has meant that we've sort of wrung our hands about (indistinct) shifting and I think that's been fantastic hearing the National Department of Health saying things like we're going to get counsellors to do the pricking, we're going to get, you know, we're going to (indistinct) shift, we're going to allow nurses to initiate therapy and I think that it's been used quite extensively as an excuse for not scaling up and again if you look at Botswana which is claiming, and I think correctly so, 80%.  Namibia, 80% coverage with far fewer healthcare staff.  TB is - Robin's going to probably talk to this - but for me the separation of the TB and the HIV programme has being an absolute disaster and this is the victory for the TB programme; this generation of respiratory cripples of I can be cured because I've got TB, you know.  It's all very well, but the consequences of TB are just incredible.  We've got these obscene TB incidence rates which Robin can talk to you just now and it's going up and because, you know, we haven't had the linked programme - which we now do thankfully, and we've missed out on a whole range of prevention opportunities.  And then the other thing is that one of the things that's not recognised nearly enough is that the strongest evidence is the antiretrovirals prevent TB.  They're also good for treating TB, but they prevent TB and that the IPT programme and the (indistinct) prophylaxis programme has proven to be an absolute disaster in terms of implementation and it doesn't matter where it's been tried really it's been very, very disappointing.  What about the role of donors?  I think it's been a very confrontational and (indistinct) approach and they've patched up some of the gaping holes in the programme; the rural areas where there was no antiretrovirals, places where nobody wants to go, the Catholics in particular I think have been very good about that, they've patched up, but I think increasing the concern around sustainability people do need to start thinking about - I mean, I understand there's an emergency at the moment, but I do think that in future things like countries like South Africa should not be allowed to get away with allowing donors to pay for drugs.  They should rather be paying for the technical support and the support to the technical experts that are in the country, but this, really I'm concerned about the, you know, about paying for blood tests for instance in a country that you'd rather be looking and saying what can we afford in the longer term.  So quickly in summary we're still treating HIV as an acute illness.  We're not treating it as the chronic disease it is.  The mortality at the moment is driven largely by late diagnosis and very poor referral systems and very tardy referral systems.  You know, one of the worst things we did in the original guidelines was say that ARVs are never an emergency.  It's been interpreted to mean that somebody with a CD4 count of 50 can wait a year to get into a programme and we aren't acting urgently enough once we've actually diagnosed them and I think that people who get antiretrovirals in our system stay there despite the system not because of it.  Our biggest reason for (indistinct) follow-up at Johannesburg Hospital now is because people change jobs and they can't come and pick up the tablets because we insist they come monthly to come pick up the tablets.  We have made it really, really hard.  Clifford Panser from one of the car manufacturing companies in Port Elizabeth told me that the reason that they put their people in programmes because it's unaffordable to be in the state chronic care programme if you've got a job.  You just can't take so much time off work and I think that again it's a health systems issue.  Adherence is good, but the failure of adherence is very, very costly and Robin's got modelling data to suggest how quickly people fail and then what the cost of that is and it's going to - as the programme matures there's going to be a bigger, bigger issue, is the cost of (indistinct) inhibitors in particular in second line.  So what did I do?  So to put myself a little bit on the line here I was like thinking about this and changed my entire presentation last night in reaction to is.  I think there's some quick and easy, relatively easy, things we can do.  I think that (Indistinct) should be first now and I think everyone recognises that.  I think it would make it much safer and easier to use than primary care.  I think we must use - fix those combinations, but I also think that drug companies need to be forced.  Andrew Bull came up with this amazing idea.  He said why don't you just co-formulate them and everyone with antiretrovirals, which is 90% of the people starting on a regiment - a first regiment - give them a red tablet and say for normal patients, red tablet; for women who want to fall pregnant, blue tablet; for those with TB here's a yellow tablet.  And stop with the - you know, why can't we - we've got such economies of scale in terms of demands from the drug companies; why can't we demand that stuff just simply to fix things and get better deals on the packaging.  I think mother to child transmission has been an absolute priority and I think that getting nurses to initiate antiretrovirals, as James said, in the antenatal clinics would go a long way to just arresting the epidemic.  And as I said the antenatal clinics and the TB clinics should start immediately.  They should be initiating therapy.  The TB clinics are actually paradoxically one of the best places to initiate antiretrovirals because they're looking after the patients.  They're dealing

with - the side-effects of TB drugs are far, far worse believe me than the antiretrovirals.  And then we need to start setting targets at every single clinic, at every single district.  So we stop with this just, you know, do the best you can type of approach.  Managers need to be held accountable to these targets and given the budgets to deal with it.  The creative and expensive things around chronic disease grants, trying to use money to incentivise for it to be retained in the system I think are the kind of creative ideas we need to think about.  You know, I've never understood why we don't pay TB patients to finish their therapy.  You know, there's this quite punitive feeling in the health system which is you got sick, you need to look after yourself, come in and help (indistinct).  And if it's a public health priority we should start looking at that.  The other thing I put there is medicine pick-ups.  It's often that we've run this thing in extensive pharmacies within the state sector when there actually is capacity in the private sector and, you know, the state sector battles to dispense stuff in a way that patients can actually have a job and take - and be sick at the same time.  I think you should expand HIV testing in health facilities and this is a big climb-down for me over the last two years as I used to think it was a bit of a waste of time and that you couldn't do it, but I honestly think that we have to start critically reviewing these community HIV programmes and I think particularly for the donors and for the Department of Health giving money to somebody to expand testing without saying the next step, so it's not good enough to know your status; you have to say how many of your patients appeared at the antiretrovirals sites at the end of the day, and that's the end point; not, you know, how many are in the counselling sessions that you do.  It's not good enough in the healthcare system.  And then we have to continue to support and review SANAC.  I think that SANAC is - at least the politics seem to have been resolved, but I think it needs to be strengthened so that the people who are looking at it are the true technical experts within the country rather than people who happen to just turn up at meetings and I turn up at a lot of these meetings so I'm critical of the view, but I do think that with the directorate and things we need to start making sure that the oversight's good.  Just one more slide.  I think the two elephants for me in the room about systems are the health system as a whole and then the retention and care problem, and it's the two things which are not being addressed, that we're talking a lot about (Indistinct) and 350, but to be quite honest with you no, the average South African does not want to be treated in the state health system and we have to confront that.  We're spending a lot of money on the state health system to - you know, we've created a massive degree of employment to provide a service nobody really wants in the community and I think that we're going to have to start addressing it.  The retention and care thing impacts on everything else.  I get these - the (indistinct) prophylaxis people are very angry with saying it doesn't work.  They say it does work.  Of course it works, but the problem is if your system is not geared towards retaining healthy people who do not need antiretrovirals then it's never going to work and it applies to the other (indistinct) infections; the whole range of other interventions.  I sometimes do think though that the state should start looking at a silo if you're going to choose one silo of chronic care.  So we treat all the HIV, hypertension, asthma patients at 7 o'clock in the morning in a forwardest approach where they can come in, get their therapy and be out of there in an hour, and the snotty-noses and the people who've stabbed each other and stuff go through the normal casualty situation.  But at the moment the systems are not designed to actually allow chronic care to occur and I think that this is something that we could start toying with as a systems-based intervention that people - because the adherence interventions, the drugs, the laboratory monitoring all lend themselves to algorithm approach that - algorithm driven approaches have been used at primary healthcare.  And finally we need some public heath leadership and we need it at right at the top.  The fact that Yogan has to like fight for resources on the HIV side without seeing a comprehensive system is wrong and in some ways I'm very nervous about the NHI thing, but for finally at least we are seeing some sort of leadership around (Indistinct) as a whole.  And I'm very irritated by the public health people who say you HIV people get all the money, yada, yada, yada - all the stuff we proposed in the 70s, you know, you should have been doing now.  And my view is simply that, you know, you were in the way to be quite honest and now get out of the way, and it needs to be fixed, but it is a problem that we're not looking at this in a comprehensive fashion and that you need some top priority setting and you need some rationing decisions which are going to be required and some tough thinking about it.  As you know, what happens when people don't take their therapy in the second line?  What do you do with people who like (indistinct) like default?  What do you do with people who come in who refuse to know their status and then pitch up at an HIV clinic or worse still in the hospital in extremeness and you want to make decisions about expensive ventilation and dialysis, and those things need to be talked about openly and discussed with the public health (indistinct).  And ja, and I think that, as I said, finally, the use of our human resources we really need to be doing more intelligently.  It's not good enough to throw up our hands and say we need more nurses, we need more doctors when our clinics are all empty in the afternoon.  Thanks very much.


MR WOOD:  [Inaudible - speaking without a microphone] ...Francois for giving me a copy of his talk a little bit earlier in this session so I can frame my comments around his random thoughts, as he describes them.  The first thing that you get is that Francois' passion reflects the passion of doctors who are used to using antiretrovirals.  I think it's universal throughout, people who had that experience.  Just looking at his list of what he would do was an interesting mix of tactical, strategic and systems approaches.  I see the switch to (indistinct) as something of a tactical issue.  I think it's more complex than it seems.  If we look at the WHO recent guideline changes they've given a potpourri of added intensified interventions that we need to do.  One would be to change treatment threshold to 350, the other one would be to introduce (indistinct) and then to consider using third-line therapies and of those the life years gained from switching to (indistinct) would be the lowest of all of them.  It wouldn't be that expensive, but I think it touches on another aspect, is if we're going to move upstream and bring people into the programme that there are other things besides cost-effectiveness that are important, parameters that we're not measuring, so the willingness for people to come in, the publicity of adverse events can actually damage our programme very much, so cost-effectiveness; I'm a big fan of that, but there other aspects and I think that (indistinct) falls into that.  It's interesting that you put it up as your number one first thing that you would do and initially I would have disagreed with that, but then the more I thought about it I thought, but these other factors probably are very important.  The third of the first things that you mentioned was the PMTCT programme and I think that, as I've said earlier, that I think this is incredibly important because not only is it important for interfering with the transmission from mothers to children, parents to children, but it is the one example of entry into the programme with people who are not sick, who are accessing healthcare at earlier stages of their HIV and I know James touched on can we use that in order to gain access to the men, but I think it's something that we really have to concentrate on because it's the only way we're going to get non-sick patients in and that's what's going to change the CD4 counts.  You didn't show it, but I suspect that the CD4 count distribution of pregnant women coming into the programme is much higher and that immediately would make a difference to your target of trying to achieve earlier treatment.  I quite enjoyed the earlier talk and Yogan's suggestion that there's sort of a military analogy here and if we would look at things that are sort of strategic and tactical and where the blockages are.  I think there are some strategic things that are achievable very rapidly.  I think the leadership component of it is important and I think Francois touched on that.  I was thinking that we've seen this great leadership change at a national level, but you emphasised the need at provincial level and if you are fighting a war having local generals that can do something is actually probably quite important.  I think the (indistinct) shifting he touched on; I think there are many components to that.  I think the shifting to nurses, and we need to change the legal framework so that they can prescribe drugs, their training programmes and I think we'll probably have to extend workers compensation and the rights of workers to our community workers as well.  Something that was touched on my Fazel is the unlocking of the private sector and I think particularly in monitoring and evaluation that there is an amazing capacity within the private sector for laboratory - which has been, because of structural impediments, has been denied access to - largely to the antiretroviral programme and I think that's something that could be addressed.  I think something that's sort of linked to that is this question of fugitive data that - data that's collected with public funds and with PETFAR funds shouldn't be sequestrated and not made available to appropriate researchers and I think this is going to be very important for the monitoring and evaluation of programmes.  The data exists, the structure is that we can't get access to it and it means that we're leading blind which I think is something which is a structural thing which could be addressed quite rapidly.  I think that philosophically, and I think Francois touched on this, that this dichotomy between increasing the quality of care of people that we've got in the programme with equity and bringing other people in and I think that's where the (indistinct) question I could have gone the other way and said well, who cares, we just want to get more people into the programme and take D4T, but (indistinct) would have a negative effect on achieving that, so I think that's a critical philosophical and my feeling is that I still think we have to have the emphasis on equity and getting more people into care.  And then you touched on the systemic - the fact that our health system is designed for acute care.  It's designed for being stabbed on a Saturday night.  It's not designed for chronic care, so we have a health system that doesn't fit the diseases that presently are taking their toll in the country.  Just to pick on one highlight; the data you showed on the early mortality.  I think actually it's easy to skip over that, but I think it really shows the integration of antiretrovirals and the dependence on other public health issues.  The early mortality is driven by late presentation, lack of urgency, health system delays, but it's also driven by lack of access to appropriate testing for the predominant diseases which are TB and Cryptococcus.  That early mortality can be made to - can be controlled if you get a reason like sister care and if fact if you look internationally at the early mortality, the early mortality is higher in the poorest countries with the highest public health burdens of disease.  And just to go back to the TB as Francois knew that I would do; I think the response of the HIV/TB epidemic really epitomises the fact that we take the management of (indistinct) stage of two diseases and we then try and integrate it together, so Alan pointed out that, you know, with HIV we're not going to get anywhere unless we stop the transmission of disease.  Nobody even thinks about that with TB.  All we're interested in is case management and in fact I believe that HIV/TB is just emphasising and illustrating that our TB control programme's failed as I think the very high TB rates amongst children under two has also shown that.  So I don't think you can see any of this stuff in isolation.  I think there are other aspects; our response to prisons.  We allow TB cultures to - culture system to exist throughout the country and at the same time we're trying to control the transmission of TB.  So in summary I'll just come to an end.  Francois thought we couldn't do the 80%.  I think we probably could, but I think practically he's probably right.  We'll probably do it a year or two later.  I think the programmes have been implemented very successfully in a somewhat dysfunctional health system throughout the country.  I think we've managed to get to the largest programme in the world in five years.  I think there's a problem in the moving target that the WHO is increasing the number of eligibles.  I think that earlier treatment is actually easier and can be down - can be given to lower echelons of treaters (sic).  I think the drugs are less toxic and I think the debate about (indistinct) highlights that.  I think the legal framework could be changed so we've got access to health resources and I think that we could get the monitoring and evaluation because we've got the public sector potential already there and technology's improving, so I think it comes down to we're somewhere between the prevention group where they started off being all failures to the PMTCT where they can treat themselves out of the transmission epidemic.  We're in somewhere where we can't treat our way out of it and we're going to acquire increasing burdens of patients with complicated disease as time goes by, so affordability will be an issue, but we're going to have to move.  I think we can do it.

MS GARRETT:  Okay.  Now, unfortunately we only have 18 minutes so what I would like to do is ask first does anybody have a specific question you want to address to either Francois or Robin before we go to general reaction comments; but any specific questions?  Peter?

MR NAVARIO:  I'm wondering about the contribution - the potential contribution of routine testing to achieving these targets that we're talking about.

MR VENTER:  It's like your retention and care programmes.  You can test as many people as you like, which is what we're doing at the moment.  We've escalated testing.  If you don't look at why the systems that are going to retain people in the system then, you know, you're actually throwing money away.  Then wait till they get sick.  That's what we're doing at the moment and then, you know, you're not giving people a diagnosis they can't - they're going to be sitting with for a couple of years before they finally make their way to a healthcare programme.  So I think, I mean, the reality is that we need to do both.  We need to escalate the testing, but you need to understand that those retentioning (sic) care systems, you know, you're wasting money if you don't improve those.

MS GARRETT:  I believe if I see two; you and Salim.

UNIDENTIFIED FEMALE SPEAKER:  So my question is - it's really how important is this D4T debate because the Liverpool School has just done modelling looking at the D4T with a lower dosage versus (indistinct) and they're saying that world-wide you get 80 people onto - if you use (indistinct) regiments versus 120 if you use D4Ts.  So now the question is how important is this going to be, given - and we're talking with donors here - I mean, how much when we think about regiments should we be starting to think of cost because I think that sort of modelling exercise becomes important and then you are weighing up, sort of side-effects versus numbers of people and if you say to people would you - what would you prefer; a bit of (indistinct) or would you rather be on treatment?  I think many people would say well, thank you very much I'd rather be on treatment, so I'd just quite like to hear from both of you.  And I think it's an important policy decision.  Do we stay at the cheaper drugs with the higher side-effect profile for numbers because there will be financial constraints?

MR WOOD:  I think you've highlighted what I was trying to point out.  We did a cost - just recently we just looked at the new WHO guidelines and tried to get a cost-effectiveness analysis of each of those different interventions and then targeted for different statuses of countries at the time.  We've already got CD4 count monitoring to get into therapy which is actually the most cost-effective.  The next thing would be to change, as you say, to 350 with a D4T regimen and then there would be a small increase, but the incremental cost-effect ratio line is the same, but the absolute benefit of changing from D4T to (indistinct) on that cost-effectiveness model it's the last choice that you would make.  I was trying to highlight that I'm beginning to have a few doubts.  It depends on what the impact is on the willingness to come into the programme when we start going earlier or stay in the programme.  So I think on the cost-effectiveness analysis and the sort of (indistinct) data, you're saying ja, that does show that it's probably the last edition that you should add to the potpourri.

MR VENTER:  D4Tdrives all the side-effects of the programme for all intents and purposes practically.  There are a couple of minor ones, but (indistinct), they're subtle, they're difficult to pick up and they're highly stigmatising and we had that front page Sowetan (indistinct) case which did an unbelievable amount of damage to the programme.  So I think that it's great on the public health level, but the upstream consequences ,you know, in terms of how people perceive the programme, you might actually damage in the process.  I also want to say things like, you know, what is the cost of switching because maybe we'll take that money from Komanani and use it there and I think those are the kinds of rationing decisions that aren't spoken about enough.  No, but seriously, in the public health sphere it's very rare that I see a rational discussion about how we're going to use our resources.  I don't understand why in HIV we have this debate when there's no debate in asthma or in maternal health in terms of what you're trying to achieve and that's why I'm talking about the public health leadership where somebody can stand above it all and say that's what we're going to spend our money on and you might find that the difference between D4T and (indistinct) in terms of expense is actually not even worth talking about next to the difference in diabetic drugs that you're using or the monitoring.  The other thing you can do is you can put to the HIV experts and say would you rather have D4T or (indistinct) or would you rather ditch the viral load that one year, and those kinds of debates again need to be - those kinds of options need to be put to people and say what's your best guess in terms of choosing it?  So I think it is very important to go down this road, but it does need calm minds to prevail in terms of looking at it and unfortunately often with these debates people are guarding their turf or fighting for their own little area of work.  I mean, the other thing is second-line therapy.  I've seen cost-effective models saying we shouldn't even bother, it's the most expensive thing we could do.

MR WOOD:  It's more expensive than introducing 350 and D4T, but we've already gone there so we can't go backwards.  So it's a question of where we go from South Africa and I think Helen's touched on the key thing.  Do we insist on equity at the moment for what we've got?  Do we move to the 350 because the WHO is sort of pushing us that way or do we change to (indistinct)?  And in the order of that decision-making tree if you were just looking at costs and benefits, you would do the (indistinct) last.  But I'm almost convinced by Francois.

MS GARRETT:  So, I said Salim was next.

MR KARIM:  I just have a quick question for Francois and Robin.  Do we know - and based on what we know about HIV prevalence and about Zimbabwean refugees and so on, do we know what is our denominator for the number of people that need antiretrovirals treatment so that we know whether we've achieved this 80%?


MS GARRETT:  Okay.  I'm going to go arbitrarily in the amount of time that remains to David then to Alan then up this side of the table in the sequence in which you flipped your cards which I could not see, so you're on the honours system.

MR KALOMBO:  Ja, thank you.  I just actually wanted to raise the same issue.  I think Francois spoke about the targets.  I can assure that every province every year do provide us - provide with a target, but the point is of the weak MNE.  This target (indistinct), I mean, their responses they're not.  Now, as we want to scale-up I think it's essential for us maybe to understand how many patients do we have actually on treatment because what the figure are saying it's just an estimate number of patients or patients initiated.  I mean, I've been talking to Yoga, it is important I think moving forward that before even you can scale-up from the 1st of February so we know exactly how many patients do we have.  Then from that moment we can begin to have a proper target and then monitor moving forward.

MR WOOD:  I think again it's an interesting area of monitoring.  I think the way we've looked at antiretroviral programmes is we've looked at it from an individual treatment point of view.  I think the reason I touched on that fugitive data story is that if you gave me all the CD4 counts that have been done by the NHLS on a yearly basis I could tell you what the (indistinct) and CD4 count of the population that you're trying to treat has done, and that's actually a totally different way of looking at what the programme's doing, but it's actually looking at an output which effects disease transmission in that community.  So I think that was one of the reasons why I put in that request in that I think we can answer some of those questions in a macro level and it's a very different way of looking at things.  I mean, if you look at all the viral loads that have been done in the NHLS you find 90% of them are beneath 400.  That type of data exists, but it's not allowed to be in the public sector and people just aren't thinking and analysing it, so I think we can answer quite a lot of those questions of who's effectively in therapy at any given time.

UNIDENTIFIED MALE SPEAKER:  [Inaudible - speaking without microphone].  You know, the trouble with you people is you don't like us economists, you don't understand us.  When we say something's cost-effective and it supports what you want then you say yes, yes, but when we say it isn't you say bullshit.  When we - you say moral integrity.  When we say the funding's getting tight then you say no, we must mobilise resources and we say be realistic, and you say no, no, no.  Come on guys, you can't run with hare then hunt with hounds.  I'm not going to treat your patients; don't mess with my economics.

MR VENTER:  Outside right now.  But Alan, I think what we battle with is we're not told how big that pie is and we're not told what the decisions are.  We're not told - and again it's about the public health leadership.  I think the Minister of Health has to sit at the top and say this is how big my pie is, this is what our priority areas are and this is how much we're going to allocate to the ARV programme and then you make a series of decisions on the best outcome you can do.  It makes sense.  I don't think - and I think the 350 debate is a case in point is that when you put it to clinicians like that, people are very happy to make those kinds of reasonable decisions.  The problem is we're not given all the data.  So for instance at the moment we've been told (indistinct) is too expensive.  Nobody knows the data.  I get the data through 15 second-hand information sources and half of them tell me that it actually costs equal to D40 and the next one tells me it's cost-equal to AZT and the other one says it's a little bit more expensive, and the problem is that's the cases that we don't know what we're working with and it's not entirely fair on us.  We can count occasionally and you're right, moral imperatives.

MS GARRETT:  Well, is there anybody here who can tell us the actual cost breakdown, the differential between D4T and volume purchase in the global market right now on (indistinct)?

MS REES:  I absolutely can't, but what I do know is that they will - I got this hot off the press - that it will never be as cheap.  I mean, (indistinct) will always be - the actual drug is a much more expensive drug.  It will always be more expensive to manufacture; it's always been more expensive.  And the differentials, as I say as far as I know, when you've done the costing, the (indistinct) prices it's 80 patients versus 120 patients.  I mean, that's the difference if you use the two different regimens and that goes back to Alan.  I support you Alan, you'd be pleased to hear, you know, that those - I think we can't run away from that and the question is how you weigh that up.  I mean, I think those are some of the difficult questions.

MR WHITESIDE:  But who's costing the side-effects of the D40?

MS GARRETT:  Okay.  Just to get back to chairing this; so I said you folks along this side... [intervention]

UNIDENTIFIED SPEAKER:  Just to comment on what Helen's just said about the cost of (indistinct).  The issue with the Clinton Foundation coming through (indistinct) those combination including (indistinct) being less than what we are paying for at the moment in this country for (indistinct), so what's the - and so coming back to Francois's point: what is the truth?  You know, if we are paying more in this country for the current medication and that's the reason for the billion rand deficit - I mean, we have to change how we're doing business.  You know, are we being taken for a ride by the generic pharmaceutical companies because of invested interest of certain parties?  I don't know, but I mean, this is a question that we need to ask and be quite honest because now we're saying, you know, look at Stavudine because, you know, the cost - we can put more people on.  Sure, I take that argument on, but the side-effects and the retention remaining in care is critical.  So I do think we need to be honest.  I do think we need to be really open and make really hard decisions.  If some political parties are going to suffer, well, our communities do come first.

MS GARRETT:  Actually because I know that she's going to say something that directly follows on from your point and that she's going to talk to tenders I'm going to go to Nicoli next.

MS NATTRASS:  No, actually Asha I've just made exactly what - the point I wanted to make.  I think we need to ask all those questions about that tendering process.  I just really wanted to argue against Alan.  I think that Francois's economics was fine as is Brian Brink's that if you - that you absolutely do need to look at side-effects and that it's really crass to do the kind of analysis that Helen Rees just did which is to say 120 versus 80 because if you don't take into account the longer-term effects and the bad effects or the side-effects on getting people into care we've completely blown it and the point is we don't know how to do that cost-effectiveness calculation because those are a lot of unknowns.  The effect of that photograph in the Sowetan is unknown.  It doesn't mean that it shouldn't be discussed by economists and economists tend to be terribly arrogant by only counting what they can see whereas if you can actually estimate and count what you can't see or make a good guess you do better economics.

MS GARRETT:  Right.  I'm going to try to return to this side of the table.

MR RANDERA:  I just wonder weather our model has been somewhat wrong.  It served us right up until now Francois and everybody else.  You know, we've managed to get 900 000 or 800 000 people on treatment, but to answer Salim's question I think we should be speaking to the 5-million people that are HIV-positive in this country, not 900 000 or 100 000.  Now, one of the things - and it might upset Alan of course because this is more money that we're talking about - what we're seeing is that bottlenecks are created one, by all the accreditation that needs to take place and I know there's talk of making it a bit simpler.  But the other thing is that, you know, HIV has been marginalised in every clinic facility and hospital in the country, so what happens to people who go to a hypertension clinic.  Somebody tests them or doesn't even test them and then says go to the HIV clinic.  The whole cascade effect comes into play again and as long as we continue to use that system it's still going to become a chronic management system, but it's going to become a vertical chronic management system and we need to move away from that idea.  I just wonder whether you guys can comment on that.

MR VENTER:  I think maybe to avoid the question slightly Fazel; the challenge does come to the economist to tell us - like I don't think anything we do in the public - well, anywhere in the medicine sector is particularly rational to be quite honest.  You know, we've got some data on the economics of ARVs.  We don't have it for cancer of the cervix.  Helen and I had this huge argument about cancer of the cervix screening, about whether it could be cost-effective or not that it's so politically unattainable to actually discuss that openly and say these are the - I suspect hypertension treatment isn't actually that particularly cost-effective.  And there's a whole range of these things and the public health person who's at the top needs to have this information so they can make these decisions and I think that, you know, we're asking for health services - we don't even know what we should be asking for in terms of the broader arena.  I do think that most HIV clinicians are quite happy with integration of services.  They see the broader healthcare system as being the problem in terms of getting their programmes going and see it as integration into a broader healthcare system as a way of approaching it.  But I think the challenges here are to start having the same approach that we're starting to use in HIV across the board for the other prevention and care of the interventions.

MR WOOD:  Just to touch on the other comment that you had about the targets and Salim sort of intimated this earlier.  I agree with you that we should in fact be looking at the proportion of HIV-positive individuals in the community.  I think there is no effective believable CD4 count population model that I know of, so whilst we were treating just on symptoms I think the (indistinct) actuarial model fitted quite nicely for the number of people who developed AIDS each year and Francois showed that sort of data and the numbers that die, but in fact as we move upstream we should be looking at the percentage of the 5-million.  I think that's right, but I think we didn't because it would have been too daunting a target in the early years and people didn't like that.  They much prefer to have a percentage of a WHO created model number and that's why I answered no to Salim earlier.

MS GARRETT:  Again, I'm very confused by much of this conversation because we're missing the most essential numbers, so first of all I don't know what tender cycle you're on right now, so the drugs that are going out the door this moment, were they tendered in 2005, 2006, 2007?  At what sort of a cost ratio?  And if we're talking about 5-million South Africans, you know, let's just ballpark back at the envelope and assume that 3-million of them have a CD4 count below 350 just for the sake of argument.  So you need 3-million people on whether (indistinct) or D4T or whatever the hell at this moment.  Do you have - have you had a tender cycle that could have (a) provide that much drug at this moment and (b) at what price?  I'm not quite sure I understand the conversation because it seems like we're going round and round in circles about what's more expensive, what's more cost-effective, but we've never had any numbers on the table.  Does anybody know?  So there's nobody here who knows the numbers?  Alright, well then that's a good place for us to stop and go to lunch.

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