Nathan Geffen, TAC

In the April/June 2009 issue, we reported Leigh Johnson’s presentation to the South African AIDS conference on unmet need for HAART. Johnson and Muhammad Adam have since published their findings in the South African Medical Journal. [1]

The authors conclude, “Significant progress has been made in expanding access to antiretroviral treatment in South Africa since 2004, but a substantial unmet need for treatment in adults remains.”

By the middle of 2008, over 560,000 people were receiving HAART, 79% of them in the public sector. Using Department of Health (DOH) criteria (CD4 count <200 cells/mm³ or WHO stage 4), the authors estimate coverage to have risen from 5% in 2004 to 40% in 2008. But using the Southern African HIV Clinicians Society (SAHCS) guidelines, which provides for treatment at a CD4 count below 350 cells/mm³, coverage is only 22%.

Table 1 provides a breakdown of the number of people on treatment by year, sector and province.

ADD TABLE

Table 1: Number of people receiving HAART by year, sector and province (from Adam and Johnson).

Table 2 provides a breakdown of estimated coverage by year and province according to AIDS sick, DOH initiation criteria and SAHCS initiation criteria.

ADD TABLE

Table 2: Estimated HAART coverage (%) by year and province (from Adam and Johnson).

COMMENT

As explained in the April/June 2009 issue, this excellent analysis must be considered the definitive estimate of coverage for South Africa. Adam and Johnson have provided data that should actually be calculated and published regularly by the DOH, at least for public sector data. There are however several reasons why the situation of having to depend on two independent academic researchers for HAART data is problematic:

(1) The data is over a year old and more current information is needed to assess the HAART rollout. The long-time taken for peer-review and the fact that up-to-date public health data is not easily available to researchers working in universities means this time lag cannot be overcome easily by university researchers.

(2) The authors explain that, “to allow for mortality and loss to follow-up after starting treatment, rates of retention are applied to [DOH] annual numbers of individuals starting therapy.” The rates used are based on Western Cape data and a modeling equation is used to estimate the number of people on treatment. The authors have also checked their results against drug sales, but this approach to determining the number of people on treatment is not ideal. Instead each public health HAART facility should maintain an accurate database of the numbers of people who have initiated treatment, continue to be in treatment, lost to follow up and died. Facilities should also maintain records of waiting lists, patients lost to follow up or death before initiating treatment, baseline CD4 counts and six-monthly CD4 counts. Then this information should be collated nationally and published regularly. Instead the DOH occasionally makes available a report of the number of people on treatment. This reliability of this report is questionable. It contains very little detail and it is unclear that it has been properly calculated based on accurate clinic data. It mixes data from provinces that track the cumulative number of people initiating treatment with data from provinces that track number of people retained on treatment.

(3) It is difficult to track progress towards the HIV/AIDS National Strategic Plan (NSP) treatment target of initiating nearly 1.4 million adults and over 150,000 children on HAART from 2007 to 2011 without regular accurate and current data published by the DOH.

The DOH is aware of these problems and has informed members of the newly formed Budget and Expenditure Monitoring Forum that it is taking steps to obtain accurate monitoring and evaluation information.

While substantial progress providing HAART has been made, even by the most modest criterion, ie AIDS sick, only half of patients were receiving treatment by mid-2008. And by the most appropriate criteria, ie the SAHCS guidelines, not even a quarter of patients are receiving HAART. To compound matters, since mid-2008 the final date for when the data for this study was calculated, many problems with the public sector HAART implementation have surfaced, the salient example being the Free State Department of Health’s moratorium from late 2008 until February 2009 on initiating new patients on treatment. The SAHCS estimated that caused 30 people to die a day.

Reference
Adam MA et al. Estimation of adult antiretroviral treatment coverage in South Africa. September 2009, Vol. 99, No. 9 SAMJ.