The researchers investigated the challenges regarding Antiretroviral Treatment (ART) programme implementation in South Africa.A qualitative method was used. The paper focused on the challenges that the South African Government is experiencing in implementing ART programme. Despite all the prevention strategies and plans that the National Department of Health of South Africa has, the HIV and AIDS is still one of greatest burden the country has ever experienced. In this paper, it is further indicated that we are all affected and it is important to work together towards UNAIDS Zero targets strategy for 2030, ZERO new HIV infections, ZERO discrimination and ZERO Aids related deaths. The research findings revealed two themes: social support and economic themes of the study. Factors reported influencing optimum adherence were also indicated and are captured in the discussion report of this paper.
Key word: Social support, Economic Support, Unemployment, Adherence, antiretroviral treatment, HIV and AIDS
This paper investigates the challenges regarding Antiretroviral Treatment (ART) programme in South Africa. This section presents a background to the study undertaken. It provides information on the focus area of the study and it outlines the research problem and the ARV roll-out programme initiated by the South African National Department of Health. In addition, it also outlines the aims and objectives of the study and the research questions to be answered by the findings.
2. BACKGROUND TO THE PAPER
The South African government recognizes that the country has a very high burden of infection, with an estimated 6.4 million people living with HIV by the end of 2012. In addition, South Africa’s landscape of the national HIV epidemic has improved dramatically since 2001. South Africa has reduced new HIV infections by 41% between 2001 and 2011 . However, as the South African government enters the final years of achieving the Millennium Development Goals in 2015, much remains to be done to reach the targets. A number of government interventions and strategies have been put in place over the years to reduce the HIV infection rates in the country. The programmes such as the HIV Counseling and Testing (HCT) awareness campaign established in 2010 , the increased call for condom use and distribution, HIV and sex education in all sectors of the society, and the medical male circumcision programmes were all aimed at reducing HIV infection.
The launch of the national HIV counseling and testing (HCT) campaign in April 2010 resulted in a remarkable increase in the number of people accessing testing . It is further indicated by the HSRC (2012) that between 2008 and 2012, annual HIV testing increased from an estimated 19.9% to 37.5% among men, and from 28.7% to 52.6% among women.South Africa has the largest antiretroviral treatment (ART) roll-out programme in the world, achieving a 75% increase in HIV treatment services between 2009 and 2011 . By October 2012, over two million people were receiving ART, surpassing the country's universal access target of 80% in accordance with the 2010 World Health Organization (WHO) treatment guidelines and offering treatment to people with a CD4 count under 350.
According to the National Department of Health (NDOH), the government is committed to ensuring universal access to antiretroviral therapy in order to improve the quality of lives and the country outcomes . In addition, the national ART roll out programme for South Africa requires human resources, financial planning and monitoring and evaluation systems, as well as institutional capacities . For ART to be able to attack and suppress viruses, patients must adhere to treatment for life. Not following instructions to take medication, collecting medication and not taking it and missing out on doses will lead to drug resistance and to the medication not to work . Keeping patients on an ART programme needs commitment from all stakeholders, patients, family, programme managers, wellness clinic staff and political leaders. Furthermore, optimal adherence to ART has the potential for turning an HIV infection from an acute illness to a manageable chronic disease such as Diabetes and Hypertension.
The South African national ART programme was conceived to reduce and meet the high burden of infection that the country experiences . South Africans hope for a good quality of life for people living with HIV and in need of ART when the Operational Plan for Comprehensive HIV and AIDS Care, Management and Treatment for South Africa was approved by the National Department of Health in 2003 . The National Department of Health’s antiretroviral treatment revised guidelines state that adults and adolescents are eligible for ART if they meet medical criteria and psychosocial considerations . Furthermore, it means that the patients should meet these criteria to be able to start the treatment; the patient should be psychologically and medically ready to start ART, because ART is not an emergency. In addition the eligibility criteria for ART initiation have been revised to increase access to treatment, with effect from 1st January 2015. The medical criteria include children under the age of 5 years old, Adolescents and Adults with CD4 of < 500 cells/mm or a diagnosis of WHO stage 3 and 4 diseases, irrespective of CD 4 count or WHO staging .
Furthermore, there is the psychosocial consideration that patients should have attended three or more scheduled visits, no active alcohol or substance abuse, disclosed of HIV status to at least one family member or joined support group and is able to visit the treatment centre on a regular basis .The strict adherence to antiretroviral therapy (ART) is the key to sustained HIV suppression, reduced risk of drug resistance, improved overall health, quality of life, and survival . In addition, poor adherence to antiretroviral medication accelerates the development of drug resistant HIV, whereas without adequate adherence, antiretroviral agents are not maintained at sufficient concentrations to suppress HIV replication in infected cells and to lower the viral load. Furthermore, it is important to identify and address challenges to complete adherence when starting ART, because adherence is such an important part of the treatment . It is clear that adherence is a cornerstone of a successful ART programme. It can promote retention of patients on ART for longer periods and the attainment of optimal health. Furthermore, The NDOH emphasizes the importance of adherence and suggests having a communication strategy that includes daily adherence reminders and re-adherence counseling at every clinic visit .
3. RESEARCH DESIGN
The research was conducted using the qualitative enquiry method to collect data. The goal of the paper was to evaluate and identify challenges of the ART implementation in South Africa. Given this goal, a qualitative method approach was called for. In this study, data were collected using interviews conducted with the people living with HIV who are on ART. Qualitative research is any data gathering technique that generates open-ended, narrative data .
3.1. Sampling strategy
Following the intensity sampling strategy as described , the researcher purposely recruited participants attending the wellness clinic in the facility. The participants for the face-to-face interviews were purposefully chosen as they present themselves at the wellness clinic. On a daily basis, clients present to a dietician consulting room for dietetic services. As they present to the Dietician (researcher), the researcher had an opportunity to request them to participate in the study. Those accepted to be part of the study were interviewed and five participants accepted to participate in the interviews.
4. DATA GENERATION STRATEGIES
Since a qualitative research design was used , the researcher followed one data generation strategy. It is discussed in greater detail below. The data collection is defined as the precise and systematic gathering of information relevant to the research purpose, objectives and questions . The researcher was totally involved and able to interact with the participants.
5. DATA ANALYSIS
The interviews data, which was collected by means of tape recorder, was transcribed. The theoretical framework used in the research guided the conceptualization of the categories and themes in the data analysis. In this study, data analysis will start with listening to the tape recordings numerous times. The tape recorded interviews will be transcribed and translated to English. Similar patterns were extracted from the interview transcripts. The data were coded and analyzed manually. Themes were identified. In thematic analysis, the researcher is predominantly interested in the emergence of themes from the collected data.
6. DISCUSSION OF THE PAPER
6.1. HIV AND AIDS IN SOUTH AFRICA
The NDOH indicates that public sector antiretroviral provision has had a slow start in South Africa due to political denials despite a raging epidemic and a World Aids Conference that shed a light on the disparities of therapy access globally . In addition, the South Africa has the largest number of people living with HIV (PLHIV), estimated at 6.4 million, and by far the largest number of people on antiretroviral therapy (ART) in the world: almost 2.5 million have started ART in South Africa with a total population of 54 million people . Besides the logistical challenges that a programme of this scale presents, the expanding number of people requiring treatment poses significant resource challenges .
Following a troubled period, in which the South African government failed to come up with an appropriate treatment plan and which was accompanied by wide controversy and active campaigning within civil society, the government announced a gradual ART roll-out in 2003 . South Africa’s decision to start offering ART at facilities and committing itself to fighting the disease has brought some relief after its long-standing indecisiveness on this issue. In addition, there are between 1.6 and 2.0 million additional PLHIV eligible for ART initiation at CD4 T-cell counts of < 500 based on the 2015 WHO Antiretroviral Treatment Guidelines [19, 11].
In addition, it is indicates that between 300,000 and 500,000 people have become infected annually over the past decade, while the capacity of the National Department of Health system to start people on ART has expanded by only 20%. It is difficult to overestimate the suffering that HIV has caused in South Africa. Not only the person living with HIV in South Africa - or in any other country - are affected, but also their families, friends and the wider community. However, after years of controversial AIDS treatment history and the refusal of the South African government to provide ART to people living with HIV in South Africa, the South African government finally announced its approval to start offering ART in 2004.
The treatment programmes have access to medication choices and monitoring that is in line with international guidelines, with the most recent improvements including fixed dosed combination (FDC) ART, including treatment for pregnant and lactating women and access to salvage regimens as reflected in the government HIV treatment guidelines . According to HSRC, it is estimated that 12.2% of the population (6.4 million persons) were HIV positive, which is 1.2 million more PLHIV than in 2008 (10.6% or 5.2 million) .
6.2. HIV AND AIDS IN THE LIMPOPO PROVINCE
The National Antenatal Sentinel HIV and Syphilis Prevalence Survey (2012) shows that the Limpopo Province is seven-highest in terms of HIV prevalence in the country, after six other provinces such as KwaZulu-Natal, Mpumalanga, Free state, North West, Eastern Cape and Gauteng.
The report further indicates that Limpopo is amongst the few provinces that have shown an increase in the overall prevalence rate, that is, from 8.8% in 2010 to 9.2% in 2012. The Limpopo Province has five District Municipalities, the Capricorn, Vhembe, Mopani, Sekhukhune and Waterberg Districts. It borders on Gauteng, the North West, Mpumalanga Provinces, the Republic of Mozambique, Zimbabwe and Botswana. There is a lot of migration to and from these neighboring countries and provinces. Dr. Mabasa, the MEC for health in Limpopo province indicated that the Waterberg District (under which the chosen research site falls) continues to be the highest in new HIV infections in the Limpopo Province estimated at 30.3% at the end of 2012 This high rate of infections in the Waterberg District is attributed to high numbers of migration of contract workers in the Lephalale Local Municipality . The ART programme implementation in the province was a call from National Department of Health for all hospitals in the country to be accredited to offer ART services .
6.3. SOUTH AFRICAN ANTIRETROVIRAL TREATMENT (ART) PROGRAMME
South Africa has the largest antiretroviral treatment (ART) programme in the world and has made significant strides in improving ART coverage ). The South African government, with the assistance of international funders and non-governmental organizations (NGOs), has managed to roll out a very effective ART programme since 2004 free of charge to the people living with HIV (PLHIV). At the end of 2009, an estimated 37% of infected people were receiving treatment for HIV . In mid-2011, following the launch of the HIV Counseling and Testing (HCT) campaign by the SA National Department of Health in early 2010, it was announced that the number of people on ART had increased significantly from 923,000 in February 2010 to 1.4 million in May 2011 . However, HRSC (2012) reported that South Africa has reached a target of universal access to treatment with 2 million people initiated on ART by October 2012.
The introduction of the revised treatment guidelines which prescribed that HIV- infected individuals should be initiated on ART at a CD4 count of 500 and less has an impact on the attainment of this . This directly promotes the strategy of using ‘treatment as prevention’ which espouses the notion that putting people on ART earlier will positively impact on the lowering of the overall number of new HIV infections and therefore result in fewer people needing treatment . With the inability of various countries to control the HIV epidemic and the increasing number of new HIV infections, the treatment as a preventative measure for HIV infections was introduced. ART has been shown to be effective in preventing the acquisition of HIV infection when given as a prophylaxis before or after exposure to HIV to prevent transmission from HIV infected persons .
A recent shift proposed in the approach to curbing the scourge of HIV is the ‘test and treat’ strategy. This is the model of universal voluntary HIV testing with immediate commencement of ART for those diagnosed HIV positive . Furthermore, it is proposed as another form of using treatment as a preventative measure for HIV infection. The model is likely; however, to have its own challenges relating to adherence and needs to be explored further as a prophylactic model for HIV. The provision of ART to persons living with HIV and requiring treatment in South Africa has brought hope to people who otherwise would not have survived. In addition, it has led to improved quality of life, reduced morbidity, mortality and the number of deaths resulting from AIDS-related illnesses and has generally prolonged the lives of many people living with the virus . In addition, The UNAIDS reports that there is a noted decline in the number of AIDS-related deaths by at least 24% since 2005 and in 2011 there were 1.7 million deaths reported . Despite these advantages, though, the ARV roll-out programme has had its fair share of challenges such as non-adherence or poor adherence to ART and the resultant high incidence of patients being lost to follow up or dropping out of the programme. Although public sector programmes for providing ART in the Sub- Saharan region have matured tremendously, a high rate of patient attrition is still evident. They further note that while much of the attrition is due to mortality, a loss to follow up or disappearance of patients from treatment, with no apparent reason, is very common.
Approximately 59% had disappeared from the system and could not be accounted for in the first year of being initiated on treatment . The international studies such as the one conducted by Atav, Senir and Darling reported that the knowledge of HIV and AIDS patients and the public in general regarding HIV and AIDS policies, such as the ART policy of South Africa, is still not sufficient to form a basis for change in behaviour among the at-risk groups and people living with HIV . According to NDOH, the ART policy of South Africa does not address the issue of poverty among people living with HIV until their CD4 count is below 500, which is when the patient qualifies for a disability grant provided by the Social Department of South Africa. Furthermore, the policy indicates that people who are HIV positive and have a CD4 count of less than 500 or have reached stage 4 of the WHO clinical staging, qualify for a disability grant and should be started on ARV immediately. Obviously the protocol of initiation of ARV has to be followed . This leads to people intentionally having sex with someone who is HIV positive, or they stop taking the ARV drugs so that they can qualify, or so that the disability grant should not be stopped. For example, high-risk groups such as commercial sex workers, due to poverty and the need to survive will engage in unprotected sex in order to earn money . High-risk sexual engagement such as sex without using a condom yields more customers and a higher income. Change in behaviour is dependent on what the individual perceives as benefits as opposed to what the individual perceives as risks or threats .
Patients are more inclined to change their sexual behaviour after the initiation of ART and prevention counseling . Sexual desire changes over time, with many in their research reporting diminished desire at 3 to 6 months of taking ART as compared to 18 to 24 months of use. Some patients reported that they feared re-infection or infecting others, or that engaging in sex would awaken the virus and weaken them, and that they might die . Hoang, Ding and Groce researches on female African-Americans indicate that most respondents believe that they will pray to God, or according to their culture, they believe that their husbands or boyfriends are being faithful . It is evident in most of these studies that patients living with HIV and AIDS lack knowledge about antiretroviral treatment .
7. LEGAL FRAMEWORK INFORMING SOUTH AFRICAN ART PROGRAMME
According to Sithole (2013), there are two important strategic documents informing the NDOH ART programme in South Africa: namely, the National Strategic Plan (NSP) and the National Antiretroviral Treatment Guidelines to assist with the implementation of the programme. These two documents are discussed briefly below.
7.1. National Strategic Plan (NSP) of 2012-2016
The NSP reflects the progress made in achieving a clearer understanding of the challenges posed by these epidemics and the increasing unity of purpose among all the stakeholders, who are driven by a shared vision to attain the highest impact of policies towards long-term vision of zero new HIV and TB infections . NDOH indicates that ART expansion programme has resulted in an increase in ART facilities countrywide to about 2 552 currently and more people accessing treatment. The NSP focuses specifically on expanding the quality and reach of health and wellness and is geared to addressing the gaps identified in the previous NSP of 2007-2011. The gaps identified include inadequate co-ordination of the public sector, private sector and non-government sector responses, the weak governance and co-ordination structures of SANAC (from ward to national level), the lack of robust monitoring and evaluation of the NSP, the failure to ensure a truly multi-sectoral and integrated response, weak focus on human rights and justice, and the lack of a comprehensive and integrated approach to HIV and TB prevention. The NSP suggests that these gaps be addressed through annual HIV testing for everyone in South Africa, initiation of every HIV-infected individual on ART when their CD4 count is 500 and less and the strengthening of adherence counseling programmes to ensure retention in care .
7.2. National Antiretroviral Treatment Guidelines 2004 and 2015
The main purpose of these guidelines is to improve the clinical outcomes of people living with HIV, to reduce morbidity due to TB/HIV co-infection, to reduce HIV incidence and to avert AIDS-related deaths in the most cost- efficient manner by ensuring that people living with HIV start with the right therapy at the right time. The National Antiretroviral Guidelines also seek to ensure timely HIV diagnosis, management, treatment and initiation of ARVs for treatment for all eligible populations to achieve best health outcomes in the most cost-efficient manner . The NDOH focused on defining adherence and formulating strategies to support and improve adherence to ART, clearly defining roles and responsibilities of the Health Care Team .The NDOH indicated that the Honourable President Jacob Zuma announced new key interventions to improve antiretroviral treatment (ART) access to special groups such as HIV positive infants, pregnant women and TB and HIV co-infection . This announcement resulted in more than 2.6 million people being initiated on ART by mid-2014 . Furthermore, in 2013, the fixed-dose combination pill (FDC) was introduced, made up of the regular three drugs used in the first-line regimen to improve adherence and retention .
In addition, in 2014, the South African Minister of Health, Dr. Aaron Motsoaledi announced that the threshold for initiation of ART will rise to CD4 count <500 cells/pl and that the PMTCT programme will now adopt the B+ approach, which entitles every pregnant and breastfeeding woman to lifelong ART regardless of CD4 count or clinical stagin.In the new guidelines effected by NDOH, the approach focused on providing the patient with a comprehensive treatment plan and on-going monitoring to ensure adherence. In January 2015, the treatment guidelines were reviewed and a new set was introduced which re-emphasized the importance of adherence and of socio- economic support so as to ensure positive treatment outcomes for patients and the identification of issues that impact on optimal adherence.