The HIV Good News by Carol Cragg

The HIV Good News by Carol Cragg

It is very easy to become disheartened, even depressed about the HIV epidemic in our country. We read that South Africa has the biggest epidemic in the world. Of our adult population 16.6% – that is 5.6 million people – are infected with the virus.
But I have been asked to share some of the good news on the HIV front with you. This is by no means intended to deny the enormous suffering of some many people living with HIV, nor to allow ourselves to become complacent. There is in fact much to be excited about.
The first encouraging fact is that SA also now has the biggest ARV programme in the world. Almost 2 million people are on ARVs – probably about 60% of those who need it. The number of those on treatment rises every year, and so too does the number of people starting on treatment. So in Khayelitsha, for example, a few years ago, about 250 people started ARVs per month – now it is closer to 500. And these 500 join the over 26,000 Khayelitsha residents who are already on treatment.

Secondly, there is increasing evidence that mortality rates which rose alarmingly in the 1990s and 2000s are progressively declining – especially amongst those hardest hit by the epidemic – young adults between the ages of 20 and 35. A recently published study showed that in KZN, the average life expectancy was 49 years in 2000 and has increased to 60. This illustrates what we have come to realise – that HIV can be viewed and treated as a chronic disease – as is the case with high blood pressure, diabetes and other so-called chronic diseases of lifestyle. This is why you might notice that I seldom use the word patient. We are rather dealing with increasing numbers of well people who happen to have HIV.
Thirdly, in many parts of the country, the number of babies born with HIV has been dramatically reduced: we have moved from a situation where, without any form of intervention, over 20% of babies born to HIV-positive mothers would contract the virus, to a position where in many areas – including the Western Cape – fewer than 4 out of a 100 babies become HIV positive. And this is set to decrease even further with the announcement in the last 6 weeks of a new policy which will see ALL HIV positive women receiving ARVs during pregnancy – and in the Western Cape at least, all these women will be able to continue this treatment lifelong. This will make it possible for Moms to breastfeed their babies with minimal risk of passing on the virus: babies will be able to derive the benefits of breastfeeding and avoid the risks of bottle feeding – especially in areas where unclean water and little or no electricity make it so difficult to prepare safe feeds. And it means that MOMs are far more likely to live to see their children grow up.

Being on ARVs not only decreases the chance of dying, but because they work by reducing the levels of virus in the blood, ARVs make it far less likely for an HIV-positive person to transmit the virus to another. Many see this as a possible way of getting the epidemic under control. This is what is behind a large research study about to start in several areas in Cape Town – it is called POPART – short for Population ART. In some of the communities, families will be visited at home regularly, and offered HIV testing. If positive, they would be encouraged to start ARVs immediately – not to delay it until their immune system has deteriorated to the point where they would qualify for ARVs under current policies. In other communities it will be ‘business as usual’. Researchers will then be able to determine whether a such a strategy would be effective in significantly reducing the spread of infection on a large scale.

Like other chronic medication, ARVs can only work if people continue to take them. Understandably not everyone manages to do this for a variety of reasons – and this raises big concerns – one of which is the possibility of developing resistance to the drugs. Thankfully adherence to ARVs in our country compares very favourably with that in other countries – estimates are that over 70% of people are still taking their ARVs after 3 years.
There are 2 recent interventions which we hope will make it easier for people to adhere to treatment. The one is a model of care piloted here in Cape Town which Rhoda Kadalie mentioned in church as few weeks ago. It is – as school kids might say – a no-brainer. It became very clear that patients who had been on ARVs for some time, and who were completely well, were spending hours at busy clinics many times a year simply to collect their medication. This was obviously a major disincentive to continue to take treatment – especially if you had returned to work. It also meant that as the patient numbers grew, the problem worsened. Scarce staff resources were being spent on people who really did not need intensive medical care to the detriment of sick patients. We now run so-called adherence clubs, facilitated by a lay person, where such patients – in whom the virus is under control, meet in large groups where they have a brief check-up and a chat, are handed their meds and are off within an hour. These clubs can be held either first thing in the morning, or even after hours – which makes it possible for people to hold down a job or simply get on with their lives. Some meet in their clinics, others in community venues such as libraries and churches and we are currently investigating whether it is possible to run such clubs from the homes of group members. In recent months, there has been much enthusiasm to adopt this model of care in many parts of the rest of the country.

The second move that should assist patients to adhere to their treatment is the so-called FDC – the single tablet treatment that many of you will have heard or read about recently. For ARV treatment to be successful, one has to take 3 different drugs, each of which works in a different way. This could mean taking a minimum of 3 tablets twice a day – sometimes many more. The FDC – fixed dose combination – combines 3 different ARVs into 1 tablet that need only be taken once a day. And thankfully, the 2 ARVs which have potentially serious, sometimes fatal side effects, are not included in the FDC – in fact they are being rapidly phased out altogether.
In summary then : the tide has certainly turned in this country: treating large numbers of HIV positive people with ARVs is saving and prolonging lives, and reducing the number of new HIV infections. More attention is being given to how to make it easier for people to stay on treatment lifelong.

Lastly, for the first time, we are hearing reports of it being possible to ‘cure’ HIV. The most recent was a baby who was tested very soon after birth and shown to be positive. The baby was started on ARVs almost immediately. It seems that this prevented the virus from establishing itself in the baby’s immune system and starting to reproduce itself there. The baby tested HIV negative some time later. Who knows where we will be in another 10 years?
Carol Cragg
on behalf of HIV/AIDS committee, RUC
26 May 2013