A great crisis and greater measures: Transforming the South African health system

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Dr. Jennifer Cooke (far left), Ambassador Eric Goosby, Dr. Aaron Motsoaledi, and Dr. Michael Sinclair listen to a question from the audience during Tuesday's Kaiser/CSIS forum on South Africa.

In front of a packed audience at the Kaiser Family Foundation (KFF), South African Minister of Health Dr. Aaron Motsoaledi painted a picture of South Africa showing that while significant progress is being made, the war against AIDS is far from over.

In some districts of KwaZulu-Natal (KZN) province, HIV prevalence is as high as 46 percent.

The death rate in the country doubled from 1997 to 2006 – six out of 10 deaths in 2006 were AIDS-related.

And maternal mortality is getting worse – 59 percent of women who died during childbirth were posthumously tested for HIV from 2005-2007, 79 percent of those tested were HIV infected. Among HIV-negative women in South Africa, 34 out of every 100,000 live births result in the mother dying. Among HIV-positive women, that number jumps nearly 10 times.

AIDS disproportionately affects people of child-bearing age, leaving the elderly behind. In his visits to KZN, Motsoaledi recounted how often he would see a grandmother caring for a household with 10 children. “They said to me, ‘These are my daughters’ children. [My daughters] are all gone.’”

A slide from Dr. Motsoaledi's presentation showing the increase in infant mortality as the AIDS epidemic progressed in South Africa.

But the children face more than just orphan-hood. In 2007, 57 percent of deaths in children less than five years of age in South Africa were due to HIV/AIDS. “A baby with HIV is fifteen times more likely to die within the first six months of life,” Motsoaledi said.

The health minister relayed these harrowing details during a forum convened by KFF and the Center for Strategic and International Studies Tuesday, alongside U.S. Global AIDS Coordinator Eric Goosby, MD.  The meeting focused on transforming the South African health system in response to the AIDS epidemic, and the devastating impact of the tuberculosis (TB) co-epidemic. These two infectious diseases together pose the greatest threat to the health and prosperity of his country, Motsoaledi said.

South Africa has the fifth highest burden of TB in the world.  But what stands out about South Africa among the ten countries with the highest TB burden is the high rate of HIV/AIDS co-infection, Motsoaledi said. In India and China in 2007, co-infection rates were 5.3 and 1.9 percent, respectively.  HIV-related TB in South Africa, however, was 73 percent.

A sea change

But all the news about HIV and TB in South Africa is not bleak.  Since the election of Jacob Zuma as president and the appointment of Motsoaledi as health minister, the days of the South African government ignoring the devastation of HIV and TB are over.   South Africa has moved from being the center of so-called “AIDS denialism” to being a leader in the AIDS response in Africa.

Since his appointment in May 2009, Motsoaledi has made efforts to further reform the health system to more effectively respond to the HIV/AIDS and TB epidemics. One of the key components of this is country ownership of the crisis.

“South Africa has always been the primary funder of treatment,” Goosby said, and while South Africa is the country with the largest number of people living HIV, it is also home to the largest number of people on antiretroviral treatment on the planet.

“It is extraordinary what has been done under Zuma given the burden of disease they are confronted with,” Goosby said.

On World AIDS DAY 2009, Zuma announced aggressive plans to initiate prevention of mother-to-child transmission interventions at 14 weeks rather than 28 weeks, in line with the World Health Organization recommendations updated in 2010. The government is also participating in an ambitious HIV testing and counseling initiative to reach 15 million people by June of 2011. Of the 9 million that have already been tested, 1 million tested positive.

Motsoaledi is urging all members of parliament to be tested, and wants to take the campaign to schools and universities. The health minister is also working with leaders of industry to incorporate HIV testing and linkages to care and treatment in the workplace.

Lessons Learned and Advances Made

Motsoaledi reflected on some of the lessons that have been learned. Early in the HIV epidemic, South Africa decreased family planning services and promoted condom use in the place of other forms of contraception, with the aim of preventing HIV in the process. The concern was that people would not use condoms if they had alternative contraceptive options.  An unintended consequence – the number of abortions in 2006 was nearly four times the number in 1997. Motsoaledi said they were now returning to promotion of family planning services, and was delighted at the prospect of a microbicidal vaginal ring currently being studied. A microbicide ring preventing HIV paired with a contraceptive would be “a revolution,” he said.

Through the country’s work with the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) program, the South African government realized it was buying the most expensive antiretrovirals on the planet. Subsequently PEPFAR helped to cut the price of imported HIV medicines by 58 percent, allowing the nation to more than double the number of people on treatment.

Another challenge is addressing TB infection rates among mineworkers, a primarily migrant population.  Many men come from neighboring countries to work in South Africa’s mines and diagnosing and treating TB gets somehow lost in transit.  Not only is their own treatment potentially disrupted when they travel home to other countries to see their families, but they potentially bring infectious tuberculosis home with them. Motsoaledi plans to call on all ministers of health in sub-Saharan Africa, as well as the labor and minerals ministers, to address this issue and create a TB/HIV plan for the entire region. 

Motsoaledi also commented on the health care worker (HCW) shortage, and that he is searching for creative ways to train and retain them. His methods include encouraging big industry CEOs to sponsor the education of doctors and nurses, as well as creating a university to train mid-level HCWs for four years, who will be able to perform some of the work that doctors can. South Africa also created some 2,000 centers to train high-quality nurses to initiate antiretroviral therapy. All of these efforts, Motsoaledi said, were to the benefit of neighboring countries as well, noting that Lesotho and Swaziland don’t have medical schools.

To combat the spread of TB, Motsoaledi said the country now has one multi-drug resistant TB hospital per province. They are also “taking the battle to households” to visit, screen and test the families of the more than 400,000 people living with TB in South Africa. Teams of five are heading out to the different provinces, and as of the beginning of February 18,000 families have been visited.

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