On-line version ISSN 2078-5135
SAMJ, S. Afr. med. j. vol.101 n.7 Cape Town Jul. 2011
FROM THE EDITOR
'No more whispers' - 30 years of HIV/AIDS and 10 years of HIV treatment in South Africa
The title is from the programme of the 5th South African AIDS conference1 held in Durban in June. The conference brought together clinical scientists, basic scientists, educators and learners, law and human rights experts, practitioners (doctors, nurses, community carers), community workers, NGOs, members of civil society and lay members of so-called key populations (e.g. sex workers), pharmaceutical industry representatives, people from the world of work, politicians and policy makers.
June 2011 marked the 30th anniversary of the recognition of the pandemic, then manifesting in New York as outbreaks among the gay population of Kaposi's sarcoma and pneumocystis pneumonia in ostensibly healthy young men. A year later the Centers for Disease Control coined the term 'acquired immune deficiency syndrome' - AIDS.
A soaring death rate led to a scramble to identify the cause. Assigning credit for the discovery of HIV was controversial, but it is agreed that Robert Gallo, a 'retrovirologist' at the National Cancer Institute, Maryland, Luc Montagnier and their research groups contributed significantly. Montagnier's group first isolated HIV, while Gallo's group demonstrated that the virus causes AIDS and generated much of the science that made the discovery possible, including a technique previously developed by Gallo's laboratory for growing T cells in the lab.2 There have since been breathtaking scientific advances, and understanding of the virus's structure, mode of replication and targeting of the immune system have led to the development of drug therapy to restore immunity, although not yet to cure infection, and tools and methods to limit transmission.
South Africa has proved particularly vulnerable. While having 0.7% of the world population we carry 17% of the global HIV burden, and 1 out of every 100 South Africans has tuberculosis. The Durban conference celebrated the enormous continuing contributions by South African professional and lay health communities. Our scientists and practitioners have played pivotal roles in the field, many reported in this journal and its sister, the South African Journal of HIV Medicine. The dark days of denialism have ended and reduction of a vicious epidemic is envisioned on the back of the National Department of Health's Strategic Priority Framework for the New HIV/STI and TB National Strategic Plan and New Primary Healthcare Revitalisation Programme. The health system's robust new approach encompasses a massive HIV counselling and testing (test one - test all) campaign, antiretroviral (ARV) treatment and expansion of medical male circumcision.3
The Conference also saw the launch of an operational plan aimed at implementing the UNAIDS Accelerated Agenda for Women, Girls, Gender Equality and HIV. This calls for national responses to anticipate and address the particular vulnerability of women and girls to HIV.
In June we also celebrated the 10th anniversary of the commencement of the Médecins Sans Frontières (MSF) programme in Khayelitsha, which has showed that people in impoverished areas are capable of adhering to schedules for taking a cocktail of drugs. As Vuyiseka Dubula of the Treatment Action Campaign, South Africa's best known AIDS activist organisation, has said: 'The West or the northern world said we were too poor to treat: "They can't even tell the time." To their surprise, we beat them on adherence. We adhere better than they do.' One of the MSF clinic's first AIDS patients was losing weight, vomiting and sick with diarrhoea in 2001, and 10 years later claims that but for the programme 'I would not have received this treatment and I would not have survived.'4 Now one million South Africans receive anti-AIDS drugs.
Significant breakthroughs occurred in 2010 in developing biomedical prevention tools for HIV. South African communities, health workers and scientists contributed significantly to these developments, including synthesis of microbicides, pre-exposure HIV prophylaxis and vaccines. In a trial of couples where one partner was HIV positive and the other negative, if the HIV-positive partner was on ARV medication, their partner was protected from infection by a massive 96%.5 Francois Venter, President of the Southern African HIV Clinicians Society, stated that this is 'possibly one of the most important HIV studies of the decade'. 1 Male circumcision offers 54% protection from HIV, while a study of gay men found that taking an ARV called Truvada before sex could prevent HIV transmission by 44%. A trial in Tanzania found that if sexually transmitted infections were treated, transmission was reduced by 42%. Finally, a microbicide vaginal gel containing the ARV tenofovir can reduce HIV infection by 39%.6
South Africa seems set to enter an era of HIV management with the prospect of arresting the epidemic! More must be done, of course, not least to offer all who test HIV positive ARV therapy timeously and before immunity is imperilled, i.e. at a CD4 count of 350 cells/µl. This explains the appeal to health professionals by Finance Minister Pravin Gordhan that we pressure the pharmaceutical industry to ensure that developing countries get cheaper ARV medication. He cited the billions of rands saved in awarding the recent ARV tender following an approach that involved greater interaction between the Treasury and the Health Department.
Most of all, South Africa needs to adopt a 'no more whispers' policy to put an end to discrimination against people living with HIV/AIDS and to ensure that no greater shame or stigma attaches to being HIV infected than it does to having TB or being epileptic.
1. The 5th SA AIDS Conference. http://www.dirasengwe.org/5thsaaidsconference.html (accessed 8 June 2011). [ Links ]
5. Treating HIV-infected people with antiretrovirals protects partners from infection. Findings result from NIH-funded international study. www.scribd.com/doc/55281522/NIH-HPTN-052-Press-Release (accessed 9 June 2011). [ Links ]
6. Whole new toolkit to prevent HIV. Karim SA, quoted by Kerry Cullinan in 'Govt ready to treat all people with a CD4 count of 350'. www.health-e.org.za/news/article.php?uid=20033178 (accessed 9 June 2011). [ Links ]