TREATMENT ACTION CAMPAIGN - Special edition, Congress August 2017 - Spotlight
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ACTION
CAMPAIGN
Special edition, Congress August 2017
TREATMENT
on the state of health in South Africa
incorporating the NSP Review
Edition #3 – August 2017In this issue www.Spotlightnsp.co.za
THE STATE OF MENTAL HEALTH AND SPOTLIGHT ON @SpotlightNSP
TAC IN 2017 PILL-TAKING HEALTH MECS
TRIBUTE Spotlight NSP
MARK HEYWOOD
Pledge for Prudence. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Published jointly by the Treatment
TREATMENT ACTION CAMPAIGN Action Campaign and SECTION27
The state of TAC in 2017. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 Editors: Marcus Low & Anso Thom
Journalists: Ufrieda Ho, Ntsiki Mpulo
LIVING WITH HIV
PROFESSOR FRANCOIS VENTER Contributors: Mark Heywood, Professor
Francois Venter, Dr Michelle Moorhouse.
Mental health and pill-taking: Getting beyond HIV. . . . . . . . . . . . . . . . . . . . . . . 9
Ufrieda Ho, Marcus Low
TREATMENT OPTIMISATION Design: the earth is round
DR MICHELLE MOORHOUSE
Spotlight is produced with the
Modernising ART. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 support of the South African
After funding shortfalls and Professor Francois Venter on Ufrieda Ho profiles the
the state of health in South Africa
Development Fund.
a difficult restructuring in dealing with the psychological Gauteng and Limpopo TREATMENT ACTION CAMPAIGN
incorporating the NSP Review
2014/2015, TAC heads to impacts of living with HIV. provincial Health MECs Spotlight on TAC provinces. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
its National Congress in a Page 9 in this Spotlight series
Edition #3 – August 2017
EDITORIAL INDEPENDENCE
SPOTLIGHT ON HEALTH MECs
much healthier state. Page 20 UFRIEDA HO The opinions expressed in Spotlight do
Page 5 Take two for Granny Gwen. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20 not always reflect the views of TAC or
Building health infrastructure – and Brand Phophi. . . . . . . . . . . . . . . . . . . . . . 22 SECTION27.
NATIONAL STRATEGIC PLAN
NSP in brief. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
STATE OF SANAC STATE OF TB IN MEMORIAM SOUTH AFRICAN NATIONAL AIDS COUNCIL
State of SANAC. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
TUBERCULOSIS The Treatment Action Campaign
State of TB . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29 (TAC) advocates for increased access
Spotlight
to treatment, care and support
services for people living with HIV,
TUBERCULOSIS
and campaigns to reduce new HIV
MARCUS LOW infections. Learn more about the
TAC survey highlights poor infection control in clinics. . . . . . . . . . . . . . . . . . . 30 TAC’s work at www.tac.org.za.
IN MEMORIAM @TAC
Farewell to two powerful activists . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
WWW.SPOTLIGHTNSP.CO.ZA
Online highlights . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
We take a look at the trials Ten things you need to We pay tribute to the late
SECTION27 is a public interest law
and tribulations currently know about the state of Kholiswa Sondzaba, and centre that seeks to influence,
faced by the South African tuberculosis in South Africa. Thandiwe (TK) Sebeni. develop and use the law to protect,
promote and advance human rights,
National Aids Council. Page 29 Page 32 particularly the right to health.
Page 27 Learn more about SECTION27’s
work at www.section27.org.za.
@SECTION27newsTRIBUTE
Pledge for
Prudence
Mark Heywood
One of the early TAC leaders and founders Prudence Mabele died
in July. Her death came as a shock, but even in death Prudence
has catalyzed discussions on resistance, treatment fatigue and
other challenges. Spotlight pays tribute to this giant of the
struggle via a heartfelt and powerful obituary delivered by
Mark Heywood at her memorial in Johannesburg last month.
My dear friend and comrade Prudence
Thank you for honouring me as a ‘friend’ granted. Sometimes we activists are so against corruption. Against those who are
to speak at your funeral. You have many ‘busy’ that we pass each other like ships parasitical on the response to AIDS. There
beautiful friends and comrades, so I am in the night. But ‘busy’ with what, if we are two streams in civil society: yours is
not sure why I am the one to speak. don’t leave time for our friendships? the stream that flows cleanly and clearly.
That is why, first, I must pay tribute to I feel I did take you for granted – Two years ago, you wrote to me to
your better friends and comrades, and you had been a part of my life since complain about people who stabbed
thank them for the support and love they the middle of the 1990s. We in-ed and you in the back. I am sorry that you died
have shown you during and after life. out-ed conferences together, marched still feeling betrayed. You said, “While I
Prudence, you were an activist – a together, mourned together, mobilised was at home sick with PCP and vertigo
warrior woman – a woman in a line of together. I remember you in the earliest … I was removed like Thabo Mbeki – at
activists; many of whom have passed, days of the Positive Women’s Network, SCF (SA AIDS Council) a motion was
some of whom are still larger than of the AIDS Consortium, of TAC. passed and my removal happened;
life. I think of Charlene Wilson, Sarah This week I found a picture of you mostly friends nominated each other,
Hlahlele, Yvette Raphael, Vuyiseka with Vavi, Zackie Achmat and me, and without a quorum.” You told me
Dubula, Sipho Mthathi, Vovo Gonyela, celebrating the victory of TAC over that “there’s a lot you do not know that
Anso Thom, Bev Ditsie, Phindi Malaza, the Pharmaceutical Manufacturers’ makes me disagree with my chair, and
Phumi Mtetwa, and Sharon Ekambaram, Association in 2001. If we could because of that I am now victimised”.
to name a few in a long line. excavate my memory, I’m sure we The people who undermined you now
Indeed, the best leaders that I would find pictures of you when we preach unity. But unity means we must
know in the response to oppression won over PMTCT; when we protested be silent about their transgressions.
and violence – of which HIV is just at the International AIDS Conference in We will build unity. Yes we will! But
a part -- are the women who have Toronto; when we re-established the SA it will not be a fake unity. It will be
risen to fight in solidarity with other National AIDS Council. Recently, I saw unity with the poor, the marginalised,
women; honest women, incorruptible, a picture of you marching to demand the violated and discriminated against.
self-sacrificing, principled. the resignation of Jacob Zuma. Unity with sex workers. Unity with the
#16 – August 2017
#16 – August 2017
Prudence, at your funeral I have to A book should be written about your vulnerable. What we won’t do is build
decide whether to speak like you – always life. We need to tell your story – not just unity with thieves and murderers.
principled, brave, bold, sometimes rude for those who know it, but for those who Remember, one of the oldest slogans
– or like me: more shy, careful, cautious, don’t; because it is a story of courage of the AIDS movement was ‘Silence =
scared about speaking truths to power. and hope. It is the story of a heroine. Death’. Today, once again, there is far
You seemed never to be scared. One truth about you, Prudence, is too much silence. Once again there is
I will try to be something in between. that you were not a hypocrite. At the too much death. We have to stop the
spotlight
spotlight
Your death on Monday 10 July left time of your death, I hear people lament silence. We have to stop the death.
me numb. It left me feeling neglectful; that civil society is divided. People tell Prudence, I want to finish my
wanting. I had suddenly lost someone I us we must ‘overcome our divisions’, tribute by making a pledge to you.
loved (I realise now that I did love you), but you never had any truck with that. I ask those reading this to repeat
but whose life and presence I took for We were always divided. We are divided my words to themselves.
2 3TREATMENT ACTION CAMPAIGN
The state of
TAC in 2017
For you, Prudence, we will:
In August 2017, the Treatment Action Campaign (TAC) will have
++Ensure that all young women have access to PrEP and other ways of protecting
its five-yearly National Congress in Johannesburg. At the
themselves, in the same way that we fought for Nevirapine for pregnant women with HIV.
Congress, delegates from TAC branches across seven of South
++Campaign for the resources and political will to stop violence and
murder against women and the LGBTQI+ community. Africa’s nine provinces will agree on TAC’s priorities for the next
++Ensure the decriminalisation of women, men and five years, and elect the organisation’s national leadership.
transgender folk who engage in sex work.
After funding shortfalls and a difficult and on the radio, TAC has been well- treatment available to people living
restructuring in 2014/2015, TAC heads represented by its current leadership. with HIV, but government did not
For you, Prudence, we will: to its National Congress in a much In particular, Yawa has refused to be want to. In 2002 TAC took the matter
healthier state. Under the leadership intimidated on international platforms, to the Constitutional Court, and won.
++Never steal of TAC General Secretary Anele Yawa, and has consistently and forcefully Yet even after that victory in the
donors have been reassured and the represented the poorest of the poor in Constitutional Court, government
++Never manipulate
organisation has been stabilised; and meetings and at conferences. Under his still did not want to make treatment
++Never deceive or lie focus is again where it should be – leadership, TAC has been given moral available. It was only after the fall
on the urgent work of fixing South authority and a sharp political edge of former President Thabo Mbeki
++Never take advantage of AIDS, TB or any other cause of ill health, for our own benefit. Africa’s public healthcare system. – something it will need to maintain, in 2008 that things changed, and
In this regard, TAC has had a major if it is to remain relevant in South government committed to rolling out
success in the Free State, where a long Africa’s current political context. ARVs. Under the leadership of Minister
For you, Prudence, we will: campaign resulted in the removal Yawa – with the support of others of Health Dr Aaron Motsoaledi, there
of former MEC for Health Benny such as Deputy General Secretary followed a massive scale-up of ARVs –
++Recognise the intersectionality of AIDS with ensuring quality Malakoane, and a court victory for Sibongile Tshabalala, Chairperson something which has been so effective
education, employment, and stopping corruption. Fighting AIDS the #BopheloHouse94 (a group of Nkhensani Mavasa and Deputy that life expectancy in South Africa
wrongfully convicted community Chairperson Patrick Mdletshe – has has gone up from 54 to over 62.
means fighting for human rights and social justice.
healthcare workers), which clarified had to lead TAC not only through Government now has mostly good
++Call on our country’s’ leaders to wake up again to HIV the law regarding the right to protest severe financial difficulties, but also health policies, and says that all people
and TB. It’s not over. It’s not half over. in South Africa. In the Free State, TAC through major changes in the context with HIV should have access to ARVs.
has shown that it is possible to hold within which we find ourselves. These Yet while the policies are good, many
++Call on Deputy President Ramaphosa and the honest members of underperforming MECs accountable. leaders have recognised that the TAC are not implemented. Policy says we
the ANC to remove President Zuma from power, because we cannot TAC has also been hard at work in the needed today is not the same as the should have ARVs and other medicines,
Eastern Cape, Gauteng, KwaZulu-Natal, TAC that was needed ten years ago. but often we have medicine stockouts.
have a good response to AIDS in a corrupt government.
Limpopo, Mpumalanga and the Western Together they have guided the Policy says clinics should have good
Cape – often advocating for better organisation through change TB infection control, but many clinics
#16 – August 2017
#16 – August 2017
healthcare services at facility level. While in at least three key areas: do not have good infection-control
Prudence, we will remember you for as long much of this community-level work measures in place. Good policies are
never makes the headlines, it remains drawn up at national level, but in
as we live. Your life was not in vain. one of the key things that differentiates
TAC from other organisations working on
1. From a policy
struggle to an
many clinics and hospitals across the
country those policies are nowhere
healthcare. Particularly impressive was implementation to be seen. Due to mismanagement
a TB infection-control survey conducted and corruption, our healthcare system
struggle
spotlight
spotlight
by TAC members earlier this year (see is in a state of crisis – a crisis for
page 30 for more on that survey). For much of TAC’s history, they which poor people pay the highest
In meetings with the Minister of campaigned for government to price. TAC’s struggle has thus shifted
Health and UNAIDS, in speeches at change its HIV policy. They wanted from fixing the policies, to fixing the
International Conferences, on television government to make antiretroviral implementation of the policies.
4 52. From an HIV struggle recent initiatives is that all TAC branches must decide to what extent it wishes to
to a healthcare were mandated to adopt a clinic. In this remain an HIV organisation, or whether
system struggle way, TAC will increase accountability it will become an organisation for all
on the front lines, where people poor people who are dependent on
For most of TAC’s history, the focus has interact with the healthcare system. the public healthcare system. To some
been on HIV and related opportunistic More broadly speaking, however, there extent, this shift has already taken
infections. TAC’s biggest struggle so has been a shift in focus in the last five place in TAC’s work; but hopefully the
far, after all, was the struggle for ARVs. years from national to provincial, as Congress will make the shift explicit,
The T-shirts that made TAC famous TAC’s struggle has moved from a policy and make it clear that TAC is open
say ‘HIV positive’ on the front. Most struggle to an implementation struggle. to all – irrespective of HIV status.
importantly, TAC is a membership- In South Africa, the National Department The second issue, and one that is
based organisation, and most of our of Health decides on policies, but probably even more important, is
members are living with HIV – so HIV will the provinces are responsible for what decisions the Congress will make
always be a critical part of our work. implementation. Thus when TAC sees regarding the current political crisis in
Yet though we have won the battle for the policies are good, but the clinics are South Africa. While it is tempting to
HIV treatment, the healthcare system is still in crisis, it is the provinces TAC must keep TAC’s focus on health care only,
falling apart. And the healthcare system hold accountable. In recent years, for the reality is that corruption and state
is falling apart not only for people example, pressure from TAC has helped capture are impacting the healthcare
living with HIV, but also for people to unseat underperforming MECs for system. For example, the economic
with tuberculosis, diabetes or cancer. Health such as Benny Malakoane in the crisis has meant that health budgets
Thus when TAC campaigns for quality Free State and Sicelo Gqobana in the have been unable to grow as one
healthcare for all, the organisation Eastern Cape. It is critical that this kind would hope – which has contributed to
is not just campaigning for people of provincial-level work continues. posts in the public healthcare system
with HIV, but also for all brothers and being frozen and left vacant. While
sisters with other diseases. We all stand provinces lack the money to employ
in the same long queues. We are all Looking ahead more healthcare workers, the country is
harmed by medicine stockouts. In this losing billions of Rands to corruption.
new phase in TAC’s history, TAC has The 2017 National Congress will set Though TAC has taken a stance
the opportunity to be a home for all the direction for TAC over the next five against corruption and state capture
poor people who need healthcare, years. Much of TAC’s success in the years in a few media statements (TAC has
not just people living with HIV. to come will depend on the quality of endorsed the Save SA movement, for
the national leadership elected at the example), these statements do not carry
Congress. More than ever before, TAC the same weight as a firm and clear
3. From the national needs brave and dedicated leaders who Congress resolution. A critical question
to the provincial can think and act strategically in the for the 2017 TAC National Congress is
and the local interests of TAC’s members. The good thus whether the organisation will take
news is that in someone like Anele Yawa, a clear resolution against state capture
TAC has always done its work on all TAC already has a very strong leader. and call for the removal of President
levels, from local to national. The heart However, it remains an open question Jacob Zuma – given that he is at the
and life-blood of TAC has always been whether Yawa will be re-elected, and centre of most state-capture allegations.
its branches. The national victories we who the rest of the leadership team If TAC sidesteps or fails to be firm and
have won were only possible because would be. One would also expect at clear on this issue, its political relevance
of the power of TAC’s branches. Now least half of the national leadership will be much diminished. TAC’s attempts
more than ever, it is important that positions to be taken up by women. to fight corruption at provincial level
TAC’s branches remain strong, and that In addition to the leadership question, will simply ring hollow if TAC can’t take
TAC’s work is driven by its members there are at least two critical issues that a strong resolution on state capture
and its branches. One of the important the Congress must resolve. Firstly, TAC and corruption at the highest level.
#16 – August 2017
#16 – August 2017
TAC leaders 1998-2017
YEAR GENERAL SECRETARY CHAIRPERSON
1998 - 2003 Mark Heywood Zackie Achmat
2003 - 2005 Siphokazi Mthathi Zackie Achmat
2005 - 2007 Vuyiseka Dubula Zackie Achmat/Nonkosi Khumalo
spotlight
spotlight
2007 - 2010 Vuyiseka Dubula Nonkosi Khumalo
2010 – 2013 Vuyiseka Dubula Nonkosi Khumalo/Anele Yawa
2013 - 2017 Anele Yawa Nkhensani Mavasa
6 7LIVING WITH HIV
Mental health
and pill-
taking: Getting
beyond HIV
Professor Francois Venter, Wits Reproductive Health and HIV Institute, University of the Wiwatersrand
Recently, I took part in a chat show on Radio 702 to discuss how to
disclose one’s HIV status to one’s sex partners. Hosted by Eusebius
McKaiser, the show was vibrant, entertaining and challenging
– made more so by the other guest, Thula Mkhize. Thula is an HIV-
positive, heterosexual man in a discordant relationship (his
wife is HIV-negative). Thula speaks openly and passionately
about his sex life, and we chatted about the ethics of disclosing
on the first or second or third date, among other things.
Dating when HIV-positive can be very behaves as if he were doing her a huge HIV field and beyond, and generates
tricky. When do you disclose your favour, despite her being completely a lot of chatter on social media.
status to a new sex partner? How do non-infectious on treatment. These Pill fatigue is a difficult concept to
antiretrovirals impact on your sex life? little and not-so-little indignities can be swallow, as a health professional. The
Why do we sometimes take risks that devastating, and can prick holes in your daily tablet we use for HIV is small
don’t seem rational? Relationships self-esteem. Getting reliable support and getting smaller, has very few
are hard, but can be so much harder after disclosure is far from guaranteed. side effects, and is becoming safer all
when you have a background condition A few weeks ago we lost Prudence the time. Public health guidelines in
that is sexually transmitted. Mbele, a beloved long-time activist South Africa recommend that a huge
The show went well; but I found living openly with HIV, who died of proportion of our population need
some of the callers talking about their TB. Prudence was famous for her ‘pill tablets for diabetes, hypertension and
#16 – August 2017
#16 – August 2017
experience of disclosure surprisingly holidays’ – a big no-no in HIV-land, as cholesterol, among other ailments,
moving and upsetting. People were it leads to further immune damage. especially as people get older. Pills are
calling in, talking about the enormous The idea of someone stopping their a part of normal life for everyone as
impact of HIV on their sex lives, and of life-saving tablets – even temporarily they get older – so why should HIV-
partners slowly pushing them away due – boggles the minds of most health positive people complain of pill fatigue?
to their status. This was not the violent, providers. Her death triggered an intense Some of those reasons relate to
ignorant stigma that we easily identify media and Facebook/Twitter reaction, anxiety and depression and stigma, now
spotlight
spotlight
and loudly denounce, but a more filled both with criticism at her choices strongly linked to delayed presentation
subtle, much more personal rejection. as well as empathy, as people shared for treatment, as well as adherence to
It reminded me of a good friend who is their own hard stories about taking their meds. Sadly, mental health issues
HIV-positive, who when she is about to antiretrovirals. Yet this notion of ‘pill are more associated with medical hot
engage in sex with a guy, says he often fatigue’ affects lots of people in the air than with any content; very few
8 9resources are allocated specifically to
this area in either the public or the
about your mood; and if you are feeling
low or anxious, it can be enormously
Just as with HIV, every single one of us knows
private sector, despite tons of data
suggesting they are important. We have
helpful just to tell someone about it.
So pay attention to your friendship
another person who is experiencing mental ill health.
some very spirited and smart mental circle, family and community; and invest
health professionals trying to change time and energy in these relationships. and helpful, competent staff. This will to take mental health seriously, and be strategy encompassing talking
this, but there is an inertia in the current help you stay mentally healthy too. bold about opening conversations with therapies, good lifestyle interventions,
health system. This is also coupled with If you are persistently depressed, your friends and family about mental removing stress, treating other
harsh societal views around mental Speak to your health it might also be possible to obtain health. The World Health Organisation health conditions, and prescription
health – depressed people are told to professional anti-depressant medications on estimates that one out of every four medications. Compassion, empathy and
pull themselves together, think positive It is likely that you will receive very little prescription. Primary healthcare clinics people suffers mental illness at some the ability to ask the patient questions
thoughts, be grateful – which are less clinical help concerning your mental have access to anti-depressant drugs, point in their lives, so you are not alone. about their unique experience of living
than helpful to people experiencing health. Many health professionals are and these can be a valuable addition You might find useful mental in their own body are crucial. The last
sometimes devastating physical woefully under-trained around mental to other counselling support. If you health information and support thing you should be doing is adding
symptoms as a result of mental ill people without HIV. Disclosing your health, and you might find yourself have the means, shop around for a through one of the smartphone apps to stigma by putting your foot in your
health. The truth is that mental ill health HIV status can be scary, but it can brushed off if you try to talk to your professional you relate to – one who is or personalised telephonic support mouth. It is not a moral failing to suffer
is probably just as stigmatised as HIV. also keep you healthy. Similarly, if you doctor, nurse or even counsellor sympathetic to mental health issues. lines that are becoming increasingly mental ill health, just as it is not a
What does all of this mean, notice your mental health is wobbling, about this. If you feel strong enough, There are many similarities between available. These may involve a cost, moral failing to be HIV-positive, or have
for someone with HIV? There disclosing this to your friends and you can ask questions and insist that taking anti-depressants and taking but there have been enough studies any sexually transmitted infection.
are no magic bullets; but this is family can help keep you healthy. your health worker answer them; or antiretrovirals. You need to take your to show that they can be valuable. As South Africans, there are many
the best advice I can offer: Of course, this does not hold true for if they can’t, that they do their own meds consistently, without interruption, Watch this space to learn more about things that grind us down: corrupt
everyone. The world can be brutal and research and come back to you. in order to achieve the best results. which ones are reliably effective. politics; lack of jobs; increasing living
violent, families may use stigmatising You have a right to mental health You may experience some side effects; What should HIV-negative people costs; high rates of violent crime;
Identify your mental diseases to play out internal politics, care, even though the reality is that but these can often be mitigated by and healthcare workers be doing? I poverty and poor service delivery;
health symptoms and not every spouse is going to be South Africa is very under-resourced changing the dose slightly, or just guess trying to avoid the trite ‘support’ alcohol abuse; and family and
It’s a good idea to pay attention to your supportive. Use common sense, and in this field. Your raising it could be waiting for your body to get used statements – from ‘Well, at least you’re relationship break-ups. If you also take
mental health, as well as your physical choose your support network carefully. helpful in transforming your own health to them. Many people take anti- alive’, to the hideous ‘We will all die one into account the reality that too many
health. The first step is noticing whether Equally, this does not mean you need worker’s understanding, too, and could depressants for months or years in day’ – would be a start. I have been at of us experienced trauma because of
you are feeling different – do you have to rush out and disclose to everyone contribute towards changes in broader order to keep their mood stable and dinners in white, middle-class suburbia the brutalising effects of apartheid,
feelings of hopelessness, persistent the moment you get your diagnosis – mental health policy for everyone, enhance their mental health. There is where someone is loudly opining it is no wonder that mental ill health
sadness, a lack of energy to get through I’ve seen quite a lot of people treating over time. Also, challenge people on nothing to fear from these drugs. about morality and its connection is so prevalent in our society. Sadly,
your normal routine, or disrupted sleep this period as a kind of confessional. social media and in public, when they with HIV, not knowing that the couple we have been slow to acknowledge
or eating patterns? If so, and if these Learning you are HIV-positive can be post trite messaging on mental health across from me are my patients. The this and implement adequate policies
persist for more than a couple of weeks, a huge shock; give yourself time to issues (the most annoying I have seen Get activated same holds for mental health issues to help mitigate mental illness.
you may be becoming depressed. think it through, and decide when is a meme saying that people with Use activism to get behind – think before saying some stupid, Just as with HIV, every single one
Do you have persistent and repetitive and who you want to disclose to. depression don’t need tablets – just organisations advocating for better stigmatising thing. There needs to be of us knows another person who is
thoughts, worrying about your life American sex therapist Dan Savage a pair of running shoes and a forest). health services, for both HIV and much more community awareness experiencing mental ill health. However,
or other problems? Do you notice famously says that disclosure on a They will be more careful next time. mental health. In a recent study we about the importance of unconditional this may be hidden – due to stigma,
physical symptoms such as shortness date (or in any other situation) tells did on truck drivers (most of whom acceptance and support of people shame, lack of understanding, and lack
of breath, churning stomach or nausea, the other person only a small thing were HIV-negative), rates of anxiety on any kind of chronic medication. of adequate treatment. As a country,
dizziness or rapid heartbeat, fear of new about you; whereas their reaction Take your medication and depression were very high; we If you’re a health professional, the we achieved a lot when we started
situations or people? If so, and these tells you everything you need to know Taking tablets every day for ‘conditions’ see similar prevalence among carers, best thing you can do is to educate taking HIV seriously: through activism,
persist for more than a couple of weeks, about them. While it can be a shock when you’re healthy is fast becoming a low-income families living in poor yourself around mental health – scientific research, transformed health
you may be experiencing anxiety. to hear from a friend or loved one fact of life for everyone, for everything housing, and inner-city dwellers. If and learn, firstly, how to accurately delivery systems and a lot of hard
that they have HIV, or depression, or from high blood pressure to diabetes. you can, donate money to help them diagnose someone with depression or work at all levels, we managed to
any other scary condition, there is no Getting onto antiretrovirals, developing campaign, and to hire good staff. anxiety; and secondly, how best to work turn the epidemic around and make
Get support excuse for casually offensive opinions habits around swallowing tablets and Become a vocal supporter of better out a treatment plan. Mental ill health HIV a manageable condition. We can
The best thing you can do is ask for or hurtful comments. You do not have staying on treatment, and finding the mental health initiatives, wherever they is rarely healed only through drugs, but do the same with mental health,
support. It is sometimes very hard to to stand for it, and you can be clear easiest system possible for getting your exist. Challenge your health provider more usually involves a comprehensive if we are motivated to do so.
reach out, especially when you may in deciding whether to continue a tablets, will move this aspect to ‘habit’
#16 – August 2017
#16 – August 2017
be afraid of people’s reactions. My relationship with an individual who rather than being a constant reminder
experience though is that families is rejecting or judgemental about of the virus. If you acknowledge
For more information and resources
and friends can be remarkably your physical or mental health. to yourself that pill fatigue might Professor Francois Venter is
compassionate; and studies have shown You can often find support groups actually be systems fatigue – weariness a medical doctor who has
on mental health, go to:
that people who are open about their through local churches, NGOs and around a health system that remains been involved in HIV patient ++ Mental Health Infaormation Centre of Southern
HIV status tend to get more support, community organisations. These don’t largely inefficient and unfriendly, and care, as well as guideline Africa, at www.mentalhealthsa.org.za
have fewer issues with adherence, and work for everyone, but can be of huge wastes so much of your time – this development and studies on ++ South African Depression and Anxiety Group, at www.sadag.
spotlight
spotlight
generally appear to be happier. In one benefit. You might find that sharing might help you to address your own new HIV treatments, for many org. Toll-free suicidal emergency number: 0800 567 567
study, people with HIV who had good your experiences and finding out more negative thought patterns about years. He had lots of support ++ South African Federation for Mental Health, at www.safmh.org.za
social support mechanisms reported about HIV will be empowering, and taking your meds, and help you to from work colleagues and ++ Lifeline, at www.lifelinesa.co.za or phone 0861 322 322
the same quality of life, once they this will help keep you both physically stick to the regime. If you can, try to friends in editing this article. ++ AIDS Helpline: 0800 012 322
were on successful antiretrovirals, as and mentally well. Also, you could talk find a clinic that has good systems
10 11TREATMENT OPTIMISATION
Modernising ART
in pregnant women as yet, but these
studies are under way. Once we have a
better understanding of this, TAF is set
to be a favourable option to replace
TDF, on account of its better safety
By Dr Michelle Moorhouse, Wits Reproductive Health and HIV Institute, profile and lower dose, which will
and Southern African HIV Clinicians Society result in significant reductions in cost.
And in fact, if DTG, FTC and TAF
Antiretroviral therapy (ART) in South Africa seems set for are co-formulated, potentially we are
looking at a future first-line regimen,
a revolution, with a new drug combination that is highly to quote Prof Francois Venter, “smaller
effective and involves only one pill a day that is smaller than than an aspirin”, which is incredibly
potent, incredibly robust, incredibly
an aspirin. One of South Africa’s top HIV clinicians explains. well tolerated, all while being
incredibly cheap – incredible, isn’t it?
South Africa, like many lower- and living with HIV (PLWH) will receive
middle-income countries, follows the a combination of efavirenz (EFV), Alternatives to EFV
World Health Organisation (WHO) tenofovir (TDF) and emtricitabine (FTC) So how do we improve on EFV? There there may be some side effects, which inexpensive pill – looks promising. ART does not exist
recommended public health approach, or lamivudine (3TC) as first-line ART. are a number of alternatives to EFV to include dizziness and anxiety. But this is Then there are also other future in a vacuum
using standardised drug regimens to FTC and 3TC, which are structurally consider that are currently available coming mainly from European cohorts, third-drug options which are not All of this is very important, while we
treat HIV. This, along with tasks shifting almost identical, really contribute very in South Africa. Rilpivirine (RPV) is one which do not have the genetic diversity available in South Africa (or indeed have such tough targets to chase –
from doctors to NIMART (Nurse Initiation little in the way of toxicity generally, option, from the same class of ARVs as of African populations. Currently a anywhere else) as yet. These include the famous 90-90-90. And to achieve
and Management of Antiretroviral and are usually continued through EFV, and is dosed at 25mg (compared massive study called ADVANCE that doravirine and bictegravir. Doravirine is that third 90, we need to modernise
Therapy) trained nurses, has enabled subsequent lines of therapy, so I am to 600mg of EFV which contributes compares DTG to EFV is under way in from the same class of drugs as EFV and treatments so that PLWH can adhere
more than 3.9 million people living not going to say much more about significantly to the size of the FDC). South Africa, and includes screening RPV. It is still in phase 3 of development to them. When there are so many
with HIV (PLWH) to access life-saving them here; I’m going to confine my RPV is much better tolerated than for these types of symptoms. DTG (registrational studies), and whether other challenges to overcome within a
antiretroviral therapy (ART) since deliberations to EFV and TDF. EFV and is incredibly cheap, which is is also available in SA already co- or not it will ever hit our shores is healthcare system, optimising ART to be
2003. ART is undeniably one of the What is great about this always good news in a drug which could formulated with abacavir (ABC) and unknown. Bictegravir, also in phase 3, as simple, safe, efficacious and robust
biggest successes of modern medicine, combination is that millions of PLWH potentially be used to treat millions 3TC; but it is not practical to roll out is a drug which is very similar to DTG as possible facilitates safer task-shifting
along with vaccines and antibiotics. around the world have been treated of people. The downside is that it is this particular FDC programmatically, and is co-formulated with tenofovir to other cadres of staff, which may help
While we have some pretty great with it for years, so there is a wealth not yet available in any FDCs in South as ABC is very expensive. alafenamide fumarate (TAF), which I will alleviate some of the human resource
treatments already, there is still room of experience with it – a bit like that Africa, can’t be used with rifampicin- But as DTG requires only a 50mg discuss a little more below, and FTC. shortages faced by healthcare facilities.
for improvement. Current first-line ART comfortable T-shirt we like to sleep based TB treatment or in anyone with a dose, if it were to be introduced into But no matter how good the drugs
is a big pill to swallow and it has some in, for us as prescribers, but perhaps high viral load when starting treatment, the public sector programme, produced are, ART does not exist in a vacuum,
unpleasant side effects, resulting in not so much for PLWH. The regimen and in the public sector we don’t do by a generic manufacturer with South An alternative to TDF and ART alone will not achieve the three
poor adherence and virological failure, has proven virological efficacy, is viral loads at treatment initiation, Africa’s buying power as the largest So, moving on to TDF: the problems 90s. ART will not fix the healthcare
and resistance develops quite easily; generally well tolerated, is simple to so it too has its warts. However, it is consumer of generic ART in the world, with TDF are in some ways similar to system. ART will not address stigma.
and it will not get any cheaper over take as it is dosed once daily, and is being studied in some interesting new DTG would be an affordable option those with EFV. The high dose means a ART will not help us achieve that
time. From the more logistical aspect, co-formulated into a single tablet combinations, so let’s not set it aside for first-line ART, and is currently high active pharmaceutical ingredient first 90: 90% of PLWH knowing their
the high dose of the drugs that make fixed-dose combination (FDC). completely just yet. Certainly, as a an alternative option in the WHO requirement, which drives up the pill status. ART will not find the missing
up first-line ART means they use more What are the problems with EFV? switch option RPV is a very good choice guidelines. With regard to DTG and TB size and the cost. And it also has some in action to test them – the men, the
ingredients, meaning they cost more; It comes with some unpleasant in patients who don’t tolerate EFV, and drugs, there is an interaction, which can toxicity associated with it. Currently, key populations, the adolescents, girls
this is also the reason the pill is so big, side effects (abnormal dreams, there are studies which support this. be overcome by adjusting the dosing we do not have any alternatives and young women – and then link
which in turn means the packaging is nightmares, hallucinations even, Dolutegravir (DTG) is another option of the DTG; but this might not be available in South Africa that are them to care to achieve the second 90.
big, and takes up more space in the and other neuropsychiatric-type already available in South Africa. Again, necessary – some studies are under way any better; but there is one which ART will not then retain them in care,
pharmacy. Clearly, we need treatments symptoms, mainly; occasionally, another low-dose drug, at 50mg. In to look into this. One of the current should be available soon, namely TAF and measure their viral load so we can
#16 – August 2017
#16 – August 2017
that are easier to take, in terms of rash); it has a very low resistance registrational first-line studies, no-one challenges with DTG is that at this (tenofovir alafenamide fumarate). TAF, see if we are reaching that third 90.
size, and cheaper. And if you compare barrier; and it requires a high dose. with virological failure developed any stage, we don’t know a lot about DTG in like the TDF in current first-line ART, Massive investment in infrastructure
first-line ART in lower-/middle-income Its safety in pregnancy has been DTG resistance, which means this drug pregnant women. Botswana made the is a pro-drug of tenofovir. TAF is given and development of systems, backed
countries (LMIC), some of the drugs established despite a bumpy start is incredibly robust. DTG was also the bold move of introducing DTG into their at a much lower dose (approximately by political will, is critical. Civil society
being used are no longer recommended in early development, and it plays first drug to ever beat EFV in a head- HIV treatment programme in June 2016, tenfold lower) than TDF. TAF is must remain engaged, and all of this
in better-resourced settings. relatively well with most other drugs, to-head study, where pretty much all including for pregnant women; and it associated with much less kidney and must be backed by a National Strategic
including TB drugs (but not all; for others had previously tried and failed, is anticipated that they will present bone toxicity than TDF. The ADVANCE Plan (NSP) that is realistic, detailed, and
spotlight
spotlight
example, some contraceptives, such and this was probably a lot to do with data on the first pregnancies at the IAS study will also compare TAF and TDF, which embodies the principles of equity
Current first-line ART as implantables). EFV is an example of the fact that DTG is more tolerable conference in Paris in July 2017, which as most studies of DTG used ABC as and access. There is a massive amount of
So, let’s look a little more closely at one of the first-line drugs which has than EFV. And as the saying goes, if it will start to fill this gap. So, we have a the backbone, and also would not have work to be done to conquer HIV in South
our current first-line ART. According to disappeared from first-line treatment sounds too good to be true… In fact, very robust drug that is well tolerated included many African participants. TAF Africa, but optimised ART is certainly
our national guidelines, most people in many wealthier countries. there are emerging data suggesting and can be co-formulated into a small, has not been studied with TB drugs or a great step in the right direction.
12 13TREATMENT ACTION CAMPAIGN
Spotlight on
TAC provinces
KwaZulu-Natal
Limpopo
In May, it came to light that KwaZulu-Natal’s healthcare
Following heavy rains in May, a malaria outbreak hit Limpopo.
services are in a state of emergency, with shocking
Clinics and other primary health facilities did not have enough
details shared by health workers in the province.
testing kits or malaria treatment to deal with the outbreak.
Reports reflected a collapsing health accessible will benefit the health of Since 2016, TAC KZN has been
Patients were therefore being to most of the facilities that were meaning that the shortage was a crisis system which is in many cases no all people living with HIV on campus. working on a campaign to ‘Help Teens
transferred to Nkhensani Hospital. relieving the burden on the hospital. for the HIV response in the area. longer delivering adequate healthcare The evidence is clear that earlier Protect Themselves’. Through our
As there were too few beds, patients In July, Mopani district in Limpopo After hearing and validating the to the most vulnerable. Hospitals are treatment reduces serious adverse engagements with the MEC of Health
at the hospital were being admitted was facing a shortage of HIV-testing complaints, TAC Limpopo escalated experiencing shortages of life-saving events, such as TB and various and the MEC of Education, and in the
only to be left in an undignified kits. After many calls from members the matter to the District Health medicines and equipment, and suffering cancers. Adhering properly to HIV KZN Provincial AIDS Council, TAC KZN
condition on the floors of the of the public who had been unable Department and the Office of the through departments that are entirely treatment is critical to staying healthy. has been advocating for better access
wards. Immediately, TAC Limpopo to take an HIV test, TAC Limpopo Mayor. The official response from depleted of staff. Major delays for Additionally, this will also help prevent to prevention methods, the roll-out
organised a meeting with the CEO intervened. Following a snap survey, government was that the supplier’s treatment and care continue to be many new HIV infections. Studies of prevention and treatment literacy
and Communications Manager of the TAC members found that the following tender had come to an end, and they felt in oncology and various other show that people who are stable on training, and easier access to treatment,
hospital to address our concerns. The health facilities had either very few, had failed to calculate the risks and put departments. In June, TAC KZN met treatment with undetectable viral including on campuses. Both MECs
hospital acknowledged the challenges; or no testing kits at all: 1) Vyeboom measures in place to avoid a stockout. with MEC of Health Dr Sibongiseni loads are highly unlikely to transmit made a clear commitment to improve
in the interim, they erected tents to Clinic; 2) Basani Clinic; 3) Hlaneki Following TAC’s intervention, limited Dhlomo, and raised these issues. In HIV to their sexual partners. youth-targeted HIV interventions. Now
deal with the influx of patients. TAC Clinic; 4) Ratanang Clinic; 5) Xivulani stock was quickly delivered to Giyani response, the MEC complained of The dysfunction in the public it is important for TAC KZN to monitor
Limpopo was not satisfied with this Clinic; 6) Mapayeni Clinic; 7) Khujwana Health Centre, Nkhensani Hospital, cost cutting and budget cuts by the healthcare system creates its own the roll-out. Treatment accessibility
action, and escalated the matter. We Clinic; 8) Giyani Health Centre; 9) and Thomo Clinic. Shortly afterwards, provincial Treasury. The response of the challenges for people to remain must be coupled with counselling and
wanted to know what the provincial Nkhensani Hospital; 10) Thomo Clinic; TAC Limpopo received a call from MEC failed to alleviate the concerns adherent. The reality is that our adherence support on campus. We
department’s plan would be to resolve 11) Dzumeri Health Centre; and 12) Giyani Health Centre extending their of TAC KZN. A suitable turnaround clinics are in crisis. People must wait also urge the University of Zululand
this crisis. Soon after engagement Ratanang Clinic. Knowing their HIV gratitude for our intervention in the plan must urgently be put in place in long queues for hours to get their to provide easy access to preventative
with the office of the MEC of Health, status is the most important thing matter. The situation must be resolved by the MEC, or TAC will be forced to HIV treatment. Sometimes medicine measures such as male and female
Dr Phophi Ramathuba, testing kits people can do to protect their own urgently at the other facilities, to escalate our advocacy around this stockouts or shortages mean people condoms, as well as pre-exposure
and malaria treatment were delivered health and avoid the spread of HIV, ensure that HIV testing can resume. crisis. The Provincial Congress will leave empty-handed. This forces people prophylaxis (PrEP). PrEP aimed at
discuss and resolve a way forward. to default, and puts their health and youth and the general population
TAC will work with SECTION27, the lives at risk. Students must take the may have an important role to play
South African Medical Association decision to miss classes in order to in reducing new infections. Further,
#16 – August 2017
#16 – August 2017
(SAMA), and the South African Human wait at the clinic; those staying in and critically, measures must be put
Rights Commission on this matter. residence must travel home to collect in place to prevent the disclosure of
In July, TAC KZN welcomed the their treatment. Our rights to health people’s HIV status on campus, which
announcement that the University of and education are in conflict. Providing would cause unnecessary stigma and
Zululand would provide HIV treatment medicines on campus will not only discrimination. For instance, people
to students and staff on campus. If promote better adherence for students should not be forced to enter buildings
implemented effectively, this should and staff at the university; it will also reserved only for collecting HIV
spotlight
spotlight
provide an easier and quicker system relieve the burden on health facilities medicines, and their clinic files must
for young people and staff at the that are already stretched to capacity. not be colour-coded or marked to show
university to collect their ARVs, and Given the increasing uptake of HIV their status. TAC KZN will monitor
Nkhensani Hospital erected tents (left) to deal with the influx of patients due to a malaria outbreak. Many patients
therefore ensure better treatment treatment through ‘Universal Test and the roll-out and advocate for other
had to lie on makeshift beds on the flloor (right). TAC kept the pressure on provincial government until resolution.
adherence. Making medicines more Treat’, this burden will only grow. campuses to adopt this approach.
14 15Mpumalanga Western Cape
“Police in Ermelo used to assault, insult For a long time, TAC Western Cape received complaints about
and arrest us often,” says Boitumelo*, Michael Mapongwana Community Health Clinic in Khayelitsha.
a sex worker from Mpumalanga.
Parents with children and babies would their children outside because of a lack met with the Health Department to
be seen in a container at the back of of space on the inside. Children with address these concerns. Finally, in
“They would arrive at our houses, kick TAC and partners escalated the the clinic. They would wait outside for illnesses shared the same space with February 2017, following pressure from
stuff, call us names, beat us. They would matter to the MEC of Health, Gillion long periods, whatever the weather those attending post-natal check- TAC, a new structure was opened that
confiscate our medications (including HIV Mashego. They wrote to the MEC and conditions, to be attended to by health ups. Late last year, TAC Western Cape could accommodate the children in a
treatment), destroy our foods, ruin our the Brigadier of the SAPS to demand workers. They would have to undress held a picket outside the clinic, and dignified and appropriate manner.
furniture, even take our condoms. And a meeting. The police had previously
after they had arrested us, we would spend refused to meet, but engaged once the
the entire weekend in the dirty, smelly, MEC was involved. In the meeting, after
and cold cell. Sometimes we would be hearing the issues, the MEC demanded
released on the Monday with R500 each. that the police stop harassing the sex
Then we would appear in court where workers and stop taking their condoms Eastern Cape
eventually the charges would be dropped.” and medications. While the police tried
Boitumelo and other sex workers in the to deny all that the sex workers said,
Ermelo area have been victimised by the photographs of beaten bodies, destroyed Since 2016, TAC Eastern Cape had received numerous complaints from
police for years. After a chance meeting homes, and medications thrown on
in the mall with a member of NAPWA – the floor, shocked the attendees of
the Clinic Committee and community members fearful of accessing
who happened to be wearing a T-shirt the meeting. The MEC instructed the health services at Philani Clinic. Mostly this was due to the bad
saying ‘sex work is work’ – Boitumelo and police to engage with all departments
other sex workers were soon introduced and ensure that the victimisation
attitude and lack of respect shown to patients by one of the nurses.
to TAC Mpumalanga. In late 2015, TAC and harassment would finally end.
facilitated a safe-space workshop where “Since October 2016 we have not This nurse had repeatedly and matter was resolved. According to the organisations, churches and partners in
an advocate from the Women’s Legal had problems with police. Since the TAC has helped some sex publicly disclosed people’s HIV community, the clinic would only be the area to meet in Queenstown and
Centre promised to represent the sex police vans are no longer coming to workers victimised by police in status and other health conditions reopened given the removal of the come up with a strategy to re-open the
workers in case of further arrests. our place, even clients come freely, and Ermelo to find their voice. without their consent. The situation nurse. This meant no-one could access clinic, to ensure people could access
“It was here that we started to feel business has been better. Now I can at had left community members not services at all. Worryingly, TB and health care. TAC met with MEC of Health
safe and confident to talk,” Boitumelo least send some money to my kids.” wanting to use the clinic at all. drug-resistant TB patients in the area Phumza Dyantyi and Clinic Committee
continues. “It wasn’t long before we got Since last year, KwaMhlanga Hospital National Portfolio Committee on Health While the Mayor had proposed could not undergo treatment reviews, members to demand a way forward. After
arrested again, in December. We were in Mpumalanga has been facing a severe visited the province and gave a damning suspending the nurse in question as their folders were locked inside this pressure, the clinic was re-opened in
told to be in court on 4 December. The crisis. A shortage of staff meant that report, which lead to the notorious threats pending a disciplinary hearing, the Sub- the clinic. They had no option but to June 2017, and the nurse was removed.
advocate came to represent us and doctors in the facility repeatedly went on made against MP Dr Makhosi Khoza. District Health Manager undermined use another facility, given that the While one battle was won, the clinic is
TAC members were there in numbers strike. They were overworked, without the TAC Mpumalanga met with the Hospital this decision. The community were nearest TB hospital is 350km away. now understaffed, with one nurse being
supporting us. We had done nothing people-power to attend to all those in CEO to raise the various challenges that understandably angry at the change. TAC Eastern Cape and the Queenstown dismissed and one more resigning. TAC
wrong. We were sleeping when the need of medical care. The maternity ward had been reported to us. The matter In April 2017 they shut the clinic down Council of Churches urgently mobilised Eastern Cape will continue to demand that
police kicked down the doors. We was overcrowded. Women would deliver was escalated to the District Health in protest, locking its gates until the the Clinic Committee, community the vacant posts are filled urgently.
were just sitting inside the house. The their babies, after which they would Department, and then the Provincial
case was withdrawn on the day.” be moved to a chair to sit for six hours Health Department. A meeting with
TAC assisted in mobilising other sex observation, and then be sent home. Gillion Mashego, the MEC of Health, led
workers and members of the LGBTQIA+ Bloody and wet sheets would remain, to the removal of the CEO. An interim
community to support us on 10 December as the next to give birth would occupy CEO was appointed in February 2017, after
in marching to the police station, to them. The nurses had no gloves or gowns; which the hospital received an injection
demand an end to the police harassment. their clothes were dirty from delivering of two million rand. The maternity ward
#16 – August 2017
#16 – August 2017
“We walked through the township singing babies. The intensive care unit (ICU) was was extended into a portion of the ICU
and holding placards. We were about 300 empty – no furniture, beds, or medical to relieve the burden on the overcrowded
in total, wearing our mini- skirts and high equipment; an abandoned, empty space. ward, and a new position to manage
heels,” remembers Boitumelo. “Police used Conditions were untenable. At the district this maternity ward has been advertised.
to say we were whores because we are People’s Health Assembly organised by The interim CEO visited hospitals in the
dressed in mini-skirts and that is why we TAC in 2016, many complaints of poor North West to benchmark and gain
wore it on the day. We wanted them to service at KwaMhlanga were made, guidance as to how to turn the crisis
spotlight
spotlight
arrest us officially on this day; but instead, with members of the District Health around. Some stability has finally been
police came to escort us – after refusing Department in attendance: reports found. TAC will monitor the situation, and
to give us permission to hold the march.” of people dying unnecessarily; people continue engaging with the new MEC.
The community shut down Philani Clinic after a nurse there had disclosed patients’ health
After this, the harassment waiting months for simple procedures. * Not her real name – changed
information without their consent. TAC assisted in resolving the issue.
and arrests did not stop. The situation was so bad that even the to protect her identity.
16 17You can also read
