Berkman, A

Lallo, U G

McNally, L M

Pawinski, R A

South African Medical Journal (SAMJ)

PERSONAL VIEWSeptember 2003, Vol. 93, No. 9  SAMJSAMJ FORUMWe note with great enthusiasm the recent cabinet decision onthe roll-out of antiretrovirals (ARVs) in South Africa.1According to information from the Treatment Action Campaign(TAC) on the cabinet document, ‘Treatment Options toSupplement Comprehensive Care for HIV/AIDS in the PublicHealth Sector’ presented to MINMEC on 9 May 2003,2,3 wenote, among other items, that the document mayunderestimate the role of ARVs in preventing HIV infection.We would like to present a case in favour of ARVs as a strategyin the fight against this epidemic.With reference to the section headed ‘Benefits of ARVtreatment’, there appears to be an underestimate of the role ofantiretrovirals in preventing new infections. The section statesthat there is ‘… no compelling evidence that ARVs wouldreduce numbers of new infections …’. Prevention of newinfections may in fact be decreased in a number of ways: (i) bydecreasing the viral load in the mother, transmission to theinfant is significantly decreased;4 (ii) decreasing the viral loadin patients reduces horizontal transmission, 5 and may wellhave a beneficial epidemic-level effect; (iii) modelling exercisesbased on examples from developed and developing countrieshave shown that antiretrovirals, even in the light of resistance,significantly decrease the transmission of HIV-1 in high,intermediate and low ARV usage scenarios.6 On the basis ofthis model and other adapted models,7 taking into account theeffect of resistance developing on ARVs,8 it is estimated that 10- 30% of new infections in South Africa could be averted if 50%of patients who require antiretrovirals were receiving them; (iv)improved AIDS care may indirectly enhance prevention effortsthrough increased uptake of voluntarily testing andcounselling, the foundation and entry point to all careinterventions;9 (v) improved care leads to de-stigmatisation ofthe disease,10,11 which improves compliance and access to healthcare.9South African prices for both first-line regimens aresignificantly more expensive than the best world prices. Thecosts could be dramatically reduced by facilitating domesticproduction or importation of generics, reflected in theimminent production of generic ARVs by South African drugcompanies,12 and affords the opportunity to double or treblethe number of patients that could benefit from ARVs.While we agree that it is imperative that any programmeshould ultimately reach those in ‘desperate need’ this shouldnot delay implementation in regions with the necessaryinfrastructure in place. It should not be assumed that this willonly be in urban areas. Several institutions in rural KwaZulu-Natal could implement ARVs immediately. The constitutionguarantees all South Africans the right to access health care,and we understand the government’s concerns regardinginitially providing ARVs to specific groups such as teachers orhealth staff. However, this would have two advantages. Itwould help maintain essential public services. It would alsoenable managers to evaluate and rectify possible problems in asub-group of the population that is better educated and betternourished before rolling out to the rest of the country, and thissub-group of patients could act as advocates for complianceissues associated with long-term HAART therapy. As manyprivately employed South Africans already have access toARVs a disparity in health care already exists.Following this announcement, we urge the government toimplement a widespread public ARV programme withoutfurther delay, starting in areas of adequate resource. A novelapproach to reach areas of most need could be to encourageprovinces with expertise, such as KwaZulu-Natal, Gauteng,Western Cape and Free State, to ‘adopt’ neighbouringprovinces to assist with setting up pilot sites and rapidlyscaling up, thus sharing expertise and resources such astraining and technical support.1. Terreblanche C. Finally ... a 'yes' from government's Dr No. Cape Times 2003; 8 Aug.http://www.iol.co.za/index.php?click_id=125&art_id=vn20030808060449695C943422&set_id=1 (last accessed 15 Aug 2003).2. TAC Releases Details of Government Costing Study.http://www.tac.org.za/Documents/TreatmentPlan/slideshowongovernmentcostingstudy.pdf(last accessed 15 Aug 2003). 3. Smetherham J-A. Will secret AIDS report get a state response?  Mercury 2003; 14 July, p. 1. 4. Garcia PM, Kalish LA, Pitt J, et al. Maternal levels of plasma human immunodeficiency virustype 1 RNAand the risk of perinatal transmission. N Engl J Med 1999; 341: 394-402. 5. Quinn TC, Wawer MJ, Sewankambo N, et al. Viral load and heterosexual transmission ofhuman immunodeficiency virus type 1. Rakai Project Study Group. N Engl J Med 2000; 342:921-929. 6. Blower SM, Farmer P.  Predicting the public health impact of antiretrovirals: preventing HIV660Launching the ARV roll-out debate into the public arenaR A Pawinski, A Berkman, L M McNally, U G LallooDr Robert Pawinski is a Research Fellow in the Department ofMedicine at the Nelson R Mandela School of Medicine,University of Natal, and an Honorary Research Fellow at theInstitute of Child Health, London; Professor Alan Berkman is aclinical Professor of Epidemiology at the Mailman School ofPublic Health, Columbia University, USA; Dr Lisa McNally is aWellcome Clinical Research Fellow at the Institute of ChildHealth, London, and Visiting Paediatric Lecturer at the Nelson RMandela School of Medicine; and Umesh Lalloo is Prosfessor andHead of the Department of Medicine at the Nelson R MandelaSchool of Medicine.SAMJ FORUMA tobacco-free hospital environment sends an important signalto patients and visitors with regard to both safety and ahealthy lifestyle. Today patients, staff and visitors increasinglyexpect an antismoking policy to be in place in hospitals andother venues where sick people are treated. Health care staffcan play an important role in the implementation of anantismoking policy in their hospital.Eighty per cent of the medical, technical and nursing staff ofthe Magenta Hospital in Italy1 were in favour of a total ban onsmoking inside the hospital. It was interesting to note thatthese workers underestimated the health risks of smoking:only 34% of doctors, 13% of nurses and 16% of techniciansidentified smoking as the main preventable cause of death inItaly at the time of the survey.A smoking control programme involving all staff memberswas instituted in a hospital in Barcelona, Spain.2 Within 18months the prevalence of smoking decreased from 51% to 40%and the percentage of ex-smokers increased from16% to 23%.There was also a noticeable change in the attitude of the healthworkers, especially with regard to encouraging patients to stopsmoking.The aim of the present study was to examine the smokinghabits of a sample of the nursing staff in clinical wards inTygerberg Hospital, and to ascertain their opinions on theintroduction of an antismoking policy.What was doneThis study constituted part of the training of fourth-yearmedical students and was carried out under the supervision ofthe Department of Community Health of the University ofStellenbosch. Permission to interview nursing staff was grantedby the authorities of Tygerberg Hospital. Participation wasvoluntary and informed consent was obtained from allparticipants. Care was taken that participation in the surveydid not impact on the participants’ work schedule.Five clinical locations representing a cross-section of clinicalactivities at the hospital were selected for inclusion in thestudy. The locations selected were obstetrics and gynaecology,trauma, psychiatry, respiratory intensive care, and the burnsunit. An anonymous, self-completed questionnaire wascompiled for the survey and tested on a few non-sampledrespondents for comprehensibility and length. The finalquestionnaire was simplified a little. The questions dealt withsmoking behaviour, the advisability of smoking in a hospital,and feelings about an antismoking policy.The questionnaires were handed individually to the nursesin the selected wards and they were requested not to discussthe contents with their colleagues. A sealed ‘post’ box with aslot cut in the lid was made so that respondents could placetheir completed answers in the box anonymously. This was661STUDENT PAPERSmoking among nursing staff at Tygerberg Hospital, Cape TownF W Retief, E Prinsloo, J Calitz, J M BarnesSeptember 2003, Vol. 93, No. 9  SAMJThe first three authors were fourth-year medical students at theUniversity of Stellenbosch when they did this research project,which was supervised by Jo Barnes, of the Department ofCommunity Health.in developing countries. AIDScience 2003; 3(11)http://www.aidscience.com/Articles/aidscience033.asp (last accessed 15 Aug 2003).7. Wood E, Braitstein P, Montaner JSG, et al. Extent to which low-level use of antiretroviraltreatment could curb the AIDS epidemic in sub-Saharan Africa. Lancet 2000; 355:http://pdf.thelancet.com/pdfdownload?uid=llan.355.9221.original_research.1248.1&x=x.pdf(last accessed 15 Aug 2003). 8. Little SJ, Holte S, Routy JP, et al. Antiretroviral-drug resistance among patients recentlyinfected with HIV. N Engl J Med 2002; 347: 385-394.http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=12167680&dopt=Abstract (last accessed 15 Aug 2003).9. Levi GC, Vitoria MA. Fighting against AIDS: The Brazilian Experience. AIDS 2002; 16: 2373-2383.10. Farmer P, Léandre F, Mukherjee JS, et al. Community-based approaches to HIV treatment inresource-poor settings. Lancet 358; 11. Farmer P, Leandre F, Mukherjee J, Gupta R, Tarter L, Kim JY. Community-based treatment ofadvanced HIV disease: introducing DOT-HAART (directly observed therapy with highlyactive antiretroviral therapy). Bull World Health Organ 2001; 79(12): 1145-1151.http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=11799447&dopt=Abstract (last accessed 15 Aug 2003).12. SAPA. Local firm launches new, cheaper Aids drug. 2003.http://www.iol.co.za/index.php?set_ id=1&click_id=13&art_id=qw1060182181723B232 (lastaccessed 15 Aug 2003).

Launching the ARV roll-out debate into the public arena

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Launching the ARV roll-out debate into the public arena

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