In considering the HIV epidemic and its impact, many of our anniversaries are sad ones. Personal anniversaries often mark losses – remembrances of the deaths of family, friends or patients. Clinicians or scientists may mark the anniversary of the first documented AIDS case in a country, or the discovery of the virus itself, but these aren’t generally moments for celebration per se. So it’s not often that we have cause to smile about an anniversary related to the epidemic. However, 1 April 2014 marks one happy anniversary worth remembering – a decade of antiretroviral therapy (ART) in the public sector.
Like many anniversaries, the exact details can depend on where you were, and sometimes dates themselves can be fuzzy. Antiretrovirals were available from the 1990s in the private sector, and a trickle was accessible through trials and small donor-funded initiatives in urban centres from the early 2000s. Some provinces moved more quickly towards making ART available ahead of the National Department of Health, often with the assistance of partners in local and international non-governmental organisations. After the announcement of a national rollout of ART in public sector facilities, some hospitals received supplies of antiretrovirals within weeks. Elsewhere, especially in clinics in rural settings, health services took years to have local providers dispensing ART. Today the number of facilities dispensing ART is expanding still, but most communities across the country have reasonable access, and ART coverage continues to increase. So perhaps this anniversary is not so much a specific date in time, but rather a particular point of inflection in the course of the health service that serves the vast majority of South Africans.
To mark this anniversary, this edition of the Journal is a special issue of sorts. We asked the Society’s members, and the public more generally, to submit their thoughts about the ART rollout over the last ten years; and the response was remarkable. We received more submissions than we could publish by far, and thank all those who submitted manuscripts for their time and consideration. And so, rather than our usual peer-reviewed scientific articles, case reports, guidelines and opinion pieces, this issue is comprised entirely of short commentaries by way of reflection, drawn from diverse perspectives from authors working across the country.
In their opening commentary, Gary Maartens and Eric Goemaere1 remind us of the incredible distances traversed during the past decade, and consider what the next ten years may hold. Writing from Bloemfontein, Dirk Hagemeister2 asks why the patient-held records, which have become such a routine part of ART and tuberculosis (TB) care for many of our patients, are less than routine for many of our doctors (and readers). In Cape Town, Richard Kaplan and colleagues3 describe how the earliest days of their ART service in Gugulethu consisted of working from a cardboard box in a borrowed office, and evolved through partnerships with communities, services and academic medicine. Kevin Rebe and James McIntyre4 describe working with the public sector to deliver care to men who have sex with men – a population that remains highly marginalised in many parts of the country and continent.
Many of these contributions are distinctly personal. Caroline Armstrong5 describes working in a Pietermaritzburg hospital before the ART rollout, and how her perspective changed in the early days of providing effective therapy to patients. Joyce Marshall6 discusses how ART began to lift the burden of stigma associated with HIV/AIDS off of her patients, while Michelle Moorhouse7 describes how her general practitioner practice in the Eastern Cape changed when ART became available. Chantél Friend8 uses the AIDS ribbon as a metaphor for the different meanings that HIV has had throughout her career. And writing from the perspective of policy development, Celicia Serenata9 describes her personal travails in contributing to the national strategic plan during 2003.
The challenges of delivering ART in rural communities are reflected from Zithulele in the Eastern Cape Province (Catherine Young and Ben Gaunt10 ) as well as Mseleni in northern KwaZulu-Natal (Aurélie Nelson11 ). And while ART was a doctor-driven service initially, today nurses initiate and manage the vast majority of South Africans on ART, so it is fitting then that Mzi Tito12 describes the experience of providing ART services in primary care around Port Elizabeth.
One area of dramatic change in the last decade has been in paediatrics, where antiretrovirals have altered the landscape of child health in this country through both prevention and treatment. Here, Ann Moore13 talks about the practical lessons learnt in providing HIV care and treatment to infected children and their families in Cape Town, while Kathryn Stinson and colleagues14 describe the changing paradigms of services for the prevention of mother-to-child transmission (PMTCT) of HIV in Khayelitsha, and the central role that maternal ART plays in preventing paediatric HIV infections. And in the final contribution, Francois Venter15 draws on his experiences of the last ten years to give us lessons for the next decade, with a mix of candour, humour and insight.
Most of the contributions have a tone of celebration (e.g. ‘how far we have come!’), and many comment on the revelation that ART represented in the lives of their patients and their own practice of medicine. However, there are also notes of sadness and frustration here – for preventable deaths and ineptitude that characterised much of the response to the HIV epidemic in an earlier period. If we needed a reminder that health and politics are inseparable, we need not look far into the past. And in some places these notes of frustration seem to echo into the present, as ART services become a standard component of primary care in South Africa. With this, the revelations of providing ART for the first time soon after 2004 appear to be accompanied by the routines of delivering chronic care through the public sector in 2014.
Whatever this anniversary means to you, I hope you find this special issue filled with new perspectives, perhaps a few knowing smiles, and at least one pause for reflection.
Happy reading.
Associate Professor
School of Public Health and Family Medicine
University of Cape Town
1. Maartens G, Goemaere E. Building on the first decade of ART. Southern African Journal of HIV Medicine 2014;15(1):7-8. [http://dx.doi.org/10.7196/SAJHIVMED.1031]
2. Hagemeister D. The secrets of the green and white cards. Southern African Journal of HIV Medicine 2014;15(1):33-34. [http://dx.doi.org/10.7196/SAJHIVMED.1036]
3. Kaplan R, Orrell C, Lawn SD, Bekker L-G, Wood R. The Hannan Crusaid Treatment Centre – early beginnings and lessons learnt. Southern African Journal of HIV Medicine 2014;15(1):35-37. [http://dx.doi.org/10.7196/SAJHIVMED.1040]
4. Rebe KB, McIntyre JA. Providing HIV care to men who have sex with men in South African state sector clinics. Southern African Journal of HIV Medicine 2014;15(1):10-11. [http://dx.doi.org/10.7196/SAJHIVMED.1026]
5. Armstrong C. Reflections on HIV care and ART – a view from Pietermaritzburg. Southern African Journal of HIV Medicine 2014;15(1):16-17. [http://dx.doi.org/10.7196/SAJHIVMED.1033]
6. Marshall J. ‘They dropped the blanket of their fear’: Reflections of HIV medicine in South Africa, 2014. Southern African Journal of HIV Medicine 2014;15(1):26. [http://dx.doi.org/10.7196/SAJHIVMED.1032]
7. Moorhouse M. Closer to zero: Reflections on ten years of ART rollout. Southern African Journal of HIV Medicine 2014;15(1):9. [http://dx.doi.org/10.7196/SAJHIVMED.1030]
8. Friend C. Reflections on a decade of HIV in my life. Southern African Journal of HIV Medicine 2014;15(1):27. [http://dx.doi.org/10.7196/SAJHIVMED.1039]
9. Serenata C. Ten years of ART in South Africa – how far we have come. Southern African Journal of HIV Medicine 2014;15(1):14-15. [http://dx.doi.org/10.7196/SAJHIVMED.1028]
10. Young A, Gaunt B. Providing high-quality care in a deeply rural setting – the Zithulele experience. Southern African Journal of HIV Medicine 2014;15(1):28-29. [http://dx.doi.org/10.7196/SAJHIVMED.1035]
11. Nelson AK. Within minutes from Mseleni to Cape Town ... Southern African Journal of HIV Medicine 2014;15(1):13. [http://dx.doi.org/10.7196/SAJHIVMED.1010]
12. Tito M. A nurse's perspective on the ART rollout. Southern African Journal of HIV Medicine 2014;15(1):19. [http://dx.doi.org/10.7196/SAJHIVMED.1034]
13. Moore HA. Reflections on six years in paediatric ART. Southern African Journal of HIV Medicine 2014;15(1):22-23. [http://dx.doi.org/10.7196/SAJHIVMED.1020]
14. Stinson K, Giddy J, Cox V, et al. Reflections on a decade of delivering PMTCT in Khayelitsha, Cape Town. Southern African Journal of HIV Medicine 2014;15(1):30-32. [http://dx.doi.org/10.7196/SAJHIVMED.1025]
15. Venter WDF. What have we learnt from the last ten years of ART? Southern African Journal of HIV Medicine 2014;15(1):39-40. [http://dx.doi.org/10.7196/SAJHIVMED.1029]