How Do You Build Hope and Strength?

IDRC-supported researchers are working with the Government of Free State province, South Africa, to roll out lifesaving antiretroviral treatment while strengthening the health care system.

“The AIDS issue has become more than a health issue, much more than a prevention issue. It has actually become a test of governance.” Zackie Achmat, Treatment Action Campaign.

For many years, HIV/AIDS activists have struggled to overcome the economic, political, and social barriers to bringing antiretroviral treatment (ART) to people with HIV/AIDS in the region where the need is most pressing: sub-Saharan Africa. With just 10% of the world’s population, sub-Saharan Africa accounts for nearly 70% of all global HIV infections and 90% of deaths from AIDS. About 2.7 million new infections occurred in the region in 2005, and by the end of that year, an estimated 24.5 million people were living with HIV.

Major Landmark, Major Challenge

In late 2003, the Government of South Africa introduced a national strategy for an ART rollout and follow-up care to all who could benefit from it. Although ART is only one part of an effective HIV/AIDS strategy that also includes prevention programs, the ART strategy was a landmark in the fight against AIDS in Africa. At the same time, it presented daunting challenges.

By the end of 2005, 5.5 million people were living with HIV in South Africa, with almost 1000 AIDS deaths occurring every day, according to UNAIDS estimates. South Africa is affluent in comparison with many of its neighbours, but its public health system is severely underfunded and overextended compared with health systems in developed countries. A badly implemented ART rollout could stretch South Africa’s health system to the breaking point, while also increasing the risk that HIV patients whose treatment was improperly administered would develop resistance to ART drugs.

The government of Free State, one of South Africa’s nine provinces, fully understood the challenges it faced in implementing a national ART strategy. Free State’s Department of Health decided that planning, monitoring, and continual feedback would be essential to an ART rollout that strengthened rather than weakened the Free State health system. This was where IDRC and its research partners came in.

An Ideal Fit

PALSA (Practical Approach to Lung Health in South Africa) research, supported by IDRC, had identified barriers to effective care for South Africa’s tuberculosis patients and had then helped overcome these barriers through improved nurse training. “The University of Cape Town PALSA research team was a natural partner for the Free State government,” says Christina Zarowsky, program manager of IDRC's  Governance, Equity and Health (GEH) program, “because in South Africa, up to 90% of people with tuberculosis are also infected with HIV.”

“The Department of Health approached the PALSA team and asked them to help design and test programs to help nurses and doctors manage ART,” explains Zarowsky. “This was part of a broader interest from the department in using research to support ART rollout planning, training, and evaluation. The PALSA team asked us: ‘Is there a way we can establish a baseline by April, when the drugs arrive?’ Fortunately, we were able to pull together a relatively large project at very short notice.”

A Pioneer in Evidence-based ART Rollout

Why was Free State among the first places in the developing world to integrate research and evidence-based decision-making into ART rollout policy and practice?

“South Africa combines a strong tradition of social demands, informed policymakers, extensive public debate, lots of AIDS research, broad awareness of the vast scale of AIDS infection, and a long history in Free State of personal and institutional relationships between the Department of Health and the universities of Free State and Cape Town,” says Zarowsky. “So the political, social, and institutional conditions are all aligned. The government wasn’t willing to just deliver 10 000 boxes of drugs to clinics and then walk away.”

Brent Herbert-Copley, director of IDRC's Social and Economic Policy program, agrees that the circumstances in Free State were ideal. “Policymakers wanted real solutions and they were open to being guided by the evidence,” he says.

Political commitment to Free State’s "get it right" approach was also crucial. Research-supported ART rollout has ultimately proved effective, but in the short term it meant that Free State did not roll out ART as quickly as some of South Africa’s other provinces. The Free State government initially faced a great deal of pressure to move more quickly.

An Integrated, Holistic Approach

GEH had supported PALSA because of the team’s strong systems approach. “What was interesting to us was how PALSA was using a scientific assessment of training methods to ask: ‘What does it take to enable nurses in a public health system to work effectively?’” says Christina Zarowsky, who was a physician in northern and rural Canada before becoming a health researcher, consultant, and academic. “PALSA was addressing a very specific, practical problem while also addressing all those other broad issues that make a system work or not work,” she says. “That’s really the heart of what GEH tries to do.”

After a baseline survey identified barriers to effective HIV/AIDS care within the Free State health care system, PALSA (which evolved to become PALSA Plus) introduced simple yet comprehensive nurse training. The results have been impressive: PALSA Plus-trained nurses have raised tuberculosis detection rates by 68% and voluntary HIV testing for these patients by 110%. In October 2005, South Africa’s National Department of Health asked the PALSA Plus team for a proposal on scaling up their approach to a national level.

The PALSA Plus team was joined by researchers from the universities of Free State and Toronto, as well as from the South African-based NGO Community Information Empowerment and Transparency (CIET). To assess community knowledge and perceptions about AIDS and ART, these researchers surveyed 4444 people across Free State and interviewed health workers in 67 facilities. They discovered that because communities had been living with AIDS for a long time, they tended to perceive ART as just one more addition to an often contradictory array of available treatments. The researchers have since been working with communities and the Department of Health to find effective ways of communicating the facts about HIV/AIDS and ART to increase the likelihood that ART will reach all who need it, including the poorest of the poor.

Feedback for Ongoing Improvements

Together, these IDRC-supported researchers have created a comprehensive “moving picture” of the Free State ART rollout and its impact on clinics, health care workers, patients, other critical health programs, and health policy. This approach provides rapid feedback from health care workers and communities on, for example, the best locations for clinics, and how to better manage drug supplies and supervise patient treatment.

Perhaps even more important, the researchers’ work and the close partnerships they have built with the Free State Department of Health have helped foster what Zarowsky calls “a culture of asking questions. There’s a real openness to research and evidence-based action, a willingness to experiment with new approaches and to concede when something isn’t working and quickly make adjustments. People feel that they have the tools and the support to be able to assess where they are, where they want to go, and how they can get there.”

The Long Road Ahead

By the end of 2006, about 6717 people in Free State were receiving ART, up substantially from 2500 in 2005, but still a long way from the goal of truly equitable access. Of Free State’s population of 2.8 million, 500 000 are HIV-infected and 30 000 are eligible for ART treatment, with about the same number becoming eligible every year. But as more ART clinics are established, as more nurses are trained to deliver ART, and as patients and communities witness the dramatic effects that ART can have on HIV/AIDS sufferers, Free State’s comprehensive, integrated approach to ART will make it possible to scale up quickly.

“The Department of Health has been very open about the frustrations of taking so long to get the ART rollout happening,” says  Zarowsky. “But now it’s shooting up exponentially because the time was taken up front to do it properly. The infrastructure is there.”

Ultimately, Free State’s approach could be a model for other governments on how to increase the chances of a successful ART rollout by using research to generate political will, understand the cultural and social context in which ART occurs, and strengthen rather than weaken public health systems. For GEH, success in Free State has paved the way for more GEH-supported research in other countries in Southern Africa, including Botswana, Lesotho, Swaziland, and Zambia.

For More Information

Research that Matters

How IDRC-supported research is addressing development challenges and making a difference in the lives of people in the South.

Fighting AIDS with Evidence IDRC-supported research teams are working with public health authorities in South Africa's Free State province to design a rollout of antiretroviral therapies that will strengthen the public health system.

More Research that Matters

IDRC Links

www.idrc.ca/geh

www.research-matters.net

External Links

www.unaids.org/en

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