Francois Venter, president of the Southern African HIV Clinicians Society, recently spoke at the Boston University School of Public Health (BUSPH) on “South Africa’s HIV Problem: Crisis? What Crisis?” In conversation with SABCOHA, Venter discusses his views on the AIDS crisis, new lines of treatment and circumcision.

Is there still an HIV crisis in South Africa?

Yes, there is still an HIV crisis in South Africa. In fact, there are multiple crises. There is a crisis of prevention as 1000 people in South Africa are infected with HIV every day. Rates of HIV infection have been increasing since 1991. But there has been a slight decrease in HIV infections among teenagers. We haven’t seen a decrease in the incidence of HIV infection among people over the age of 35.

• There is a crisis of mortality as about 1000 South Africans die of AIDS every day.

• There is a crisis of treatment because only 40% of South Africans who need antiretrovirals are getting them. In South Africa, only 30% to 50% of pregnant women who need prevention-of-mother-to-child treatment get it.

• There is a TB crisis. TB rates are through the roof and this is entirely driven by the HIV crisis.

• There is a crisis in terms of not enough people getting tested for HIV. Only 2% to 5% of South Africans take HIV tests every year. Often people who test HIV-positive only test very late and so the chances of improving their health becomes very limited. More HIV testing sites need to be set up in South Africa.

How is South Africa dealing with this multiple HIV crisis?

One of the major steps the South African government has taken to deal with the HIV crisis was to introduce the National Strategic Plan on HIV/AIDS and STIs 2007-2011 (NSP) last year. The NSP outlines various ways to manage HIV in terms of treatment and prevention. Other than the NSP, there is a solid civil society programme on HIV, some companies have excellent HIV/AIDS workplace policies and programmes and there has been very good condom distribution throughout South Africa.

Why are so few South Africans who need ARVs able to access them?

It’s appalling that in a country like South Africa, which is relatively rich and has a reasonably good health care system, only 40% of people who need antiretrovirals are on them. I believe the healthcare system hasn’t taken the issue of getting ARVs to people seriously enough. Not enough is being done to hold people accountable in terms of distribution of antiretroviral drugs. More sites need to be set up for people to access them, and it needs to be easier for people to get antiretroviral treatment. Many people have to sit in clinics for hours waiting to access ARVs which means they miss a full day of work. In order for more people to get ARVs there needs to competent, creative leadership and access to treatment needs to suit people’s lifestyles and be quick and efficient.

What should businesses be doing to deal with the HIV crisis in South Africa?

I believe more managers should lead by example and test for HIV in order to encourage their staff to test. Managers don’t necessarily need to know if their staff members are HIV-positive or HIV-negative, but they should certainly encourage them to test.
HIV testing services need to be expanded into more workplaces, and I think companies which really make efforts to encourage their staff to test should be given tax breaks. It makes economic sense for all staff to regularly test for HIV because the healthier people are, the more productive they are.
While some South African companies are really making an effort to respond to the HIV crisis, in general, South African companies have deferred responsibility in terms of dealing with HIV. It makes bad business sense not to take HIV seriously.

Do you believe government has let go of its denial on the HIV/AIDS crisis in South Africa?

No. I think the Minister of Health is doing everything she can to stop the antiretroviral treatment programme. She has not taken responsibility for dealing with HIV seriously, and she’s not playing a leadership role.

You worked on developing the National Strategic Plan on HIV/AIDS and STIs 2007-2011 (NSP). Is the NSP on track?

Of all the NSP’s targets, the only one which has definitely been reached is the number of adults who are on treatment. Some of the other targets are not easily measured, so we just don’t know. But in many, we are not succeeding. There are 400 000 adults on treatment in the public sector and 90 000 adults on treatment in the private sector. We need to really start evaluating why we aren’t reaching the NSP’s targets. We can’t congratulate ourselves on the NSP if it isn’t making a difference in the lives of people on the ground.

You say HIV prevention efforts in South Africa have failed. Why do you think they’ve been such a failure?

We haven’t been sophisticated enough about how we tackle HIV prevention. Our HIV prevention messaging isn’t targeted at specific groups. It’s the same for people in rural and urban areas and this one-size-fits-all approach doesn’t work. But HIV prevention is really hard. Throughout the world, people have failed in HIV prevention. Although in Zimbabwe and Kenya there has been a decrease in infection rates we’re still not completely sure why this has happened.

Studies have found that circumcision reduces HIV transmission rates. Do you think South Africa should introduce mass male circumcision as an HIV prevention intervention? What would some of the implications of doing this be?

The reason why circumcision reduces HIV transmission rates is because the foreskin, which is removed during circumcision, has cells which make it very likely to contract HIV. Mass circumcision should only form part of a package of HIV prevention services which include HIV testing, HIV/AIDS education, screening for TB etc -- it shouldn’t simply be rolled out on its own. I think circumcision-linked HIV prevention programmes would be a great opportunity to get large numbers of men together and provide them with HIV testing and education. Throughout the world, men tend to test for HIV later and much less often than women. One of the reasons for this is that women are much more used to using health care services, as they access these services for pregnancy care, and often have health-related childcare responsibilities.

Have the studies that show circumcision reduces HIV transmission rates caused an increase in men in Southern Africa getting circumcised?

Since the studies came out there has been an increase in circumcision rates in Botswana and Swaziland, but not in South Africa. Certain southern African governments have started discussing mass circumcision programmes.

Health Minister Manto Tshabalala-Msimang recently expressed doubts about the merits of male circumcision in preventing HIV transmission, saying new research suggested the procedure might make women more vulnerable to the disease. What do you think about this statement?

In a situation where an HIV-positive man has just been circumcised and has unprotected sex with a woman who is HIV-negative, then the woman is more likely to contract HIV. But this is only in the first few weeks after circumcision because the circumcision process can cause some small sores on the penis. Issues like this really show the importance of circumcision being part of a proper health risk reduction programme which includes information about the importance of using condoms even if you’ve been circumcised.

Swiss HIV experts recently said that HIV-positive individuals who follow their ARV treatment consistently and who do not have any sexually transmitted infections cannot infect their sexual partners. What do you think about this statement?

This is a controversial statement, and I agree with it to some degree. ARVs can bring down a person’s viral load to the point where it’s undetectable, and if a person’s viral load is undetectable and he/she has no STIs then he/she can’t transmit the virus. But when HIV-positive people have sex they can never really be sure of their viral load unless they received their results that morning. The way this statement is packaged to communities is very important.

What are the latest advances in treatment? What are the implications?

There are a number of new ARVs which are much safer than previous ones. Now there are ARVs which only need to be taken daily, in one tablet. Before there was only a first and second line of ARV therapy, but now if these lines of therapy fail, there is a third and fourth line of therapy. This third line of therapy is available in America and Europe, but it will be accessible in South Africa in the next two years.
ARVs offer great hope to people, especially those who have money and are on medical aid. I’ve seen people taking them get so much better. ARVs are fantastic, they’re magical.

Is South Africa’s health care system coping with the number of people on ARVs?

I think the health system is not coping with anything, let alone HIV. I think it is imperative for all of us to work with the Department of Health to improve the public health system as a whole. They have a very difficult job, often with too few skilled people doing too much work. I am often amazed at the commitment of people who work in the services, often in very difficult circumstances.

* Dr Francois Venter is president of the Southern African HIV Clinicians Society,
clinical director of the University of Witwatersrand’s Reproductive Health and HIV Research Unit and a lecturer in the Department of Medicine at Wits. He is one of the few public sector HIV physicians in South Africa, and has expertise in the use of antiretroviral therapy in developing countries.
Is there still an HIV crisis in South Africa?

Yes, there is still an HIV crisis in South Africa. In fact, there are multiple crises. There is a crisis of prevention as 1000 people in South Africa are infected with HIV every day. Rates of HIV infection have been increasing since 1991. But there has been a slight decrease in HIV infections among teenagers. We haven’t seen a decrease in the incidence of HIV infection among people over the age of 35.

• There is a crisis of mortality as about 1000 South Africans die of AIDS every day.

• There is a crisis of treatment because only 40% of South Africans who need antiretrovirals are getting them. In South Africa, only 30% to 50% of pregnant women who need prevention-of-mother-to-child treatment get it.

• There is a TB crisis. TB rates are through the roof and this is entirely driven by the HIV crisis.

• There is a crisis in terms of not enough people getting tested for HIV. Only 2% to 5% of South Africans take HIV tests every year. Often people who test HIV-positive only test very late and so the chances of improving their health becomes very limited. More HIV testing sites need to be set up in South Africa.

2. How is South Africa dealing with this multiple HIV crisis?

One of the major steps the South African government has taken to deal with the HIV crisis was to introduce the National Strategic Plan on HIV/AIDS and STIs 2007-2011 (NSP) last year. The NSP outlines various ways to manage HIV in terms of treatment and prevention. Other than the NSP, there is a solid civil society programme on HIV, some companies have excellent HIV/AIDS workplace policies and programmes and there has been very good condom distribution throughout South Africa.

3. Why are so few South Africans who need ARVs able to access them?

It’s appalling that in a country like South Africa, which is relatively rich and has a reasonably good health care system, only 40% of people who need antiretrovirals are on them. I believe the healthcare system hasn’t taken the issue of getting ARVs to people seriously enough. Not enough is being done to hold people accountable in terms of distribution of antiretroviral drugs. More sites need to be set up for people to access them, and it needs to be easier for people to get antiretroviral treatment. Many people have to sit in clinics for hours waiting to access ARVs which means they miss a full day of work. In order for more people to get ARVs there needs to competent, creative leadership and access to treatment needs to suit people’s lifestyles and be quick and efficient.

What should businesses be doing to deal with the HIV crisis in South Africa?

I believe more managers should lead by example and test for HIV in order to encourage their staff to test. Managers don’t necessarily need to know if their staff members are HIV-positive or HIV-negative, but they should certainly encourage them to test.
HIV testing services need to be expanded into more workplaces, and I think companies which really make efforts to encourage their staff to test should be given tax breaks. It makes economic sense for all staff to regularly test for HIV because the healthier people are, the more productive they are.
While some South African companies are really making an effort to respond to the HIV crisis, in general, South African companies have deferred responsibility in terms of dealing with HIV. It makes bad business sense not to take HIV seriously.

Do you believe government has let go of its denial on the HIV/AIDS crisis in South Africa?

No. I think the Minister of Health is doing everything she can to stop the antiretroviral treatment programme. She has not taken responsibility for dealing with HIV seriously, and she’s not playing a leadership role.

You worked on developing the National Strategic Plan on HIV/AIDS and STIs 2007-2011 (NSP). Is the NSP on track?

Of all the NSP’s targets, the only one which has definitely been reached is the number of adults who are on treatment. Some of the other targets are not easily measured, so we just don’t know. But in many, we are not succeeding. There are 400 000 adults on treatment in the public sector and 90 000 adults on treatment in the private sector. We need to really start evaluating why we aren’t reaching the NSP’s targets. We can’t congratulate ourselves on the NSP if it isn’t making a difference in the lives of people on the ground.

You say HIV prevention efforts in South Africa have failed. Why do you think they’ve been such a failure?

We haven’t been sophisticated enough about how we tackle HIV prevention. Our HIV prevention messaging isn’t targeted at specific groups. It’s the same for people in rural and urban areas and this one-size-fits-all approach doesn’t work. But HIV prevention is really hard. Throughout the world, people have failed in HIV prevention. Although in Zimbabwe and Kenya there has been a decrease in infection rates we’re still not completely sure why this has happened.

Studies have found that circumcision reduces HIV transmission rates. Do you think South Africa should introduce mass male circumcision as an HIV prevention intervention? What would some of the implications of doing this be?

The reason why circumcision reduces HIV transmission rates is because the foreskin, which is removed during circumcision, has cells which make it very likely to contract HIV. Mass circumcision should only form part of a package of HIV prevention services which include HIV testing, HIV/AIDS education, screening for TB etc -- it shouldn’t simply be rolled out on its own. I think circumcision-linked HIV prevention programmes would be a great opportunity to get large numbers of men together and provide them with HIV testing and education. Throughout the world, men tend to test for HIV later and much less often than women. One of the reasons for this is that women are much more used to using health care services, as they access these services for pregnancy care, and often have health-related childcare responsibilities.

Have the studies that show circumcision reduces HIV transmission rates caused an increase in men in Southern Africa getting circumcised?

Since the studies came out there has been an increase in circumcision rates in Botswana and Swaziland, but not in South Africa. Certain southern African governments have started discussing mass circumcision programmes.

Health Minister Manto Tshabalala-Msimang recently expressed doubts about the merits of male circumcision in preventing HIV transmission, saying new research suggested the procedure might make women more vulnerable to the disease. What do you think about this statement?

In a situation where an HIV-positive man has just been circumcised and has unprotected sex with a woman who is HIV-negative, then the woman is more likely to contract HIV. But this is only in the first few weeks after circumcision because the circumcision process can cause some small sores on the penis. Issues like this really show the importance of circumcision being part of a proper health risk reduction programme which includes information about the importance of using condoms even if you’ve been circumcised.

Swiss HIV experts recently said that HIV-positive individuals who follow their ARV treatment consistently and who do not have any sexually transmitted infections cannot infect their sexual partners. What do you think about this statement?

This is a controversial statement, and I agree with it to some degree. ARVs can bring down a person’s viral load to the point where it’s undetectable, and if a person’s viral load is undetectable and he/she has no STIs then he/she can’t transmit the virus. But when HIV-positive people have sex they can never really be sure of their viral load unless they received their results that morning. The way this statement is packaged to communities is very important.

What are the latest advances in treatment? What are the implications?

There are a number of new ARVs which are much safer than previous ones. Now there are ARVs which only need to be taken daily, in one tablet. Before there was only a first and second line of ARV therapy, but now if these lines of therapy fail, there is a third and fourth line of therapy. This third line of therapy is available in America and Europe, but it will be accessible in South Africa in the next two years.
ARVs offer great hope to people, especially those who have money and are on medical aid. I’ve seen people taking them get so much better. ARVs are fantastic, they’re magical.

Is South Africa’s health care system coping with the number of people on ARVs?

I think the health system is not coping with anything, let alone HIV. I think it is imperative for all of us to work with the Department of Health to improve the public health system as a whole. They have a very difficult job, often with too few skilled people doing too much work. I am often amazed at the commitment of people who work in the services, often in very difficult circumstances.

* Dr Francois Venter is president of the Southern African HIV Clinicians Society,
clinical director of the University of Witwatersrand’s Reproductive Health and HIV Research Unit and a lecturer in the Department of Medicine at Wits. He is one of the few public sector HIV physicians in South Africa, and has expertise in the use of antiretroviral therapy in developing countries.