The above image celebrates a bright day in December 2002, when Nelson Mandela came to visit our clinics in Khayelitsha. He came to offer political support, while we were confronted with strong HIV denialism from the National Government. He left people in no doubt regarding his personal convictions when, without hesitation, he swiftly put on the HIV positive T-shirt, an image which made world headlines.
By endorsing this T-shirt, he identified with the political struggle to gain access to ARVs. To have the world’s foremost statesman come to a destitute township like Khayelitsha, take off his shirt and don a strongly political T-shirt symbolised in one gesture what we had tried to do for a couple of years: make ARV treatment accessible to the poorest and most affected, as close as possible to where they live, in a country still completely divided along socio-economic lines.
This is what this clinical guide is about: it aims at motivating and equipping primary care health staff with necessary knowledge to treat HIV-related conditions and initiate adults, children, pregnant women on ARVs within their own clinic, even if they have no support available from a specialised health care centre. It aims to support HIV care at the grassroots level.
When we drafted the first edition of this guideline in 2000, we had no idea if we would succeed in such a tremendous challenge. This is the 8th edition and, in the meantime, major progress has been made in Khayelitsha: 28 000 on ART, including 3 500 children and a mother-to-child transmission rate reduced to 1.3%. Similar exponential coverage has taken place nationwide, despite a much later start.
This has had an immediate impact on reducing mortality by 27% in the last 5 years; increasing life expectancy in KwaZulu-Natal (KZN), a high HIV burden province, from 49.2 years in 2003 to 60.5 years in 2011. These figures are definitely impressive, but many challenges remain, mostly qualitative ones: we have to find innovative ways to keep initiated patients in long term care with undetectable HIV viral loads and, even more, we need to reduce new infections, particularly in young women, and eliminate vertical transmission; all of this in the absence of an effective vaccine, probably for the next decade.
This guideline is not close to becoming obsolete; despite impressive ART coverage, we still see ‘late presenters’ with advanced opportunistic infections coming to our clinics and hospitals. These patients often require high-level diagnostic and treatment procedures and, for this reason, a complement to this guide, aimed at addressing such complex cases referred for hospital care, will be soon released.
‘AIDS is a war against humanity’, said Nelson Mandela on that day in 2002. In making his symbolic gesture, he offered his own humanity to head the battle while giving many the courage to fight our worst enemies: stigmatisation and ignorance.
Let us together continue on this path, striving together to provide an increased quality of care to the people.
This guideline is dedicated to the memory of Madiba.
Eric Goemaere, February 2014
- Date June 30, 2015
- Tags ARV, Diagnosis, Hepatitis, HIV, Monitoring, Opportunistic infection (OI), Patient education and counseling, PMTCT, TB