An anti-retroviral clinic in rural Kwazulu-Natal, South Africa is full of patients who patiently wait for their turn to receive HIV medicine.
Smiling shyly, a 51-year old woman clasping a brown paper bag upends her medicines in front of Nokubonga Potelwa, who explains how to take the drugs that were long snubbed as toxic by the South African government.
AdvertisementPotelwa hands the woman a photocopied calendar, with a picture of a sun and a moon drawn in each day where she has to mark off that her medicines were taken, and uses a red crayon to indicate with an X, the day she should return.
Emmaus hospital, nestled among the majestic Drakensberg mountains in the AIDS-stricken province is one of several rural hospitals recording astonishing successes in ARV-treatment, having already hit ambitious targets set for 2011.
After the cabinet adopted on May 4 2007 a five-year AIDS plan which aimed to halve new infections by 2011 and have 80 percent of patients on treatment, South Africa's once sluggish and embarassing AIDS response has taken new shape.
"I am happy, because I am going to live a healthy life," the woman says quietly in Zulu.
With five and a half million HIV infections, in a population of 48 million, South Africa has the world's worst AIDS rate.
From President Thabo Mbeki's questioning of the link between HIV and AIDS, and a long battle by activists to see the provision of anti-retroviral treatment, government was reluctantly prodded into rolling out ARVs in 2004.
The slow rollout, and constant conflict between activists and health minister Manto Tshabalala-Msimang reached its zenith in 2006 when the minister's promotion of vegetables over ARVs saw her displaying beetroot, garlic and lemons at the world AIDS conference in Toronto, Canada.
The international backlash spurred the development of a new National Strategic Plan driven by a restructured AIDS council that has seen civil society relentlessly driving the fight against AIDS.
"More people are coming in and testing, there are many more on ARVs. Ay its a big difference," says Potelwa who has seen the hospitals' ARV rollout go from zero to on-target in her three years as an AIDS counsellor.
To Dr Bernhard Gaede, who heads up the AIDS clinic at Emmaus, the trick to wading through the pitfalls of rural healthcare, such as doctor shortages and long distances is decentralising, empowering nurses to perform more functions.
The initial guidelines for implementing ARV treatment from initiation to adherence at central hospitals resulted in chaos, with long waiting lists around the country.
"Very quickly, with a small amount of space and small number of staff we became very congested. We could only put five people a week on ARVs," said Gaede.
By training nurses at the five Primary Health Care clinics around Emmaus to do testing and adherence, and sending doctors there to initiate patients, 80 percent of the HIV positive community -- 20,000 people of a population of about 150,000 -- is now on treatment.
Government figures at the end of February showed that 420,000 people were now receiving ARVs nationwide, a sharp rise on the figure of 273,000 at the end of 2006.
"We improved transport to clinics, and by having doctors there the goal (in the NSP) of strengthening the health care system actually began to happen."
Denise Hunt, executive director of the AIDS consortium networking organisation, who is on the plenary of SANAC, said while there was not yet statistical evidence to measure the targets that had been set, the signs were positive.
"There is a lot of anecdotal evidence that we have come quite far in the journey. I think we have made a lot of progress, it is very exciting to see there are the success stories."
She said rural hospitals like Emmaus showed that with "creative thinking, when it is applied, the targets are ambitious but they are reachable."
Both Gaede and Hunt agree the civil society component of SANAC made a huge difference in the progress that had been made, even when the renewed goodwill between government and activists faltered.
Hiccups at the end of 2007, such as when deputy health minister Nozizwe Madlala-Routledge -- who played a big role in the development of the NSP -- was fired, sparked fears that politics could see the AIDS plan backslide.
"We all had a space last year around the deputy minister of health being fired. We all became very anxious and probably quite depressed," said Hunt.
"If government starts losing momentum civil society has to keep up the pressure."
One of the other successes has been the recent release, after many delays, of new guidelines allowing for the use of dual therapy to treat pregnant women before going into labour and their newborn babies, shown to drastically decrease chances of the HI virus being passed from mother to child.
There was an outcry when government in February charged a rural doctor, Colin Pfaff, for misconduct, when he raised donations to provide dual therapy before the protocols were officially implemented.
Gaede said it was "absurd", and added that comments by a local government minister that antiretroviral drug AZT, used in dual therapy, was toxic showed "lots of people are still completely in the way."
While many areas of the NSP still had a way to go, such as getting more people to test and improving prevention messages, Hunt said the work that had been done was inspiring.
"Although sometimes it's shaky, it's inspiring to see the plans that are been made. We are still speaking the same message.
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