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Item Open Access Initial anticipations and experiences of antiretroviral therapy among managers at ART-assessment facilities in the Free State(University of the Free State, 2006) Janse van Rensburg-Bonthuyzen, Ega; Heunis, ChristoEnglish: Before the implementation of ART, and again seven months later, interviews were conducted with facility managers and nurses leading PHC programmes. Their perceptions of the impact of ART are discussed. A positive finding was that ART assessment site managers had been optimistic about ART from the outset, and by the end of the sevenmonth period even more so. Nurses leading other PHC programmes were initially concerned about overcrowding the facility due to ART, but this problem did not feature prominently during the follow-up survey. ART programme nurses’ perceptions of the problems at their facilities mostly related to staff and space. On the whole the data show that pessimism preceding the implementation of ART was in many respects allayed with implementation.Item Open Access Human resources for ART in the Free State public health sector: recording achievements, identifying challenges(University of the Free State, 2006) Steyn, Francois; Van Rensburg, Dingie; Engelbrecht, MichelleEnglish: The shortage of human resources for health poses a serious threat to public sector ART in South Africa. In the Free State, recruitment of staff for ART emphasises the challenges of securing the necessary number and categories of health professionals. Amongst others, not all posts were filled, and some appointments left vacancies in other programmes and facilities. Practice indicates that sites should be staffed according to the demand for the service, instead of general staffing norms. It is argued that health workers who currently do not work in the programme should receive training in ART in order to spread workloads more evenly in facilities. The realities of staff frustrations and discontent also call for improved supervision and support. The study suggests that the strengthening of the health system via human resources for ART is still to transpire. To achieve this, improved strategic planning is required.Item Open Access Scaling up antiretroviral therapy: experience of the Joint Clinical Research Centre (JCRC) access programme(University of the Free State, 2006) Mugyenyi, Peter; Kityo, Cissy; Kibende, Samson; Ssali, Francis; Kabuye, Goeffrey; Otim, Thomas; Tugume, Stefano; Byaruhanga, Rose; Kabugo, MichaelEnglish: Despite Uganda’s success in lowering the rate of HIV infection, numbers of people already infected and progressing to AIDS continue to rise. The JCRC pioneered the use of antiretroviral drugs in Africa since 1992, and developed a successful model that incorporates drugs logistics, adherence and sustainability strategies, as well as regional referral centres of excellence and laboratories. JCRC rapidly established 35 satellite centres in the various districts, currently providing antiretroviral drugs to over 35 000 out of 70 000 patients on therapy. Increased access to treatment proceeds contemporaneously with improving infrastructure, while addressing critical human resource needs by ongoing training. This model provides data that inform a way forward for a robust, high-quality and sustainable ART programme, and aims to integrate into an improved national continuum of health care delivery.Item Open Access Home-based care as an indispensable extension of professional care in ART - a plea for recognition and support(University of the Free State, 2006) Hlophe, HlengiweEnglish: The Centre for Health Systems Research & Development is currently conducting a longitudinal study to assess the implementation of public sector anti-retroviral treatment (ART) in the Free State. Home-based care (HBC) is central in achieving good patient follow up, continuity of care and patient adherence to treatment. This paper considers the role of HBC in strengthening the ART programme and identifies barriers to effective HBC. To this end, group interviews were conducted with HBCs in the Free State. Problems in respect of training, resources, stipends, support, supervision and management were revealed. Amongst HBCs and primary health care nurses confusion occurred about HBCs’ roles and duties. It is recommended that gaps in policy implementation in respect of HBC should be addressed and that HBCs’ roles should be clarifiedItem Open Access From the nurse's mouth: the Fezile Dabi ART assessment site experience(University of the Free State, 2006) Du Plooy, ShirleyEnglish: HIV/AIDS, together with the implementation of a public sector antiretroviral treatment (ART) programme and the transformation of the health system, places unprecedented pressure on facilities with insufficient nursing personnel. Based on information gathered from group interviews, this paper presents the experience of nurses working at ART assessment sites in Fezile Dabi. Empirical data represent the following domains: perceptions and experiences surrounding the impact of ART, general and staffing needs, training, patient drug-readiness training, the value of volunteers, support and supervision from ART programme managers, and emotional support for and coping mechanisms of staff. Recommendations take account of floor-space, management, additional staff, confidentiality, practical training, drug-readiness training, and coping strategies.Item Open Access The Free State's approach to implementing the Comprehensive Plan: notes by a participant outsider(University of the Free State, 2006) Van Rensburg, DingieThis study reviews the first two years of implementation of the Comprehensive Plan in the Free State, within the national framework and amid external influences. The features and principles of the province’s approach are analysed, in particular the phased, multimodel, PHC-centred nature and its emphasis on partnerships and inclusiveness. As implementation progresses, constraints and deficiencies are seen to emerge: a lack of leadership and support, a flawed national-provincial relationship, a lack of comprehensiveness, programme verticalisation, drug insecurity, chronic indecision and lack of action, a fixation on operational issues with concomitant neglect of strategic matters, and breakdowns in communication and co-ordination. Despite notable progress in implementation, it is necessary to rethink and redesign aspects of the approach. By identifying the major lessons to be learnt from the Free State’s experience, this study attempts to inform such rethinking and redesigning, as well as highlighting lessons for application elsewhere.Item Open Access Expanding access to ART in Sub-Saharan Africa: an advocacy agenda for health systems development and resource generation(University of the Free State, 2006) McCoy, DavidEnglish: Providing universal, effective and sustainable access to ART in sub-Saharan Africa (SSA) requires a broader advocacy agenda encompassing the development of health care systems and the generation of much larger resources for the health sector. Presently, health care delivery in SSA is characterised by a patchwork of poorly co-ordinated and governed public, NGO and private services, a situation which contributes to the undermining of national stewardship and coherent health planning. The challenge of expanding access to ART in SSA cannot be divorced from the challenge of liberating countries from poverty. The international public health community needs to use its voice and its authority to support ongoing campaigns to, for example, eradicate the debt burden and to raise public finance at the global level.Item Open Access Reflections on ART policy and its implementation: rebuilding the ship as we sail?(University of the Free State, 2006) Schneider, HelenThis paper reflects on the early experience with ART implementation in South Africa in the light of the policy goals of increasing ART access whilst improving prevention and strengthening the public health system. It reviews evidence on the state of ART roll-out and suggests that achievements to date have been significant, even if unevenly distributed and not meeting the set targets. The paper then considers what may be important future challenges — ensuring sustainable financing, addressing health system weaknesses (especially those related to human resources), building integrated systems of care and prevention, and developing appropriate national stewardship of the programme. Dealing with these challenges will be essential, both for building equitable ART access and leveraging wider benefits from the large investments in ART.Item Open Access Emerging threats to equitable implementation of ART in South Africa(University of the Free State, 2006) Stewart, Robert; Padarath, Ashnie; Milford, CeciliaEnglish: The Comprehensive Plan for the expanded treatment of HIV in South Africa was lodged in November 2003. The guiding principles of this plan are “universal access to care and treatment for all, irrespective of race, colour, gender and economic status”, and equitable implementation. However, there are concerns that the provision of antiretroviral treatment will exacerbate existing inequities, thereby undermining the very system that it seeks to build. Using a monitoring framework developed by EQUINET, this contribution seeks to identify the shortfalls in programme implementation and threats to achieving the equity goals that are emerging. Findings highlight ongoing concerns around weak monitoring systems and data collection that enable the development of equity profiles at a sub-national level, while limiting the extent to which progress in meeting the guiding principles may be assessed.Item Open Access Social dynamics fuelling the spread of HIV/AIDS in the Free State: implications for prevention, care, treatment and support(University of the Free State, 2006) Redelinghuys, NolaEnglish: This article examines some of the socio-economic and socio-cultural factors that may have shaped a social context conducive to the spread of HIV/AIDS in the Free State. Among the factors identified driving the spread of the disease in this province, low levels of socio-economic development, population mobility, and gender inequality are paramount. The article further reasons that the successful implementation of strategies aimed at HIV prevention, treatment and care, such as the Comprehensive Plan of 2003, hinges on the social context enhancing or inhibiting the implementation thereof. Lastly, it is reasoned that the issues of planning and strategy development for the prevention of HIV/AIDS should slot into broader social policy and planning at the national and provincial levels. Amongst others, this would include policy and planning that target those socio-economic and socio-cultural forces which are fuelling the spread of the disease.Item Open Access The demographic and development landscape of HIV and AIDS in the Free State, South Africa(University of the Free State, 2006) Pelser, AndreEnglish: Many of the current and expected demographic changes in southern and South Africa are destined to emanate from the influence of HIV and AIDS on the population structure. This article elucidates the most important demographic trends and changes to which the population of the Free State will be subjected over the next few years. Some implications of these changes for human development in the province are also explored. It is argued, inter alia, that an integrated development strategy — one that is mainstreamed with HIV/AIDS prevention and antiretroviral treatment (ART) campaigns — is pivotal as part of a comprehensive response to address the spread and impact of the epidemic in the Free State.Item Open Access Public sector antiretroviral treatment: the challenge of patient retention(University of the Free State, 2006) Booysen, Frikkie; Anderson, Shaun; Meyer, KobusEnglish: Compliance with follow-up is needed to ensure that the public sector antiretroviral treatment programme in South Africa is successful and sustainable. This paper investigates the nature of factors associated with the retention of public sector ART patients in the primary health care-driven model. Data from a cross-sectional survey among patients are used. Income and social support are important facilitators of patient retention. Yet, income may also impact negatively on patient retention where entire families rely on a single breadwinner for their livelihood. Substance and alcohol abuse and stigma, according to the evidence, may impede patient retention. Avenues for further research are proposed and suggestions are put forward as to possible solutions to these policy dilemmas.Item Open Access Integration of ART: concepts, policy and practice(University of the Free State, 2006) Heunis, Christo; Schneider, HelenEnglish: The recent implementation of ART in the South African public health sector necessitates renewed debate on the integration of key primary health care (PHC) programmes. Integration of PHC is really best understood in relation to its opposite, i e verticalisation or selective PHC. This paper discusses these approaches in international and South African contexts. Integration as it has been applied to HIV, namely the continuum of care and TB-HIV integration, is also considered, with specific reference to the Free State. We then present the “voices” of programme implementers on the theme of integration in this province. Both in the literature and in the interviews with implementers, the need for integration is supported. However, there is also recognition that the vertical and integrated approaches should not be exclusive, but should both feature in ART roll-out, particularly in the inception phases of the programme