Warming up

Assignment, reading, weather… everything warmed up during my first week in Tshwane (Pretoria). In the media HIV/AIDS was in the news as former soap star Lesego Motsepe died having stopped treatment in 2012 to exclamatory headlines: ARV SHOCK! HIV+ Lesego opts for beetroot Manto style – a reference to former Health Minister Manto Tshabalala-Msimang  who denied South Africans access to antiretroviral therapy, advocating healthy eating.

Firstly, at work. How great it was to see the truly impressive progress made in three short years. Blog followers from my Eastern Cape assignment and anyone who’s looked back at earlier posts may remember that in late 2011 the NIM-ART (Nurse Initiated and Managed Antiretroviral Therapy) programme was just starting.

Maria Rantho Clinic

Lesego Motsepe, former soap star and AIDS activist who died this week

As part of my re-introduction I visited primary care facilities in the township areas of Winterveldt, Ga-Rankuwa and Soshanguve built 35km outside Pretoria at the time of apartheid. And what a long way NIM-ART has come in a short time. I sat with Sisters Rose, Stephi and Ann who competently and confidently managed long queues of booked and walk-in patients from cohorts of four to five thousand people with HIV per clinic.

When I arrived I asked one of the sisters if she knew why I was there. To my chagrin she replied “Because we are the worst performing clinic in the district”. If that was the worst then it was a pleasure to tell her – and her sub-district manager – how truly impressed I was. In a week when the Sports Minister caused a stir using the language of a BBC 5live 606-caller as he lambasted Bafana Bafana – “What I saw was a bunch of losers” – motivating staff by praising their impressive vocation and dedication to NIM-ART might be considered..? In the Mail & Guardian newspaper public HIV testing services were praised by a scientist who spent several fruitless days trying to get a private test and tried the public health service in desperation:

There were quite a lot of people waiting to be tested but the whole process went very quickly. The nurse [] was well informed – you could tell all the staff had been well trained for this

Not only were nurses that I saw managing HIV caseloads the size of the very largest UK centres but doing so in primary care. The variety of problems was beyond what many UK-based HIV specialists would see in a very long time. There were complex treatment questions, TB symptoms, defaulters returning to HIV and TB management, orphans brought in by family members and the visibly sick with advanced HIV / TB disease; there were infants and people in their seventies, some were pregnant – and there’s another good news story. Nurses are struggling to complete their NIM-ART portfolios since effective prevention of mother to baby transmission was introduced in 2010 with the consequence that insufficient new-born and very young cases of HIV exist for them to manage.

Let’s not get too rose-tinted: I am here for a reason. At a time when international donors are contemplating the withdrawal of funding significant challenges lie ahead if South Africa’s ambitious HIV programme is to achieve its targets: millions more need testing and life-long therapy, multi’ and extremely drug resistant TB are on the march and the overall number of TB cases has not fallen; significant gaps exist in funding staffing and infrastructure; there are reports of drug stock-outs – though not in the facilities that I visited – and the questionable quality of data means that the true magnitude of loss to follow up is uncertain. The day before I was there, the Minister for Health visited one of the Soshanguve clinics and found a patient who had waited from 07:30 until 12:00. He blasted ministerial hot breath under the poor manager’s collar.

I’ve finished my first South African novel on the new Kindle, Karen Jayes’s shockingly violent For the Mercy of Water set in a near future beset by drought, corruption, brutality and water wars.

Then there’s terrifically warm hospitality of David and Ann Cameron which has made my first week in South Africa so positive. David and I take a brisk forty-minute walk at 05:30 before the mercury rises to the low-to-mid thirties each afternoon. They’ve taken me to visit the Voertrekker Monument last Sunday and Sammy Marks’s House, allowing local history to seep under my skin. Add to that the pleasures of flora and fauna – I’ve been welcomed back to Pretoria by a cacophony of bird-calls and returns including onomatopoeic hadeda ibis, bright yellow weavers, egrets and a delightful pair of grey loerie on the Camerons’ balcony.

Haa-dee-daa ibis

Next week I go out in the field with NIM-ART mentors and mentees carrying out interviews, (hopefully) focus groups and issuing questionnaires – gathering evidence from the coal-face of the successes and challenges of NIM-ART that lie behind the numbers. Hot stuff.

NIM-ART Nurse Ready to Return

With the distractions of Christmas and New Year behind me, suddenly it’s only a matter of days until I fly again to Oliver Tambo International, Johannesburg. Second time in South Africa I’ll be met by (the good) David Cameron who has kindly offered to put me up in Pretoria for my first two weeks on assignment.

In 2011 my objective was to help to get NIM-ART (Nurse Initiated and Managed Anti-Retroviral Therapy) off the ground in the primary care clinics of Graaff-Reinet and surrounding district through clinical mentoring. Three years later I’ll be helping to evaluate the impact of NIM-ART and NIM-ART mentoring in four districts in Gauteng, Mpumalanga and Limpopo (two) provinces. Linda Murray has made the interesting suggestion that I use some of the flight time to list my expectations so that I can reflect upon them at the end of my assignment…

      

Janet Hearn has advised me on antimalarials as it’ll be hot and humid with Anopheles mosquitoes keen to bite my parts in parts. Janet gets posted by Médecins Sans Frontières to more challenging locations than primary care clinics in north-eastern South Africa: Darfur, Turkish/Syrian border, etc. She describes her pre-assignment feelings as “terror coupled with excitement”. I’m happy to say that I am not experiencing terror. However South Africa’s violent crime statistics are widely reported – in the words of one of my South African patients, “there are so many car-jackings” – so in order not to end up as another crime statistic I’ll be sensible. I’m looking forward to it; a little daunted but in the sort of good way that’ll put me on my mettle.

What’s changed? Most obviously, on 5th December 2013 Nelson Mandela died. On a cold Sunday afternoon on the Sussex coast I watched Mandela: Long Walk to Freedom. Scenes of his birthplace in lush, sun-drenched Transkei heightened my desire to get back there and I thought that the movie was as good a representation of his autobiography’s 784 pages as is possible in 152 minutes with strong actors convincing as Nelson and Winnie Mandela.

In other changes, South African HIV treatment guidelines have embraced new antiretrovirals in new classes – welcome a second protease inhibitor, atazanavir and an integrase inhibitor, raltegravir – opening up the possibility of effective third-line therapy. A recent study has reported “astounding” results from the South African HIV treatment programme:

The roll-out of antiretroviral therapy (ART) in South Africa has achieved “astounding” results, a mathematical model published in the online edition of the Journal of Infectious Diseases shows. Each person who started HIV therapy between 2004 and 2011 had an individual gain in life expectancy of 11 to 13 years. The estimated population lifetime survival benefit for all people initiating ART in this period was 21.7 million life-years. Increasing the number of people linked to care and expanded access to second-line therapies could increase the gain to 36 million life-years.

In 2011 I left my caseload in the capable hands of Caron Osborne; on Friday I’ll leave it in the capable hands of Heather Renton. At home, Steve and Chris are at universities, leaving Angela in a quieter house. Without Angela’s blessing and her being prepared for some quiet times at home – plus the support, interest and good wishes of so many others – it would be harder to go. Thankyou all.

Reference: Michael Carter, http://www.aidsmap.com/page/2810573/?utm_source=NAM-Email-Promotion&utm_medium=aidsmap-news&utm_campaign=aidsmap-news with a link to the original article.

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South Africa 2011 vs 2014

2011	2014
Cacadu district (Graaff-Reinet)	Tshwane District (Pretoria) Nkangala District (Witbank area) Capricorn District (Polokwane / Pietersburg) Vhembe District (Zimbabwean border)
1.4 million South Africans on antiretroviral therapy	2.4 million South Africans on antiretroviral therapy
First and second line therapy	First, second and third line therapy
Global Medic Force (New York)	Foundation for Professional Development (Pretoria)
Clinical mentoring – implementation	Roving mentoring – evaluation
Oscar Pistorius preparing for London 2012	Oscar Pistorius preparing for Pretoria court March
Long Walk to Freedom – book	Long Walk to Freedom – movie
Rough Guide to South Africa – book	Rough Guide to South Africa – Kindle
Rugby World Cup Quarter Final: Australia 11 v South Africa 9	Cricket: three test series v Australia. Feb-March