Home / 2005 / 2005 - Lusikisiki ARV programme - Dr Hermann Reuter
Lusikisiki ARV programme - Interview with
Dr Hermann Reuter
On this source tape we conducted and interview with Dr Hermann Reuter of Medecins Sans Frontieres in Lusikisiki in the Eastern Cape. Dr Reuter and the MSF team set up a ARV clinic in this rural community to show that ARVs could be administered in resource poor communities with limited infrastructure.
Hermann Reuter: Today is a very significant day for us, we are celebrating the second year anniversary of the antiretroviral programme in Lusikisiki. The first patients started on the 28th of October 2003 and at that stage we were very excited to have permission to use antiretrovirals, it was a very new thing. The government had just agreed in October 2003 that ARVs should be part of a comprehensive HIV package at hospitals, mainly, and we immediately were keen to start a programme at clinics because we thought it would have much better access for rural people to come to clinics rather than having to make their way to hospital. Now two years later, our strategy has paid off, by providing antiretrovirals at clinics, we were able to recruit much faster, we were able to reach a much broader base of the community and so much that we've managed in two years in a rural area to recruit more than (interruption) ...
Hermann Reuter: (continues) By decentralising the programme to clinics, we have 13 points in Lusikisiki where people can access antiretroviral drugs, for that reason we have no waiting lists and we've got now, more than a thousand patients using antiretrovirals. Also at the ceremony, we celebrate the fact that our patients are doing well on antiretrovirals, that they're healthy, that they get few side effects and that they take their medication regularly so much so that more than 80% have got an undetectable viral load at a 6 monthly screening for all viral load tests. What we also are very proud of is that our mother-to-child-transmission programme is very well integrated with our antiretroviral programme because both services are provided at the same clinic, so as soon as a mother who's pregnant is tested HIV positive, we give a CD4 count test, if it is low then immediately she can start with triple therapy antiretrovirals at the same facility which would both protect her health and also give protection to the baby. We've got more than 50 women who are now using antiretrovirals during their pregnancy and this is significant in many bigger centres, you would have the antiretroviral programme being in a different facility and the pregnant woman has to move from one facility to the other and either she doesn't get good anti-natal care or she doesn't get on to antiretrovirals and then after delivery, if you want to start on antiretrovirals, now you sit with a problem that the Nevirapine single dose might have caused resistance and so on, so we don't face any of those problems. Also at the clinic, we provide TB treatment and many of the TB patients are HIV positive, have low CD4 counts and can therefore immediately access antiretrovirals at the same time as using the TB treatment. So today is a reason for celebration and we want to show it to the rest of South Africa that antiretrovirals are possible in rural areas, where we work with 50% of staff compliment but we feel that by providing antiretrovirals, it is actually easier managing patients, the staff is more motivated because we see patients getting better and we've got a high level of community participation which helps us to screen more people for HIV to get more support for people who test positive and the celebration is part of that community mobilisation to get feedback to the community and to get feedback from the community; how they feel about the programme. Today we heard antiretroviral users talking about the need for counsellors, as this programme has a partnership between the NGO Medicin Sans Frontieres and the Department of Health and Medicin Sans Fontieres is employing adherence counsellors, the request was expressed by the patients, by the service users that these adherence counsellors should also be employed by the Department of Health. At the moment, the Department of Health doesn't have a category of adherence counsellors and therefore the concern was expressed that huge responsibilities of making this programme a success lie with adherence counsellors.
Hermann Reuter: Yes, the model that we're showing was the first antiretroviral programme in the Eastern Cape and we're happy that the Eastern Cape has taken up the model to many other sites, the model of including clinics in the provision of antiretrovirals. There's still a debate about whether a patient should start off in hospital and then be referred to clinics or whether they should start antiretrovirals in the clinics. We are much in favour of the model here; patients actually start antiretrovirals at the clinics because we see often hospitals and clinics would give different messages to the patients and patients get confused by these different messages. Also in the TB programme we see often, patients that start TB treatment at a hospital who then have to continue at clinics often get lost to follow-up. If at a clinic a patient gets lost to follow-up, we know about the patient, we can chase them at their home, send them a community caregiver home and basically we call that person.
Hermann Reuter: Often people who get diagnosed with TB at hospitals would then be asked to take treatment at the clinics and they would not come to the clinic, the hospital does not follow up on the patient, the clinic doesn't know about the patient yet and cannot recall the patient by a community caregiver. So these people then come back to the institution a month later being very, very sick with TB that hasn't been treated although it's been diagnosed and we don't want the same scenario to happen with HIV, that people start antiretrovirals at a hospital, get sent to a clinic but the clinic follow-up doesn't happen and nobody feels responsible for the patient. So for us, it is very important that patients actually start with treatment at the clinics, also because a lot of pregnant women who get seen at clinics, get tested for HIV, get tested HIV positive would be enrolled to the mother-to-child-transmission programme but would not get antiretrovirals whereas if the policy is to start antiretrovirals at clinics, you could start that mother on antiretrovirals at the clinic, get onto antiretroviral therapy, keep the mother healthy and protect the child. In the Eastern Cape, a few sites have started with providing antiretrovirals at clinics, we're happy for that and we would like to see it in all provinces of South Africa.
Hermann Reuter: When HIV testing started in South Africa, there were human rights concerns that people were tested and the legal structures weren't in place and there was a lot of discrimination against people who were tested positive and we introduced very strict rules on ... people should be informed properly, should be counselled and should sign a consent form to protect, in a way, the health services against possible discrimination that would affect that service user. Nowadays, the World Health Organisation is saying that it's more of a human rights abuse, not getting people onto treatment as now HIV can be treated with antiretrovirals and more of an abuse if the person doesn't get tested because the main obstacle on getting people on treatment is that so few people have been tested for HIV and we as health services are being negligent, we allow people to come to our facilities with other problems, we could have offered them a HIV test but they leave the facility without being tested for HIV, so they don't know about their HIV status and they might get opportunistic infections soon afterwards that could have been prevented had we tested them in the first place. So worldwide, there's a move now towards something called opt-out testing which has already been implemented in Botswana, our neighbouring country. In South Africa now, we are at a step where some services, we're saying we're applying opt out strategies. For instance in the mother-to-child-transmission programme, the new protocol was issued last month, which said all pregnant women should get an HIV test unless they are opting out. What that means is like traditionally at a maternity unit, if pregnant women come to a clinic, they will get a test for syphilis, they will get a test for blood group matching and perhaps they will get a test for HIV. Unfortunately most women thought that they would be tested for HIV anyway because they know that there's so much talk in the media about protecting your baby and they didn't realise that those bloods that were taken were not tested for HIV and many women thought: "Oh my blood is clean, I don't have HIV" and were very surprised two years later when that child was sick with HIV, we've seen it many a time. So we're very glad that the government has taken a step to say that all pregnant women should be tested for HIV.
Hermann Reuter: For our facilities, this holds many problems because many facilities now in the rural areas would only test 10% of pregnant women not because the women don't want to test but because of lack of staff and now we will see that suddenly if we test all pregnant women, we won't have enough staff to actually perform those tests, which puts a challenge onto us. What we tried in Lusikisiki to compensate for that is to give our counsellors as much responsibility as possible and we're educating the counsellors for doing the whole testing and counselling on their own without a nurse having to be directly involved in it. Obviously there needs to be a sister in charge at a facility, that supervises the process, that checks that quality control measures are adhered to, but we have seen that counsellors are very capable of performing the test on their own. This would relieve professional nurses from having to do this duty. However, the provincial guidelines still stipulate that a professional nurse should be doing the actual testing and that the counsellors should just do counselling. We can see that this, with the shortage of staff of our facilities having about 50% of the nurses that should be there, will not be able to cope with the protocol and we have to decide which rule to break, either we break the protocol and we don't test all the women or we break the rule of nurses having to do the test and we say: "Let the counsellors do the test but at least we will follow the government protocol of testing each person who comes to the clinic" and for me that is the most ethical choice because in this way we can stop the HIV epidemic and that is what the health services should be there for.
Hermann Reuter: The protocol of maternity units was always to offer PMTCT programmes to people. In reality because of the shortage of staff, what happened in most facilities is that in the morning a health promoter would talk about PMTCT and then give the mothers the choice to go to a counsellor to be informed in more detail about HIV, about PMTCT and then they could opt for that or could decide after that if they could be tested for HIV. What we're saying now is that each woman should have compulsory individual counselling so that there's no choice of women opting out of being counselled and thinking: "No this is not for me, I don't have time for this" but that it's part of the basic services that each woman that comes to an anti-natal service gets, is that you need to be counselled on an individual basis. Because we find often, on an individual basis, you can actually address the concerns of a woman and can actually only motivate for her and talk to her about the benefits of testing. Also what we see now is that as we take blood from any woman who books for anti-natal care, when we do those bloods, immediately we do the test (interruption) ... Also now, as we take the blood, the routine bloods, we immediately use some of that blood for HIV testing and the facility has to ensure that the woman has counselling before the bloods are taken so that she can say, at that stage, please don't test it for HIV. But we believe that the attitude at the facilities will change because before it was basically up to the patient to decide: "Yes, I'm brave enough to be tested", whereas now it's basically for the facility to provide the test and only if there's special reasons why the individual decides not to be tested they would basically have to explain to the facility why they don't want to be tested.
Hermann Reuter: Yes, I mean the other tests would often go off to a laboratory whereas the HIV test could be done at the facility with the rapid test testing kit but it would happen immediately and it wouldn't be seen as something as if HIV services are outside other ante-natal care services, it will be more seen as this is part of a routine HIV service which it should be because for me as a doctor, it was always a big ethical dilemma, that we tested women for syphilis, where there's a prevalence of women who've got syphilis but we didn't test them for HIV where there's a 33% prevalence of HIV and we know that HIV is a fatal disease to the child whereas syphilis often doesn't have those dire consequences for the child. So I'm very happy that the Department of Health is now giving some priority to HIV care and is actually acknowledging the catastrophe of mothers not being tested for HIV.
Hermann Reuter: I believe if HIV testing is seen as routine testing it will decrease the stigma, it will be seen as a normal test, the HIV positive diagnoses will be seen as a normal diagnosis and I think it will do a lot to take away the mysticism and the confidentiality issues that were linked to HIV. Obviously I believe as a human rights activist, that confidentiality about somebody's status is important but it has often become a mystic kind of secrecy thing rather than a confidentiality thing.
Hermann Reuter: Before we get to that, I've seen in some facilities where people get group counselling and generally about 30% of the people that get good counselling decided to get an HIV test. However, when people got individual counselling, usually about 95% of the people actually decide to have a HIV test and this is not because the nurses force people to have a HIV test, because in most of those facilities the counselling was done by a counsellor who didn't force people but who actually managed to deal with the questions of the individual and it made people realise that this might be something about me. Everyone talks to a group of people and says: "Decide to have a HIV test", people think they are talking to this one, it can't be relevant for me. But once you do that person-to-person counselling, people actually realise: "I've had sex, I could be at risk of HIV" and this is what is important, that people realise this testing is about their health and about their baby and they don't see it as just something for the group for somebody else. Now what this means for a woman who comes to a facility, because some people argue: "Oh people won't come to ante-natal care services anymore because they will be scared, because they will hear: "I will get a HIV test" because people don't want to be tested for HIV, so we will get more deliveries outside. I think this is not the case because once we've got a big population that has been through ante-natal care and have tested for HIV, often we see that these women are still healthy and they go out to the community and they actually talk about it and I think that Treatment Action Campaign are a good example of this, of people openly living with HIV, going to the community and educating more people. And so I believe the more people we test HIV positive at our maternity facilities, the more it will actually encourage other people to understand the importance of testing during pregnancy. And as we do in Lusikisiki, we allow some people who've been tested for HIV to do talks and to actually do the health talks and not to have health workers do the talks but actually people who've been through the process saying: "This is why I did my test and this is how it benefited me and I encourage you also to test" and I think that should continue that although I said it should become a routine test, I think it's important to keep that mobilisation in the community and the education of that community at a very high level.
Hermann Reuter: Ok, now if you look at other services apart from maternal care, I think it would be a good policy if everybody could be tested. As I say, we're struggling with enough healthcare workers to actually implement this, so to start off I think that we should look at a few indicator illnesses where we say that everybody who has got TB should be tested, everybody who's got a sexually transmitted illness should be tested and there's a few other marked illnesses like pneumonia, like shingles and obviously more serious illnesses like meningitis where people need hospitalisation, I think there is no choice but to say that there should be opt out strategies for those illnesses as well. But to say that everybody who walks into a facility, that includes all your geriatric patients with stroke, with hypertension at 60 years, who've got a lower risk of being infected with HIV, it might not be feasible at this stage for all facilities to offer them a HIV test. Although I think in the long run, the health services have got a responsibility to allow every South African the opportunity to know their HIV status.
Hermann Reuter: Routine testing will benefit South Africa to allow more people to know their HIV status. There are many chronic illnesses like sugar diabetes, hypertension and the biggest obstacles to treating them is that they often go unnoticed until complications have already occurred, the same applies to HIV. Our hospitals struggle with occupancy of people struggling with opportunistic infections because we didn't diagnose the infection early enough and we didn't prevent those opportunistic infections. By testing everybody early, this means we can intervene in the process in which HIV destroys the immune system and we can start using antiretrovirals before those people actually need hospitalisation. And if we could test everybody in the community, we could get everybody to antiretrovirals before they get too sick and I think this should be the aim of us. Furthermore, through testing people, we make people aware of their HIV status and I think this is one of the most important prevention messages that we can give, we have seen over the last 20 years we have promoted condoms and we were not very successful in actually stopping the spread of HIV, I believe the more people we test for HIV through that individual counselling, those patients that test negative would have realised the importance of staying negative and through testing other people HIV positive, we can help them to then realise that for them condom use is really a reality that they need to adopt. In my experience, in our clinics we have seen a definite increase of condom use amongst people who know their HIV status.
Hermann Reuter: Ok, people might feel that the opt out strategy is forcing people to undergo a test that they don't want to do, strangely enough when we look at other illnesses, if you look at caner, we don't ask people: "Do you want to be tested for cancer?" They come with an illness, we test them and we tell them: "You've got cancer." Why HIV is different is because HIV is spread sexually and by telling somebody you've got HIV, basically says something about their sex life and because we feel that sex life is something private, we sometimes feel that we are infringing on their privacy by implying that they are sexual beings. But I think that with the age of HIV, we have to see sexuality as something normal, something part of humanity and I don't think that anybody should feel shy about offering people HIV testing on a opt out basis.
