This morning I am flying to Durban, South Africa (well, by way of Europe, for 2 weeks!), to begin a 9-month Fulbright grant in Public Health. I will be conducting independent research on the costs, benefits and impacts of HIV treatment models in South Africa.
Some food for thought
South Africa’s complex history of apartheid has shaped a landscape of enduring socioeconomic inequality and a legacy of apartheid that will live on for decades. Nevertheless, South Africa has moved forward to create a unified, democratic, “rainbow nation.” South Africa is warm, vibrant and sophisticated, I place I will feel privileged to call home. Travel the beautiful Durban beaches, Cape Town rocky coastline and Drakensburg Mountains; read about the prolific South African-based scientific research being conducted.
Despite this extraordinary progress, HIV threatens the social fabric of the country, as well as its economic and political viability. South Africans have responded to this challenge and demonstrated their will to tackle the epidemic. AIDS activists, including members of Treatment Action Campaign and others, successfully lobbied for publicly provided AIDS treatment in the early 2000s and continue to campaign for HIV education and treatment literacy to reduce AIDS stigma. They have also played a vital role in challenging the system of HIV treatment delivery.
However, 12 years after the historic Durban AIDS conference and on the heels of the first conference to return to the United States in 22 years, and we still have not turned the tide on the epidemic. South Africa is currently burdened with the most number of people in the world living with HIV and is continually challenged to meet an incredibly high demand for treatment—both for individuals and public health (more on that later). Rhetoric is not the answer.
To add fuel to the fire, PEPFAR has recently begun transitioning from financial to technical support to South Africa. In an era of constrained resources and fiscal austerity, research on ways to optimize public health dollars spent and find additional system-wide efficiencies is particularly timely.
My research
For too long, South Africa’s health policy was not adequately aligned with the health workforce and infrastructure landscape—doctors are largely concentrated in the urban hospitals and in the private sector and are in short supply in rural, disadvantaged communities where nurses run most clinics. Until 2010, initiation and management of HIV treatment, which is called antiretroviral therapy (ART), was limited to doctors practicing at accredited sites. Although publicly provided ART is free, infrastructural and resource constraints imposed substantial indirect costs on patients, including transportation costs and lost income from missed days of work. Large public hospitals accrued long waiting lists for ART and patients got sick and died waiting for treatment.
Recognizing the lingering effects of apartheid, pilot projects emerged across the country to “decentralize” HIV services to primary heath clinics through nurse-provided treatment. The results were impressive. In a study of one program in Lusikisiki township in the Eastern Cape province, TAC and Médecins Sans Frontières (MSF) showed that for every health outcome—ART adherence, viral load, mortality, loss-to-follow-up—patients managed by nurses performed as well or better than patients managed by physicians. In light of the encouraging results from these pilot sites, South African national policy is catching up. This small body of research led to policy guidance in April 2010 recommending that nurses provide comprehensive HIV/AIDS services at the primary health clinic level.
Over two years have passed since this landmark policy change, and I want to understand the costs, benefits and impacts on the health care system, individuals and communities. My research will be based at CAPRISA (Centre for the AIDS Programme of Research in South Africa), a preeminent research institute, performing rigorous studies that are guiding the development of progressive interventions and policy. Quarraisha Abdool Karim, an absolute rock star in the global health field who co-directs CAPRISA with her husband Salim, will mentor me.
I hope to use this blog as a platform to discuss global health policy and research in South Africa and beyond as well as my experience as a Fulbright student. It will be most successful if it is interactive, so please leave comments or email me if you have suggestions (Jamie.alex.cohen@gmail.com).
Thanks for reading!
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