by Kerry Cullinan
When Helen Joseph Hospital became one of the first public hospitals in Gauteng to provide antiretroviral (ARV ) drugs in April last year, many staff and patients doubted whether the drugs would really work.
“There was a lot of disbelief and suspicion about the drugs,” says Dr Francesa Conradie, a clinical consultant.
Today, the hospital’s Thembalethu Clinic runs the country’s biggest ARV treatment programme with over 3 000 patients on the drugs “and we have seen some amazing things”, says Conradie.
Her current favourite patient is a grandmother who came to the clinic a few months back with a CD4 count of 5 (healthy people have a CD4 count of at least 800) and three young grandchildren to support.
“After four months on [ARV ] treatment, her CD4 count is 195 and she has a new lease on life,” says Conradie.
“Patients on ARVs can live well for a substantial period of time. Mathematical models calculate that the drugs can extend a person’s life by 25 years. Compare this to cancer treatment, which may extend a quarter of patients’ lives for six months.”
The clinic sees around 100 patients a day, with Thursdays being the busiest day when up to 200 people attend.
The clinic’s backbone is Sister Sue Roberts, who has been with the clinic since it first opened in 1992.
In the waiting room, she greets a number of the 100 or so patients, most of whom are healthy-looking people under the age of 40. Only two look ill. One is a skinny women in a wheelchair who was brought over from outpatients. Another is a male hospital patient in pyjamas.
“Over 60% of our patients are women,” says Roberts. “It was a relief to finally be able to put patients on treatment last year as half of the 2000 patients we had then needed the drugs.”
Public demand for treatment was so high that a new clinic had to be built, using funding from the US President’s Emergency Plan for AIDS Relief (PEPFAR ).
This opened in August and has the benefit of sharing space with a non-governmental HIV research and training organisation, Right to Care.
Right to Care assists clinic staff with difficult cases, provides volunteer doctors from the private sector, treats private patients and conducts research. In addition, it funds the salaries of the data capturers that work in the clinic.
“Before we had antiretroviral drugs, when our patients’ CD4 counts fell below 200, we gave them Bactrim [to try to prevent them from getting pneumonia]. After a few months, they stopped coming because they were dead,” says Conradie, who is based with Right to Care. “Now there are hitches, but the benefits far outweigh the hitches.”
One of the hitches is the drug’s side effects, particularly for Stavudine or d4T. Although only about 10% of patients experience side effects and only 1% of these are serious, Conradie is on a mission to get Stavudine replaced with a drug from the same class called Tenofovir, which is newer and has less side effects.
“We are swapping five to 10% of our patients on Stavudine because of side-effects,” says Conradie.
The most common of these is peripheral neuropathy - pain or numbness in hands, feet and legs. Over a longer period, the drug is also know to cause lipodystrophy, which is the development of abnormal fatty deposits in certain places such as the stomach and shoulders along with wasting of the face, arms and legs.
Another problem is a lack of time compounded by staff shortages. The high patient volume means that training people to take their medication properly is squashed into two sessions.
The first is a group information session and the second, an individual consultation which includes input from a dietician. Free fortified porridge, Philani, is available for those who need it.
Patients’ adherence is checked clinically via viral load tests rather than through more time-consuming but patient-oriented approaches such as pill counts.
“Ninety percent of our patients’ viral loads are undetectable, which means there is good adherence,” says Conradie.
“Our staff have lots of motivation and our patients are extremely motivated,” says Roberts.
Conradie adds that “sites like this are driven by people’s passion, not political will”.