The challenges surmounted, and those still ahead

A number of people have over the years played a role in the development of the TAC and our battle for antiretrovirals. There are too many to mention. In the following pages a small group of people who played a role in one way or another and represent various constituencies, share their recollections of the past and their dreams for the future.

What does 10 years of antiretroviral therapy in South Africa mean to me and my paediatric colleagues?
It is a sign of just how much has changed in 10 years when I have to explain to medical students what the signs and symptoms of paediatric HIV are and how to spot these. Five years ago the students knew all the complications and hardly required a lecture on this, and 10 years ago they were all virtually experts on this disease as it was so rampant. Our paediatric wards in 2004 were more than half filled with HIV-infected and often dying children, mostly infants. Today, the sight of an infant dying from HIV, while not a rarity, is quite uncommon and certainly not the daily occurrence it was a decade ago. The wards are less crowded and HIV-infection probably accounts for not more than 20 percent of our in-patients. There has been a dramatic decline in the incidence of opportunistic infections, and our in-hospital mortality rate has plummeted.

When I go up to the Paediatric HIV clinic at the Rahima Moosa Mother and Child Hospital, called the Empilweni Cinic, it dawns on me that this clinic is one that now caters for teenagers, and that age group is what defines this population of survivors. Fewer younger children being seen and, now, surviving older kids remaining in our care – many now reaching adulthood – means that this cohort of patients is ageing.

So, from the lens of a paediatrician in the public health sector, who has been fortunate enough to bear witness to the changing and evolving pattern of paediatric disease in a country with the largest number of HIV infections globally, the journey has been nothing short of spectacular.

The successes that we have achieved as a nation over this past decade have come on the back of much advocacy and campaigning from a wide range of civil society players coupled with governmental action supported by international partners, notably USAID through the PEPFAR initiative.

While the relationship between government and civil society is no longer adversarial, the need for strong advocacy and civil society participation in the treatment and prevention programme is no less important today than it was 10 years ago. My greatest fear is that complacency on our part will cause us to slide back into the dark old days of this pandemic. We have an opportunity today to hold onto the gains and achieve even more if we reflect on the key success factors that have brought us to this point. As a nation we have the expertise and the means and, more than ever, we have the political leadership in health we so desperately lacked at the beginning of this pandemic.
What are the paediatric problems that we now have to deal with in 2014?

On-going mother-to-child transmissions despite our best efforts. This is a reality and we have to continue to be vigilant in reducing transmissions to a minimum as well as detecting those that do become infected.

Improving the pick-up rate of all HIV-infected infants early so as to get them into treatment as soon as detected.
An ageing paediatric population and, therefore, an increasing adolescent HIV population with its own challenges and needs.

Transitioning care from adolescence to adulthood.

Increasing numbers of children and adolescents who require second- and even third-line therapy.

Improving on the paediatric ART formulations and improved treatment regimens.

A perception that paediatric HIV is no longer a problem.