Preventing AIDS is more effective than treating it, says a South African whose 28-year dedication to the cause has brought the promise of a turnaround in this devastating pandemic.
After treating his first HIV and AIDS patients in 1985, Professor Geoffrey Setswe realised he would have to step out of the safe confines of the Impala Platinum mine hospital in Rustenburg, South Africa, where he was working as a nurse.
These were early instances of an indiscriminate disease that would soon reach pandemic proportions in his native South Africa, where 5.6 million people are infected – 11 per cent of the population.
“Many people that I grew up with died before they could reach the age of 30, others before they could reach the age of 40,” says Professor Setswe, now a prevention specialist and head of the School of Health Sciences at Monash South Africa.
The spread of the disease among his miner patients in the 1980s alerted Professor Setswe to the possibilities of finding a way to interrupt the cycle of transmission.
In the case of Impala Platinum, many of the miners were visiting the same local sex workers, and condom use was sporadic at best. With colleagues, the young nurse started an informal program to promote condom use to these sex workers, and – in contravention of the health authority’s policy of distributing condoms only from clinics – began handing them out where miners congregated.
Then, as now, his focus was on healthy people. “If 11 per cent of the population is HIV-positive, that translates to 89 per cent of the population being HIV-negative. We should provide prevention programs to ensure these 46 million people remain HIV-negative,” he says.
“I am a proactive person, a practical person and I want things that work out. It helped me to realise that prevention has got a bigger power than just waiting for people to get infected and to try and put them on treatment. If there’s no treatment they die and there’s nothing you can do for them.”
Critical to this approach is behaviour change, something he eventually saw with the miners. At first resistant to the idea of boxes of condoms being placed in toilet blocks, they themselves ultimately started putting the boxes there for their colleagues.
“While I think it’s a good thing to have a good treatment program, I also think there should be a very good prevention program, whether it’s for HIV/AIDS or hypertension, or diabetes, or any other disease.”
Professor of Public Health at Monash University Australia (he is based in South Africa) and founder of the University of the Witwatersrand’s AIDS Research Institute, Professor Setswe has played a key role in influencing South Africa’s policy on HIV/AIDS prevention. Among his projects is a joint Oxfam Australia and Monash-funded project to encourage community engagement in South Africa’s new National Health Insurance scheme. At Monash South Africa he has introduced courses such as a postgraduate diploma in management of HIV/AIDS and health.
Since 2008, Professor Setswe has served as co-chair of the Technical Task Team on Research, Monitoring and Evaluation for the South African National AIDS Council (SANAC). “We help the government to identify research that has been conducted on HIV and related matters and to translate research findings into policies and programs for responding to AIDS,” he says.
For example, research evidence showed that circumcising men could reduce the transmission of HIV/AIDS. The team recommended a mass medical circumcision program, which the government has adopted.
Path back from national denial
AIDS reached pandemic levels in South Africa during the late 1990s under the presidency of Thabo Mbeki. Mr Mbeki ignored scientific evidence about AIDS and refused to allow antiretrovirals to be distributed in the public health system. But his government was forced to make the drugs available to AIDS patients after two landmark court cases launched by the Treatment Action Campaign between 2000 and 2004.
Now 1.7 million South African people living with HIV/AIDS are receiving antiretrovirals in the largest treatment program in the world. “There is a bad side to the story, but there is also a positive turnaround in the past two to three years. The incidence of new cases is going down and the prevalence is levelling off,” Professor Setswe says. Since treatment has become available, HIV/AIDS no longer has such a stigma.
From 2010 to 2011, when the government offered free HIV testing combined with screening for diabetes and hypertension, 20 million tests were performed. While 11 per cent of the total population is HIV positive, recent research showed that among the sexually active group of people aged 15 to 49 years old, the prevalence is 18 per cent.
It is particularly high among certain risk groups, with 29 per cent of pregnant women testing HIV-positive. In some townships in KwaZulu-Natal province more than 40 per cent of pregnant women are affected.
The plight of these pregnant women derives from the reality that one in five of their potential partners is infected with HIV/AIDS. Poor and with low levels of education, many women have scant knowledge about how to avoid the disease. Their partners may use condoms rarely or inconsistently. With unemployment high, the men tend to migrate to cities such as Johannesburg to work, where they may have affairs or rely on sex workers, and then return home to infect their wives or partners.
Making a difference
By administering dual therapy (two antiretrovirals) to HIV-positive pregnant women, health workers can reduce by 96 per cent a baby’s chances of being born with the disease, Professor Setswe says. “It’s the miracle of research that we are able to do that for children.”
But maternal mortality is still unacceptably high, and many mothers who die during delivery are HIV-positive or have AIDS. Professor Setswe says it reflects a broader problem with the public health system, which deals with 85 per cent of patients but is struggling with lack of funding, loss of staff and poor administration.
The private health sector treats only 15 per cent of patients but employs more than 65 per cent of doctors, 90 per cent of dentists, 80 per cent of pharmacists and more than 40 per cent of nurses. “If you go to a private hospital in South Africa, you’ve got all the specialists around you – you’ve got the best medical care that you can get in the world. In contrast, the public health service is terrible.”
The new Minister of Health has introduced a 10-point plan for dealing with problems in the public health system. Funds from South Africa’s new National Health Insurance scheme, being phased in over 14 years, will be used to scale up the quality of the public health system, to rebuild hospitals and train health professionals as hospital CEOs.
“We have to jack up the public health system to come to the level of the private health system,” Professor Setswe says. This includes recruiting more health professionals and reopening 105 nursing colleges that were closed down.
In the joint project with Oxfam Australia, Professor Setswe and his team have trained NGOs to hold community consultation meetings about the health insurance scheme. As well as allowing the community to hold government accountable, Professor Setswe says it has also resulted in a plain language, question-and-answer-style guide on the scheme.
Life journey
The youngest of 10 children of a domestic worker, Professor Setswe emerged from a poverty-stricken background in Soweto. His parents separated soon after he was born and when his mother could not afford to care for him, an elderly friend offered to adopt baby Geoffrey.
He stayed with her until he was 12, when his own mother was able to look after him. His older siblings helped pay for his schooling from their meagre salaries and he was the first in his family to matriculate.
Although he wanted to go to medical school, black people at that stage had to apply to the apartheid government for a permit to attend the predominantly white medical schools. “So I accepted their politics by going straight into training as a nurse at Impala Platinum mines in Rustenburg.”
After his epiphany treating people with AIDS, he studied part-time for a degree and became a lecturer in nursing. In 1996, two years after Nelson Mandela was elected president of a democratic South Africa, Professor Setswe won a Fulbright Scholarship to do a Master of Public Health in the US. He completed a doctorate in public health in South Africa.
As head of the School of Health Sciences at Monash South Africa, he sees his responsibility as developing a new generation of health professionals who will contribute to the prevention of HIV and health problems. He has introduced new degrees, including a Bachelor of Public Health and degrees in psychology.
“So while we are training doctors and nurses to treat disease, I would also like to see many young people getting trained in the same approach that I have to preventing disease.”
