Mail & Guardian (Johannesburg) - January 23, 2004

He steered straight to the core of the matter: "It will let me live longer," said Maliti (57), a resident of Langa, Cape Town. "When I heard about the medicine, I started walking again. I was feeling alive."

For hundreds of thousands of other South Africans awaiting the life-extending medicine, there are still mountains of bureaucracy and practical problems to dig through before the roll-out is a reality. April or May - a half year after the government's announcement - is mentioned as the earliest possible date for the start of a large-scale programme.

But this week's medicine for Maliti was proof that things can happen faster with the right combination of determination and funding. Maliti is one of the patients in a programme in Langa run by the Cape Town municipality, the Western Cape provincial government and ARK, a British-funded NGO led locally by Dr Ashraf Grimwood.

Grimwood was part of the task team that wrote the national treatment plan passed by the government in November. Thanks to foreign funding and eagerness from the local authority, he has been able to steam ahead with implementation and test drive many of the recommendations in the national plan.

While other organisations such as Médécins sans Frontières have long supplied poor patients with anti-retrovirals on a trial basis, the programme in Langa is the first operating entirely within the framework of existing public health facilities. To Grimwood, supplying medicine to Maliti and his fellow patients is proof that a mass roll-out is indeed possible, but also a mammoth task.

"The national roll-out will be the largest public health programme the world has undertaken in relation to HIV. To supply 1,4-million people with medicine is going to take a lot of determination and leadership," he said.

"We have to do things properly, but urgently. It's not to criticise government, but I sometimes have the sense there is a lack of appreciation of the urgency."

A crucial factor in the roll-out will be ensuring adherence. With anti-retrovirals there is no space for the lax attitude with which many patients - whether or not HIV-positive - ignore warnings of future resistance and stop their intake of, for example, antibiotics before finishing the course.

"Traditionally, adherence to medicine is about 50%. We need to get to 97% or above. Anything below, you have a 20% to 25% risk of failing," said Grimwood.

"You get one chance. After that it gets very difficult," said pharmacist John Ireland, who is employed by ARK to distribute the anti-retrovirals. He spent last weekend printing his own labels and instruction sheets for medicine.

This pioneer spirit is echoed by the so-called patient advocates, a central part of the programme. Largely volunteers, they receive an incentive of about R800 a month for their efforts to inform the community.

One of them, Maria Siyaya, has been assigned to Maliti. Initially she will visit him twice a day to ensure he takes his pills at intervals of exactly 12 hours. She has already counselled the couple for more than seven hours.

"I am going to pinch some of his tablets," warned Maliti's partner Nombulelo Joni (52), who seemed to be only half joking. Her HIV infection has not yet reached the stage where she is in line for treatment. But her eagerness to access the medicine is well known in the community, said patient advocates.

"People are becoming impatient. They don't want to be told that medicine is coming - they want to see it happen," said Qholokazi Nomtshongwana, a community advocate."It's exciting," she said as Maliti prepared to receive his medicine. "But it's also scary ... Some people are going to get serious side effects. We have to be realistic."

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