Professor Gary Maartens on public health in the Western Cape

Maartens is the chief specialist physician at Groote Schuur hospital and a professor at the University of Cape Town, where he is head of the Division of Clinical Pharmacology. At Groote Schuur he consults in general medical wards and in the clinical infectious diseases unit.

His main research interests are tuberculosis (TB), and the effectiveness and cost-effectiveness of antiretroviral therapy in resource-limited settings.

The Treatment Action Campaign (TAC) and the Centre for Economic Governance and AIDS in Africa (CEGAA) presented the findings of their research Budget Monitoring and Expenditure Tracking (BMET) at the meeting in Khayelitsha last week, stating that 93% of patients were satisfied with the service they received at clinics. But what is the view of public healthcare from the medical profession? Gary Maartens shares his personal thoughts.

GroundUp: Can you tell us about the projects you are involved in that serve the communities living in Western Cape townships?

Maartens: My current projects are hospital and clinic-based. We are developing simple tools to improve the diagnosis and treatment of severe HIV-associated chest diseases and TB.

I am involved in two projects due to start soon on ambulatory HIV-infected people who are starting antiretroviral therapy: one on HIV-associated neurocognitive disorder and the other on preventing a complication of HIV-associated TB (shortly after starting ART an inflammatory reaction often occurs in patients with TB, making them ill).

We are using the Khayelitsha cohort (together with some others) to accurately determine the tolerability of individual antiretroviral drugs.

GroundUp: What are the biggest health challenges for people living in Western Cape townships that you are aware of?

Maartens: The biggest problems in terms of infectious diseases for adults are: TB, HIV and sexually transmitted diseases (STIs). For children, the infectious diseases are TB, HIV, diarrhoea and respiratory infections. As for non-communicable health challenges, they are diabetes and hypertension, trauma, violence and substance abuse, such as use of alcohol and ‘tik’.

GroundUp: What can people do to help prevent them becoming infected with infectious diseases?

Maartens: Always have safe sex and use a condom, this will help prevent getting HIV & other STIs. TB is more tricky to prevent but the most important thing is early recognition, so people should get to a clinic as early as they can if they suspect having TB. It is also worth people covering their mouth when they cough to avoid the spread of TB. People should also always wash their hands with soap and water before meals and after going to the toilet to avoid the spread of diarrhoea and respiratory infections.

GroundUp: What can people do to avoid gaining weight and developing diabetes?

Maartens: It is very beneficial to have a good diet and do exercise. Having blood pressure and glucose levels checked regularly at clinics is also important.

GroundUp: In November it was announced that the South African government had negotiated savings of about US$250 million in its latest antiretroviral (ARV) tender, which is the first to include a three-in-one tablet. The triple fixed-dose combination ARV will allow South Africa to move to new, simpler HIV treatment and prevention of mother-to-child HIV transmission (PMTCT) guidelines in April 2013. This is fantastic news but what else can the government can do to help prevent the spread of infectious diseases?

Maartens:

• People must learn how important coughing etiquette is to stopping the spread of TB. Using appropriate ventilation and masks in institutions would also prevent the spread of TB. Education is vital.
• Early recognition of TB is also crucial. Major strides have been made with new diagnostics that help people start TB treatment early.
• Identifying HIV infection earlier is important to reducing transmission. Once people know they have HIV, they should change their lifestyle. They should also seek treatment with antiretroviral therapy.
• Expanding HIV testing would also help. The Western Cape do extremely well with testing in pregnancy and in TB patients.
• To prevent HIV infections, condoms should be widely available (condom availability is pretty good in the Western Cape). Prevention of Mother to Child Transmission (PMTCT) is also important and the Western Cape is doing well with this.
• Educating the public – particularly young people about safer sex – is very important, though national campaigns in this area have been widely regarded as ineffective to date.
• The government should encourage hand washing to reduce diarrhoea and respiratory infections.
• Vaccine delivery is very good in the Western Cape but they could consider adding the HPV vaccination. [The Human Papilloma Virus vaccine prevents cervical cancer.]

GroundUp: Is there anything more the government can do to help prevent weight gain and diabetes?

Maartens: Promoting a healthy lifestyle is the most important thing.

GroundUp: Is there anything more the government could do in terms of public health delivery in Western Cape Townships?

Maartens: Unlike many other provinces, we have a good infrastructure; few staff shortages and we don’t run out of drugs. ART has been started on about 80% of those in need. The major problem is getting people to complete their TB therapy and stay in care once on ART. There is also a shortage of trained nurses. And more must be done to improve adherence to the treatment for non-communicable diseases. The HIV model is a good approach to follow. It is patient-centred and uses lay counsellors. Strengthening and expanding rehab programs would also be worthwhile.

GroundUp: What can people do themselves to support their health when suffering from HIV/AIDS and/or TB?

Maartens: Get involved with groups like the Treatment Action Campaign. Learn about your disease and take responsibility for reducing transmission. Take treatment and communicate to health care workers if side effects occur. You should also know your rights about disability grants.

GroundUp: How do you think public health delivery has improved since apartheid in the Western Cape?

Maartens: This is a complex question. There has been an increased focus on primary care, which is good. The Western Cape has been innovative in delivering TB and HIV care.

On the negative side, the massive HIV pandemic, most of which occurred post-liberation, has swamped the public health system. There has also been a loss of trained healthcare workers to immigration. Under-funding teaching hospitals has also had a negative impact on training and specialist care, but this has improved lately.

GroundUp: What are the most exciting things happening in HIV/AIDS and TB research at the moment?

Maartens:

HIV

• Better programmes for Prevention of Mother to Child Transmission (PMTCT)
• The positive effects of starting antiretroviral therapy earlier
• Prevention strategies such as: Pre-exposure prophylaxis, or PrEP, [using antiretrovirals before sex to reduce the risk of HIV infection], microbicides and vaccines.
• Outcomes of nurse-initiated antiretroviral therapy
• Optimal use of antiretroviral therapy in children
• Optimal use of resistance tests and viral loads in resource-limited settings
• Third line regimens for resource-limited settings.

TB

• New point of care diagnostics
• New TB drugs promise shorter courses of therapy and better outcomes for drug resistant TB
• Better understanding of the role of isoniazid preventive therapy
• Optimal timing of anit-retroviral therapy initiation
• Managing drug interactions better.

GroundUp: How does public healthcare in the Western Cape compare with others regions in South Africa?

Maartens: We are ahead on almost every indicator.

GroundUp: How is public health care in South Africa perceived internationally by the medical profession?

Maartens: I’m not sure but in the HIV & TB research field we are very prominent and have made major contributions.