Treatment Action Campaign (TAC) e-newsletter to 3 August 2001 ------------------------------------------------------------- To subscribe/unsubscribe: send an email to subscribe@tac.org.za with subscribe or unsubscribe in the subject line. The TAC e-newsletter is only sent to people who request it, or people we believe should receive it. To contact TAC by email: info@tac.org.za To contact TAC by phone: 27 21 364 5489, 27 11 403 7021 or 27 31 304 3673. IN BRIEF: -------------- * Reprinted below is an article on TAC's court action for mtctp that appeared in the Business Day (31 July), by Pat Sidley. (See IN DEPTH) * TAC wrote a letter to the Kaiser Foundation regarding the booklet Impending Catastrophe Revisited which appeared in South Africa's major Sunday newspapers a few weeks ago. The booklet was disappointing, because it undermined treatment access. We have since met with the Kaiser Foundation. They have assured us of their commitment to the principle that people with HIV should be treated. (See IN DEPTH) * A study by University of Cape Town researchers, Catherine Orrell, Motasim Badri and Robin Wood destroys the myths that Africans or poor people cannot adhere to antiretroviral treatment. We have written a statement on their research. (See IN DEPTH) * A roundup of the main TAC events in the last few days in the provinces is printed. (See IN DEPTH) * BRIEF: According to various news reports, the Nigerian government will commence a programme to treat 15,000 people (10,000 adults, 5,000 children) with antiretrovirals supplied by generic manufacturer Cipla from 1 September. This is an important breakthrough in treating people in sub-Saharan Africa. * BRIEF: TAC has produced a document called Guidelines to Opportunistic Infections. It can be downloaded from: www.tac.org.za/oidoc.pdf NOTE: mtctp is an abbreviation for (m)other-(t)o-(c)hild (t)ransmission (p)revention of HIV transmission. ####################################### IN DEPTH: --------- (Reprinted from Business Day written by Pat Sidley) STATE COULD FACE LEGAL ACTION OVER NEVIRAPINE TAC and doctors may institute court challenge if drug is not provided THE Treatment Action Campaign (TAC) and close to 100 paediatricians have asked the health department to make Nevirapine available in all public health hospitals for HIV-positive pregnant women. The department has until the end of this week to reply, or it faces legal action likely to take the form of a Constitutional Court challenge. The issue has thrown up the fact that many health-care professionals within the health department have been frustrated by the lack of progress in supplying the drug, proven to be cost-effective as a means of reducing the transmission of the virus from mothers to their babies. Many have said that it is political interference "from on high" (a reference to the cabinet and President Thabo Mbeki's views) which is preventing the supply of the life-saving drug. Nevirapine is an antiretroviral drug which has been found to substantially reduce the chances of passing the HI virus from a pregnant mother to her child. Mark Heywood of the TAC confirmed yesterday that the letter had been sent and that the matter would go to court if a satisfactory answer was not received by Friday. "We have given (the department) 14 days to explain why they are not making Nevirapine available," Heywood said. The matter was being handled by the Legal Resources Centre in Johannesburg. Government announced last year it would supply the drug on a trial basis to 18 sites around the country, two per province. Heywood said the drug was registered with the Medicines Control Council, was known to be effective and safe, and there was no reason doctors in the public health system should not give the inexpensive drug to pregnant HIV-positive women. He said about 75000 babies are born HIV positive every year. This is about 30% of the babies born to HIV-positive mothers. He said it was likely if the drug was widely available, at least 20000 more babies would be born HIV negative. It is the knowledge that HIV can be prevented for these babies, but is not, that is causing division within the health department, according to several wellplaced sources. Health Minister Manto Tshabalala-Msimang let the issue slip yesterday while launching the AIDS helpline run by Life Line when she said legal action was once again pending against her department. Helen Schneider, director of the health policy unit at Wits University, said there was frustration among health department functionaries throughout the civil service. She said it seemed that health officials want to dispense the drug, but sensitivity to political issues was stopping this. AIDS policy was highly politicised, she said. Schneider said doctors were faced with dying babies, which was a preventable tragedy. Jul 31 2001 12:00:00:000AM Pat Sidley Business Day 1st Edition ############################################################################## TAC WRITES LETTER TO KAISER FOUNDATION The South African Sunday newspapers recently included a LoveLife report entitled Impending Catastrophe Revisited. It was commissioned by the Kaiser Foundation. The report describes the potentially catastrophic results of the HIV/AIDS epidemic for South Africa, if nothing is done. Yet it failed to draw the logical conclusion from these predictions, i.e. that treatment is an essential component of alleviating this catastrophe. Actually, many of the statements in the report undermined treatment. TAC therefore wrote the following letter to the Kaiser Foundation. The letter was copied to all LoveLife's affiliates. We have since met with the Kaiser Foundation and they have assured us of their commitment to the principle that people with HIV/AIDS should be treated. LETTER TO KAISER FOUNDATION REGARDING IMPENDING CATASTROPHE REVISITED Drew Altman and Michael Sinclair 15 July 2001 Henry J Kaiser Family Foundation By Fax: 011 646 3500 Dear Mr Altman and Mr Sinclair KAISER FOUNDATION POSITION ON TREATING PEOPLE WITH HIV In a recent issue of the Sunday Times, a Love Life report entitled Impending Catastrophe Revisited (ICR) was published. The report was commissioned by the Henry J Kaiser Foundation and produced by Abt Associates. The publication predicts that AIDS deaths in South Africa will rise from 120,000 in 2000 to over 540,000 in 2010. These are the lives of primarily poor and black people. ICR also describes the resulting impact on households and women, growth in the number of orphans, pressure on the health-care system, and negative effects on business due to the morbidity and mortality caused by AIDS. Yet the report fails to reach the conclusion that treating people with HIV, using antiretroviral medicines where necessary, will contribute to alleviating these effects and save millions of lives. Instead, the Abt Report equivocates and consigns people to a premature death based on a dubious methodology of what is "cost-effective". The report admits that demanding antiretroviral medicines is "morally correct and justifiable", but then devotes over two pages, based on "research" that has become out-of-date, to explain why antiretroviral therapy is not cost-effective and another two pages to the necessity of "rationing" in the public health care sector. Old arguments against antiretroviral therapy based on lack of infrastructure and adherence problems in poor countries are described, but the growing evidence that these issues can be overcome is ignored. The report implies that advocates for antiretroviral treatment ignore "the many ways that persons with AIDS can be assisted." The Treatment Action Campaign is the firmest voice for antiretroviral therapy in South Africa but it also advocates unequivocally for the treatment of opportunistic infections; eliminating and preventing new infections and reducing poverty. Despite significant work by government and civil society on social security, ICR fails to even mention campaigns for a Basic Income Grant or Child Support Grants to alleviate the burden of HIV/AIDS on poor and child-headed households. The report uses eight pages to demonstrate the cost-effectiveness of prevention, with the clear implication that prevention and treatment are separate strategies accessing the same scarce resources. Yet prevention programmes in South Africa have failed and continue to fail primarily because of this false dichotomy. Treatment and prevention are complimentary. Voluntary counselling and testing combined with the offer of treatment, improve prevention by giving people a reason to determine their HIV status and therefore an opportunity to learn how to modify their sexual behaviour. Failing to offer treatment drives the disease underground, which renders prevention programmes ineffective. That treatment is essential is not only the view of the Treatment Action Campaign; it is also the view of many bodies including the United Nations, Medecins Sans Frontieres, the Botswana and Brazilian governments, the Congress of South African Trade Unions, business leaders such as Clem Sunter and Brian Brink of Anglo American and companies such as Daimler Chrysler and BP. Not only is treating people critical from a human rights standpoint, but it is necessary to ensure the future social and economic stability of Southern Africa. Treatment and prevention are both essential. They should not compete to access scarce resources. Rather, those scarce resources should be massively increased to ensure that all useful strategies for combating the HIV/AIDS pandemic are implemented. In the USA, your organisation funds and participates actively in the drafting and promotion of Guidelines for the Use of Antiretroviral Agents in HIV-Infected Adults and Adolescents (5 February 2001) - its work is commendable from a scientific and moral point of view. Your work to ensure equity and healthcare reform in that country and abroad is to be commended. We therefore address the following plain language questions to the Kaiser Foundation: 1. Is it the viewpoint of your organisation, relying on questionable research methodologies, to consign poor and black people to a premature death because saving their lives is not "cost-effective"? 2. Does your organisation apply a different standard to the lives of people with HIV/AIDS in the USA and in South Africa? 3. Is it the viewpoint of your organisation that health care should be rationed instead of expanded given the magnitude of the HIV/AIDS epidemic? 4. Is it the viewpoint of your organisation that prevention and treatment are irreconcilable opposites? These questions are asked frankly and seriously. It was George Orwell who said that "political speech and writing are largely the defence of the indefensible." Today this applies equally to HIV/AIDS and the English language. The South African Constitution enshrines the rights to life, to dignity and to health-care. Furthermore the United Nations Development Report 2001 states "Both prevention and treatment are top priorities in not only saving lives and reducing human suffering, but also in limiting the future impact on human development and poverty reduction efforts." Clearly the question that Impending Catastrophe Revisited should have examined is how to make antiretroviral treatment on a universal basis possible, not whether it is "cost-effective". We cannot imagine the effects of HIV/AIDS, left unchecked, on the social fabric of all our communities. In South Africa, apartheid devalued life. A lawless state sent millions to prison under the pass laws - men, women and children - creating disrespect for the rule of law. Lives lost in resistance to, and even in defence of apartheid showed that the state cared little for human dignity and life in South Africa. That changed with the advent of democratic majority rule and a constitutional state that protected the liberty, dignity and equality of individuals. But, the constitutional promise is compromised by the legacy of apartheid. A fact recognised by our Constitutional Court in Soobramoney: "We live in a society in which there are great disparities in wealth. Millions of people are living in deplorable conditions and in great poverty. There is a high level of unemployment, inadequate social security, and many do not have access to clean water or to adequate health services. These conditions already existed when the Constitution was adopted and a commitment to address them, and to transform our society into one in which there will be human dignity, freedom and equality, lies at the heart of our new constitutional order. For as long as these conditions continue to exist that aspiration will have a hollow ring." (BCLR 1997 (12) 1696 CC at 1700) HIV/AIDS further undermines our aspiration to freedom, dignity and equality. Collectively, we have neglected our constitutional duties. The demands of transition, the crime wave - particularly crimes against people - further devalued life. Denying people with HIV/AIDS treatment including ARVs is the same as denying youth in schools condoms or refusing to discuss respectful interactions that will reduce harm in our sexual lives - these are issues that will destroy our lives and the value of life itself. We all face a choice - as individuals; government; private sector; health care providers; civil society; people with HIV/AIDS; as well as international governments and agencies. HIV/AIDS is an emergency. It has the potential to destroy communities, health care services, economies and above all the lives of people - if we do not intervene proactively. If we choose to intervene, we can save lives, increase quality of life, prevent new infections, save communities, economies and our region. The actions required include major public investment in health care services to treat HIV/AIDS including the provision of antiretrovirals; further investment in microbicide and vaccine research; and poverty reduction measures such as the provision of a basic income grant for all people. By addressing our questions, you will assist a positive intervention to save lives. Yours sincerely, Nathan Geffen Zackie Achmat TAC National Executive TAC Chairperson CC: Love Life, Health Systems Trust, Reproductive Health Research Unit, Planned Parenthood Association of South Africa, Advocacy Initiatives, Bill and Melinda Gates Foundation *********************** "WE TAKE OUR MEDICINES AND WE CONTROL OUR LIVES" - ADHERENCE TO ANTIRETROVIRAL THERAPY IN SOUTH AFRICA Study shows that Africans with HIV/AIDS take their medicines as prescribed. "Before I had thrush, tuberculosis and pneumonia. I was very ill. Then I took antiretrovirals. Now I cannot wait to take my antiretroviral medicines every day. They have saved my life and made me feel better and I know I have to take them every day, three times a day, otherwise I will get ill again", says Nontsikilelo Zwelidala from Nyanga in Cape Town. Zwelidala who has HIV/AIDS is on a clinical trial based at Groote Schuur Hospital. Her sentiments are echoed by Matthew Damane who says: "I have heard people say that you need fridges to take these medicines - it is not true. You have to change your routine and get used to the idea of taking medicines. You have to be disciplined and you cannot party all the time. These medicines have improved my health, they have given me the opportunity to control my life again and that is why I will continue taking them every day." Damane is on a Medicins sans Frontieres primary care based ARV programme in Khayelitsha. " I am not surprised that the Somerset Study shows that people with HIV/AIDS in South Africa take their medicines properly. The health care workers at that hospital support their patients and promote their understanding of the medication" says Dr. Hermann Reuter who works on the MSF programme. For him patients and their care-givers must work together as equals: "Healthcare workers must assist patients. We must build treatment literacy about HIV medicines and allow patients to assert control over their lives including decisions about their health and medicines. Many of our patients know that fluconazole is used for cryptococcal meningitis and thrush. They know the difference between the generic Biozole and the brand name Diflucan. They know the difference between antifungals and antiretrovirals. None of them studied medicine or pharmacy, they are poor people with HIV/AIDS who are taking control over their lives." Approximately 17 million Africans have died of AIDS, including 2.4 million who lost their lives in 2000. But for the estimated 25 million people in sub-Saharan Africa living with HIV, it does not have to be a death sentence. Antiretroviral medicines (ARVs) can significantly lengthen and improve the lives of people with HIV/AIDS. Drugs such as AZT, Nevirapine, Lamivudine, Stavudine, Nelfinavir, and Didanosine are antiretroviral medicines. They should be used in combination with a minimum of three drugs of different classes. But, taking triple-drug antiretroviral therapy is not easy. People with HIV/AIDS must stick to a strict and often complex schedule, taking many tablets several times per day for life. In addition, these drugs produce toxic side effects in a minority of patients. Despite these real problems, there is overwhelming evidence that the benefits of ARV treatment outweigh the risks. However, unlike in Europe, America and Brazil most people in poor countries, particularly sub-Saharan Africa, do not have access to ARVs. They are too expensive to buy privately and, except for Botswana, African governments do not supply them. FALSE CLAIMS: POOR PEOPLE WILL NOT TAKE THEIR MEDICINES Another obstacle to the provision of ARV therapy to people in South Africa and other poor countries is the idea that "in settings of high illiteracy patients would not take their antiretroviral drugs correctly, thus promoting and spreading drug resistance". This position was repeated by the South African Minister of Health, Dr. Manto Tshablala-Msimang in the United States in June 2001. To explain why the government will not make ARV therapy available to save the lives of people with HIV/AIDS, Minister Tshabalala-Msimang used this justification: "What we need is literacy so these people can understand the importance of completing your course of TB therapy, of antibiotics. People don't have watches. ....It's the whole issue of poverty and underdevelopment, and if we don't address that we can't get started." This argument suggests that poor people who cannot read and write will not be able to take their medicines. This theory had been disproved in Brazil where the government makes ARV medicines available to people with HIV/AIDS. It has been disproved in Haiti, Botswana, Ivory Coast, Senegal and poor communities in the United States. Now, it has been disproved in South Africa. EVIDENCE - POOR PEOPLE TAKE THEIR MEDICINES A study at Somerset Hospital performed by researchers Catherine Orrell, Motasim Badri and Robin Wood of the HIV Research Unit at the University of Cape Town provides evidence that poor people with HIV/AIDS in urban Africa take their medicines as prescribed. The Somerset Study analysed ARV therapy adherence and found that Minister Tshabala-Msimang's prejudices are strongly contradicted. The study cohort consisted of 287 HIV-positive patients from the Cape Town area representing both genders and three home languages - Xhosa, English, and Afrikaans. Patients used different antiretroviral therapies that varied in complexity of the dosage. After 12 weeks of taking ARV therapy, the average patient took their ARV tablets as prescribed 95% of the time. For those that completed the full 48 weeks of treatment, the average adherence was 92% (i.e. the average person in the trial took their medicine correctly 92% of the time). These numbers more than matched those found in many other countries, showing that the overwhelming majority of patients adequately follow their drug regimens and that concerns for potential adherence problems in Africa, due to socio-economic, cultural and racial differences, have no scientific basis. Overall adherence was good irrespective of gender or language. However, there was slightly lower, but statistically significant (only just), adherence among Xhosa-speaking male patients. The researchers hypothesize that this is because medical staff assisting the patients at the site only speak English and Afrikaans. They conclude that it is important for patients to have access to medical consultation, education and counseling in their own language. This could also be a result of the fact that many Xhosa-speaking people are less likely to own cars and more likely to live further away from the hospital where the trials were conducted. In the end, these minor differences in adherence between language groups cease to be significant when looking at the 82% of participants who completed the full 48 weeks of treatment. Only six patients out of 287 who commenced therapy were taken off the programme due to poor compliance. COMBINING PILLS An important factor that did have a statistically significant influence on adherence was the complexity of the drug regimen. For those patients whose regimen called for three times daily dosing, adherence was reduced, though still high. This regimen format was more complex than the others used in the study (twice daily dosing and twice daily dosing with food restrictions). Treatments involving fewer pills (e.g. AZT/lamivudine in combination, or AZT/lamivudine/abacavir in combination) are easier to adhere to. Therefore, pressure must be put on drug companies to manufacture multiple combinations in one capsule and to register these medicines in developing countries. Patents actually stand in the way of other useful combination capsules being developed. For example, a useful combination medicine would be ddI, d4T and nevirapine. BMS own the patents on ddI and d4T and Boehringer Ingleheim own the patent on nevirapine. Without voluntary or compulsory licenses, these three medicines cannot be combined into one capsule and sold in a TRIPs-compliant country. One generic manufacturer has announced its intention to produce this combination therapy. PATIENT AUTONOMY AND DIRECTLY OBSERVED THERAPY The most important finding of the Somerset Study proves that all people with HIV/AIDS irrespective of race, language or sex have the potential to become and remain responsible patients who adhere to their medicines. The Harvard Consensus Statement (2001) is one of the most important interventions to support the provision of antiretrovirals in all poor countries. However, it suggests directly observed therapy (DOT) - the WHO recommended method for tuberculosis treatment - as the model to ensure that people with HIV/AIDS adhere to ARV therapy. In defence of personal freedom and dignity, many activists have argued that the Harvard approach - the DOT model - supports the idea that poor people in African countries are not capable of taking their medicines. Other pessimistic critics such as the study by Abt Associates that argues against ARV treatment for people with HIV/AIDS in South Africa, claim without any foundation that the DOT model will not work for HIV/AIDS because of the differences between TB (short-term) and HIV (long-term). There may be a germ of truth in both criticisms but both lack foundation in large-scale ARV programmes in poor countries. Given the scale of the epidemic and its intersection with poverty, substance abuse (widespread alcoholism), other epidemics (STDs, tuberculosis, malaria), lack of transport, low levels of treatment literacy and other social factors a DOT model in particular contexts may be appropriate. The Treatment Action Campaign recommends that an integrated model based on increased treatment literacy among people with HIV/AIDS, their families, friends and communities combined with patient autonomy and directly observed therapy where indicated be developed. In every model including directly observed therapy, the dignity, individual need and freedom of the person with HIV/AIDS must be promoted. The results from the Somerset Study offer important evidence to support the provision of ARV treatment for HIV-positive people in sub-Saharan Africa. These crucial drugs can be administered in Africa with similar success to that of the developed world. It is indisputable that ARV therapy would result in a marked drop in deaths of those infected with HIV while reducing the number of opportunistic infections and hospitalisation. It is possible to live a productive, healthy and fulfilling life with HIV. Life-prolonging antiretrovirals can make it possible. ----------------- Andrew Natsios, Director of USAID, is Proven Wrong! "Ask Africans to take their drugs at a certain time of day, and they do not know what you are talking about." -- Andrew Natsios, Bush Administration's new chief of USAID Andrew Natsios has demonstrated that he is racist and ignorant, to the point where he regards black lives as expendable. It is no wonder that USAID continues to be regarded as one of the world's most disreputable aid agencies. Andrew Natsios, the Bush Administration's new director of USAID, has argued that although ARVs can indeed treat HIV/AIDS and potentially save countless lives, this therapy is not the answer for Africa. According to Natsios, since Africans don't have a "Western" sense of time, it is unlikely that such a tightly structured and time-critical drug regimen would have much success. The Somerset Study has shown that Natsios's comments, besides being racist, are wrong. Africans are no less capable than their Western counterparts at taking their drugs on time and adhering to a rigid schedule. ------------------------- Statistics from the Study ------------------------- Study duration = 48 weeks (adherence data was also co-allated for 12 weeks, but ignored here). 287 patients commenced therapy. At 48 weeks adherence data was available for 234 patients. Data was collected by counting tablet returns. (The following 4 lines are accurate to within 4 patients -- data read off a graph) 120 patients adhered 95% (or more) of the time to their treatment requirements for 48 weeks. 160 patients adhered 90% (or more) of the time to their treatment requirements for 48 weeks. 200 patients adhered 80% (or more) of the time to their treatment requirements for 48 weeks. 220 patients adhered 70% (or more) of the time to their treatment requirements for 48 weeks. Only 15 patients adhered less than 70% of the time. The median (i.e. half the patients performed better than this, half worse) adherence rate at 48 weeks was 93.3%. The mean (average) adherence rate at 48 weeks was 91.5%. Of the 287 original patients, 53 were not included in the above analysis. This is why: 12 were withdrawn due to toxic side-effects. 10 patients were lost to follow-up (i.e. they disappeared). 8 withdrew consent to continue the trial. 8 patients did not bring their tablet returns, so no data could be collected on them. This does not mean they did not adhere and they continued to participate in the trial. 6 patients were taken off the trial for poor compliance. 6 patients were taken off the trial because they experienced "virological failure", a situation where their viral load increases above a particular point and the sponsoring drug company refuses to allow them to continue the trial. 2 patients died. 2 patients became pregnant and their dosages had to be changed or stopped temporarily, rendering them ineligible for tallying adherence data. There were no statistically significant differences between average adherence by language and gender at 48 weeks and ranged between 88% and 95% adherence for the average person per group. At 12 weeks, there was a slight statistical significance for Xhosa men having slightly poorer adherence (p=0.049). Researchers point out that staff at the site only spoke English and Afrikaans. Drug Adherence Data This table shows what percentage of the time, the average patient adhered to their treatment for the following drugs: AZT 79.8% Lamivudine 92.8% Abacavir 95.2% AZT/Lamivudine in combination 94.8% Lamivudine 92.8% d4t 93.8% ddI 89.0% Nevirapine 90.4% EMV 95.4% APV 91.2% NLV 92.6% DLV 82.6% Trial drug (protease inhibitor) 98.3% (Thanks to Orrell, Badri and Wood) ############################################ TAC Events in the Last Few Days Kwazulu-Natal (KZN) Province ----------------------------------------- A training workshop for people with HIV/AIDS (PWA's) and care givers took place in Mpophomeni a township outside Pietermaritzburg. The workshop was attended by more than 40 participants. A programme of action was drafted. It focuses on the youth, churches, local development structures and the health sector. The workshop was also attended by the mayor of Howick. He promised strong political support for the campaign. TAC volunteers visited a hospital in Mpangeni. There is no mtctp programme at the hospital but HIV positive pregnant women can buy NVP at the hospital chemist for R31.00. This arrangement was initiated by the hospital doctors. Many mothers still cannot afford nevirapine at this price. TAC volunteers also visited Greys hospital in PMB. This is one of the mtctp sites in the province. The hospital also has an HIV clinic running for 5 days a week. There are 3 doctors working at the clinic and 4 nursing staff. The clinic is well run. The mtct programme has begun but staff feel that it needs to improve. TAC KZN will start the SIBUSISO Treatment Literacy workshops in the second week of August. Sibusiso Mkhize was a TAC member who died last year of AIDS last year. These workshops will be on-going and will run every Wednesday. We aim to train as many people as possible. We will be meeting with the KZN MEC for health in the next few days to discuss various concerns about the epidemic in the province. TAC and AIDS Consortium workers drafted a pamphlet on mtctp for Cosatu. (Thanks to Zamo for this report.) Gauteng Province ------------------------ On 24 July, TAC volunteers visited the Vaal to discuss mtctp and other treatment issues. There was concern from nurses that fluconazole is not sufficiently available in the Vaal region. Bambanani, Sebokeng and Boipatong clinics/hospitals were visited. Bambanani is launching a TAC branch this Saturday. In May representatives from the Department of Health and Pfizer ran a workshop on fluconazole at Boipatong clinic. They spoke at length about the need for control. Detailed plans were presented to the pharmacist on how they will monitor and record the use of fluconazole as part of a clear referral plan. To date, NOT A SINGLE CAPSULE has reached the clinic. Nor does the clinic have sufficient stock of cotrimoxozole (essential for preventing various opportunistic infections, particularly PCP). Wits students have now come on board to work with TAC in the province. We hold monthly seminars at Wits University which are directed to the students and the workers in the institution. We have already had three meetings discussing various topics. Ralph Barold is the coordinator of these seminars. TAC has also established a good working relationship with Nehawu (Health-care workers trade union) in most of their regions. Nehawu is very influential in many if not all the public hospitals in Gauteng. Recently TAC has established structures in East Rand (Natalspruit Hospital) and Vaal (Sebokeng). In each area we have a team of dedicated people comprising nurses, workers, PWAs, religious-sector participants, NGO participants and CBO participants. East Rand has not formally launched TAC but the structure there is strong. Branches in North (Tembisa) and West (Soweto) Gauteng will start shortly with the dates to be announced soon. The aim is to have committees in these areas whereby people will be able to access TAC information easily, without going to the city centre. Our general meetings have improved with a large number of people now attending. The Nkosi Johnson School of Literacy has had three successful workshops with more than 120 people attending each workshop. There is another two workshops coming before we start the actual training of TAC cadres in Gauteng. There are three volunteers who work in the TAC Gauteng office most days. Their names are: Thando, Fanayi and Fulu. They are doing excellent work. Another volunteer, Thembani, has done an enormous amount of work on MTCTP. She has contacted many sites in Gauteng and spoken to government officials regarding implementation issues. The Gauteng database is also up and running with more than four hundred members in it. Starting from the beginning of September we will be posting invitations, minutes and newsletters to our members. The Gauteng office has helped extensively with the mtctp court-case preparations. TAC Gauteng needs an urgent discussion on a strategy for improving JHB hospital. We are scheduled to meet with the dean of the Medical Faculty, Max Price, on 27 August. (Thanks to Sharon and Pholokgolo for this report.) Western Cape ------------ On 2- 6 July, UWC hosted an mtctp Workshop as part of its winter school programme. Attending were MTCT co-ordinators and health workers from the different provinces of South Africa. On Thursday and Friday, TAC was presented on NGO and Community involvement in mtctp programme implementation. The Western Cape office has since held a series of meetings with NGOs to explain issues surrounding mother-to-child transmission prevention and why TAC has threatened to take the Minister of Health to court over the issue. The staff and volunteers have helped extensively with court case preparations. TAC has developed a clinics survey and TAC volunteers have started going to clinics in the Western Cape to get them filled in and to discuss health-care issues with clinic staff. ###################################