MANZINI, 7 September 2010 (PlusNews) - South Africa, home to the world's largest HIV treatment programme, is trying to pull off the most extensive global HIV testing campaign but the ambitious initiative is facing some daunting realities.

Launched in April 2010, the campaign aims to test 15 million South Africans over 12 months. But five months in, even Health Minister Aaron Motsoaledi admits the initiative has stalled. The government is preparing to re-launch the campaign and expand its reach to schools and workplaces, but Mark Heywood, vice-chairman of the South African National AIDS Council (SANAC), has highlighted evidence of poor funding, monitoring and implementation.

With an adult HIV prevalence of about 18 percent, just over one million South Africans were on antiretroviral (ARV) treatment as of May 2010, according to National Health Council data. If the campaign is successful in diagnosing more people with HIV and referring them to care, an additional 590,000 people could be eligible for treatment by April 2011, according to health department estimates.

At the recent annual meeting of the Rural Doctors Association of Southern Africa (RuDASA) in Swaziland, Heywood presented data showing that poor linkages between testing services and HIV care may be preventing those who test positive from getting treatment.

Although the data is incomplete, government statistics show that between April and July 2010, about 1.7 million people tested for HIV as part of the campaign. However, of 300,000 people who tested HIV-positive, only half were referred to any related health services. A poor referral system may also explain why, despite a surge in the uptake of voluntary counselling and HIV testing (VCT), only an additional 3,000 people were put on ARVs in the campaign's first two months.

"There's almost no monitoring and evaluation of HIV testing... and a disconnect between the numbers of people testing and the numbers of people accessing treatment," Heywood told IRIN/PlusNews.

Quality control

In the same period, government statistics show that an additional 300,000 people came for HIV testing and underwent pre-test counselling, but did not get tested. The reasons are unclear, but it may point to problems with the implementation of VCT.

Presenting yet-to-be published research by health consultancy Strategic Evaluation, Advisory & Development, from 36 clinics providing VCT nationwide, Heywood said that even before the national testing initiative put pressure on HIV testing services, less than 5 percent of the clinics surveyed complied with national VCT protocols. The research also showed that the average time allotted for post-test counselling was just five minutes and that health workers administering the rapid HIV tests let the test process for only half as long as recommended by the manufacturer.

"If we know this is the state of the health system, what risks are we taking by building on this a campaign to test 15 million people?" asked Heywood. "Don't get me wrong, I think we should be doing this, but I think this is a question we have to take very seriously."

Coercion allegations

As facilities come under pressure to meet large monthly targets for HIV tests conducted, there have also been worrying indications that the "V" in VCT is being compromised. The Treatment Action Campaign (TAC), a local AIDS lobby group, has received anecdotal reports of coercive testing in KwaZulu-Natal and Eastern Cape provinces.

"There's no monitoring of what you could call adverse events... instances where people are being told that unless they agree to be tested, they will not be provided with healthcare [but] I've heard that from a number of people," Heywood said. "That's how [this campaign] is being interpreted at the ground level and there's no check to correct that."

that could be acting as a central reporting body for such concerns are hamstrung by a lack of clear mandates.

Heywood credited the testing campaign for helping to speed up the adoption of task-shifting strategies nationally, including allowing nurses to initiate ARVs, but he said the government had not budgeted for important components of the campaign, including a mass communications strategy.

"There was no proper budgetary preparation for the [testing] campaign," he told IRIN/PlusNews. "The parts of the campaign that could be absorbed into existing budgetary allocations, such as ARV therapy, can be catered for but elements such as mass media and communications are completely unfunded... There's no mass media because there's no money."