2003 – it was the best of times and it was the worst of times for people in South Africa with HIV/AIDS. The national minister of health at the time promoted treatment based only on a diet of vegetables – beetroot, to name just one. The Treatment Action Campaign and clinicians were resolute in the need for treatment. Communities were spending weekends at funerals for young people. It was indeed desperate times!

In November 2003 the minister of finance announced that South Africa could afford to provide free antiretroviral treatment while respecting the World Trade Organisation’s trade related intellectual property rights agreement (TRIPS). There was reason to be optimistic: free antiretroviral treatment had arrived, and there were more than 100,000 adult patients in KwaZulu Natal (KZN) needing it.

In KwaZulu Natal, the long awaited decision to provide free antiretroviral treatment at accredited public sector facilities was taken. There was so much to be done: laboratory services, information systems, pharmaceutical supply chains, training of health professionals on the new drugs, and, most importantly, using the available evidence from the local research studies which showed that treatment supporters played a vital role in patient adherence and keeping loss to follow-up rates low.

In 2003 in KZN, antenatal seroprevalence of HIV peaked at 39%, and 1% of first antenatal attendees aged 25-29 were HIV positive. Our PMTCT (prevention of mother to child transmission) programme used a single drug that did not replicate the clinical trial reduction in vertical transmission that was expected. Despite this one could not help but revel in the sense of renewed optimism and progress.

There was one nagging question- what about the children? Everyone knew they needed treatment but were not quite sure about the “what” and the “how,” as the paediatric HIV guidelines were still being finalised. The danger was that if the wait was too long, the momentum of the initiative would be lost and we would have two separate programmes: one adult and one paediatric.

The offer of CHIVA (a charity that provides support to help local staff develop the skills they need to use antiretrovirals and manage HIV as a chronic disease) to train, mentor, and support our health professionals in paediatric HIV on the basis of more than 10 years of experience in the UK was welcomed. The volunteers were experienced and committed. The KZN mentoring and support programme paid for accommodation and travel and the volunteers quietly got on with visiting the accredited facilities. Slowly but surely the number of treated children increased. From those early days – the number of children on treatment in KwaZulu Natal has reached over 40 000 meeting the target that 10% of all patients on treatment should be children.

There is still much to be done to ensure the paediatric HIV programme remains strong and achieves optimal patient outcomes. The new challenges are changing drug regimens, safe transition of older children from the paediatric programme and nurse-initiation of antiretroviral treatment. There is no time to be complacent.

Thilo Govender used to work as the principal epidemiologist for the KwaZulu Natal Department of Health. He has recently joined CHIVA Africa as deputy director and is now based in the UK.