As Africa slowly gets to grips with providing anti-AIDS drugs - increasing the number of people on treatment from 100,000 in 2003 to 1.3 million in 2006 - the dire shortage of doctors and nurses is now jeopardizing more widespread provision of the lifesaving therapy, according to a report Thursday by Medecins Sans Frontiers.
"The international community says it wants to achieve universal access, and in Khayelitsha we were coming close, but at a certain point things started to collapse," said Eric Goemaere, who heads MSF - also known as Doctors Without Borders - in a sprawling Cape Town suburb.
"We are absolutely saturated, we have come back to waiting lists, and it feels again like we are losing the battle," he said.
Southern Africa is hardest hit by the AIDS epidemic, accounting for the vast majority of the 40 million infections and the daily death toll of 8,000. Despite the advances of providing treatment taken for granted in rich countries, more than 70 percent of the Africans in need of treatment are still waiting.
On an average day, around 200 AIDS patients flock to see Mpumelelo Mantangana and her closely knit medical team at a clinic in an impoverished part of town. Many others languish at home, not for lack of drugs but rather lack of health workers to administer them.
At the clinic started by MSF in Khayelitsha - where about 30 percent of adults have the AIDS virus - nearly 6,000 people are currently receiving anti-retroviral therapy. But the number of new people starting treatment each month dropped from 270 last May to 100 in December - mainly because of lack of health workers.
Mantangana, a nurse at the clinic, says her workload has soared as other nursing staff have left for greener pastures in the private sector or abroad. She understands them - the work is exhausting and the pay is peanuts.
"I work purely because of passion for what we are doing. People come in and they are very sick and we see them get better. That is the only thing which gives us strength," she said in an interview at the clinic, gazing at the long lines of people waiting patiently on wooden benches on the concrete floor.
South Africa has 393 nurses and 74 doctors per 100,000 people, but a high percentage work in the private sector and shortages are especially acute in rural areas. This compares to 247 doctors and 901 nurses per 100,000 people in the United States.
In tiny Lesotho, which is also ravaged by AIDS, there are just 5 doctors and 63 nurses per 100,000. In Malawi, it is 2 doctors and 56 nurses and in Mozambique 3 doctors and 20 nurses.
The MSF report, which focussed on the four southern African countries, made grim reading. It said that in the Thyolo district of Malawi, a single medical assistant can see up to 200 patients per day. In Mavalane district in Mozambique, many patients died during the two month wait to start treatment because of the lack of doctors and nurses. In one of Lesotho's main hospitals, more than half the professional nursing posts were vacant.
The report said that countries would only be able to cope with the crisis by "task-shifting" - allowing nurses to do work assigned to doctors, medical assistants to do the work of nurses and using more community workers.
Malawi is already doing this and a new AIDS plan recently adopted in South Africa also decentralizes treatment and care away from hospitals and gives community a much bigger role. Lesotho also has nurse-based treatment - but there simply aren't enough nurses.
The report also pointed the finger of blame at donor governments, who were willing to pay for antiretroviral drugs and new clinics but not contribute toward staff salaries to operate them.
For instance, it said the US Millennium Challenge Account had committed an unprecedented $US 140 million to improve physical infrastructure at health facilities. But no plans had been made to recruit the estimated 600 additional health care workers needed to staff the facilities.
"People living with HIV/AIDS do not only need drugs and clinics; they need trained, motivated health care workers to diagnose, monitor, and treat them," the report said.