Sunday Times - Sunday, 30 November, 2003
Claire Keeton

Hopefully 2003 marks the last year of mounting deaths and conflict over Aids and the start of a commitment by government and activists to combine forces to provide treatment while eliminating stigma and discrimination.

The year got off to an shaky start when negotiations over treatment at the National Economic Development and Labour Council failed to deliver results, and the Treatment Action Campaign launched a civil disobedience campaign in March.

Away from the spotlight doctors, nurses and politicians agitated for accelerated access to treatment.

In April, the TAC suspended its campaign to allow the government time to respond to a joint Health Department and Treasury task team report costing antiretroviral treatment.

In July, the TAC leaked the report, showing that full access to treatment would result in 1.7 million deaths being deferred until after 2010.

"This was an important turning point," says TAC treasurer Mark Heywood. "Once the report was in the public domain, it made it more difficult for government to retreat."

However, the breakthrough came later, when Cabinet declared on August 8 that the Health Department should develop an operational plan for an antiretroviral treatment programme.

Dr Nono Simelela, the department's head of HIV/Aids, said: "The report set the stage for the current operational plan."

The Cabinet made the decision days after South Africa's first Aids conference - a powerful talk shop drawing together local and foreign Aids experts - ended in Durban.

Aids conference chairman, Professor Jerry Coovadia, said: "The Cabinet decision was the culmination of many different threads, which began to be spun at the International Aids conference in 2000."

He said that cheaper drugs and clinical trials in South Africa and providing proof that treatment programmes work, were among those threads.

Western Cape head of HIV/Aids, Dr Fareed Abdullah, confirmed: "It seems the decision-makers in Cabinet were convinced that there was enough experience in the country to make treatment doable."

The successful scaling up of the programme to prevent mother-to-child transmission of HIV also contributed to this shift. Since 2000, 80,000 women have benefited from such programmes, roughly halving the rate of HIV infection among their newborn babies.

Coovadia said: "This programme has acted as a catalyst, and in the next few years we will see the fruits in many ways. At a minimum, children with HIV will become a diminishing medical problem."

Last week Cabinet adopted a detailed, operational plan for treatment, which will begin by providing treatment at sites in each of the country's 56 health districts.

Clearly there is no time to lose. The country is entering a phase of the epidemic where mortality is starting to exceed the incidence of infection, according to epidemiologist Quarraisha Abdool Karim.

While Botswana has the highest proportion of HIV-positive adults (about 38.8%), South Africa has the highest number of infected adults worldwide. An estimated 5.3 million South Africans - 20% of the adult population - are HIV-positive and an estimated half a million have developed Aids.

But, according to the latest national antenatal sero-prevalence survey results, the rate of new infections may be stabilising. From 2001 to 2002, prevalence rates among pregnant women increased marginally from 24.8% to 26.5%, while dropping among those under the age of 20, from 15.4% to 14.8%.

Dr Olive Shisana, a director at the Human Sciences Research Council, attributed this to prevention messages reaching the youth.

She said their research showed, for example, that "condom use at last sex" among women, of 20 to 24 years old, had roughly tripled from 14.4% in 1998 to 47% in 2002. Access to free condoms, using outlets such as shebeens and spaza shops, has been expanded nationally.

Another advance this year, said Simelela, was the strengthening of partnerships against HIV/Aids. "Now we are working, for example, with traditional healers and leaders. This is a big step forward."

Simelela said that prevention was the best strategy against HIV/Aids.

While this is uncontested, prevention strategies aren't yet working, according to those in the field.

Abdullah said: "We need to scale up prevention and look at more focused interventions."

On the positive side, antiretroviral treatment projects, in places such as Khayelitsha, have boosted prevention efforts. "Khayelitsha has the highest rate of testing in the country and the highest rate of condom use," said Abdullah.

The National Association of People Living with HIV/Aids agreed that there was increasing willingness to undergo voluntary testing. Association spokesman Thanduxolo Doro, said: "With the promise of treatment, people are more ready to test for HIV.

"Support groups, such as Parents Living with HIV/Aids, are helping to rebuild self-esteem and mobilise communities," added Doro.

He said a higher number of people suffering from Aids had received social assistance grants this year.

The TAC, which has 7,000 volunteers, confirmed that support groups made a critical difference to coping with HIV/Aids - but warned that stigma was still common.

Heywood said: "For poor people, HIV remains a terrifying experience . . . Stigma and discrimination still silence people." Yet he added: "Stigma is fragile and it could be broken quickly and deeply when the right elements come together."

For example, in Lusisikisiki in the Eastern Cape, some TAC members have spoken out about being infected and are conducting door-to-door HIV/Aids education sessions .

TAC volunteer Nocawe Jijamba, 26, said: "When I disclosed I was HIV-positive, people did not believe me and said I was being paid to lie. But I told them I had reason to test and disclose as our government had promised antiretrovirals."

In addition to the green light for treatment, the start of two Aids vaccine trials this month has raised HIV/Aids awareness in communities.

Although it will take about 10 years to know if the vaccines work, the preparation of volunteers for their first shots has made an impact.

About 80 volunteers will take part in the initial phase of the trials in Soweto and Durban, but hundreds of volunteers will be enrolled when the trials enter their next phase.

These trials have catapulted South Africa to the forefront of the global race to find an Aids vaccine.

For the first time, South Africa is seen to be leading the way in the struggle against Aids in Africa.

Commending South Africa, the UN special envoy for HIV/Aids in Africa, Stephen Lewis, said: "The decision to engage in treatment is one of the most significant of the year. What South Africa does has a ripple effect on Africa. This acts as a beacon of hope."
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