Important note: Information in this article was accurate in 2004. The state of the art may have changed since the publication date.
Sunday Times (Johannesburg) - Sunday 18 Jul 2004
Claire Keeton: Bangkok
She threw the first punches on the opening night of the International Aids Conference in Bangkok this week by hitting out at the shortcomings of the key Aids drug nevirapine and, as it wound up on Friday, she was still on the offensive back in Pretoria.
"Mr Lewis is invited to visit our country and realise how little he knows about the South African health system," the minister declared.
"Last year the UN secretary-general singled out South Africa for tripling its resource allocation for HIV/Aids programmes... The head of UNAIDS has recently acknowledged that South Africa will 'soon have the largest HIV treatment programme in the world'," Tshabalala-Msimang charged.
At a special meeting in Bangkok, held to clear up the confusion surrounding nevirapine, Lewis urged South Africa to accelerate treatment, saying: "It seems almost unbearable that those who survived the cancer of apartheid could now die from this communicable disease."
Lewis, who has visited South Africa many times, accepted the minister's invitation to come again, while reiterating his belief that the roll-out was taking far too long.
Lewis said: "I do not take exception to the minister's response and I'm aware of what South Africa is doing. We differ on the implementation of the treatment plan."
Tshabalala-Msimang has been quick to raise the alarm about anti retroviral drugs without reference to their efficacy, as she demonstrated again this week in Bangkok.
Evidence about nevirapine resistance is mounting and in the long run it seems likely to reduce the success of Aids treatment for mothers on the most common, cheap triple combination of drugs.
But in singling out resistance, Tshabalala-Msimang was out of step with the international clinicians and scientists meeting in Bangkok.
Supporting the World Health Organisation guidelines, they were unanimous that nevirapine worked and should be used for preventing mother-to-child HIV transmission (PMTCT) until better alternatives were accessible.
Treatment Action Campaign (TAC) chairman, Zackie Achmat, said at the conference: "South Africa does not have a problem with nevirapine. The problem is with the health minister."
At the earlier Barcelona and Durban conferences, Tshabalala-Msimang highlighted the toxicity of drugs including nevirapine; this time she highlighted nevirapine resistance to validate her views.
Nevirapine is widely and effectively used in South Africa and globally to prevent HIV-positive pregnant women infecting their babies.
Mother-to-child treatment programmes in South Africa reach about half the pregnant women needing them and save about 175 babies from HIV infection daily.
Dr Kgosi Letlape, chairman of the South African Medical Association, accused the minister of misinforming the public about the problem and "putting the [PMTCT] roll-out programme in jeopardy".
The controversy exploded when the Medicines Control Council announced on Monday that it would "no longer recommend the use of nevirapine monotherapy" during labour for PMTCT, indicating that the drug could be de-registered for this purpose.
This threat to PMTCT programmes dominated the agenda for South African delegates.
African delegates reacted with concern to the Medicine Control Council' s announcement, since nevirapine is the backbone of many of their PMTCT programmes.
In response, UNAids, Unicef and the Elizabeth Glaser Pediatric Aids Foundation released a joint statement expressing strong concern about South Africa's announcement.
"There is considerable data showing the efficacy and safety of single-dose nevirapine," they said.
By Wednesday, temperatures had cooled enough for council registrar Precious Matsoso and government delegates to share a platform with representatives of these agencies and the TAC to resolve the problem.
At the meeting Matsoso clarified that single-dose nevirapine would not be stopped until there were better alternatives in place.
When it comes to research, South Africans are at the forefront of investigating PMTCT as a small study on reducing resistance led by Dr James McIntyre, and another study on resistance at six months by Professor Lynn Morris, showed.
McIntyre's trial showed that adding the drug combivir to single-dose nevirapine sharply reduced resistance.
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