Important note: Information in this article was accurate in July 2000. The state of the art may have changed since the publication date.
On June 19, South Africa's Health Minister, Manto Tshabalala-Msimang launched a new five-year AIDS plan. The plan provides for broader access to HIV testing and counseling, which are now unavailable in almost half of the country's clinics. Prevention activities are a key priority, including expanded information, education and communication campaigns, continued support for vaccine research and enhanced procedures for monitoring trends in HIV and AIDS in the country. The plan also stresses the protection of the human and legal rights of people affected by HIV, especially workers and children.
Another goal is improved care for people with AIDS, including the treatment of opportunistic infections at the primary health-care level. Access to antiretroviral drugs remains a nettlesome topic since no new money is being budgeted for this or any of the other programs. Many South African AIDS experts and activists still question the government's commitment to fighting the epidemic.
South Africa has the fastest growing epidemic of HIV in the world. The Ministry of Health estimates that 4.2 million South Africans carry the virus, and about 1,700 more people are infected every day. Those most at risk are poor black people, particularly those who have been socially displaced, such as migrant workers, truck drivers, sex workers and miners from rural areas and their wives, girlfriends and children back home.
Last fall, President Thabo Mbeki began to solicit the opinions of an obscure group of Northern scientists and activists, including University of California Berkeley professor Peter Duesberg. This group believes that AIDS is not caused by HIV but rather by a vague collection of environmental factors such as malnutrition, chemical pollution, recreational drugs and the very antiretroviral drugs used to suppress HIV. The AIDS "denialists" may not agree about what actually causes AIDS, but most seem to believe that the tens of thousands of scientists who work on HIV and AIDS are, unwittingly perhaps, part of an industry-led conspiracy to justify the multibillion dollar market in antiretroviral drugs. This conspiracy, the AIDS denialists say, relies on the demonization of HIV, a harmless virus in their eyes, and the promotion of wildly expensive, toxic drugs that have life-threatening side effects.
Many people were surprised when President Mbeki began expressing interest in their ideas. Their surprise increased in May, when Mbeki appointed a new international panel to outline an "African" response to the AIDS epidemic. The panel was divided half-and-half between AIDS denialists and experts who maintain that HIV is the cause of AIDS. Mary Crewe, head of the Centre for the Study of AIDS at the University of Pretoria, believes that the interest Mbeki has taken in the AIDS denialists is typical of the government's confused and paralyzed response to the epidemic. "It is as if we have just become aware of [AIDS] and are struggling to find ways to understand it," she has written.
Meanwhile, potentially effective programs are languishing. In fiscal year 1999-2000, the AIDS Directorate in the Ministry of Health failed to spend 40% of its budget. The government last winter appointed a National AIDS Council, which included an athlete, a TV producer, numerous politicians and two traditional healers, but did not include South Africa's most important scientists, doctors and non-governmental AIDS organizations. Even the government's media campaigns have been criticized for being ineffective and expensive. During National Condom Week, the government distributed free condoms, which, regrettably, were stapled to a card.
Around 200 South African babies are born with HIV everyday. If they and their mothers were given AZT around the time of delivery, up to half of these babies would be spared HIV infection and AIDS. As long ago as 1997, AZT manufacturer Glaxo Wellcome offered South Africa at a 70% discount on AZT used in public maternity wards. A two-dose course of another anti-HIV drug, nevirapine, which is similarly effective at preventing mother-to-child transmission, is estimated to cost only two to eight dollars. The Health Ministry repeatedly turned down Glaxo's offer, and did not provide nevirapine, either. The government has contended at various times that the drugs were either still too expensive or too toxic. Neither will be offered to pregnant women attending public hospitals until the drugs are further investigated.
When asked what he had to offer people with AIDS, a doctor at one public hospital east of Johannesburg responded, "We have no [antiretroviral] drugs here, not even for needle-stick injuries." When doctors and nurses accidentally stick themselves with bloody needles, they may expose themselves to HIV. Someone who is exposed to HIV through a contaminated syringe can reduce the chance of becoming infected by about 80% with an immediate course of antiretroviral drugs. Kits of such "post-exposure prophylaxis" drugs are supposed to be available in all South Africa's hospitals for health-care workers at risk of needle-stick injuries. This doctor says that they have been absent at least "since the President started talking to [the AIDS denialists]." Patricia Lambert, a lawyer who works with the Health Minister, responded that all hospitals were supposed to have antiretroviral kits for needle-stick injuries. According to Interpol, South Africa has the highest rate of reported rape in the world. A woman's chances of being raped in South Africa are four times greater than in the United States. Charlene Smith, a Johannesburg journalist, is campaigning for the state to provide post-exposure prophylaxis in public hospitals for rape survivors. Smith herself was raped in April 1999, and a week later, she wrote a newspaper account of her race to obtain antiretroviral drugs during the hours following her ordeal. As with needle-stick injuries, these drugs can also reduce the chances of HIV infection after rape.
Aware of the need to obtain the drugs quickly, she pleaded with a series of indifferent health care workers at hospitals and pharmacies in order to obtain them. She then found that a full course of treatment, consisting of a month of AZT, 3TC and Crixivan, would cost R4500 (about $780). Had the government accepted Glaxo's offer of AZT at the reduced price, a combination of AZT and 3TC, which works almost as well, would have cost the public sector only R200 (about $33).
Smith has managed to persuade private hospitals to stock "starter kits" of three days worth of AZT and 3TC for post-rape prophylaxis, which rape survivors can purchase for R170 (about $30). But public hospitals do not stock the kits, and the full 28-day course of drugs is unavailable to most of South Africa's rape victims, who generally are poor and black.
Many of South Africa's community health-care clinics are not equipped or staffed to manage persons with HIV or AIDS. Worse yet, at a recent parliamentary hearing in Cape Town, several HIV-positive individuals testified that health-care providers frequently refuse to meet their needs. Noriri Lamati said that health workers at a hospital in Eastern Cape province turned her away, even for complaints not related to AIDS. Lamati claims she was told, "You know there is nothing we can for people with HIV. They just die." Sindiswa Godwana testified that hospitals did not even dispense multivitamins for people with AIDS. The new AIDS plan may force hospitals to pay attention to people with HIV.
Antiretroviral drugs for pregnant women, rape survivors and people with HIV in general may remain out of reach, though. Dr. Costa Gazi, a Member of Parliament for the opposition Pan-African Congress of Azania who has been critical of the government's AIDS policies in the past, says that the new plan "doesn't sound very inspiring, especially because the use of antiretroviral drugs isn't included."
Zackie Achmat of the Treatment Action Campaign, an activist group that has been campaigning for affordable AIDS treatment in South Africa, says that the plan looks like a good one, and he hopes it is implemented. Still, he worries that the plan's goals are too broad. He believes that two key priorities should be the provision of antiretroviral drugs for the prevention of mother-to-child HIV transmission and access to antiretrovirals and drugs for opportunistic infections for all HIV-positive South Africans. At present, these drugs are scarce and available only at great expense from private pharmacies.
Gazi is encouraged by the fact that Health Minister Tshabalala-Msimang has endorsed efforts to press for compulsory licensing and parallel importation of patented pharmaceuticals, including antiretroviral drugs. Compulsory licensing would permit South Africa to manufacture its own generic versions of these drugs, and parallel importation would permit South Africa to import them from countries such as Thailand and India, where inexpensive generic versions of many patented drugs are already sold. "I hope she'll pursue this," says Gazi. "It's the first time we've heard this is her intention."
In 1997, South Africa attempted to enact a law that would allow parallel imports and compulsory licenses for pharmaceuticals, but a consortium of Western pharmaceutical companies tied the proposal up in the South African courts while the United States threatened trade sanctions. Glaxo Wellcome last May offered AZT and 3TC to poor countries at 20% of world market prices under certain conditions. Four other companies indicated that they might eventually offer similar discounts for their antiretrovirals. Tshabalala-Msimang again has argued that the drugs would still be too expensive for South Africa.
Achmat is encouraged that the Health Ministry may now be revisiting the push for parallel imports and compulsory licenses, but he wants to see action right away. "If the minister showed political will, it could take only about three months to get a license to import and manufacture [generic versions of patented drugs]."
The real test of the new AIDS plan will in be the nature of its implementation. "The government really needs to lead on action," says Achmat. But action has not been the strong suit of South Africa's AIDS programs so far. Mary Crewe observes, "We have all these plans. We plan and plan and plan… We have the fastest growing epidemic in the world, and the fastest growing number of plans to deal with it." Crewe calls the South African response to AIDS "frozen." This paralysis, she believes, emerges from the scale of the epidemic, which is "so huge it's enough to freeze anybody," as well as from the nation's unique social complexity. South Africa is partly a modern industrialized country and partly a rural African one, so it needs an AIDS response appropriate "both to inner city New York and to rural Uganda."
For Crewe, the most frustrating thing is that the government has not drawn sufficiently on the expertise of local community-based AIDS organizations, nor has it tapped the grassroots energy generated during the anti-apartheid struggle. "I find it fascinating that Mbeki keeps talking about how the solutions have to come from the 'African people' and not from foreign experts," Crewe says, "but the South African people want AZT for pregnant women. They also want rape prophylaxis and more funding for treatment of people with AIDS. At what point do you accept what the people are asking for?"
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