Treatment Issues: Newsletter of Experimental AIDS Therapies - Volume 17, Number 7-8, July / August 2003
Bob Huff

An announcement has been made. Is that enough to finally stop the river of death in South Africa? After years of refusal, the government there has asked that a plan be developed to bring antiretroviral drugs to several million of its citizens who will surely die if their HIV disease continues untreated. At a pace of over 1000 deaths per day in a country twice the size of Texas, the mortality rate in South Africa has not yet peaked, and hundreds of thousands more will surely die before the plan is written, the implementation rolled out, and the drugs begin to flow to hospitals and clinics.

It’s still only an announcement to make a plan, but it feels like a glacier has tumbled into the sea. The battle to treat the dying in South Africa has been long and tragically unnecessary. This is a country where apparently nothing comes easily, but persistence is rewarded. After an 80-year struggle to defeat the institutionalized racism of apartheid, a new government finally emerged in 1994 led by a freedom fighter schooled on a windswept prison island in Capetown’s Table Bay. Nelson Mandela, a hero and living saint, led the country through the transition to freedom with vision and magnanimity — and South Africa survived. But as liberation found its feet, HIV was flourishing, scarcely noticed, sweeping through the cities, townships and countryside.

Unfortunately, Mandela’s presidency never seriously addressed HIV as infection rates ran unchecked and prevalence soared to a quarter and then to half of the population in some areas. Because AIDS is a slow disease, the stark horror of the rising death toll was deferred until Mandela had been succeeded by a new president, Thabo Mbeki, a political leader who had been formed, not on Robben Island, but in the best European and Russian schools of economics and revolution.

In the late 1990s, seeing that the miracle of antiretroviral drugs was preventing death in the rich, northern countries, groups of doctors and activists began to call upon the South African government to recognize the crisis and avert millions of deaths by finding a way to bring medicines to the townships. A new generation of heroes emerged to take up this struggle, most famously Zackie Achmat, who vowed to not treat his own HIV disease until antiretrovirals were available to all his countrymen.

The challenge was immense. The prices for AIDS drugs in the North were completely unaffordable for South Africa, and the international drug makers resisted coming to a practical accommodation because they feared that their markets in the rich countries would be hurt if cheap drugs were diverted to Northern pharmacies. They also were bound to serve and protect the emerging international system of intellectual property protection that was being designed by the World Trade Organization. Already, Brazil was tackling its own HIV crisis by ignoring patents and making affordable generic copies of AIDS drugs at home to treat its hundred thousand citizens who would die without them. Generic makers in India were gearing up to make the drugs available for pennies on the dollar of what the majors charged. Threatened, the corporations blindly fought back without a thought for the cost.

The activist Treatment Action Campaign (TAC) began to graphically demonstrate that HIV treatment was crucial and feasible in South Africa. Achmat and others smuggled generic fluconazole from Thailand to help people dying horrible deaths from AIDS-related cryptococcal meningitis. Pfizer, the official maker of fluconazole, refused to make the drug available at a reasonable rate until TAC’s defiance and publicity exposed their stance. When it came to HIV drugs, the pharmaceutical industry responded with a policy of obstruction and disinformation. They dismissed claims that prices or patents were the problem, arguing that clean water and infrastructure of the sort found in industrialized nations needed to be in place before complicated antiretroviral drugs could be introduced. Industry apologists in the U.S. government publicly doubted if Africans could learn to tell time. In South Africa, led by GlaxoSmithKline, the big pharmaceutical companies joined a lawsuit to defend their market and block affordable generic drugs from entering the country.

Taken alone, the deadly obstruction of the drug industry could have been surmounted. Eventually, as generic drugs became available, market forces, activist pressure and public opinion compelled the big companies to drop the lawsuits and lower prices. Affordability unlocked a wave of small pilot treatment programs using generic drugs that demonstrated that antiretroviral therapy in a resource-poor setting was feasible and effective. A few lives were finally being saved. But, tragically, the South Africans faced a much more formidable obstruction in one who should have been an ally: President Thabo Mbeki.

In 2000, a year when the International AIDS Conference was finally to be held below the equator in the heart of South Africa’s epidemic in Durban, and just as the world seemed poised to respond to the wildfire consuming the region, Thabo Mbeki revealed that he had found evidence on the Internet saying that HIV was not really what was killing so many of his people; that the problem was actually poor nutrition and tragic history; “a uniquely African catastrophe.” He soon stunned the AIDS community by announcing the formation of a Presidential AIDS Advisory Panel populated by a handful of dissident scientists who disputed the link between HIV and AIDS. With the medical and scientific worlds’ attention finally turning to South Africa and hopes running high that the raging epidemic there could be muted, it was becoming horrifyingly clear that the country’s leadership was embracing a policy of denial and refusal. The surreal pronouncements of the President and his Minister of Health variously ran: “The cause of AIDS is not known; the treatments are deadly in themselves; and, no matter, since we can’t afford to treat everybody, we won’t treat anybody.” Whether explained by paranoia, Soviet science, intellectual stubbornness or cold political calculation, Mbeki seemed entrenched. The growing activist movement, now joined by Mandela, regretfully found itself pitted against a government that had liberated them less than a decade before.

It’s been over three years since the Durban conference and the world has changed in many strange ways. In developing nations, resistance by the pharmaceutical industry has retreated, money from the U.S. and a Global Fund has been promised to buy life for HIV-infected Africans, pilot programs have shown that treatment works as well as it does in rich countries, and affordable and practical combinations of generic drugs are now available, with prices continuing to fall. In South Africa, after years of legal challenges, demonstrations and civil disobedience led by TAC, the government has apparently now withdrawn its objection to saving its citizens and a plan is being readied to make antiretroviral treatment widespread. Hopefully, South Africans will soon be free to start the next, perhaps more difficult phase of their struggle. Last month, as disease began to rob him of his strength, Zackie Achmat decided to accept HIV medicines. If the tragic farce of denial and obstruction in his country has truly come to an end, he may soon be joined by a million of his comrades.

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