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The AIDS epidemic in South Africa is one of the most severe in the world. When faced with such a serious crisis, the decisions that a government makes can have a huge influence on whether the situation improves or deteriorates. A strong and urgent response is clearly needed in South Africa, but is the government doing enough? And could they have done more in the past to prevent the spread of HIV?

While the work of non-governmental AIDS organisations and civil society groups in South Africa has been widely commended, the government’s response has been severely criticised, both domestically and internationally. Much of this criticism has focused on the lack of access to antiretroviral treatment across the country. The government has also been condemned for failing to provide drugs that could prevent mother-to-child-transmission of HIV.

Many argue that the government’s failure to act on these problems has been linked to unorthodox attitudes towards AIDS held by certain government officials. President Thabo Mbeki has questioned scientific consensus on whether HIV causes AIDS, and health minister Manto Tshabalala-Msimang has continually promoted nutrition rather than antiretroviral drug treatment as a means of treating AIDS.

The combination of these various different issues has led many to condemn South Africa’s response to AIDS, including Stephen Lewis, UN Special Envoy for HIV/AIDS in Africa, who stated in 2006 that:

"South Africa is the unkindest cut of all. It is the only country in Africa... whose government is still obtuse, dilatory and negligent about rolling out treatment. It is the only country in Africa whose government continues to propound theories more worthy of a lunatic fringe than of a concerned and compassionate state… I’m of the opinion that they can never achieve redemption.” ¹

Some question whether such public opposition will help the situation, or simply make the government more reluctant to act. Given the controversial approach that the South African government has taken to AIDS, however, it is easy to see why such harsh criticism has arisen.

HIV treatment provision in South Africa

While richer countries began to use a combination of antiretroviral drugs (ARVs) to effectively treat HIV in 1996, this treatment was for a long time only available to a small minority of South Africans who could afford to pay for private healthcare.

The Treatment Action Campaign (TAC) – an organisation led by Zackie Achmat, who would later become a Nobel Peace Prize nominee for his campaigning – was started in 1998 with the aim of putting pressure on the government to increase public access to ARVs. Achmat, himself HIV positive, publicised the situation by refusing to take ARVs until they were available to all South Africans. He argued that the cost of providing treatment and preventive education was ultimately less expensive than the economic impact of an unchecked AIDS epidemic.

In March 2003, the TAC laid culpable homicide charges against the health minister and her Trade and Industry colleague, claiming that the pair were responsible for the deaths of 600 HIV positive people a day in South Africa who had no access to antiretroviral drugs. By this time many poorer African countries were already implementing public treatment programmes, including Uganda, Nigeria and Zambia. South Africa's neighbour Botswana had started providing ARVs in early 2002.

The government eventually approved plans to provide public access to the drugs in November 2003, in the form of the Operational Plan for Comprehensive Care and Treatment for People Living With HIV and AIDS. This followed years of debate in South Africa about the cost of implementing such a scheme and the effectiveness of antiretroviral drugs; the government had frequently argued that an increase in access to antiretroviral treatment was not necessarily the best way to stop the AIDS epidemic, and that other treatment options needed to be considered. The government’s change in attitude towards ARVs was partly a result of a court battle in which GlaxoSmithKline and other pharmaceutical companies agreed to allow low-cost generic versions of their drugs to be produced in South Africa. This made South Africa one of the first African countries to produce its own AIDS drugs.

While the decision to start an ARV treatment program was widely commended, many have since expressed dismay at the slow pace at which the drugs are being made available. Although the government’s 2003 plan aimed to have 381,177 people on government-funded ARVs by 2005-2006, only 85,000 people in the public sector were receiving treatment by September 2005.² Figures since then have been somewhat inconsistent.

The latest World Health Organisation estimate is 325,000 South Africans receiving ARVs at the end of 2006, equating to one third of those in need of treatment.³ According to government figures, around 418,000 patients had started treatment by February 2008. However, the pharmaceutical company Aspen, which makes most of the antiretroviral drugs used in South Africa, estimates that only 340,000-350,000 were still on treatment in February 2008 (others have died or stopped taking the drugs). Aspen has calculated that no more than half of those who need treatment will be receiving it by mid-2009.⁴

Debate has also focused on access to treatment in South Africa’s prisons, which are believed to have an extremely high prevalence of HIV. Since prisons are not accredited ARV sites they cannot distribute drugs directly. HIV positive prisoners have to be provided with transport and security to visit accredited sites and often have to pay for identity documents before they are allowed to access treatment, which most cannot afford.

In March 2006, 242 inmates at Durban’s Westville prison initiated a hunger strike in protest at the lack of ARVs available to them, and the following month fifteen of those prisoners took the government to court in an attempt to force them to provide the drugs directly through the prison system. In June, they won their case - the government was ordered to ensure that the prisoners at Westville and "anybody else in a similar situation" be provided with treatment.⁵ There is hope that this ruling will force the government to improve ARV access in other prisons as well, but for the moment there are still large numbers of HIV positive inmates who are not receiving treatment. The government is currently planning a survey to establish the level of HIV infection amongst prisoners in South Africa, since the precise number affected is currently unknown. A study in 2003 suggested that around 41% of prisoners were HIV positive.⁶

Preventing mother-to-child transmission of HIV

Another area of controversy in South Africa has been the provision of antiretroviral drugs to pregnant women who are HIV positive. HIV can be passed on from a mother to her child during pregnancy, labour, birth or breastfeeding; when the right drugs are provided, the chances of this occurring are substantially reduced.

In 2000, the South African Department of Health announced plans to provide two prevention of mother-to-child transmission (PMTCT) sites in each province of South Africa. There was still, however, discontent about the lack of antiretroviral drugs available to pregnant women with HIV.

The following year, the TAC took the government to court, seeking an order to make nevirapine (an antiretroviral drug proven to be effective and economical in reducing the transmission of HIV from mothers to their babies) available in all state hospitals and clinics. Many health care professionals had become frustrated by the government's lack of progress in supplying the drug, which, the government argued, was due to questions about its toxicity. Doctors had started applying to non-governmental organisation for grants to pay for nevirapine, and in some cases used their own money to buy the drug. Official policy stated that the doctors were forbidden to provide nevirapine, and those who did so risked being disciplined or sacked.

Later that year, the High Court ruled against the government, ordering that nevirapine be made available to all pregnant women with HIV. A subsequent government appeal was overturned, but they continued to display reluctance about distributing the drug, and even threatened to revoke its approval in 2003 unless the company that produced it (Boehringer Ingelheim) could provide additional data proving that it was safe. Although the government eventually made nevirapine available at many hospitals, health centres and clinics across South Africa, the Department of Health has continued to question its safety, in spite of the consensus medical opinion.

In August 2006 the World Health Organisation published new guidelines recommending that all developing countries should introduce "dual therapy" – whereby HIV-positive women are given the drug AZT as well as nevirapine – as a national policy. This approach had been employed in the Western Cape province since 2004, where the rate of mother-to-child transmission was cut to 8%, compared to 22% in KwaZulu-Natal, where only nevirapine was used. Yet although the government acknowledged that dual therapy should be introduced, a policy on implementing this improvement was not published until February 2008. Before this publication, doctors in most provinces were prohibited from providing AZT for preventing mother-to-child transmission. The protocol described in the new South African guidelines – though much better than nevirapine alone – is still inferior to what the World Health Organisation recommends.⁷

It is estimated that during 2006, around 64,000 babies became infected through mother-to-child transmission in South Africa.⁸ AVERT is calling for rapid improvements in PMTCT strategies worldwide in our Stop AIDS in Children campaign.

President Mbeki and AIDS ‘denialism’

The slow provision of antiretroviral drugs in South Africa has been influenced by the attitudes that certain politicians have taken to AIDS. In particular, President Mbeki has consistently refused to acknowledge that HIV is the cause of AIDS; he argues that HIV is just one factor amongst many that might contribute to deaths resulting from immunodeficiency, alongside others such as poverty and poor nutrition:

“Does HIV Cause AIDS? Can a virus cause a syndrome? How? It can’t, because a syndrome is a group of diseases resulting from acquired immune deficiency. Indeed, HIV contributes, but other things contribute as well.” ⁹

Although Mbeki has never declared outright that he rejects the link between HIV and AIDS, he has continually inferred as much through statements such as this. He has also failed to publicly state that he believes HIV to be the cause of AIDS.

While international scientific consensus holds that antiretroviral medication is an effective treatment for HIV, Mbeki has claimed that it is harmful and unsafe. Drug companies, he argues, have exaggerated the importance of antiretroviral treatment in order to further their profits.

In 2000 Mbeki included a number of ‘AIDS dissidents’, such as the controversial American scientist Peter Duesberg, in a committee set up to advise the government on tackling the AIDS crisis. ¹⁰ In the same year, hundreds of delegates walked out of the International AIDS Conference in Durban in protest after Mbeki reiterated his view that HIV is not wholly responsible for AIDS. ¹¹

In October 2000, Mbeki stated that he would withdraw from the public debate about whether HIV causes AIDS, after admitting that his stance had created confusion amongst the public. Since making this statement he has largely avoided the issue of what causes AIDS, but has repeatedly suggested that the impact of AIDS in South Africa may have been overstated.

In 2002 the Cabinet issued a statement on their latest AIDS campaign, declaring:

“In conducting this campaign, government’s starting point is based on the premise that HIV causes AIDS” ¹²

While this remains the official stance of the government, President Mbeki’s biographer Mark Gevisser confirmed in 2007 that Mbeki continues to question scientific consensus on AIDS. ¹³ Zackie Achmat, leader of the Treatment Action Campaign, argues that the real hindrance to antiretroviral drug provision in the country is not lack of funding, but the attitude of the government:

“The biggest problem we have in South Africa is that we have a President who doesn’t believe that HIV causes AIDS.” ¹⁴

Doubting antiretroviral drugs: ‘alternative’ treatments

Alongside ‘AIDS denialism’, the response to AIDS in South Africa has also been held back by suggestions that antiretroviral drugs do not work, and that nutrition or other treatment methods are more effective. Members of the South African government have constantly reiterated that ARVs are just one aspect of their treatment approach, and that there are other measures that can help to treat HIV. Manto Tshabalala-Msimang has questioned the effectiveness of ARVs, and famously urges people to eat lots of beetroot and garlic to fight off HIV. At the 2006 International AIDS Conference in Toronto, these food products were even displayed prominently on South Africa’s exhibition stand. Allegedly, ARVs were only added to the display when reporters started to question their absence.

While it is true that a good diet is an important part of treatment, it is certainly no substitute for antiretroviral medication, as the health minister has suggested. Her stance has angered many, including the revered South African cleric Desmond Tutu:

"We are playing with the lives of people, with the lives of mothers who would not have died if they had had drugs. If people want garlic and potatoes let them have them, but let's not play games. Stop all this discussion about garlic." ¹⁵

The health minister has also voiced support for the Dr Rath Health Foundation, an organisation that promotes vitamin supplements as a substitute for ARVs. The foundation has previously published adverts in South Africa claiming that ARVs are toxic and cause AIDS. In August 2005, The Advertising Standards Authority ruled that such statements were a threat to public health, and that the organisation would not be allowed to make such claims in future adverts. Manto Tshabalala-Msimang later stated in newspapers that:

“No reason exists to criticise Rath, his treatments and his foundation” - Manto Tshabalala-Msimang - ¹⁶

The Dr Rath Health Foundation continues to promote its ineffective vitamin treatment in South Africa despite widespread international condemnation. The organisation has been banned from almost all other countries in which it has tried to operate. The TAC, which recently won a court case to prevent the Rath Foundation from wrongly labelling them ‘a front for the pharmaceutical industry’, has strongly criticised the government for failing to condemn the organisation.

“ARVs are the only known treatment that is consistently effective in delaying the progression from HIV to AIDS”

The health minister continues to make statements that play down the importance of ARVs, and it is likely that the attitude taken by her and other politicians has been central to the slow rate of progress in providing access to treatment. Amongst the scientific community there is little doubt about the benefits of ARVs; a recent study in South Africa reported that 93% of HIV positive people surveyed were alive after one year of treatment. ¹⁷

In late 2006, more than eighty prominent scientists from around the world – including the co-discoverer of AIDS, Robert Gallo, and Nobel Prize winner David Baltimore – signed a letter that was sent to the South African government, calling for:

"The immediate removal of Dr Tshabalala-Msimang as Minister of Health, and for an end to the disastrous, pseudo-scientific policies that have characterised the South African government's response to HIV/AIDS." ¹⁸

Some people argue that the South African government should at least be commended for respecting traditional African healing methods, and for not simply bowing to the pressures of Western governments and pharmaceutical companies by promoting ARVs as the only solution to AIDS.

In truth though, there is indisputable evidence that ARVs are the only known treatment that is consistently effective in delaying the progression from HIV to AIDS. For the government of a country so badly affected by AIDS to not fully back such treatment seems irresponsible and negligent.

Traditional medicines and HIV

One reason for the support that alternative HIV treatments have gained in South Africa is the popularity of traditional medicines. Around 80% of people living in African countries consult traditional African healers and use traditional African remedies, ¹⁹ even if they use conventional medicines as well. Some of these traditional methods of treatment are potentially harmful to people living with HIV; for instance, some people (such as the health minister) claim that African potato boosts the immune system and thereby helps to fight off AIDS, yet a recent study shows that people taking antiretroviral drugs should not eat African potato, because it lowers the level of antiretroviral chemicals in the body and increases the likelihood of HIV developing resistance to the drugs.²⁰

At the same time, other nutritional and herbal medicines can be beneficial in treating HIV, when used alongside ARVs. Traditional healers are treated with respect in South African society, and in 2004 the Traditional Health Practitioners Bill was passed to formally recognise and regulate their legitimacy. Many such practitioners recognise the benefits of antiretroviral drugs, and counsel people living with HIV to continue with ARVs.

The TAC argues that traditional healers have an important role to play in the treatment of HIV:

“Their cultural importance combined with their close involvement within communities puts traditional healers in a unique position to help fight HIV.” - Zach Rosner, TAC - ²¹

How has misinformation affected HIV transmission rates in South Africa?

It is impossible to measure the exact impact that misinformation about AIDS had on the number of people becoming infected with HIV in South Africa. There is, however, a lot of anecdotal evidence suggesting that the attitudes taken by Mbeki and other politicians have led many to question conventional wisdom about HIV. It is likely that this climate of complacency has led people to ignore safer sex messages, in some cases resulting in them becoming infected with HIV.

In terms of mother-to-child transmission of HIV, it is indisputable that the rate of transmission would have been lower in the past were it not for the government’s hesitant approach towards nevirapine, which they doubted despite evidence from around the world that it was safe and effective. If the South African government had approved this drug at an earlier stage, it is likely that many children’s lives would have been saved.

People carrying out AIDS prevention campaigns in South Africa have complained that it is difficult to get their message across to the public when so many people have adopted the view taken by politicians such as Mbeki and his health minister that AIDS is somehow ‘open to question’. For example, one journalist working alongside health workers in March 2007 reported that:

“An interview with Manto Tshabalala-Msimang was broadcast on national radio. I was in Lusikisiki, in the old Transkei, at the time, and the interview enjoyed a large audience… the health minister appeared to be broadcasting a contradictory message [to that put across by healthcare workers]. Some of Lusikisiki’s health-care workers were angry with her that morning; they felt she was undermining their authority and setting back their work”. ²²

Latest developments

Criticism of the South African government's AIDS policies reached a head around the time of the August 2006 International AIDS Conference in Toronto, with speakers, activists and media coverage of the event focusing on the lack of progress being made in South Africa. The embarrassment caused by all this attention may have accelerated changes in the government’s stance on AIDS. Shortly afterwards, it was announced that the South African National AIDS Council (SANAC) ­– a body that had existed since 2000, but which was criticised for being inactive and ineffective – was to be revived, with the Deputy President Phumzile Mlambo-Ngcuka at its helm. At a conference, the Deputy President stated:

"We must take our fight against Aids to a much higher level… we must tighten up so that ARV drugs are more accessible, especially to the poor. Education and prevention of HIV infection must be scaled up. Our people want us to unite on this issue in the best interests of the health and wellbeing of our nation. Working together we can defeat this disease." ²³

On December 1st, World AIDS Day, the government revealed a draft National Strategic HIV/AIDS plan to guide SANAC from 2007 to 2011. In March 2007, this plan was formally launched. It takes a stronger stance on treatment provision than previous strategies, and emphasises the importance of co-operation between the government and civil society groups. Civil society groups have commended the plan as a positive change in direction. The primary aims of the plan are to:

• Reduce the number of new HIV infections occurring in South Africa by 50% by 2011.
• Reduce the impact of HIV and AIDS on individuals, families, communities and society by expanding access to an appropriate package of treatment, care and support to 80% of all people diagnosed with HIV. ²⁴
  

When the strategic plan was first released, there was a new-found climate of hope among AIDS activists. The TAC heralded it as "a new credible plan with clear targets", and announced that "the eight year struggle to end government and HIV denialism and confusion has ended". ²⁵

On top of this plan, another reason for such optimism was the increased involvement of then deputy health minister Nozizwe Madlala-Routledge in the government's AIDS response. With the controversial health minister Manto Tshabalala-Msimang unable to attend her post due to illness, Madlala-Routledge was able to exert a greater influence, criticising those who promote alternatives to antiretroviral therapy, and advocating a strong and firm response to AIDS based on scientific evidence. She made a point of publicly taking her family to be tested for HIV, in the hope that this would encourage other South Africans to do the same – an unprecedented move amongst South African politicians.

In August 2007 Madlala-Routledge (who had been a driving force behind the national strategic plan) was fired by Thabo Mbeki for travelling to a meeting in Madrid, Spain, without his permission. Madlala-Routledge claims that she was unfairly dismissed, and organisations have condemned the firing as unjustified and of great detriment to the national struggle against AIDS. Some have suggested that Mbeki had been looking for an excuse to dismiss Madlala-Rouledge because she had challenged claims that he and the health minister had made about the science behind HIV and AIDS, and the importance of antiretroviral drugs. ^{26 27}

The way forward

There is hope that the rate of AIDS deaths will begin to fall now that the government has started to take a firmer stance on treatment access. There is still, however, a desperate need for the rollout of ARVs to occur more rapidly. Many people living with HIV still have no access to treatment, and many HIV positive women who are pregnant are not being provided with drugs that significantly reduce the chances of mother-to-child transmission. There is also a long way to go in terms of HIV prevention, and encouraging people to access HIV testing facilities.

While recent developments give cause for optimism, South Africa is still suffering from one of the most severe AIDS epidemics in the world, and there are no signs that HIV prevalence is declining. Fast, effective action will be needed if progress is to be made. With almost 1,000 people dying from AIDS every day in South Africa, there is no time for hesitation. It has been suggested that by 2012 around 1.5 million people will still die from AIDS-related illnesses if the treatment scale-up continues at the current rate.²⁸ Around 200,000 of these lives would be saved if universal access to treatment were to be achieved by 2011.

Mark Heywood, head of the AIDS Law Project (a prominent HIV/AIDS organisation in South Africa), summed up many people’s feelings when he stated of the government’s response:

"They have lost at least five years. They're behind on prevention. They're behind on treatment. They're behind on planning for the social impact of HIV. But it's not too late to prevent a whole other generation of people from getting HIV." ²⁹

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