The history of HIV and AIDS in South Africa is perhaps the most controversial of any country. It is littered with examples of government inaction and harmful interference, pseudoscience, and conflict between politicians, AIDS organizations and scientists. The after-effects of some two decades of counterproductive policies are still being felt today in a country that has the world’s largest HIV epidemic.

The early days

Though some people are more at risk than others of becoming infected with HIV, South Africa’s epidemic has grown so large that it affects people from all walks of life. However, the early history of HIV in South Africa was contained, like in the early phases of epidemics elsewhere, among gay men. In 1982, two white homosexual men were diagnosed with HIV. Both were flight stewards and had recently visited the United States.¹ Out of 250 blood specimens taken from homosexual men in Johannesburg, South Africa’s largest city, 32 (12.8%) were infected. Half the sample had had more than 20 different sexual partners in the previous 12 months.²

The initial concentration of HIV within the gay community led to the belief that AIDS was a homosexual disease, with the wider population largely ignoring the risks, and the apartheid government excusing itself from acting. Cases of haemophiliacs becoming infected through infected blood and blood products led to a moralization of the epidemic, with this group being portrayed as innocent victims, in contrast, of course, to homosexuals who were seen as bringing the disease upon themselves.³

The first black South African was diagnosed with AIDS in 1987.⁴ Among mine workers, it was often Africans from other parts of the continent, particularly Malawi, who had a higher prevalence. Frequent contact with other Africans living with HIV allowed the virus to spread throughout the country.

“…it was infection by diffusion across a long, much-permeated northern frontier and through individual contacts in many sectors of a mobile, commercialized environment.”⁵

In the 1990s the South African epidemic was very much linked to the wider continental epidemic such that the dominant strains of HIV were also found across Central Africa. Some areas of high prevalence were also located near truck routes leading into Swaziland and Mozambique.⁶

By July 1991, the number of AIDS cases attributable to heterosexual transmission equaled those due to homosexual transmission, and since then the former has become by far the dominant transmission route.⁷

First national response

The late eighties and early nineties saw AIDS make its way onto the national agenda. However, in the turbulent political climate many groups attached conspiracy theories and unfounded political and racial motivations to the spread of HIV. The official publication of the African National Congress (ANC) in exile alleged that HIV could have been developed in a laboratory, with others suggesting it was spread by police tear gas or through the deliberate infection of black sex workers by ex-ANC collaborators. Conservative parties claimed that whites were being threatened by AIDS through the process of desegregating public facilities.⁸

This period also saw the first steps of a more rational, coherent response to the epidemic. The Maputo Statement on HIV and AIDS in Southern Africa was issued following the 1990 Fourth International Conference on Health in Southern Africa, which brought together ANC representatives, other anti-apartheid figures and health workers as well as those involved in tackling the epidemic in other countries. The document outlined the necessary features for tackling the epidemic including a focus on prevention and the rights of infected individuals.⁹

At the meeting, Chris Hani the general secretary of the South African Communist Party and head of the ANC’s armed wing, said: “We cannot afford to allow the AIDS epidemic to ruin the realization of our dreams.”¹⁰

The creation of the National AIDS Coordinating Committee of South Africa (NACOSA) in 1992 brought together a wide range of actors including political parties, trade unions, academics, business organizations, and civic groups to foster a response to the burgeoning epidemic.¹¹ NACOSA’s National AIDS Strategy envisioned a broad approach to tackling HIV with action on all fronts including prevention, research, human rights, counseling and welfare, with the involvement of a number of government departments. South Africa’s National AIDS Plan was adopted within months of the country’s first democratic election in 1994, and there was optimism that an epidemic on the scale experienced by other African countries at the time could be avoided.¹²

Optimism turns to disappointment

Within the first few years of the decade, as the country made the transition from apartheid to democracy, the infection rate began to rapidly increase. Prevalence among antenatal clinic attendees – a frequently used indicator of HIV prevalence – rose from 0.7% to 2.2% between 1990 and 1992.¹³  However, it was still the early stages of what was becoming a generalised epidemic and it seemed that South Africa was ready to tackle the epidemic head on. As Mary Crewe writes:

“South Africa, in 1994, with an infection rate below 5% was ready for the epidemic - ready in the sense of having information about the epidemic in the USA and Europe, ready in the sense of having seen the epidemic in other African states, and Latin America. Ready in having a group of highly literate AIDS specialists in prevention, care and research that could drive the programme.”¹⁴

The action that had been so promising, however, did not materialize. Various reasons have been suggested for this. Among these is bureaucratic restructuring, including the devolution of powers to provincial governments, which resulted in a lack of a shared, coherent strategy.¹⁵ However, one commentator has said this reason lacks credibility and that “There is a limit to how long a government can blame its own bureaucracy without being held to account for that failure.”¹⁶

Another reason given for AIDS not being considered a priority was that many other matters needed addressing. The government, it has been suggested, preferred to focus on policy areas that symbolised optimism for the future:

“It was also a time when the new government would prioritize positive programmes, such as housing, jobs, education and wider healthcare issues. AIDS warnings and the message of safer sex were not subjects congenial to those savouring the euphoria of freedom.”¹⁷

One indication that HIV and AIDS would not be prioritized by the new government was the placing of the AIDS Programme Director in the Ministry of Health, rather than the President’s Office, as laid out by the National AIDS Plan, which would have carried more weight.¹⁸ This also meant that AIDS would be regarded more as a health issue as opposed to a multifaceted epidemic that required the coordination of many government departments.

Failed initiatives

A number of high-profile initiatives in the mid 1990s, far from signifying the move toward an effective response, actually marked the beginning of an era characterized by the South African government’s unhelpful reaction to the epidemic.

One often cited example is the controversy surrounding the AIDS awareness play, Sarafina II, based on a musical screenplay. The script was “widely panned as confused and irrelevant” and the government did not receive permission to spend so much European Union money on the budget.¹⁹ AIDS organizations believed the money could have been better spent on local projects, and saw the fact they were not consulted on the play as a sign they were being marginalized.²⁰ The programme director of a Cape Town AIDS support group said,

Nelson Mandela later cited the saga as one of his administration’s worst mistakes.²¹

“There is a deep sense of loss in the NGO community which feels it is no longer involved in the struggle to support people with Aids in South Africa.”²²

The manner in which Sarafina II was commissioned led, according to a NACOSA parliamentary briefing, to “a rift between the Department of Health, NACOSA and NGOs, as well as public derision about and hostility to HIV/AIDS work and programmes.”²³

“There is a deep sense of loss in the NGO community which feels it is no longer involved in the struggle to support people with Aids in South Africa. ”

Quickly following the Sarafina II scandal was another equally damaging episode in the government’s AIDS strategy. An antiviral treatment called Virodene, based on antifreeze, was being tested on a small scale by researchers at the University of Pretoria. South Africa’s drug regulatory authority, The Medicines Control Council (MCC), refused to allow the researchers to continue with the trials believing Virodene was dangerous and that the official trial protocol had not been carried out. This argument led to the researchers portraying themselves as victims of the AIDS establishment and appealing to support from the government. The chair of the MCC, Peter Folb, was publicly pressurized by health minister Dlamini-Zuma, who claimed he was being disloyal to their party, the ANC, for refusing to back the drug. This was but one instance of the politicization of science that was a major aspect of the South African government’s approach towards HIV and AIDS.

Sarafina II and Virodene can be seen as desperate ‘solutions’ to a problem the government realized was beginning to spiral out of control. When these failed to work and drew criticism from people working within the HIV field, the government’s damaging stance became further entrenched and hostile to its critics.

The fight for antiretroviral drugs begins

The first major battle over the provision of an established, effective antiretroviral drug (ARV) was for AZT (also known as Zidovudine). In this instance its potential was in the prevention of mother-to-child transmission (PMTCT). In 1998, it was announced that a trial using a short course of AZT in Thailand had cut the mother-to-child transmission (MTCT) rate in half. This led South African advocates and researchers to call for the drug to be provided to pregnant mothers. Mark Heywood, of the AIDS Law Project, said,

“Our country cannot afford 50,000 children being born with HIV this year and an increase on that number next year and an increase on that number for many years to come.”²⁴

However, its use was rejected in all ANC-run provinces on cost grounds despite the manufacturer cutting the price and economists believing the use of AZT would result in cost savings. The health minister Dlamini-Zuma also justified her opposition to the use of AZT by saying the government would prefer to focus on prevention rather than treatment, despite the drug being put forward as a preventive measure. The Western Cape, not under the control of the ANC, went ahead with providing AZT in 1999.²⁵

The Treatment Action Campaign – an organisation led by Zackie Achmat, who would later become a Nobel Peace Prize nominee for his campaigning – was launched in 1998 as a result of the battle for the PMTCT drug, AZT. The group grew into one of South Africa’s leading voices for the rights of people living with HIV and AIDS directing its energy towards the government and pharmaceutical companies whose policies stood in the way of people receiving treatment. Achmat, himself HIV positive, publicised the situation by refusing to take antiretroviral drugs until they were available to all South Africans.

The departure of health minister Dlamini-Zuma, following the controversy over AZT provision and her conflicts with AIDS organizations, led to her being replaced by Dr Manto Tshabalala-Msimang, often referred to simply as ‘Manto’. She was greeted with optimism when she first became health minister, meeting with NACOSA, drug manufacturers, doctors and those involved in projects on the ground. However, optimism faded as she, and newly-elected President Thabo Mbeki, who had appointed her, once again brought arguments doubting the effectiveness of MTCT drugs to the fore. Mbeki claimed AZT was toxic, with Manto saying the drug weakened the immune system and even led to mutations in babies.²⁶

Similar arguments were made against providing another antiretroviral drug, nevirapine, for prevention of mother-to-child transmission, despite a then recently published Ugandan trial showing a single dose substantially reduced the risk of infection.²⁷

Dissent and denialism evolves

The arguments and polices against providing AZT and nevirapine, personified by Mbeki and Manto, soon evolved into a much wider questioning of all antiretroviral drugs including those used as treatment. This was part of a wider branch of thinking, referred to as denialism, which argued that HIV did not cause AIDS and instead resulted from socio-economic factors or ‘lifestyle’ choices.

Dissident views on HIV were guaranteed greater prominence by the creation of the Presidential AIDS Advisory Panel. Mbeki sought advice from the panel on issues such as the use of antiretrovirals and whether HIV causes AIDS. The inclusion of both HIV scientists and AIDS denialists effectively afforded greater prominence to denialists who normally would not have such a high profile. Mbeki’s approach to determining the ‘truth’ behind scientific fact was strongly indicated by him not seeking the advice of South African scientific authorities such as the Medical Research Council.²⁸

“As long as Mr Mbeki is being advised by people with no credibility we as South African scientists feel dangerously marginalized in the search for solutions to HIV/AIDS. ”

The Presidential AIDS Panel was far more than an arena for honest debate as a means to move forward with an issue. As Nicoli Nattrass, Director of the AIDS and Society Research Unit at the University of Cape Town, writes: “The panel served as a means for Mbeki and the Health Minister to portray AIDS science and policy formation as deeply contested and contestable. This in turn provided them with the space to resist the introduction of AZT and other ARVs on the grounds that ‘more research was needed’ into their toxicity and effectiveness.”²⁹

The sidelining of science was also evident in the make-up of the South African National AIDS Council. The body should have contained representatives from across society, yet there were no scientists, medical practitioners or representatives from the Medicines Control Council or Medical Research Council. The one representative from organizations involved in HIV/AIDS was not from any of the prominent groups like TAC or the AIDS Law Project.³⁰

The conflict between the president and the scientific community continued with a number of public letters and statements. Mbeki inferred that scientists who stuck to the established view that HIV causes AIDS were suppressing freedom of speech or were servants of the pharmaceutical industry. Three South African scientists offered a rebuke in the journal, Nature, writing:

“As long as Mr Mbeki is being advised by people with no credibility we as South African scientists feel dangerously marginalized in the search for solutions to HIV/AIDS.”³¹

Criticism of Mbeki’s policies culminated in the Durban Declaration, signed by 5000 researchers from established medical and research bodies around the world (not including those working for commercial organizations) outlining the science behind AIDS. It did not particularly mention the controversy unfolding in South Africa, though it did state that “HIV is the sole cause of the AIDS epidemic”.³²

 

The Durban Declaration coincided with the XIII International AIDS Conference happening in the city in July 2000. The conference was notable for the participation of Nkosi Johnson, a 12-year old HIV-positive orphan. His speech to the audience, which included Thabo Mbeki, addressed stigma and misunderstanding surrounding HIV and bravely called for AZT to be provided for PMTCT:

“I just wish that the government can start giving AZT to pregnant HIV mothers to help stop the virus being passed on to their babies. Babies are dying very quickly…”³³

Nkosi Johnson died the following year on June 1, National Children’s Day. Following his death, his adoptive mother Gail said, “Nkosi's done more for AIDS than anyone in South Africa. Nkosi gave AIDS a face for South Africa and Africa.”³⁴

However, even the courage of a boy orphaned and killed by AIDS could not shake Mbeki’s stance. The president also faced pressure from the influential Congress of South African Trade Unions and South African Communist Party, as well as his party, some of whose members were actually taking ARVs. Still, none of this overrode his conviction, developed through his relationship with AIDS denialists, that antiretroviral treatment was poisonous and would not be provided to South Africans living with HIV.

First victories for ARV provision

South Africa currently has the largest antiretroviral programme in the world with over half a million people receiving ARVs. However, treatment provision would be far higher had it not been for the policies of Mbeki and Manto. One study calculated that over 330,000 people lost their lives between 2000 and 2005 due to the government not making ARVs as widely available as was possible.³⁵ It took many years of intense campaigning on PMTCT and treatment to pressure the government to act.

PMTCT

Nevirapine was registered by the Medicines Control Council in April 2001, a date, it was later discovered, that had been delayed for at least six months due to technicalities that should have taken just days to correct. The Treatment Action Campaign asked the health ministry why the drug was not being made available following its registration and then filed a constitutional claim against the government in August 2001. Once again, the government’s response mentioned concerns over safety and side effects. The court found in favour of TAC in December 2001, and did so again in July the following year, after a government appeal.  After the first ruling, several provinces took matters into their own hands and began rolling out PMTCT programmes, a sign of the central government’s weakening authority over HIV/AIDS. The government was now obliged to provide the drug. Manto grudgingly accepted the ruling telling a press conference that the court’s decision meant “I must poison my people”.³⁶

Antiretroviral treatment

Attention then became focused on the provision of antiretroviral drugs for treatment. In 2002, South Africa’s National Economic Development and Labour Council, which brings together representatives from government, business, unions and community organizations to push social and economic policy forward, formulated a draft national treatment plan. However, Manto refused to sign. This was a motivating factor in TAC’s use of civil disobedience as a means to achieve a public antiretroviral treatment programme.

TAC’s actions included a march of over 10,000 people on parliament during President Mbeki’s State of the Nation address on February 14, 2003. This was followed by more militant actions such as occupations of police stations and government buildings, and the disruption of speeches. Everywhere Manto went, and each time she spoke in public, she was heckled and interrupted by TAC members and others, including Achmat. The campaign left TAC members vulnerable to criticism and its white members were accused of racism. However, more groups were joining TAC’s cause including the South African Medical Association, and the group was gathering international support. The ANC was also experiencing internal dissent. Towards the end of 2003, the cabinet announced the public health service would provide antiretroviral treatment, with the Department of Health’s Operational Plan outlining targets for the number of people on treatment.

Progress was slow on making ARVs available however. It wasn’t until September 2004 that treatment guidelines were issued, and March 2005 that manufacturers who would supply the ARVs were chosen. Furthermore, little action was being taken to ensure that drugs were affordable. Ironically, having depicted the struggle for ARVs as a plot backed by large pharmaceutical companies, the government relied on more expensive brand-name ARVs rather than generic drugs produced in developing countries.³⁷

Several incidents signify the controversy surrounding the delay in making treatment available to all. In a demonstration in July 2005 against an Eastern Cape hospital’s slow pace of ARV provision, protestors were fired upon with rubber bullets and tear gas.³⁸ The following Spring, 242 inmates in Durban’s Westville prison staged a hunger strike, in protest at the unavailability of treatment.³⁹ A court order in June required the Department of Correctional Services to provide treatment to all those requiring it.⁴⁰ By September, three of the fifteen inmates that had brought the case had died.⁴¹

The roll out of antiretroviral therapy gathered pace from mid-2005, though the number receiving treatment still lagged behind the Operational Plan’s targets.⁴²

Raw garlic and lemon skin

“Raw garlic and a skin of the lemon – not only do they give you a beautiful face and skin but they also protect you from disease.”

- Manto Shabala-Msimang

The government’s decision to make ARVs available in the public sector did not spell an end to spurious claims about ARV treatment.  An issue that took centre stage for the duration of Manto’s tenure as health minister, was the claim that nutritional supplements were an effective alternative to antiretroviral therapy. A good diet is essential for everyone, especially those living with HIV, but Manto continuously claimed that foodstuffs could successfully treat HIV:

“Raw garlic and a skin of the lemon – not only do they give you a beautiful face and skin but they also protect you from disease.”⁴³

At the August 2006 World AIDS Conference in Toronto, South Africa’s stand displayed an assortment of vegetables including garlic, beetroot and African potato. The exhibit was ridiculed as the ‘salad stall,’ and only later were ARVs included, though these were reportedly borrowed from conference delegates.⁴⁴ At the conference, UN Special Envoy for HIV/AIDS in Africa Stephen Lewis took the opportunity to criticise Manto, and the government’s policies in general,  calling South Africa the “only country in Africa whose government continues to propound theories more worthy of a lunatic fringe than of a concerned and compassionate state.”⁴⁵

Not only was Manto’s promotion of nutrition-as-treatment damaging in that it added confusion to the issue of HIV treatment, but some of the very foods she was promoting can actually cause damage to the immune system. A trial of the effect of African potato extract on HIV patients had to be cancelled after most recipients developed severe bone marrow suppression after just eight weeks.⁴⁶

The ‘natural answer to AIDS’

Manto’s stance on antiretrovirals created an environment very conducive to individuals and organizations promoting nutritional supplements as therapies for HIV. Foremost among these was Matthias Rath whose full page newspaper adverts contained headlines such as ‘Why should South Africans continue to be poisoned with AZT? There is a natural answer to AIDS.’ Rath portrayed himself as a maverick going up against the big guns of the pharmaceutical industry who treated South Africans as guinea pigs for their toxic chemicals. Those who supported antiretroviral treatment were portayed by Rath as in the pocket of drug companies, a charge not unfamiliar to activists and doctors who had challenged the government’s refusal to make ARVs available. In 2006, the Treatment Action Campaign refuted this claim winning legal action against the Rath Foundation which accused it of being a front for, and receiving money from, drug companies.⁴⁷

Rath had a history in Europe and North America, and began operating in South Africa in 2004, starting with townships in the Western Cape. He launched an unauthorized trial of his own VitaCell concoction in the Khayelitsha township in 2005.⁴⁸ Based on the testimony of several of Rath’s trial participants, Leslie London, Professor in Public Health at the University of Cape Town later told the Cape High Court that there were “serious breaches of the ethical conduct of research related to informed consent and confidentiality”.⁴⁹ These included participants not being fully informed about the trial protocol, asking for consent only after obtaining clinical information,  and the offering of financial incentives. Rath’s promotion of  multivitamins led to a petition signed by 200 health care workers claiming that Rath was endangering their patients:

“Many of us have had experiences with HIV-infected patients who have had their health compromised by stopping their anti-retrovirals due to the activities of this Foundation.”⁵⁰

The actions of Dr Rath were facilitated in large part thanks to Manto whose ear he had: “I had a meeting with Dr Rath alone... (on) April 16, 2005. We discussed his concern for people infected with HIV and suffering from the impact of Aids.”⁵¹ Manto, like other South African politicians, did not attempt to distance herself from Rath or criticise his work, instead claiming he and his foundation were “not undermining the government’s position. If anything, they are supporting it.”⁵²

In June 2008, the Cape High Court ruled against Rath and the government, in an action brought by TAC and the South African Medical Association. It declared the trials illegal and prohibited any advertisements touting the benefits of VitaCell for AIDS patients, pending a review of the pill by the Medicines Control Council.⁵³

Manto makes way for new people

Manto’s inaction in tackling the epidemic, and her embrace of figures such as Matthias Rath, led to 80 scientists including HIV co-discoverer Robert Gallo, and Nobel laureate David Baltimore, urging President Mbeki to sack her:

“We therefore call 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.”⁵⁴

Manto was hospitalised in late 2006 requiring a liver transplant (she passed away due to related complications in December 2009). This allowed the deputy minister of health, Nozizwe Madlala-Routledge, to assume a greater role. She, alongside the deputy president Phumzile Mlambo-Ngcuka, were given responsibility for AIDS policy, in particular to reinvigorate the South African National AIDS Council. This involved reaching out to civil society groups such as TAC and health workers, with whom bridges had been effectively burned during the previous years. Madlala-Routledge also signified a break with  Manto’s controversial approach, publicly doubting her boss’s claims.

In March 2007, the HIV and AIDS and STI Strategic Plan for South Africa: 2007-2011 was launched marking a tangible shift in policy concerning antiretroviral treatment. Its key objectives included providing antiretroviral drugs to 80% of people who need them and cutting new infections by 50% by 2011.⁵⁵

Later that year,  political manoeuvering again seemed to prevent an effective response to HIV and AIDS when Madlala-Routledge was sacked by Thabo Mbeki. It was suspected by many, including the deputy minister, that she was sacked for being too outspoken about her seniors.

Manto was eventually removed as health minister, in September 2008, by President Kgalema Motlanthe who saw out Thabo Mbeki’s presidential term. Mbeki had been forced to step down after losing the ANC leadership election to Jacob Zuma, who then became president in May 2009. Both Motlanthe and Zuma had had a very mixed record on AIDS and while they could not be accused of continuing the worst aspects of the Mbeki/Manto era, both have made damaging statements regarding HIV. Motlanthe was linked with the ANC’s promotion of Virodene in 1998, and as late as 2002 was making statements that could be interpreted as doubting the benefits of ARVs. However, by 2004 he was an advocate of ARVs, saying: “We are in the same boat with the TAC now”.⁵⁶ Zuma himself was given a very lukewarm reception due to his comments on HIV. During his rape trial – in which he was cleared of raping an HIV-positive woman – he said he did not use a condom, but had showered afterwards to reduce the risk of HIV infection.⁵⁷ By 2009, though, it appeared Zuma, in a landmark speech, had acknowledged the gravity of the South African HIV epidemic, outlining past failures and calling for everyone to rise to the challenge to tackle it.⁵⁸

Perhaps Motlanthe’s biggest achievement was replacing Manto with Barbara Hogan. Like Madlala-Routledge, Hogan brought an air of optimism to those working in the HIV and AIDS field. The TAC welcomed her by stating: “She has been one of the few Members of Parliament to speak out against AIDS denialism and to offer support to the TAC, even during the worst period of AIDS denialism.”⁵⁹

However, Hogan did not last very long as health minister. After Jacob Zuma was elected president in May 2009, he put Aaron Motsoaledi in charge of health. Activists were initially dismayed by Hogan’s departure, as she was very willing to cooperate with civil society and had pledged to achieve the goals of the Strategic Plan. However, Motsoaledi has made several positive gestures indicating that the government will do what it takes to combat South Africa’s AIDS epidemic. These include a promise to vastly increase condom distribution. Furthermore, in a highly symbolic move, he donned one of TAC’s trademark “HIV Positive” T-shirts at the International AIDS Conference, showing just how far the government had moved on since Manto.

In December 2009, Archbishop Thabo Makgoba encouraged people to use Manto's recent death as a starting point towards better times:

"So let us use the death of Dr Tshabalala-Msimang as a milestone on our journey, a signpost towards a future with an Aids-free South Africa."⁶⁰

Moving forward

In assessing the present state of the epidemic, it is important to understand the history of HIV and AIDS in South Africa, and how public policy plays a major role in determining its course. As Mark Heywood, director of the AIDS Law Project and deputy chair of South Africa's National AIDS Council, said:

“What we're seeing are the chickens of Mbeki's AIDS denialism coming home to roost. We wasted from 2000 to 2006 with the president putting it about that maybe there wasn't a thing called HIV at all. As far as prevention is concerned, that's the period when the epidemic was moving into its exponential growth phase.”⁶¹

Though the difficulties presented by a denialism-embracing government are behind South Africa, the response to the epidemic is far from satisfactory. The country has over 5 million people living with HIV, and there are major issues with providing treatment on such a large scale. Patients often receive treatment far too late, and national treatment guidelines have been heavily criticised. Stockouts of antiretrovirals in Free State in 2008 resulted in the deaths of 30 people a day, and there are reports of continued shortages in 2009. Many doubt that South Africa will be able to achieve the goals of its National Strategic Plan by 2011.

There is further concern surrounding South Africa’s future costs for antiretroviral treatment programmes. A report has forecasted significant strain on the health system by 2020, unless South Africa experiences economic growth.⁶²  Based on current spending levels, projected costs suggest 40% of the health budget will be absorbed by ARV programmes.⁶³

The need for a health system that prioritises prevention instead of focussing solely on treatment has been recognised by Motsoaledi. During his first interview since taking office he identified the need for a primary care based health system and increased roll out of prevention programmes.⁶⁴ He said:

“Common sense should tell us that we need to prevent and stop this disease from spreading otherwise it’s just going to become an expense to everybody” ⁶⁵

Cabinets approval of the new HIV and AIDS prevention and treatment programme is a success for the move towards prevention.⁶⁶ The planned ‘HIV Counselling and Testing Campaign’ (HCT)⁶⁷ indicates a shift from the current voluntary based testing, where most people must ask for a test, to routine testing, where everyone is offered a test and can refuse.⁶⁸ From April 1st 2010 the HCT campaign will be operating in all health authorities and aims to reduce the rate of infection by 50% by 2011.⁶⁹

The acknowledgement by Motsoaledi and the cabinet of the need for a greater preventative response to HIV suggests South Africa’s approach to the management and control of HIV and other infections is set to improve.

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