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History of HIV & AIDS in South Africa
The history of HIV and AIDS in the Republic of 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, HIV/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.1
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.2 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.3
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.4
The first black South African was diagnosed with AIDS in 1987.5 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.”6
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.7
By July 1991, the number of AIDS cases attributable to heterosexual transmission equalled those due to homosexual transmission, and since then the former has become by far the dominant transmission route.8
First national response
The late eighties and early nineties saw HIV and 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.9
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.10
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.”11
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.12 NACOSA’s National AIDS Strategy envisioned a broad approach to tackling HIV with action on all fronts including prevention, research, human rights, counselling 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.13
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 1992.14 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.”15
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.16 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.”17
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.”18
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.19 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.
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.20 HIV and 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.21 The programme director of a Cape Town AIDS support group said,
“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
Nelson Mandela later cited the saga as one of his administration’s worst mistakes.23
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.”24
“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 the government for support. 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 in South Africa 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.”25
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 1999.26
The Treatment Action Campaign (TAC) – 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.27
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.28
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. Manto became known for advocating for the effectiveness of good nutrition in repressing the virus, saying “I don’t know how many (South Africans) with HIV would want to take antiretrovirals”. Controversially, at the 16th Global AIDS Conference in Toronto, the South African Department of Health presented a display of garlic, lemons and beetroot, with bottles of ARVs added after complaints were made.29
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.30
“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.”31
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 the Treatment Action Campaign or the AIDS Law Project.32
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.”33
The influence of Mbeki’s denialism continued until he was asked to step down as president by his party in 2008.34
The end of AIDS denialism within the South African Government
Jacob Zuma, also of the ANC party, was appointed as president in 2009.35 Signifying for many the end of state-endorsed denialism,36 in October of his first year of presidency he gave a speech that acknowledged HIV and AIDS as one of the two most important challenges in South Africa.
“We need to move with urgency and purpose to confront this enormous challenge…most importantly, all South Africans need to know their HIV status, and be informed of the treatment options available to them. ” - President Zuma37
Jacob Zuma’s presidency has since been laced with controversies. He was accused of rape for which he was acquitted on the basis that the alleged rape had actually been consensual sex. However, the accusation remained highly controversial because he openly admitted that to prevent himself becoming infected with HIV during this incident he had showered after having sex.38 However, Zuma has made efforts to reduce the stigma around HIV testing, through going public about his own HIV status, which he reported was negative.
In 2010, the government launched the HIV testing and counseling campaign (HCT),39 part of a process of meeting the targets set out in the National Strategic Plan (NSP). Each person receiving counselling and testing was to receive 100 condoms, with the campaign involving a host of other prevention initiatives such as information, education and mass mobilisation. The latest NSP aims to ensure that 80 percent of people who need it have access to antiretroviral drugs and to drastically reduce HIV-related stigma.40
- 1. WHO/UNAIDS/UNICEF (2011) ‚'Global HIV/AIDS Response: Epidemic update and health sector progress towards Universal Access 2011'
- 2. Ras GJ et al (1983, 23rd July), 'Acquired Immunodeficiency Syndrome: A report of two South African cases', South African Medical Journal 64
- 3. Sher R (1989, 7th October), 'HIV infection in South Africa, 1982 - 1988 - review', South African Medical Journal 76
- 4. Abdool Karim SS et al (2009, September), 'HIV infection and tuberculosis in South Africa: an urgent need to escalate the public health response', The Lancet 374:9693
- 5. Van der Vliet V, 'South Africa Divided Against AIDS: a Crisis of Leadership' in Kaufman KD and Lindauer DL eds. (2004), 'AIDS and South Africa: The Social Expression of a Pandemic', Palgrave Macmillan Ltd
- 6. Iliffe J (2006), 'The African AIDS epidemic: A history', James Currey
- 7. Iliffe J (2006), 'The African AIDS epidemic: A history', James Currey
- 8. Whiteside A and Sunter C (2000), 'AIDS: The Challenge for South Africa', Human & Rousseau Tafelberg Publishers
- 9. Van der Vliet V, 'South Africa Divided Against AIDS: a Crisis of Leadership'
- 10. Heywood M and Cornell M, 'Human Rights and AIDS in South Africa: From Right Margin to Left Margin', Health and Human Rights 2:4
- 11. Van der Vliet V, 'South Africa Divided Against AIDS: a Crisis of Leadership'
- 12. Van der Vliet V, 'South Africa Divided Against AIDS: a Crisis of Leadership'
- 13. Heywood M and Cornell M, 'Human Rights and AIDS in South Africa: From Right Margin to Left Margin', Health and Human Rights 2:4
- 14. Van der Vliet V, 'South Africa Divided Against AIDS: a Crisis of Leadership'
- 15. Crewe M (2000), 'South Africa: Touched by the vengeance of AIDS', South African Journal of International Affairs 7:2
- 16. Crewe M (2000), 'South Africa: Touched by the vengeance of AIDS', South African Journal of International Affairs 7:2
- 17. Nattrass N (2004), 'The Moral Economy of AIDS in South Africa', Cambridge
- 18. Van der Vliet V, 'South Africa Divided Against AIDS: a Crisis of Leadership'
- 19. Nattrass N (2007), 'Mortal Combat: AIDS denialism and the struggle for antiretrovirals in South Africa', University of KwaZulu-Natal Press
- 20. Nattrass N (2004), 'The Moral Economy of AIDS in South Africa', Cambridge
- 21. Van der Vliet V, 'South Africa Divided Against AIDS: a Crisis of Leadership'
- 22. Daily Mail & Guardian (1996, 26th July), 'Zuma's revenge'
- 23. Daily Mail & Guardian (1997, 1st Jan), 'EDITORIAL: Not the Sarafina III show!'
- 24. Quoted in Van der Vliet V, 'South Africa Divided Against AIDS: a Crisis of Leadership'
- 25. CNN (1999, 6th May), 'Cash-strapped S. African government cuts AIDS drug programs'
- 26. Africa News Service (1999, 1st May), 'Cape Will Give Pregnant Women AZT'
- 27. Van der Vliet V, 'South Africa Divided Against AIDS: a Crisis of Leadership'
- 28. Guay LA et al (1999), 'Intrapartum and neonatal single-dose nevirapine compared with zidovudine for prevention of mother-to-child transmission of HIV-1 in Kampala, Uganda: HIVNET 012 randomised trial', The Lancet 354(9181)
- 29. JournAIDS (2012) ‘The Politics of HIV in South Africa’
- 30. Nattrass N (2007), 'Mortal Combat: AIDS denialism and the struggle for antiretrovirals in South Africa', University of KwaZulu-Natal Press
- 31. Nattrass N (2007), 'Mortal Combat: AIDS denialism and the struggle for antiretrovirals in South Africa', University of KwaZulu-Natal Press
- 32. Van der Vliet V, 'South Africa Divided Against AIDS: a Crisis of Leadership'
- 33. Rybicki E et al (2000), 'AIDS dissidents aren't victims'
- 34. The Guardian (2008, 20th September) ‘Thabo Mbeki to step down as South African president after ANC request’
- 35. Africa Confidential ‘The President:Jacob Gedleyihlekisa Zuma, Mr ’
- 36. Treatment Action Campaign (2009, October 10th) ‘Landmark Speech by President Zuma’
- 37. The Presidency Republic of South Africa (2009, 29th October) ‘ADDRESS BY THE PRESIDENT OF THE REPUBLIC OF SOUTH AFRICA, HE MR JACOB ZUMA, TO THE NATIONAL COUNCIL OF PROVINCES (NCOP)’
- 38. BBC News(2010, 25th April) ‘South Africa’s Zuma reveals he is HIV-negative’
- 39. Republic of South Africa (2010, 25th March) ‘Outline of the national HIV Counselling and Testing (HCT) campaign’
- 40. South African National AIDS Council (2011) ‘National Strategic Plan 2012-2016’