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History of HIV & AIDS in South Africa

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, HIV and AIDS organisations and scientists.

The effects of this slow and interrupted response are still being felt in a country that currently has the world’s largest HIV epidemic. 1 Though certain groups are more at risk of HIV transmission than others, South Africa has a serious generalised epidemic affecting people from all sectors of society.

The early days of HIV in South Africa

Similar to the early phases of HIV epidemics elsewhere, HIV in South Africa was contained among gay men (men who have sex with men). In 1982, two white homosexual men were diagnosed with HIV. Both were flight stewards who had visited the United States. 2 Red AIDS ribbon badge, South Africa

A study from 1989 reported an HIV prevalence of 12.8 percent among homosexual men in Johannesburg. Half of these men reported having more than 20 different sexual partners in the previous 12 months. The initial concentration of HIV within the gay community led to the belief that the virus was a homosexual disease. As a result, the incumbent apartheid government excused itself from intervening, with the wider population largely ignoring their risk of HIV transmission. 3

The emerging epidemic was moralised by reports of haemophiliacs who became HIV-positive via infected blood transfusions and blood products. 4 In contrast to homosexuals who were considered to have brought the epidemic upon themselves, this group were portrayed as innocent victims. 5

By July 1991, the number of AIDS cases attributable to heterosexual transmission equalled those due to homosexual transmission challenging widespread prejudice that HIV and AIDS was a 'gay disease'. Since then, HIV transmission between heterosexual people has become the dominant transmission route in South Africa. 6

The initial response to HIV in South Africa

In the late 1980s and early 1990s, HIV and AIDS made 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 African National Congress (ANC), who were in exile, alleged that HIV could have been developed in a laboratory, while others suggested it was spread by police tear gas or through the deliberate infection of black sex workers by former ANC collaborators. Post-apartheid, conservative political parties claimed that white South Africans were made vulnerable to HIV transmission through the desegregation of public facilities. 7

However, this period also saw the first steps towards a more rational and coherent response to the epidemic. In 1990, the Maputo Statement on HIV and AIDS in Southern Africa was issued following the Fourth International Conference on Health in Southern Africa. This brought together ANC representatives, other anti-apartheid figures and healthcare 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 individuals living with HIV. 8

At the meeting, Chris Hani, 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.” 9

The establishment 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 organisations, and civic groups to foster a collaborative response to the burgeoning HIV epidemic. 10 NACOSAs 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 countries in sub-Saharan Africa could be avoided. 11

Optimism turns to disappointment

In the early 1990s, with the end of apartheid, HIV prevalence increased rapidly in South Africa. Specifically, HIV prevalence among antenatal clinic attendees – a frequently used indicator of HIV prevalence – increased from 0.7 percent to 2.2 percent between 1990 and 1992. 12

Despite these worrying statistics, it seemed that South Africa was ready to tackle the HIV epidemic head on:

“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.” - Mary Crewe, University of Pretoria 13

However, despite promising intentions to tackle the epidemic, these intentions did not translate into action. A number of factors have been attributed to this lack of action including bureaucratic restructuring. It was argued that the devolution of powers to provincial governments resulted in a lack of a shared, coherent strategy. 14 This was dismissed by one commentator who said; “there is a limit to how long a government can blame its own bureaucracy without being held to account for that failure.” 15

Others have suggested that efforts to combat the epidemic were not a government priority and instead, policy focused on 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.” 16

Moreover, the AIDS Programme Director was placed in the Ministry of Health rather than in the President’s Office, as proposed by the National AIDS Plan. This would have acknowledged the epidemic as a multifaceted issue requiring the coordination of all government departments to tackle the epidemic effectively. 17

Failed initiatives

In the mid 1990s, a number of high-profile initiatives in South Africa, which aimed to mobilise an effective response to the epidemic, failed to have the desired effect and were plagued by controversy.

  • The Sarafina II scandal

The most cited example is the controversy surrounding the AIDS awareness play, Sarafina II.

In 1995, the Department of Health awarded a large contract to internationally renowned playwright Mbongeni Ngema to produce a sequel to the musical about AIDS directed at young people. 18 The script was “widely panned as confused and irrelevant” with the government not receiving permission to spend as much European Union money on the budget as they did. 19 Indeed, local HIV and AIDS organisations believed that the money could have been better spent on local projects, and interpreted the fact they were not consulted on the musical as a sign they were being marginalised:

“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.” 20

The manner in which Sarafina II was commissioned according to a NACOSA parliamentary briefing led 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.” 21 Nelson Mandela later cited the saga as one of his administration’s worst mistakes. 22

  • The Virodene controversy

Quickly following the Sarafina II scandal was another equally damaging episode in the government’s HIV and AIDS strategy.

An antiretroviral drug called Virodene, based on antifreeze, was being tested on a small scale by researchers at the University of Pretoria. It was subsequently found that Virodene had no antiviral effects. 23

Soon afterwards, the Medical Control Council (MCC) was effectively dissolved when its chairman and several other officials were fired, prompting speculation that this action was the result of the MCCs blocking of clinical trials of the drug. 24

In 2002, it was revealed that the ANC "secretly arranged millions of rands in funding for Virodene". 25

The fight for antiretroviral drugs (ARVs) in South Africa

The first major battle over the provision of an established, effective antiretroviral drug (ARV) was for Zidovudine (AZT). In 1998, it was reported that a trial using a short course of AZT in Thailand had cut the mother-to-child transmission (MTCT) rate in half. This led advocates and researchers in South Africa 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.” 26

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 long-term savings. The health minister at the time, Dlamini-Zuma 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, started providing AZT in 1999. 27

Treatment Action Campaign Rally, Cape Town

In the battle for AZT, the Treatment Action Campaign was established in 1998. Led by Zackie Achmat, who would become a Nobel Peace Prize nominee for his campaigning, the group became 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 prevented people receiving antiretroviral treatment. Achmat, who was living with HIV, publicised the situation by refusing to take antiretroviral drugs until they were available to all South Africans. 28

The departure of health minister Dlamini-Zuma following the controversy over AZT provision and her conflicts with HIV and AIDS organisations, was replaced by Dr Mantombazana 'Manto' Edmie Tshabalala-Msimang. Dr Manto's appointment was initially recieved with optimism as she met with NACOSA, drug manufacturers, doctors and healthcare workers on the ground. However, optimism faded as she, and newly elected President Mbeki, brought controversial arguments doubting the effectiveness of drugs to prevent mother-to-child transmission (PMTCT) to the fore. Mbeki claimed AZT was toxic, while Manto said the drug weakened the immune system and even led to mutations in babies. 29

A similar debate occurred around another PMTCT drug, nevirapine, despite a trial in Uganda showing a single dose substantially reduced the risk of HIV transmission from mothers to their infants. 30

Denialism evolves

Former President of South Africa, Thabo MbekiThe arguments and polices against providing AZT and nevirapine, soon evolved into a much wider questioning of the HIV and AIDS epidemic known as 'denialism'. This school of thought argued that HIV did not cause AIDS, and instead, resulted from socio-economic factors or ‘lifestyle’ choices.

Indeed, 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 a series of complaints. 31

Indeed, denialist views on the epidemic were a feature of the newly created Presidential AIDS Advisory Panel. Mbeki sought advice from the panel on issues such as the use of antiretroviral drugs and whether HIV causes AIDS. The inclusion HIV and AIDS denialists only afforded them greater prominence in the debate with Mbeki refusing to seek the advice of South African scientific authorities such as the Medical Research Council:

“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.” 32

The side-lining of science was also evident in the make-up of the South African National AIDS Council (SANAC). The body was supposed to have representatives from across society, yet there were no scientists, medical practitioners or individuals from the Medicines Control Council or Medical Research Council. 33

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” 34

The end of denialism in South Africa

In 2009, Jacob Zuma was appointed as president signifying for many, the end of state-endorsed HIV and AIDS denialism. 35 In October of that year, he gave a speech acknowledging the epidemic as one of the most important challenges South Africa faces:

“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.” 36

Indeed, South Africa has made great strides in tackling its HIV epidemic during Zuma's presidency. The National Strategic Plan (NSP) 2007-2011 oversaw a dramatic scaling up of South Africa's antiretroviral treatment (ART) programme which is now the biggest in the world. Moreover, its HIV and AIDS programmes are almost completely self-funded. 37 The latest NSP (2012-2016) aims to build on this progress and centres around the UNAIDS vision of "zero new HIV infections, zero discrimination, zero AIDS-related deaths" as well as its own commitment to "zero new infections due to mother-to-child transmission". 38

However, Jacob Zuma’s presidency has not been without controversy. In 2010, he was accused of rape for which he was acquitted on the basis that the alleged rape had actually been consensual sex. 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. 39

For information about the current state of the HIV epidemic in South Africa, visit our HIV and AIDS in South Africa page.

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