Special report on a decade of democracy - HIV/AIDS

SOUTH AFRICA: Special report on a decade of democracy - HIV/AIDS


The government's response to HIV/AIDS has become an election issue

JOHANNESBURG, 9 Apr 2004 (PLUSNEWS) - In May 1994, a month after being sworn in as the ruling party, the African National Congress (ANC) drew up a National Health Plan, with technical assistance from the World Health Organisation and the United Nations Children's Fund.

The plan dealt at length with HIV/AIDS, pointing out that, "In view of the devastating implications of the epidemic for South Africa, it is mandatory to define prevention and control interventions, plus comprehensive care for those already infected, within the context of the Bill of Rights."

The ANC called for the development and implementation of an effective HIV/AIDS strategy by the end of 1995.

Only now, a decade later, is a comprehensive treatment plan being rolled out.

By the end of 2002, an estimated 5.3 million South Africans, in a population of more than 42 million, were infected with the virus.

As a result of HIV/AIDS, the South African Bureau for Economic Research predicted in 2001 that growth would decrease by half a percent for each year through to 2015, production costs could rise by up to 2.3 percent annually, and prime interest rates could increase to 2.9 percent per year between 2002 and 2015.

According to the Bureau, by 2015, South Africa's total labour force would decrease by 21 percent, including a 16.8 percent decline in highly skilled workers, a 19.3 percent drop in skilled workers and a 22.2 percent decrease in semi-skilled and unskilled workers.

Not only the work force is being affected: a recent survey revealed that one in every five young South Africans aged between 15 and 24 are infected, with the epidemic disproportionately affecting women.

The study, conducted by the University of the Witwatersrand's Reproductive Health Research Unit, found that nearly one in four women aged 20 to 24 were testing HIV positive, compared to one in 14 men of the same age. By the age of 22, one in four South African women has HIV.

The ANC had a "sound policy in place regarding its approach to HIV/AIDS. Unfortunately, other priority needs, such as education, diverted our resources, and then the subsequent confusion about the causal link between HIV and AIDS delayed the process towards treatment of people living with HIV/AIDS," Sadiq Kariem, the secretary of the ANC's health secretariat, told IRIN.

Critics point the finger of blame over the delays and "confusion" at President Thabo Mbeki and his willingness to listen to the views of AIDS dissidents.


In 1994, with Nkosazana Dlamini-Zuma at the helm of the health ministry, access to cheaper AIDS drugs was a priority.

She moved for the amendment of the Medicines and Related Substances Control Amendment Act, allowing compulsory licensing that would enable the government to use a patent without the consent of the patent-holder in certain cases, and parallel imports, which meant the government could shop around for patented drugs at cheaper prices from foreign suppliers of antiretrovirals (ARVs), rather than sourcing them from the manufacturer's local subsidiary. The legislation came into effect in 1997.

The Pharmaceutical Manufacturers' Association (PMA) challenged the amendment in court.

That year saw the emergence of the AIDS activist group, the Treatment Action Campaign (TAC). "Realising the need to lobby for cheaper (ARVs), TAC was formed in November 1998," recalled Mazibuko Jara, the organisation's spokesperson at the time. TAC stood with the government in the court case.

The organisation led a series of demonstrations outside several pharmaceutical companies that were party to the lawsuit. The PMA acquired an interdict in 1998, preventing the government from implementing the amended act until the court case had been resolved.

"Dlamini-Zuma was a people's minister - her priority was to provide access to cheaper medicines. She came to our meetings, wanted to attend our demonstrations - we worked together," said Jara.

The trial dragged on for three years. In the meantime, power at the health ministry changed hands after the second general election in 1999. Dlamini-Zuma moved on to take charge of the foreign affairs portfolio, with Manto Tshabalala-Msimang replacing her at the health ministry.

The relationship between TAC and the government began to deteriorate during that period, said Jara. "The president's [Mbeki] views on HIV/AIDS had become known by then. The government began dragging its feet on the court case involving the amendment to the Medicines Act - it was no longer a priority," he pointed out.

So TAC began lobbying the pharmaceutical companies nationally and internationally, sparking a series of global demonstrations. "The entire world community was watching the court case now," said Jara.

"Not since the campaign on breast milk substitutes has there been such a widespread mobilisation of international civil society on a health issue. For the first time, one of the most powerful multinational corporation lobbies became accountable to civil society, government and their shareholders, for profiteering at the expense of health and lives," recounted TAC chairman Zackie Achmat while addressing the UN Commission on Human Rights in 2002.

The relationship between the government and TAC soured. TAC's hand was strengthened when the labour federation, the Congress of South African Trade Unions (COSATU), joined its campaign. Finally, in 2001, the PMA dropped the lawsuit.

"Drug prices plummeted in South Africa and internationally. The majority of our people who are employed [40 percent are unemployed] earn less than R2,000 (US $316.48) per month. In 1998, when TAC started its campaign, a month's supply of ARVs cost between R2,500 ($395.60) and R4,500 ($712) per month. Now they cost between R700 ($110.73)and R1,800 ($284.58) per month. The generic ARVs used by MSF [Medicines Sans Frontiers] in its pilot ARV project in Khayelitsha [informal settlement] in Cape Town, cost R450 ($71.20)," Achmat told the UN body.


Meanwhile, in January 1999 Kariem launched the first of the sites dispensing Nevirapine for prevention of mother-to-child transmission (PMTCT) of HIV/AIDS outside Cape Town in the Western Cape province. He had previously had Dlamini-Zuma's support, but said he now faced "resistance" within the ANC.

"I wanted to introduce at least two sites in each province as part of the [pilot] study. We battled with the resistance. Unfortunately, certain leaders of the ANC had come under the influence of the AIDS dissidents," Kariem said.

The project was finally approved, and 18 sites dispensing Nevirapine to pregnant mothers across the country were allowed.

The controversy over AIDS policy surfaced again in 2000, when Mbeki questioned the link between HIV and AIDS during an interview with the news magazine, Time: "...you cannot attribute immune deficiency solely and exclusively to a virus," he said.

In the same year, MSF and the TAC launched their first ARV trial in Khayelitsha. The two organisations wanted to prove to critics that ARVs could be dispensed and responsibily used by poor communities.

After the success of the PMTCT pilot project, TAC began campaigning for the rollout of anti-AIDS drugs in all hospitals. In KwaZulu-Natal an estimated 40 percent of women giving birth are HIV positive. The PMTCT project in the province managed to save more than half the babies born to infected mothers from the virus where Nevirapine was administered.

In August 2001, TAC launched a court case demanding that the government make Nevirapine more widely available. Later that year, the Pretoria High Court ruled in TAC's favour.

However, the government decided to appeal the judgment in the Constitutional Court, while Tshabalala-Msimang continued to question the efficacy and safety of Nevirapine.

When asked during an interview on national television if the government would be prepared to follow the court order to roll out a Nevirapine programme, Tshabalala-Msimang was quoted as saying: "No, I think the courts and the judiciary must also listen to the authorities."

In early 2002, an AIDS dissident lobby group within the ANC produced a document entitled, "Castro Hlongwane, Caravans, Cats, Geese, Foot & Mouth and Statistics: HIV/AIDS and the Struggle for the Humanisation of the African". According to the weekly newspaper, Mail & Guardian, the document cited studies that claimed ARVs killed people.

Believed to have been co-authored by a senior ANC leader, Peter Mokaba, it claimed that the HI virus and AIDS were part of a conspiracy to dehumanise Africans.

In April the Constitutional Court rejected the government's appeal and ordered it to start distributing Nevirapine.

Later that month, the South African cabinet issued a statement agreeing to a rollout of the PMTCT programme and promising to work to lower the cost of ARVs. It went on to recognise that ARVs could improve the health of people with HIV, "if administered at certain stages ... in the progression of the condition, in accordance with international standards."

TAC, COSATU, the government and other role players then sat down together to draw up the country's first comprehensive treatment and prevention plan for HIV/AIDS advocating the rollout of ARVs in all public hospitals.

However, the widely publicised dissident stance taken by Mbeki and Tshabalala-Msimang continued to stall the process.

A research paper by the Centre for Policy Studies, "Towards effective delivery: Closing the gap between policy and implementation in South Africa", identified "lack of political leadership" as one of the factors undermining the government's HIV/AIDS plan.

Other factors listed by the study were "limited appreciation of the gravity of the problem and a general dismissal of the cost implications of the epidemic; confused authority lines among policy-making bodies; a lack of reliable statistics and data; ineffective consultation and communications with implementers; limited effective co-ordination between provincial and national government departments; a lack of resource and technical capacity; and deficient managment systems."

While government seemed to dither, major private companies like Anglo American introduced their own treatment programmes for staff, aware of the epidemic on their balance sheets. Anglo American announced it would pay for ARVs for its workers as part of its expanded HIV/AIDS strategy.

Although some major firms took action, an International Business Owners Survey of 250 medium-sized companies by accounting firm Grant Thornton Kessel Feinstein (GTKF) showed that 69 percent of the respondents did not have an AIDS policy, while 85 percent had not even commissioned a risk assessment.

"Unfortunately, AIDS is not seen as a strategic issue and it appears companies will not act until the disease starts impacting on their bottom line," Clem Sunter, a strategist for Anglo American, was quoted as saying.

In growing tension with the government, TAC threatened civil disobedience if business and government did not sign the earlier agreed framework agreement of the HIV/AIDS plan by December.

Senior ANC officials responded by accusing the TAC of being anti-government.


In early 2003, South African Finance Minister Trevor Manuel announced plans to almost double the amount spent on HIV/AIDS. Over the next three years, R3.3 billion (US $400 million) would go towards extending preventative programmes and finance "medically appropriate" treatment for HIV/AIDS.

In March 2003, TAC activists laid charges of culpable homicide against Tshabalala-Msimang and the Minister for Trade and Industry, Alec Erwin, holding them responsible for 600 HIV/AIDS related deaths a day.

In August that year, the cabinet issued a statement instructing the health ministry to develop an operational plan for the rollout of ARVS, as a "matter of urgency." According to news reports at the time, some members of the cabinet had put considerable pressure on Tshabalala-Msimang to develop the plan.

Finally, in November, after one false call, government announced it had the plan ready. It envisages that "within a year, there will be at least one [antiretroviral] service point in every health district across the country, and within five years, one service point in every local municipality." It aims to have 1.4 million people on treatment within five years.

"Without the extent of democracy and tolerance that exists in South Africa today, TAC would not have been able to wage the struggle that we did against the unscientific stance on HIV/AIDS taken by the president and the minister of health. For that we are extremely grateful. Ten years ago, pre-1994, we would never have been able to achieve the victory we did, under the apartheid regime," commented Nathan Geffen of TAC.

In February this year, Tshabalala-Msimang announced that the government was still evaluating the health services before they could dispense the drugs. TAC then sent her a letter demanding the purchase of an interim supply of ARVs for dispensing.

Since cabinet approval of the Operational Plan for Comprehensive HIV and AIDS Care in November last year, very little has happened countrywide to implement the programme, TAC charged. Six months after the go-ahead, many provincial health departments are still unable to provide concrete information on their rollouts.

At the beginning of March, the Mail & Guardian newspaper reported that only patients living in Gauteng, the Western Cape and "at a push" the Free State would be assured of access to free ARV treatment within the year. At the time, only 13 sites had been accredited, all in the Western Cape Province.

"We still have to continue our struggle, to ensure other provinces follow suit," said Geffen.

This month Gauteng, South Africa's most populous province and its business heartland, began dispensing ARVs in five selected hospitals. Provincial Premier Mbhazima Sholowa, a former COSATU office bearer, was quick to point out that a lot had to be done before an effective and sustainable rollout could occur and reach a planned 10,000 people within a year.

"It is important to understand that there was a great deal of planning that had to happen," said Sholowa. "I know it is a beginning, and I know that we are in for the long haul."


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