Spluttering in the face of the Aids calamity

Communities usually stand together when faced with wars or natural disasters, but in South Africa, civil society and government have been at loggerheads over HIV/Aids virtually since the ANC took office in 1994. The situation has deteriorated since Mbeki became president. In April 2002 the government, realising it was losing support because of its handling of the epidemic, issued a statement acknowledging the efficacy of anti-retroviral drugs (ARVs) and offering free ARVs to rape survivors. This seemed to augur a new united front against the disease, but tension is once again mounting over the government’s apparent reluctance to make ARVs available in the public sector, as well as its continued association with Aids dissidents. In February 2003 the Treatment Action Campaign (TAC) organised a mass protest march to coincide with the opening of parliament. It was supported by over 10 000 people. When Mbeki refused even to acknowledge them, the TAC angrily announced that it would embark on a defiance campaign until the government made an unequivocal commitment to a public-sector ARV programme and finalised a national prevention and treatment plan with Nedlac. The government does have an HIV/Aids strategy, but it is a broad set of guidelines rather than an operational plan, and its implementation is very uneven. Nevertheless, progress is being made. The budget allocation has been increased from R342 million in 2001/2 to R3,6 billion in 2005/6. By the end of 2003, 400 million condoms will have been distributed, and 658 hospitals and clinics now offer ARVs to pregnant women and their newborn babies. However, it should be remembered that the mother-to-child programme was fully implemented only after the TAC brought court action against the health minister. Richard Feachem, head of the global Fund to Fight Aids, TB and Malaria, was here recently to sign grant agreements worth over R300 million. He found many positive signs and said he was confident that it was not a question of if, but when, the public sector began to deliver ARVs. However, he learned that nothing can be taken for granted concerning the government’s stance on Aids: the signing never took place. It was stalled because the government wanted to clear up some ‘technicalities’ first. In the meantime, communities around the country still refuse to confront HIV/Aids openly, the death toll is mounting, and actuaries predict that life expectancy by 2010 will be around 36. Silence and denial prevail because the president refuses to speak out.

It is hard to believe that we live in a country where 40 per cent of those aged between 15 and 49 died of Aids-related illnesses in 2000, according to the Medical Research Council. Hard, because there is still a disturbingly high level of denial from communities and from government about exactly how badly we are affected by HIV/Aids and there is no coherent operational plan to address the virus. There is also a general lack of consensus about exactly what we need to do to prevent new infections and how to treat those who are already infected - conservatively estimated to be around five million people.

In the face of wars and natural disasters, communities usually stand together and try to make a plan. But in South Africa large portions of civil society and government have been at loggerheads over government's approach to the HIV/Aids virtually since the new government took charge in 1994. The conflict has worsened, however, since Thabo Mbeki became president in 1999 and opened the door to dissidents who do not believe that HIV causes Aids.

A year ago, on 17 April 2002, cabinet finally realised that it was losing popular support because of its stance on HIV/Aids. Thus, Cabinet issued a "statement of hope" in which it conceded that anti-retroviral (ARV) drugs could slow the progression of Aids and said that it would offer rape survivors free ARVs as post-exposure prophylaxis.

It seemed that South Africa had finally turned a corner, and stakeholders could now concentrate on fighting HIV/Aids instead of fighting one another. But in recent months tension has once again mounted between government and sections of civil society over government's apparent reluctance to properly explore the provision of ARVs in the public sector.

In addition, government's continued association with Aids "dissidents" who dispute that HIV causes Aids once again raised temperatures, particularly since health minister Manto Tshabalala-Msimang invited dissident Dr Roberto Giraldo to advise her on nutritional matters following an earlier invitation to him to address a Southern African Development Community nutrition conference.

The biggest expression of public disappointment in government's approach to HIV/Aids took place on 14 February 2003 when the Treatment Action Campaign (TAC) organised a march on parliament to coincide with its opening. The march was supported by over 10 000 people.

Despite the massive protest outside parliament's door, president Thabo Mbeki made only the briefest of references to how government was committed to addressing HIV/Aids in his state-of-the-nation address to parliament. TAC activists had remained hopeful up to the last moment that Mbeki might make an important announcement on HIV/Aids in his address. However when he failed to even acknowledge them, an incensed TAC leadership announced shortly after the march that it would be embarking on a defiance campaign until government made "an irreversible and unequivocal commitment to a public sector ARV programme".

According to the TAC, South Africa is now "out of sync with most SADC countries who have commenced treatment programmes". Botswana offers free ARVs through public health, while Namibia and Mozambique have recently announced plans to treat 200 000 and 100 000 people respectively, with ARVs over the next few years. Another of the TAC's civil disobedience demands is that government "returns to the negotiations at Nedlac and makes a commitment to signing a Framework Agreement with business, labour and community on a National HIV/Aids Prevention and Treatment Plan".

For months last year, government, business and civil society had been negotiating over the plan at the National Economic, Development and Labour Council (Nedlac). The TAC thought the negotiations had progressed "very well" and "consensus was reached within the HIV/Aids task team on most areas of the Framework Agree- ment, including the principles and challenges of ARV access".

However, when the TAC met deputy president Jacob Zuma last October, he indicated that government might need until February to finalise the agreement. The TAC agreed to wait until then. But, although business has since agreed to proposals made, government has yet to return to Nedlac with its mandate.
The TAC believes that the talks were "derailed by political opposition" caused when health officials Dr Ayanda Ntsaluba and Dr Nono Simelela reported back to Tshabalala-Msimang. "From the optimism of the negotiations we now feel that we are back in a dark and difficult situation - once again characterised by political denial about HIV," the TAC said. "President Mbeki's refusal to recognise the gravity of the HIV epidemic in his state of the nation address seems to be proof of that."

Government responded by denying that any agreement had ever been reached and stated that it would only be able to decide on whether ARVs could be used in the public sector once a joint Treasury-Health Department task force costing the matter had reported back.

However the TAC has condemned that approach, saying: "We cannot be reassured by the existence of a secretive committee of the Departments of Health and Finance, whose research cannot be subject to public scrutiny, but which will form the basis for a cabinet decision of enormous import. This policy causes many preventable deaths."

While the TAC's defiance campaign has not been particularly well organised and has largely been confined to young people rather than a broad cross-section of people, it has once again highlighted government's inability to inspire confidence in its efforts to fight HIV/Aids.

Government does have an HIV/Aids strategy, but it is simply a broad set of guidelines and not an operational plan with targets for every clinic, school, municipality and province. As a result, the implementation of the HIV/Aids strategy is very uneven in the country. Gauteng province has for a number of years run an impressive multi-sectoral HIV/Aids programme; yet Mpumalanga has virtually no HIV/Aids programme and consistently fails to spend its budget for the disease.

Moreover there is no one who holds a high position in government who is consistently speaking out about HIV/Aids. Deputy president Zuma has been designated to do so. But he has been devoting most of his energies to brokering a peace plan for the Congo.

Despite government's inability to fully commit itself, and communicate even its partial commitment, to fighting HIV/Aids, progress is being made. Government has increased the budget allocation for HIV/Aids from R342 million in 2001/2 to R3,6 billion in 2005/6.

It expects to distribute 400 million free condoms before the end of the current year, using outlets such as shebeens as well as clinics. According to a government press release in mid-April, 658 government hospitals and clinics now offer HIV-positive pregnant women and their newborn babies the ARV, Nevirapine, to prevent mother-to-child HIV transmission. By the end of December last year, almost 7 000 babies had been given Nevirapine. As the transmission rate from HIV positive mothers to their babies is around 30 per cent, that means that the programme has saved about 2 100 babies from HIV infection.

However, while government is now claiming its mother-to-child programme as an achievement, it should not be forgotten that government was forced to extend its offer of Nevirapine to all its health facilities after the TAC brought court action against the health minister and her provincial counterparts. Had it failed to roll out the Nevirapine programme, government would have faced a contempt of court charge.

The government statement listed another achievement: voluntary HIV counselling and testing (VCT) was available at 982 sites at the end of 2002. Internationally VCT is considered key in getting people to take personal responsibility for their HIV status, either by changing their behaviour to ensure they remain HIV negative or adopting healthy lifestyles if they test positive.

However, a recent assessment of the government's VCT services by the Health Systems Trust found that most of the test sites were in health facilities, thus many of those who went for the test were either sick or pregnant and had been referred by health workers. In essence that means very little "voluntary" testing was occurring.

Professor Richard Feachem, who heads the Global Fund to Fight Aids, TB and Malaria and was recently in South Africa, found that there are many positive aspects to government's fight against HIV/Aids. "From the mood in the country, it is not a question of if, but when, the public sector delivers anti-retroviral drugs," Feachem told journalists in Durban.

Feachem added that his view was informed by the fact that public health clinicians were being trained in ARV use, that there had been a large increase in the HIV/Aids budget, and that there was a joint treasury-health department task force to consider the cost of ARVs. Feachem was in the country primarily to sign three grant agreements worth about R328 million which had been awarded to South African organisations by the Global Fund 18 months ago, but held up after government made a fuss over the process that led to the award of one of the grants to KwaZulu-Natal. The signing never happened, however. Government stalled because some "technicalities" in the agreement needed to be cleared up first. Thus Feachem learnt, as most South Africans have now learnt, that while indications can be positive, nothing can be assumed when it comes to government's stance on HIV/Aids. Time and again, last minute excuses can delay or undermine government programmes on HIV/Aids. As a result, many citizens are cautious about accepting government statements on HIV/Aids at face value until the concrete delivery of services happens.

Their scepticism goes to the heart of the problems with government's approach to HIV/Aids: it's terrible inconsistency, which is exacerbated by extremely poor communication. Tshabalala-Msimang's staff seems to have given up dealing with the media and there is a dysfunctional relationship between the minister and senior health department staff. The Government Communication and Information System (GCIS) continues to apply gloss to cabinet's eloquent "statement of hope". But government officials fail to inspire either hope or confidence, particularly when Tshabalala-Msimang, finance minister Trevor Manual and president Mbeki address the question of HIV/Aids.

At the same time, communities still refuse to name HIV/Aids as the driving force that is wiping out citizens in their prime. Denial about Aids being the cause of death is the order of the day as families hide behind the notion of "respect for the dead" to pretend to the living.

Yet the figures speak for themselves. There was an increase of 70 per cent in the death rate of female teachers under the age of 39 in KwaZulu-Natal from 1999 to 2000, according to a study of personnel salary records by the Health Economics and HIV/Aids Research Division (HEARD) at the University of Natal. An average of 55 teachers a month died in KwaZulu-Natal in 2000, and the average age at the time of death was 36. By 2010, actuaries predict that life expectancy in South Africa will be around 36.

Thus, failure by the politicians to recognise HIV/Aids as a massive social threat is matched by communities' denial and silence. Until communities are prepared to name the threat posed by HIV/Aids and pressurise their councillors, MPLs and MPs to take up the issue, politicians will be able to get away with their lacklustre approach to HIV/Aids.

Their approach has taken root and flourishes because the most powerful person in the country, president Mbeki, refuses to speak out about how South African citizens should protect themselves from HIV/Aids and care for those already infected. Many politically ambitious public representatives consequently believe that by not taking up HIV/Aids they are in step with the president. Until they can be jolted into action by their constituencies, an operational plan on HIV/Aids, which sees drugs to treat opportunistic infections and anti-retroviral drugs in every clinic, will not become a reality in South Africa.