One million deaths later: South African government continues to stall on AIDS treatment

A row has erupted between the Treatment Action Campaign (TAC) and the South African government over TAC’s July 13 decision to leak a long-awaited report on the costing of a comprehensive HIV/AIDS prevention and treatment programme.

TAC has accused the government of deliberately delaying the release of the report and thereby stalling on the provision of antiretroviral (ARV) provision once again.

An interdepartmental task team was appointed in October 2002 to calculate the costs and benefits of universal antiretroviral treatment. The team, comprising high-level officials from the Department of Health, the Treasury and several provincial governments, completed its report in April 2003.

The report clearly indicates that an antiretroviral programme, in addition to other interventions, would defer hundreds of thousands of deaths. The report was accepted on May 9 at a meeting of provincial and national Health ministers. On May 14, Minister of Health Tshabalala-Msimang indicated that a cabinet decision on the proposals would be taken later that month. However, when it became known that Tshabalala-Msimang and the minister in the President’s Office, Essop Pahad, had referred the document back to its drafters to answer questions on infrastructure, TAC decided to release the document.

The South African government has been placed in an increasingly untenable position with respect to its policy on HIV/AIDS. According to the South African Medical Research Council’s Burden of Disease Report, released in May 2003, AIDS is the single biggest cause of adult mortality in the country, accounting for 39 percent of all deaths, at least five times more than the next largest single cause, homicide/violence.

Estimates of the number of HIV-infected individuals in the country vary from 5 million (Medical Research Council) to 6.5 million (Actuarial Society of South Africa).

According to the model developed by the Actuarial Society of South Africa (ASSA), the epidemic is entering its mature phase. “The total number of people infected with HIV is reaching its peak, which is the natural course of the epidemic,” they say. “This is because the number of new infections has slowed down and because people who are infected are dying.” Based upon the model, it is predicted that if no interventions are undertaken, mortality will peak in about 2010 at an estimated 800,000 deaths per annum. The number of maternal orphans will in turn peak in 2015 at about 1.8 million new orphans each year.

Although Tshabalala-Msimang continues to dispute such predictions, an increasing number of voices from big business, academia and now within government are warning about the dangers an unabated epidemic poses to capitalist development in South Africa.

The TAC civil disobedience campaign

Towards the end of 2002, a senior HIV/AIDS task team at the National Economic Development and Labour Council (Nedlac)—a statutory body that brings together representatives from labour, government and civil society in a forum for negotiation and agreement on matters to do with the economy, labour and development—jointly developed and negotiated a Framework Agreement for a National HIV/AIDS Prevention and Treatment Plan.

This document recommends the rollout of a national programme to prevent mother-to-child transmission, the provision of ARVs to rape survivors and access to ARVs by people living with HIV/AIDS. The agreement also aimed to prevent new infections, combat discrimination, make provision for voluntary testing and counselling, ensure the treatment of opportunistic infections and the provision of ARVs at public health institutions.

However, by December 2002 it became clear that the government had no intention of signing the deal. TAC, a nongovernmental organisation that seeks to put pressure on the government to change its HIV/AIDS policy and one of the main participants in the talks at Nedlac, accused the government of scuppering the deal.

The Congress of South African Trade Unions and the South African Communist Party lent their voices to the call to sign the agreement. Tshabalala-Msimang strenuously denied the existence of such an agreement and, in February 2003, President Mbeki came out in defence of his Health minister: “There is no such agreement, I don’t know where the idea comes from that there is. It is false.”

Frustrated by the intransigence of the South African government, TAC launched a civil disobedience campaign. On March 20, 100 TAC volunteers marched to Cape Town’s Caledon Square police station and laid charges of culpable homicide against Tshabalala-Msimang and the Minister for Trade and Industry, Alec Erwin.

The demonstrators demanded an investigation into the deaths “of many thousands of people who died from AIDS or AIDS-related illnesses and whose deaths could have been prevented had they been given access to treatment.” They concluded, “We believe that many thousands of people can bear witness to these horrible crimes.” The government, in its turn, lambasted the TAC for “bullyboy tactics” whilst continuing to deny the existence of the Nedlac framework agreement.

On April 30, TAC decided to suspend its civil disobedience campaign and agreed to meet with the South African National Council on AIDS at a meeting chaired by Vice President Jacob Zuma. The meeting, initially scheduled for May 15, was postponed several times but was eventually held on June 17.

Among the matters for discussion was the wide-scale provision of antiretroviral drugs at public facilities to people living with AIDS and the finalisation of the Nedlac framework agreement on a national prevention and treatment plan for combating HIV/AIDS. After the meeting Zuma issued a public statement indicating that the South African government was “committed to the provision of ARVs.” But he refused to place a timeframe on such action. The cabinet has yet to consider the costing report.

It is clear that the South African government is once again stalling on the matter of antiretroviral provision. This is but one of a seemingly endless string of delays, which include the failure to sign a deal with the Global Fund to fight AIDS, tuberculosis (TB) and malaria and the failure to release the results of last year’s annual survey of HIV prevalence rates amongst pregnant women.

Thus far, 1 million South Africans have died of AIDS, with a further 600 dying each day, but there is no sense of urgency in government.

The leaking of the costing report and the threat of a renewed civil disobedience campaign indicate a growing anger and frustration within the general membership of TAC. Zackie Achmat, the TAC chairperson and a self-confessed ANC loyalist, describes himself as being on the “right wing” of TAC. However, he has expressed doubts about his ability to contain the anger of the TAC membership. Operating from the perspective of protest politics, TAC has served as a conduit for this anger, deflecting it from the government.

The government’s intransigence and its contemptuous treatment of TAC indicate the limitations of the TAC’s perspective.

On July 29, the Medicine Controls Council gave Boehringer-Ingelheim, the manufacturer of the antiretroviral drug nevirapine, 90 days to prove that the drug is safe and efficacious.

When this period lapses, health professionals could be forbidden from using nevirapine to prevent mother-to-child transmission. Penalties could include a period of imprisonment of up to 10 years. Those infected persons who are currently using the drug would still be able to continue using it.

The MCC’s decision is based upon their rejection of the pivotal Ugandan study which proved that a single dose of nevirapine to a woman in labour, followed by a few drops to the neonate, is sufficient to halve HIV transmission from mother to child. American authorities questioned the results of the study last year, but after an investigation revealed that while there were some administrative problems with the trials, there was no reason to doubt the results. The MCC is in possession of a detailed report on these investigations.

Doctors and medical researchers in South Africa expressed their dismay at the actions of the MCC. Professor Hoosen Coovadia, an internationally renowned paediatrician, stated, “The implications for the country’s programme to prevent mother-to-child transmission, and for the reputation of our country are really very profound. I think we are now going back to the stage from which we thought we had advanced—that is, all the controversy around HIV/AIDS.”

There are suggestions that the MCC has succumbed to political pressure. It should be remembered that in 1997 the South African government disbanded the Medicine Controls Council and forced the resignation of its chairman after the Council refused to give permission for human trials on Virodene, a supposed AIDS “cure” manufactured from an industrial solvent. News reports at that time revealed that the ANC had purchased a 6 percent share in the company manufacturing the drug and was hoping to realise massive profits if the drug proved successful. It is not unlikely that similar pressure has been applied once again.

1. HIV/AIDS profile of the provinces of South Africa—indicators for 2002, Centre for Actuarial Research, Medical Research Council and the Actuarial Society of South Africa. 2002. (Dorrington, R. E., Bradshaw, D. and Budlender, D.).

2. Initial estimates from the South African National Burden of Disease Study, 2000. Burden of Disease Research Unit and Medical Research Council (Bradshaw, D.; Groenewald, P.; Laubscher, R.; Nannan, N.; Nojilana, B.; Norman, R.; Pieterse, D.; Schneider, M.).

3. Treatment Action Campaign (TAC) Report for January 2002-February 2003.

4. Nedlac Framework Agreement on a National Prevention and Treatment Plan for Combating HIV/AIDS, 2002.