South Africa's Struggle with AIDS

The Conflict

South Africa has the largest number of people in the world living with HIV/AIDS. Several socioeconomic and political issues have prevented the country from mounting an effective AIDS strategy.

Socioeconomic

• Twenty-two million South Africans live in conditions of abject poverty. They are often undernourished and lack basic health needs, such as decent shelter and running water.
• A high rate of migrant labor facilitates the spread of HIV/AIDS.
• The low status of women, and attitudes that condone multiple sex partners for men, make women particularly vulnerable to HIV infection. Fifty-six percent of South Africans living with HIV/AIDS are women.
• South Africa lacks an effective infrastructure through which to deliver health services to its indigent population and lacks the financial resources to pay for expensive AIDS drugs.

Political

• AIDS emerged as a serious problem in South Africa just as the ANC succeeded in ousting the apartheid government that had deprived blacks of basic rights. Preoccupied with the job of creating a new, democratic government, the ANC did not at first make AIDS a top priority.
• ANC leaders have rejected the AIDS advice of white scientists and health officials. They insist that they must find African solutions to HIV/AIDS, and have resisted authorizing the use of AZT and other AIDS drugs for indigent South Africans.
• The international community has been late in responding to the AIDS crisis in South Africa. Financial assistance from international organizations has been a fraction of the amount specialists say is needed.
• Multinational drug companies did not agree to lower prices for AIDS drugs in South Africa until late in the 1990s. Even then, South Africa insisted that the cost was too high.

When scientists and health officials from around the world who study acquired immuno-deficiency syndrome (AIDS) met in Durban, South Africa, in July 2000, it was a momentous occasion. For the first time in the 13 years since its creation, the International AIDS Conference was to be held in a developing nation—which activists hoped would highlight the extreme urgency of the fight against AIDS in Africa, the continent most devastated by the disease. But instead of cooperation and resolve, the meeting brought controversy and division. Several delegates threatened to boycott the conference to protest the AIDS policy of South African President Thabo Mbeki, who rejected Western approaches to diagnosis and treatment and argued that Africans should find their own solutions to the pandemic. Despite grim statistics showing that almost 20 percent of South Africa's adult population is infected with HIV, and that 5,500 people die of AIDS in sub-Saharan Africa each day, Mbeki continued to insist that poverty, not AIDS, was his country's leading cause of death.

Many saw Mbeki's stance as evidence of South Africa's failure to recognize and address the urgent problem of AIDS treatment and prevention. Mbeki's public comments and policies—particularly his opposition to azidothymidine (AZT), a drug effective in preventing a pregnant woman from transmitting the human immunodeficiency virus (HIV) to her fetus, and his statement that HIV does not cause AIDS—created a furor among researchers and health officials. Five thousand scientists, in protest, signed the Durban Declaration, stating that scientific evidence proves unequivocally that HIV causes AIDS.

Disappointed though many conference attendees were with South African health policies, the Durban conference did focus international attention on the magnitude and complexity of the AIDS problem in Africa. Within less than a year the United Nations (UN) called for concerted efforts to fight the pandemic in Africa; organizations urged Western nations to fund the AIDS war in developing countries; pharmaceutical companies agreed to slash prices of antiretroviralanti-retroviral drugs; and South Africa approved the use of Western drugs for indigent patients. The world's attention had finally been caught—but not in time to stem massive social, political, and economic devastation.

Historical Background

A Mysterious New Killer

AIDS was first identified in 1981 in Los Angeles, California, and in New York City after young and middle-aged adults with no previous serious health problems began to die from infections and malignancies that almost never cause trouble in the general population. By 1983 researchers identified HIV as the cause of this new disease, AIDS. HIV destroys or impairs immune system cells and progressively destroys the body's ability to resist infections and some types of malignancies. AIDS is considered the last stage of HIV infection, and it is fatal.

HIV is transmissible but not contagious. It is contracted mainly through exposure to blood, semen and other genital secretions, and breast milk. It can also be transferred across the placenta during pregnancy, infecting the unborn child. Because the first AIDS cases were found among gay men, it was initially believed that homosexual contact was the primary means of transmission. It is now known, however, that heterosexual intercourse is the major mode of transmission worldwide, accounting for 70 percent of all HIV infections.

The interval between infection with HIV and the appearance of conditions associated with AIDS is, on average, ten years. Affected individuals may remain without symptoms for several years, during which they can unwittingly spread the disease. As HIV weakens the immune system, individuals become susceptible to numerous diseases. Often, these are opportunistic infections—infections caused by organisms that rarely cause harm in healthy individuals, such as cytomegalovirus, Pneumocystis carinii, toxoplasmosis, candidiasis, herpes simplex virus, herpes zoster, tuberculosis, and atypical Mycobacterium. Affected individuals also experience an unusually high rate of certain cancers, including Kaposi's sarcoma, tongue and rectal cancers, and non-Hodgkins B cell lymphoma. Death results from the persistent ravages of diseases and malignancies from which the body can no longer defend itself.

Through the 1980s and early 1990s, AIDS cases in the United States increased alarmingly, with no cure and few treatment options. In the early years of the pandemic AIDS patients suffered not only the physical devastation of the disease, but also the shame with which it was associated. Because most known AIDS cases at that time were concentrated in the gay community, as well as among intravenous drug users, the majority culture often stigmatized victims, blaming them for bringing the disease on themselves through "immoral" behavior. Some people went so far as to suggest that AIDS was a punishment from God for engaging in homosexual activities. Yet, as more and more young men died in their prime, activists took up the cause. The gay community rallied to fight misconceptions about the disease and to remove the guilt and shame with which it was often associated. At the same time, AIDS was starting to spread beyond the gay community and intravenous drug users. Demanding funds for AIDS research, activists also promoted educational outreach to warn people of behaviors that increased the risk of contracting HIV: sharing contaminated needles for injecting drugs, and engaging in "unsafe" sex—homosexual or heterosexual intercourse without using a condom. In time, slowed rates of new infections showed that individuals were changing behaviors to minimize their risk of contracting HIV.

Therapy for the first AIDS patients was limited to treatment of the individual infections they contracted and was ineffective in slowing the course of the disease. But in 1987, when annual AIDS deaths in the United States reached 16,000, the first drug known to retard the advance of the disease, AZT, was introduced. By 1996, three-drug combination therapy with antiretroviral drugs became standard treatment in developed countries, precipitating a sharp decline in annual AIDS deaths. Though AIDS remains incurable, these therapies offer the hope of prolonged life and relative health to those patients who receive them.

AIDS in Africa

Though most AIDS research has benefited patients who live in developed countries—which enjoy sophisticated health care systems and a high standard of living—the disease has wrought its most extreme devastation in underdeveloped regions of the world, particularly sub-Saharan Africa. United Nations (UN) epidemiologists estimated in 1991 that, by 1999, some 9 million people in sub-Saharan Africa would be HIV-positive. By 2000 data showed the infection to be 2.5 times that number. Out of a total population of 640 million in the region, the annual death rate from AIDS reached 2.4 million, and the HIV infection rate ranged from 5.06 in Nigeria to 35.8 in Botswana. By contrast, on December 2, 2000, Kevin Toolis of the British newspaper the The Guardian reported that Britain, with a population of 59 million, had 31,000 people living with AIDS and a prevalence rate of only 0.11 percent; Germany, with a population of 82 million, had 37,000 AIDS cases and a prevalence rate of 0.10 percent; and the United States, with a population of 276 million, had 850,000 people living with AIDS and a prevalence rate of 0.61 percent.

In South Africa, where more people are infected with HIV than in any other country, 4.2 million people—19.94 percent of the adult population—are HIV-positive, and the rate of new infections is among the highest in the world. According to statistics from the World Health Organization (WHO), some 250,000 South Africans died of AIDS during 1999, and the pandemic has orphaned an estimated 420,000 children. In early 2001 the rate of new infections in South Africa was 1,700 per day.

So huge is the problem of AIDS in developing countries that UN Secretary-General Kofi Annan declared AIDS "a major challenge for human security." In March 2001, U.S. Secretary of State Colin Powell named Africa's AIDS epidemic a national security issue for the United States.

Several factors make AIDS in Africa, as well as in other underdeveloped areas, much more difficult to combat than in developed countries. Poverty, political oppression, migration, and social violence create an environment in which HIV and AIDS can flourish. Lack of education and a reticence to openly discuss sexual matters further exacerbate the problem. At the same time, many areas lack the infrastructure necessary to offer HIV testing or to deliver health services to those most in need. Indeed, the vast majority of HIV-positive individuals in sub-Saharan Africa receive no treatment whatsoever.

South Africa

South Africa is the hardest hit by HIV/AIDS. With 4.2 million HIV-positive adults and children, it has the largest number of people living with HIV/AIDS in the world. Of these, 56 percent are women. In 1999 alone, the country suffered 250,000 adult and child AIDS deaths. And experts point out that this is merely the tip of the iceberg. According to Institute for Security Studies analyst Martin Schonteich, in "Age and AIDS: South Africa's Crime Time Bomb?" (African Security Review, 1999), the people now visibly sick and dying in South Africa represent only one percent of those infected in 1990. The dramatic increase in new infections since then will lead to catastrophic death figures within a few years. In 1998 Minister of Health Nkosazana Zuma estimated that HIV would reach its peak in South Africa in 2010, with 6.1 million infected. It is estimated that South African AIDS deaths between 1995 and 2005 will reach 7.4 million. In 1998 alone, more than 100,000 South African children were orphaned because of AIDS; this number could reach one million by 2005.

Shockingly, few South Africans receive treatment for HIV infection or AIDS. According to a November 30, 2000 report by Chris McGreal in The Guardian ("AIDS: South Africa's New Apartheid"), doctors estimated in 2000 that only 10,000 of the country's 4.2 million HIV-positive individuals can afford expensive antiretroviral therapy, which costs between US$10,000 and $15,000 a year in developed countries. Most of those who get the drugs are gay white men or members of the new black elite. The vast majority of black South Africans suffering from HIV/AIDS receive no treatment because the government has refused to administer AZT and other antiretroviral drugs to those who rely on the public health system, claiming that the drugs' safety and effectiveness were in question and that their cost was prohibitive. This circumstance has led people to call AIDS in South Africa "the new apartheid" and to suggest that failure to provide treatment would be an act of genocide.

The Legacy of Apartheid

Of all the developing countries confronted with AIDS, South Africa should have been well prepared to devise an effective strategy against the disease. The country has an industrialized economy and well-educated elected leaders. But in 1993, when officials began to recognize the scope of the AIDS problem, South Africa was consumed with political issues that deflected attention away from public health. Members of the African National Congress (ANC) were poised to take control away from the apartheid government in the country's first democratic elections.

Under apartheid, the white minority in South Africa had created a racially segregated society that kept people of color, particularly blacks, in inferior positions and denied them basic human rights. This system also created conditions that facilitated the spread of HIV infection. Because blacks were forced to live in separate townships far outside of white areas, where jobs were nonexistent, a pattern of migrant labor emerged. Many had no choice but to travel long distances to find work in urban centers or in the mining industry; denied permission to bring along wives and families, these men often resorted to sex with prostitutes or casual partners for the extended periods that they were away from home. Of the thousands of political dissidents who fled to Zambia, Tanzania, Uganda, and other countries to escape apartheid oppression, some were exposed to HIV in those countries and brought it back with them when they returned to South Africa.

Apartheid policies had also eroded trust in established health services, which were mostly staffed by white physicians.

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Indeed, fears and suspicions that had burgeoned under apartheid affected the new government's approach to AIDS.

During the elections, apartheid leaders used fear of AIDS, which they associated with the stereotype of the promiscuous and irresponsible black male, to shake public confidence in the ANC. When the ANC proved victorious and Nelson Mandela was elected president, apartheid supporters expressed doubt that his black administration would be competent to govern the country. Amid jubilation and hope for the new regime there also existed defensiveness and division. Faced with the task of building a new, democratic South Africa, leaders resented the fact that AIDS could deflect resources from such crucial goals as housing and jobs for a country with approximately 22 million people living in "third world" conditions of abject poverty. Some even refused to admit that AIDS was really a problem.

The Status of Women

Attitudes toward women in South Africa also exacerbate the spread of HIV. Though HIV infection in other parts of Africa occurs at the same rate in men and women, in South Africa, 56 percent of infected individuals are women, with the highest infection rates among women aged 20 to 30. Low social status and lack of power make women particularly vulnerable. In an HIV Insite report on South Africa (2001), Lisa Garbus cited a 1998 South African Medical Research Council study claiming that 90 percent of men studied believed it was common for men to have multiple sex partners. Two out of three men believed women had no right to refuse sex or insist that their partner use a condom. Indeed, women frequently report being beaten if they object to sex with partners they know are HIV-positive.

Additionally, the belief among some men that having sex with a virgin will cure them of AIDS contributes to sexual abuse of young girls, who contract HIV on average five years earlier than men do. Almost a third of South African teenage girls report being raped as a virgin. In South Africa, Garbus reports, a woman is raped every five minutes, and gang rape is common. When women fear violence from men, they are even less able to say no to sex or to insist on condom use. At the same time, women are the most deprived sector of the population—56.4 percent lack income of any sort. Many are forced to become sex workers to survive, leaving them even more vulnerable to sexual violence and HIV infection.

The high rate of sexually transmitted diseases (STDs) in South Africa—approximately 11 million cases annually—is also a major factor facilitating HIV transmission. Evidence shows that HIV infection is more likely to occur when an individual suffers from certain STDs, particularly gonorrhea and genital herpes.

Denial and Divisiveness

Though the ANC's first AIDS policy was tentative, at least the party had a policy. The apartheid regime's HIV program, was almost non-existent. Nkosazana Zuma, appointed South Africa's first black minister of health by then-President Nelson Mandela, developed an AIDS plan calling for $64 million to devote to education, mass media campaigns, distribution of free condoms, and support programs for HIV-positive individuals. Zuma also urged the creation of a national AIDS commission and suggested that the country's AIDS program be run from the president's office, to ensure it a high level of visibility and respect. But Zuma balked when asked to address other issues contributing to the spread of AIDS, such as the role of migrant labor.

In his first budget, Mandela approved only $15 million for AIDS and assigned the AIDS initiative to the health department. Instead of helping to promote HIV and AIDS awareness, Mandela remained silent. He made no public statement about AIDS until late 1997, when he delivered a speech to the World Health Organization (WHO) in Switzerland. He made no public reference in South Africa to AIDS until 1998, after he had been in office more than three years. Official silence on AIDS, many believed, caused some blacks in rural areas to doubt the actual existence of AIDS and to reject condom campaigns as a ruse to limit black population growth.

Zuma, however, was committed to increasing AIDS awareness. She spent $3 million producing an AIDS awareness play reminiscent of the popular musical Sarafina. Despite its good intentions, the play, many felt, communicated a simplistic message about AIDS. Many activists criticized Zuma for spending one-fifth of her annual budget on this project. Their negative perceptions were further cemented when Zuma announced her plan to require HIV-positive individuals to publicly acknowledge their status. Though the health minister intended this as a means of removing the stigma from HIV infection, activists objected that it compromised confidentiality and further stressed AIDS patients. Zuma's staff responded that confidentiality was a Western preoccupation, not an African matter.

African Solutions to African Problems

Tentative as South Africa's first AIDS campaign was, it was distinguished by a strong conviction that black Africans should be skeptical of white authority and should create their own, uniquely African, solutions to the AIDS pandemic. Nowhere was this attitude more evident than in the government's decision to promote research on Virodene P058. This drug was discovered by three researchers in Pretoria, who claimed the substance could cure AIDS. In 1997 Zuma sought funding and approval for the drug. Though Peter Folb, who directed the approval agency, objected that Virodene research was flawed and further study of it was needed, Zuma and then-deputy president Thabo Mbeki pressured him to approve it. Soon, however, it was revealed that Virodene, which contained an industrial solvent as its active ingredient, was not only ineffective against HIV but was also carcinogenic.

The push for approval of Virodene, officials complained, had been a purely political decision, not one based on scientific expertise. In John Jeter's article "South Africa's Advances Jeopardized by AIDS" (July 6, 2000), he quoted Quarraisha Karim, first director of South Africa's national AIDS program, as saying, "There was this sense that this drug would be the thing that would offset the perception …of Africans as substandard and less than capable… This was driven by this need to show the world: 'Yes, Africans can do this. We can do this. Virodene became our redemption."'

As late as 1999, when Bristol-Myers proposed to Zuma a new AIDS initiative to fund medical research and education projects, the South African government responded negatively. Zuma's assistant, Nono Simelela, responded that Britsol-Myers should come to Africa to learn how to deal with the virus in the developing world. Simelela further objected to clinical trials in South Africa using drugs that were not affordable to a vast majority of the population.

Money and Drugs

Though many AIDS workers were deeply frustrated with the government's approach, its distrust of Western motives certainly had some basis. By the time AIDS became a crisis in Africa, wealthy nations, where antiretroviral treatments were proving effective, were losing interest in fighting the disease. Though a classified U.S. Central Intelligence Agency (CIA) document, Interagency Intelligence Memorandum 91-10005, predicted the scope of the disaster for Africa when it was first circulated in the late 1980s and warned that the response from developed countries would have at best only a marginal effect, U.S. government response was tepid. The first U.S. budget after release of the document allocated only $124.5 million for overseas AIDS control and remained flat for the next seven years. Small as this amount was, it far exceeded allocations from other countries; the combined AIDS assistance from Europe, Australia, and Japan barely exceeded the U.S. figure.

At the same time, bureaucrats argued about how to distribute the limited funds available. The U.S. Agency for International Development (USAID) balked at paying for AIDS testing overseas, arguing that it was too expensive and that those who tested positive would then want treatment, which would be even more expensive. Duff Gillespie, who supervised AIDS assistance for USAIDS, felt that overpopulation was a much more important problem in Africa than AIDS was, and resisted channeling funds away from the budget for population control. Also at issue was cost-effectiveness. With the number of HIV-positive individuals skyrocketing, many analysts argued that treatment was financially impossible, and recommended focusing solely on prevention programs.

Indeed, the cost of antiretroviral treatment was staggering. Antiretroviral regimens, which do not cure AIDS, must be administered for the entire life of the HIV-infected individual. And this drug therapy costs between $10,000 and $15,000 per patient each year—a figure far beyond the capacity of South Africa to pay. Though the World Health Organization began as early as 1991 to address the need to make therapies affordable for developing countries, little was actually accomplished until almost a decade later. The major pharmaceutical companies that manufactured AIDS drugs lobbied against plans to offer these drugs at cost, claiming that governments and other sectors were responsible for finding reasonable means of providing the drugs; pharmaceutical companies were concerned primarily with research and development.

One contention against this claim is that drug companies feared that drugs sold to Africa at a steep discount might be re-exported to wealthy countries for a profit. This, in turn, could encourage AIDS patients in developed countries to demand lower prices as well. Also at issue was the protection of intellectual property rights. In 1993 then-U.S. President Bill Clinton, at the urging of pharmaceutical companies, pressed to extend patent laws worldwide. In 1995 the World Trade Organization drew up an agreement on Trade Related Aspects of Intellectual Property Rights (TRIPS), which protected the exclusive marketing rights of patent holders. This meant that the companies that had developed new drugs could control their pricing and marketing. At the same time, TRIPS forbade developing countries from making or purchasing generic (and cheaper) versions of patented drugs.

Yet pressure to make antiretroviral therapies affordable began to mount. In 1998 the executive board of WHO endorsed a Revised Drug Strategy, which stated that public health concerns should have precedence over commercial interests. Soon after, the UN published "Globalization and Access to Drugs," which stated that drug patents conflicted with the human right to equal health care. In response, Glaxo Wellcome (now GlaxoSmithKline), developer of AZT and the two-drug package known as Combivir, announced that it would offer AIDS drugs to developing countries at prices substantially less than in the developed world. Pfizer, which manufactures the anti-fungal treatment Diflucan, needed by 10 percent of AIDS patients, offered to donate the drug to South Africa. Later that year pharmaceutical giants Merck, Hoffman-La Roche, Bristol-Myers Squibb, Glaxo Wellcome, and Boehringer Ingelheim agreed to big discounts on AIDS drugs to developing countries, though they did not specify exact prices. In 2000, the Clinton administration offered $1 billion for the purchase of AIDS drugs. This generous-sounding amount, however, was really a structure of Export-Import bank loans, at commercial interest rates; it was rejected. Though the World Bank, reversing its policy not to underwrite loans for health care, announced a $500 million funding pool to fight AIDS, it still considers antiretroviral drugs to be cost-ineffective. According to the World Bank's concept of "disability-adjusted life year," it is a net loss for a country to spend $1,000 each year to save the life of an individual who earns only $500 a year.

By the time Thabo Mbeki succeeded Nelson Mandela as president of South Africa in June 1999, it was clear that the country was in the midst of a full-blown AIDS crisis. The AIDS strategy that the country had adopted in July 1994 proved ineffective, and in 1997, a review led to a reformulation of national priorities to fight AIDS. In 1998 Mandela created a multi-sectoral ministerial task force on HIV/AIDS, as well as the National AIDS Council. The government also launched a national educational campaign to urge safer sex practices and the use of condoms. But the crucial matter of testing and treatment had yet to be addressed.

Known as an independent and original thinker, Thabo Mbeki quickly distinguished himself for his reluctance to accept Western approaches to AIDS. Though his earlier support for Virodene had resulted in embarrassment, he continued, as president, to insist that solutions to South Africa's AIDS problem should take into account the differences between AIDS in developing countries and AIDS in the West. After studying the opinions of a range of AIDS experts, some of whom questioned the safety of AZT, he determined that the drug was too toxic to administer to pregnant women. Yet AZT is routinely used to prevent maternal transmission of HIV in the United States, Canada, Britain, and most European countries.

The AZT Controversy

Some suggest that part of Mbeki's resistance to AZT and other antiretroviral drugs was their astronomical cost. Since the vast majority of HIV-positive people in South Africa depend on the public health system, the government faced an impossible financial burden if it were to import expensive AIDS drugs. But South African concerns about the safety of AZT are not completely

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unfounded. The drug, first developed as a cancer treatment in 1960, can have serious long-term side effects, including loss of muscle, anemia, depression of white blood cells, and bone marrow damage. Other side effects can include nervousness, headaches, dizziness, nausea, stomach pain, confusion, loss of appetite, muscle aches, fever and sweating, sore throat, and abnormal bruising or bleeding. A rare side effect, according to the AIDS Treatment Data Network, is lactic acidosis, caused by damage to liver cells. Dr. Peter Moore, sub-Saharan medical director for GlaxoSmithKline, the maker of AZT, told the Johannesburg Mail and Guardian in "Truth and Lies about AZT" (December 1, 1999) that serious side effects such as cancer, anemia, and reduced white blood cell count occurs in about five percent of patients who take the drug for more than six months. When AZT was first approved for AIDS treatment, doses were much higher than are presently recommended; the usual dose has been adjusted to 300-600 mg per day.

The safety of AZT for pregnant women has also been questioned, especially because initial laboratory tests on mice suggested that the drug could cause cancer in the affected fetus. Subsequent research, published in the January 13, 1999, edition of Journal of the American Medical Association, (Culnane, "Lack of Long-Term Effects") reported no adverse effects among the group of infants studied. According to the previously cited Johannesburg Mail & Guardian report, providing AZT to pregnant women who are HIV-positive could cut the number of South African babies born with HIV—estimated at 600,000 per year—in half.

In February 2001 the U.S. Department of Health and Human Services revised its treatment recommendations regarding antiretroviral drugs. The new guidelines specify that treatment with these drugs should not begin until HIV-positive patients begin to show symptoms of AIDS; earlier, physicians were encouraged to begin aggressive treatment immediately after a patient tested positive for HIV. Also troubling is research released by the University of California at San Diego that indicates that 14 percent of newly diagnosed HIV cases have strains of the virus that are resistant to antiretroviral drugs, suggesting that overuse of these treatments has contributed to the mutation of HIV just as overuse of some antibiotics has been conducive to the development of bacteria that do not respond to known treatments.

The HIV Controversy

Mbeki also questioned theories of how AIDS develops. Two types of HIV are currently recognized. Subtype B is the type spread most often through homosexual contact and intravenous drug use, and occurs more often in the United States, Europe, Australia, Japan, and the Caribbean. Sub-type C, found most often in South Africa and India, seems to spread more often through heterosexual contact. Noting these differences, Mbeki stated in a letter to international leaders on April 3, 2000, that he planned to invite to South Africa an international panel of scientists, which included American researchers Peter Duesberg and David Rasnik, as well as British scientists Gordon Stewart and Andrew Herzheimer, to discuss new approaches to AIDS. He also suggested that focusing on HIV might not be the best response for South Africa. "A simple superimposition of Western experience on African reality would be absurd and illogical," he wrote. "I am convinced that our urgent task is to respond to the specific threat that faces us as Africans. We will not eschew this obligation in favour of the comfort of the recitation of a catechism that may very well be a correct response to the specific manifestation of AIDS in the West. We will not, ourselves, condemn our own people to death by giving up the search for specific and targeted responses to the specifically African incidence of HIV-AIDS."

The international AIDS community reacted with horror. Nor were they reassured when, at the Durban conference, Mbeki said in his opening remarks that poverty is a more deadly threat in South Africa than is AIDS. The Times diplomatic editor Richard Beeston reported in "Mbeki Controversy Jeopardises Conference Aims," (July 12, 2000), that Justice Edwin Cameron, a white High Court judge in South Africa who is gay and suffers from AIDS, stated at the conference that Mbeki's stance "has created an air of unbelief amongst scientists, confusion among those at risk of HIV and consternation amongst AIDS workers." The controversy stirred by Mbeki's comments overshadow the issue of getting help to the country's AIDS sufferers.

Mbeki insisted that his remarks had been misunderstood. In defense of the president, South Africa's MEC for Health, Dr. M. Sefularo, made the following statement at the AIDS Conference:

It is unfortunate that President Thabo Mbeki has been misunderstood on the question of HIV and AIDS. The President has never denied either the existence of AIDS nor the causal relationship between HIV and AIDS. He has never said that HIV does not cause AIDS. What we are saying or asking is—'What is it about us in Sub-Saharan Africa, about the HIV virus, about our condition, culture, beliefs, our relationship to the rest of the world and our response to the HIV that has allowed AIDS to so catastrophically destroy individuals, families and communities to a point where it is possible that our economic development, freedom, security and our very existence as a people and a nation may be reduced to nothing?' That is the challenge. We reiterate our view that it is inappropriate to blame everything around this epidemic on the HIV virus. Clearly, the relationship between HIV and other social ills afflicting our society such as poverty and disease, particularly TB and STDs, is complex. We reaffirm our view that a comprehensive response in our country needs to recognise this reality.

In a September 4, 2000 interview with Time Europe, Mbeki clarified his position.

Clearly there is such a thing as acquired immune deficiency. The question you have to ask is, what produces this deficiency? …A whole variety of things can cause the immune system to collapse. Endemic poverty, the impact of nutrition, contaminated water, all of these things, will result in immune deficiency. If you take the African continent you add to that things like repetitive infections of malaria, ordinary STDs—syphilis, gonorrhea, etc. All of these will result in immune deficiency… The problem is that once you say immune deficiency is acquired from that virus your response will be antiretroviral drugs. But if you say the reason we are getting collapsed immune systems is a whole variety of reasons including the poverty question which is very critical, then you have a more comprehensive response to the health condition of a person.

When asked directly whether he agreed that a direct link exists between HIV and AIDS, Mbeki responded "No, I am saying that you cannot attribute immune deficiency solely and exclusively to a virus."

By September 2000, however, Mbeki had begun to distance himself from the controversy. Senior officials of his ANC party urged him to acknowledge publicly that HIV causes AIDS, and his office admitted that his unpopular stance had cost him credibility. At the same time, pharmaceutical companies, under increasing pressure to make AIDS drugs affordable to developing countries, began negotiating offers. In 1999 Bristol-Myers Squibb announced its Secure the Future initiative, which pledged $100 million over five years to fight AIDS in Africa. But as of December 2000, 77 percent of funds pledged to Secure the Future have gone to U.S. charities and research institutions; only 10 percent of the funds have gone to programs in South Africa. Though five major pharmaceutical companies agreed in March 2001 to offer drastic price cuts on AIDS drugs, only Glaxo has specified a particular price. The companies are still concerned about protecting patent rights. Rather than allow generic AIDS drugs to be sold in Africa, 42 multinational drug companies joined a lawsuit brought by the Pharmaceutical Manufacturers Association of South Africa (PMA) seeking to block the South African government from enacting a 1997 law allowing it to import generic versions of patented drugs. British Prime Minister Tony Blair backed the drug companies, citing the importance of protecting intellectual property laws, but a torrent of international criticism harmed their case. After secret negotiations between the drug companies and the government, brokered with the assistance of UN Secretary-General Kofi Annan, the parties reached a settlement announced on April 19, 2001, which in essence allows South Africa to buy the cheapest available antiretrovirals.

Recent History and the Future

AIDS threatens to reverse many of the gains South Africa has made in recent years. Most obvious is life expectancy. Laura Garbus reported in "South Africa" (HIV Insite, 2001) about a study suggesting that fewer than 50 percent of South Africans now living will reach age 60, compared with an average of 70 percent for developing countries and 90 percent for industrialized countries. She also noted that, without AIDS, life expectancy in South Africa would presently be 65—it is instead 55. The falling life expectancy rate in the country has significant implications for South African society.

The impacts of AIDS will undoubtedly be catastrophic for families and communities. Among adults, HIV and AIDS generally affects young individuals who are likely to be parents and family breadwinners. As HIV-positive adults become increasingly ill, they can no longer work; at the same time, the lack of hospitals and health centers in rural areas means that vast numbers of AIDS patients must be cared for by relatives. This places a disproportionately high burden on women, who are already South Africa's most marginalized group. It also erodes the family structure by exacerbating poverty, and by stigmatizing those affected by AIDS.

By 2005 AIDS is expected to leave approximately 1 million maternal orphans (those whose mothers have died) in South Africa. Care for these children will also fall on family groups; in some cases, orphaned children may become heads of families. With this unprecedented number of AIDS orphans a corresponding increase in crime is likely. Numerous studies in several countries show that crime rates are closely related to age, with teenagers and young adults committing most crimes. In 1996 census data indicated that 34 percent of the country's population was under the age of fifteen, with the largest segments aged five to nine and ten to fourteen; the number of juveniles and young adults as a proportion of the population is expected to peak between 2010 and 2020. By 2010 one out of every four South Africans will be between the ages of 15 and 24. With AIDS expected to bring some 7.4 million deaths in South Africa between 1995 and 2005, and to leave one to two million orphans by 2010, huge numbers of young people left without parental figures and traumatized by the extreme suffering of AIDS will become part of the demographic group most likely to commit crimes.

Economic impacts from AIDS are also expected to be significant. One estimate suggests that the disease will cause South Africa to lose 10.8 percent of its workforce by 2005, and 24.9 percent by 2020. In the article "The Worst Say to Lost Talent: Business and AIDS," The Economist (February 10, 2001) reported that a typical South African company will lose 20 percent of its workforce by 2010, and that each HIV-positive workers will cost a typical company about twice his or her annual salary. The mining industry, which relies heavily on migrant labor, will be particularly affected. Figures suggest that 10 percent of South African mine workers could succumb to AIDS. The disease cost the industry 114 million rand in 1995, a figure that could rise to 1.5 billion rand in 2010. Indeed, a special United Nations report on AIDS suggests that AIDS "may cut productivity growth by as much as 50 percent in the hardest-hit countries." Because South Africa's population is expected to decline by 23 percent by the year 2015, but per capita income is expected to remain stagnant, demand for South African goods will be affected. At the same time, companies will be hard-pressed to provide benefits such as health and life insurance. They will also face difficulties replacing skilled workers who succumb to AIDS.

Government Response

By the end of 2000, Mbeki's government agreed to accept donated AIDS drugs and to begin treatment of HIV-positive prenatal patients with nevirapine, a drug that reduces the risk that a pregnant woman can transmit HIV to her fetus. But despite further concessions from drug companies early in 2001 about pricing and patents, the government stated that it could not make antiretrovirals more widely available because the infrastructure to deliver them was inadequate and the price—$2 per day in the public sector and $4 per day in the private sector—was still too high.

The government's HIV/AIDS/STD Strategic Plan for South Africa 2000-2005 lists prevention as its top priority. Its recommendations include making condoms available in all government department buildings; providing condoms at truck stops, mines, brothels, and borders; making clinics and other health facilities "youth friendly;" and training midwives and other reproductive health care providers on HIV/AIDS counseling for pregnant women. A significant part of its prevention strategy is the involvement of "all sectors of government and civil society," including traditional leaders, faith-based organizations, business, entertainment, and the media. The Plan's second priority—the treatment, care, and support of infected individuals—includes measures aimed at ensuring a dependable supply of appropriate medications for treatment of opportunistic infections and other conditions, improving health care infrastructure and training, and poverty-alleviation programs aimed at addressing the root causes of AIDS. The Plan also addresses research, monitoring and surveillance, and questions relating to human rights, including workplace HIV/AIDS policies and the possibility of decriminalizing commercial sex work.

In addition, South Africa has implemented an aggressive educational campaign on HIV/AIDS, aimed primarily at young people aged 12 to 17. The campaign, "Love Life," uses billboards, radio, television, and newspapers to deliver its message about safer sex and condom use. The program hopes to reduce the rate of HIV infection by half within five years. Love Life uses direct language and addresses once-taboo subjects, such as masturbation, foreplay, and gay sex, to encourage open discussion of sexual matters. Love Life also visits sports facilities and schools, and runs the Love Train, a railroad train that travels throughout the country displaying its safer sex message on South Africa's largest billboard.

The government has also established 20 specialized "rape courts" and is developing a rape protocol that may include compulsory HIV testing for all persons arrested in sexual assault cases. South Africa is also revising legislation relating to employment, which may result in classification of HIV/AIDS as a disability, thus protecting infected individuals from discrimination and unwarranted dismissal.

Private Sector Response

Private companies have also implemented policies to deal with AIDS. AngloGold, the country's largest gold mining company, gives its workers and their girlfriends AIDS leaflets printed in various African languages, and also hires specialists to train peer educators among miners and prostitutes. The company also offers voluntary HIV testing and counseling, as well as free treatment of STDs, which, if untreated, can increase the likelihood of HIV infection by 50 percent. South African Breweries (SAB) presents role-playing exercises designed to show workers how fast HIV infection can spread. Like AngloGold, the company also offers testing, counseling, and STD treatment. In February 2000 South Africa's telephone company, Telkom, purchased 5 million condoms to distribute to its workers via restroom vending machines. The company estimates that it will dispense about 100,000 condoms each week.

Health insurance companies, too, are devising measures to cope with the burden of AIDS. Some have established special facilities for HIV/AIDS patients, which allow the companies to cap guaranteed benefits for HIV treatment. As of 2000, average coverage was about $4,000 per person each year. Increased demand for coverage as more infected people become sick, however, is expected to strain the industry, and companies may have to limit health insurance coverage further, as death benefits are expected to rise markedly by 2002.

Anticipating high rates of personnel losses in the coming years, some companies have changed hiring and training practices. Mondi, a company that manufactures paper, trains its employees in a variety of specific jobs so they can easily replace workers who become ill. Other companies may hire as many as three workers for each skilled job to ensure coverage if employees die. In other cases, companies are mechanizing and outsourcing services to subcontractors in order to function with fewer employees.

Further Needs

Despite new commitments to fight AIDS in South Africa, much remains to be done. The UN AIDS office estimates that at least $1 billion is needed to fight HIV/AIDS in Africa. This figure, however, is much lower than other estimates. Jeffrey Sachs, director of Harvard University's Center for International Development, suggested in the New York Times article "The Best Possible Investment in Africa" (February 10, 2001) that wealthy countries need to spend between $5 to $10 billion each year for the next decade to combat AIDS in Africa. The smaller figure, he notes, is the amount that Europeans determined to spend on mad cow disease, which has killed about 80 people while AIDS in Africa has claimed about 17 million lives to date. Sachs observed that prevention and community support measures would cost about $3 billion annually, and treatment would cost between $2 and $7 billion.

In 2000 the United States authorized just under $200 million in development aid to fight AIDS overseas. Its projected budget for 2001 seeks to add about $50 million to this amount. The U.S. contribution represents about half of the AIDS funds from all industrialized countries.

Money and drugs, however, are not enough to stem the tide of AIDS as it washes over South Africa. While governments and pharmaceutical companies argue over various points, the main issue remains that a generation is dying of AIDS in South Africa. The people must be informed and, educated about the risks, precautions, and available treatments, provided with all available information and all available options to give them the best chance at life.

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—E.M. Shostak

Chronology

1981 The first cases of AIDS are identified in Los Angeles, California.

1987 AZT, the first drug effective in treating AIDS, is introduced; death rate in the United States is 16,000, while death rate in Africa is approximately 150,000.

1990 The first cases of AIDS are identified in South Africa.

1996 Three-drug antiretroviralanti-retroviral combination therapy becomes standard AIDS treatment in developed countries but remains too expensive for African countries; death rate in Western countries slows while death rate in sub-Saharan Africa soars to 1.5 million. Most AIDS patients in South Africa receive no medical treatment.

1997 Then-deputy president Thabo Mbeki and health minister Nkosazana Auma pressure for approval of Virodene, a drug discovered by South African researchers, which they believe can cure AIDS; it is later found to be carcinogenic and ineffective against AIDS.

1998 Five multinational pharmaceutical companies offer to sell AIDS drugs to Africa at substantial discounts.

1999 Mbeki announces that AZT is too toxic to administer to pregnant women.

April 2000 Mbeki suggests that HIV is not the cause of AIDS in Africa. Death rate in developed countries continues to decline dramatically; death rate in sub-Saharan Africa reaches 2.4 million.

May 2000 Five major pharmaceutical companies offer to cut the price of AIDS drugs for Africa by as much as 80 percent.

July 2000 The International AIDS Conference opens in Durban, South Africa. Many threaten a boycott to protest Mbeki's stance against AZT and refusal to acknowledge that HIV causes AIDS. Mbeki opened the conference by stating that extreme poverty, rather than AIDS, was the country's leading killer.Five thousand scientists around the world sign the Durban Declaration, stating that evidence that HIV causes AIDS is "clear-cut, exhaustive and unambiguous."

August 2000 South Africa rejects an offer of $1 billion in annual loans from the United States to purchase drugs for AIDS treatment.

December 2000 Mbeki's government accepts a $50 million donation of the drug fluconazole from the Pfizer pharmaceutical company and gives conditional approval for nevirapine, a drug that reduces the risk of HIV being transmitted from an infected pregnant woman to her fetus.

February 2001 The Indian drug company Cipla agrees to sell generic versions of AIDS drugs for $350 per patient per year to Doctors Without Borders, and for $600 per year to governments of low-income countries.

February 2001 At the Eighth Annual Retrovirus Conference in Chicago, Illinois, participants draft a comprehensive plan for treating AIDS in Africa that calls on wealthy nations to cover the cost of drugs.

March 5, 2001 Forty-two multinational drug companies sue the South African government, seeking to block the government from enacting a law allowing it to import generic versions of patented drugs.

March 2001 Cipla requests permission to sell generic versions of eight HIV drugs in South Africa. Merck Company agrees to sell two antiretroviral antiretroviral drugs to poor countries at cost. Bristol-Myers Squibb announces that it will no longer try to block companies from making and selling generic versions of its HIV drugs in Africa. Mbeki announces that his government will not declare AIDS a national emergency in order to obtain generic drugs.

April 2001 Pharmaceutical companies withdraw from their lawsuit; the South African government continues to refuse to make antiretrovirals widely available.

ADULT HIV/AIDS INFECTION RATES

Estimated HIV Infection Rate in South Africa Among Women Attending Prenatal Clinics

Thabo Mvuyelwa Mbeki

1942- Thabo Mvuyelwa Mbeki succeeded Nelson Mandela as president of South Africa in 1999. The son of teachers and activists, he has devoted his life to the struggle to end apartheid in South Africa and build a new, democratic country. He spent much of his youth in exile, earning a graduate degree in economics in Britain and working for the banned African National Congress (ANC).

Mbeki returned to Africa in 1971, when he was appointed Assistant Secretary to the Revolutionary Council of the ANC in Lusaka, Zambia. Two years later, he was sent to Botswana, where several key ANC leaders were living in exile. During the next decades Mbeki continued to work for the party. In 1989 he led the ANC delegation that participated in secret talks with the apartheid government, which led to the release of ANC political prisoners and finally gave the ANC legal status. In 1993 he was elected ANC chairperson. Mbeki served as executive deputy president of South Africa under its first post-apartheid president, Nelson Mandela.

Mbeki's fervent belief in South Africa's ability to solve its own problems, many say, led to an AIDS policy that was nothing short of disastrous and that undermined his political credibility. But his supporters insist that Mbeki's position was based on his willingness to look at all the facts, including dissident views. Late in 2000 Mbeki retreated from his controversial stance on HIV and AIDS and authorized South Africa's public health department to begin using antiretroviral drugs in the fight against AIDS.