In South Africa, a Dramatic Shift on AIDS

By Craig Timberg
Washington Post Foreign Service
Friday, October 27, 2006

JOHANNESBURG -- The South African government is seeking to shake off years of international denunciation for its handling of the AIDS epidemic -- including a fixation on the supposed protective powers of beets and lemons -- while expanding treatment, testing and prevention programs, officials and activists say.

In public comments and private meetings over the past six weeks, Deputy President Phumzile Mlambo-Ngcuka has emphasized that the government now believes unequivocally that HIV causes AIDS, a connection that President Thabo Mbeki once publicly questioned. She has also said that antiretroviral drugs must be the centerpiece of the government's response while playing down the dietary recommendations long cited by Health Minister Manto Tshabalala-Msimang as key to fighting AIDS.

"The beetroot and all that lemon stuff is out the window," an adviser involved in recasting the government's policy said on condition of anonymity because he was not authorized to speak publicly about it. "These guys are now serious about getting it right."

Driving the recent change is a growing realization of the severity of AIDS in South Africa -- an estimated 5.4 million of 47 million citizens have HIV, among the highest totals in the world -- and concern that the controversy surrounding the disease was damaging the country's international reputation.

The Treatment Action Campaign, the country's leading AIDS activist group, said that after years of hostility and legal battles, government officials were working cooperatively with members to realize some of their long-standing demands, such as setting targets for dramatically expanding the availability of antiretroviral drugs through the public health system. Mlambo-Ngcuka, who has taken control of the national AIDS commission, has met privately with the group.

"There's clearly a shift taking place," said Zackie Achmat, the head of the Treatment Action Campaign.

Officials say that Tshabalala-Msimang, often ridiculed as "Dr. Beetroot," will maintain some role in AIDS policy, but activists say they are confident she has been effectively marginalized by the appointment of Mlambo-Ngcuka to oversee the government's response to the disease. Government officials privately acknowledge that Tshabalala-Msimang had become an embarrassment, and activists say the tenor of conversations with the government has changed dramatically since the deputy president took over.

"I'm still skeptical, and I'm still waiting for the proof," said Francois Venter, head of the Southern African HIV Clinicians Society. "But there's been a switch, the most hopeful switch in years, over the past four or five weeks."

Mbeki's comments questioning the relationship between HIV and AIDS stirred international outrage in 2000, and the government lagged even some less developed African nations in introducing subsidized antiretroviral drugs, which can prolong the lives of those with the disease by many years, perhaps decades. The first government program distributing the drugs began here in April 2004. South Africa's far smaller northern neighbor, Botswana, began two years earlier.

The South African program has grown steadily in the past 2 1/2 years and now reaches about 200,000 people with AIDS -- roughly one-quarter of those estimated to need the medicine immediately. But the demand for the drugs has grown faster than the program could handle despite major new government spending, including $400 million for AIDS programs this year alone.

"There were weaknesses on the implementation side of things," a government spokesman, Themba Maseko, said from Pretoria.

A turning point came in August, at the International AIDS Conference in Toronto, where Tshabalala-Msimang sponsored a display featuring lemons, beets and garlic but no antiretroviral drugs. An interview that Tshabalala-Msimang had with ABC's "Nightline" that same week renewed fears that she and Mbeki did not accept the two-decade-old scientific consensus that HIV causes AIDS.

"President Mbeki said, 'It cannot be the virus alone, we must look at other, other issues that predispose people to the immune system being depressed,' and I am of the same view also," Tshabalala-Msimang said on "Nightline."

The following day, Stephen Lewis, the U.N. special envoy for HIV/AIDS in Africa, denounced the South African government's view as "wrong, immoral and indefensible." Two weeks after that, 81 AIDS scientists from South Africa and around the world signed a letter calling on Mbeki to fire Tshabalala-Msimang.

The president refused. But those events, combined with a government report blaming AIDS for a massive surge of deaths among South Africans in their 20s, 30s and 40s, prompted Mbeki to appoint Mlambo-Ngcuka to lead an urgent review of AIDS programs, pushing Tshabalala-Msimang out of the spotlight, officials say.

In a speech to labor leaders on Sept. 19, Mlambo-Ngcuka said, without qualification, that HIV causes AIDS. She acknowledged "shortcomings" in the government's response to the disease so far. She mentioned the value of a sensible diet but made clear its limits.

"It should be stressed that a healthy lifestyle and good nutrition are not alternatives to treatment," she said, according to a transcript.

Mlambo-Ngcuka also called for peace between the government and its many critics on AIDS. "Our collective response has for too long been undermined by finger-pointing and despair. I appeal to you that we change that," she said.

AIDS activists said they initially reacted warily, but after meeting privately with Mlambo-Ngcuka, including a session Tuesday in Cape Town that lasted nearly two hours, they have grown more confident of the government's desire to improve its handling of the disease.

The activists say they are pushing for several concessions, including a target of treating 1 million South Africans with antiretroviral drugs. They also want targets for expanding HIV testing and for cutting the rate of new infections. Prevention efforts have largely failed in South Africa, experts say, even as Zimbabwe and several East African countries are showing success in curbing new infections.

Maseko, the government spokesman, said that after years of resisting calls from activists, officials have decided to set firm targets for expanding prevention programs and the availability of antiretroviral drugs in the five-year government plan due for release Dec. 1, celebrated around the globe as World AIDS Day.

"We will be accelerating implementation to make sure those who need treatment are getting it," he said.

As discussions continue, activists say the shift in the government's intentions is tangible and hope officials are capable of carrying through on their new promises.

"They have lost at least five years," said Mark Heywood, head of the AIDS Law Project at Witwatersrand University in Johannesburg. "They're behind on prevention. They're behind on treatment. They're behind on planning for the social impact of HIV. But it's not too late to prevent a whole other generation of people from getting HIV."

Rapid Rise in Deaths
AIDS has driven a surge of deaths among South Africa's men and women in their prime, the age groups from 20 to 49.
Rapid Rise in Deaths
SOURCE: Statistics South Africa | The Washington Post - October 27, 2006
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