Senzeni Tshabalala can feel the virus beginning to nudge her toward death. A pair of glands on her neck are swollen. Bumps have appeared on her skin. Pain sears her chest when she eats, which is not often anymore. And depression has settled over this once-vivacious woman as she dwells on what her life could have been without AIDS.
Yet angry as she is about her condition, Tshabalala said she was determined not to resort to the treatment doctors say would most likely save her life: anti-retroviral drugs. Though they have transformed AIDS into a manageable disease for many people in the United States and other wealthy countries, Tshabalala fears the drugs' side effects and said she had more faith in traditional cures.
"I'm an African," said Tshabalala, 26, who has three children and favors stylish jeans and a short, spiky hairstyle. "I don't believe in anti-retrovirals. I believe in traditional healers."
After years of struggling to make anti-retrovirals available in the developing world, medical authorities have been startled to discover that many people in the advanced stages of AIDS are reluctant to take them -- or accept the treatment only when death is so near that the medication can no longer reverse the slide.
This reluctance amounts to a powerful and unexpected barrier to curbing a disease that is ravaging the continent. In South Africa alone, 600 people with AIDS die each day, analysts say. About 5 million people here are infected with HIV, the virus that causes AIDS, more than in any other country.
Tshabalala worries that anti-retrovirals will make her temporarily manic, as they did to her estranged husband, or will reshape her figure, as they did to a friend a few miles north in Soweto. Enlarged breasts, thinned arms and an accumulation of fat at the base of the neck -- called a "buffalo hump" -- are among the unpleasant side effects experienced by some people on anti-retrovirals. Even more common are rashes and severe pain in the feet.
Beyond the fear of side effects, there is also widespread skepticism of Western medicine in a culture in which traditional healers are revered. Twice a week, Tshabalala walks down a dirt path to visit Annah Radebe, a Zulu healer. At Radebe's corrugated tin shack, where pictures of Jesus hang on her cardboard wall, Tshabalala drinks a clear potion made of a boiled grain and roots.
More than 100 residents in this hardscrabble township south of Johannesburg drink this concoction to treat HIV, Radebe said. Tshabalala said it cleans the HIV infection from her blood; the sores on her skin are from the toxins leaving her body, she said.
Years after anti-retroviral therapies revolutionized AIDS treatment in the United States, public figures in South Africa still say few positive words about them, even though studies show that when taken properly, they can almost entirely arrest AIDS, driving the virus to undetectable levels. A government-issued public health brochure that Tshabalala keeps in a folder at her home devotes 50 pages to dealing with the disease -- and even includes a draft will -- but never mentions anti-retrovirals.
Many AIDS activists blame the unease about anti-retrovirals on President Thabo Mbeki and his health minister, Manto Tshabalala-Msimang, who have frequently criticized them as toxic and long resisted making them widely available through the government health system.
In the eight months since the government began a program to distribute anti-retrovirals nationwide, demand has outstripped supply in most areas. Officials estimate that it will take several more years to get the medicine to all who need it, although many of the sickest people, such as Tshabalala -- whose measure of immune strength is dangerously low -- are able to more quickly receive free anti-retrovirals from the government.
But as the drugs become available in areas where skepticism lingers, doctors and activists say, the nation will need a broad education effort to convince many people with AIDS that anti-retrovirals do more good than harm.
"A very big part of the problem is the government is still in denial," said Zackie Achmat, South Africa's leading AIDS activist and head of the Treatment Action Campaign. "Not sufficient numbers of people are getting to know about anti-retroviral medication. . . . You need to have a demand for a program in order for it to work."
Instead of pushing anti-retrovirals, Mbeki and his health minister have repeatedly emphasized good nutrition and clean water as keys to treating AIDS. Tshabalala-Msimang has recommended a diet including African potato, garlic, beets and olive oil.
Mbeki has said little about AIDS over the past year but previously prompted international rebuke by suggesting that factors other than HIV caused the disease. Conflicting messages on AIDS remain stubbornly common in Africa, even among the most educated. Wangari Maathai, the Kenyan environmentalist who won the Nobel Peace Prize this month, suggested in recent interviews that HIV was crafted by Western scientists as a biological weapon.
Such ideas are dissuading many profoundly sick people from seeking powerful remedies only now becoming available on a wide scale.
"Mbeki scared a lot of patients," said Francois Venter, a physician who treats people with AIDS with free anti-retrovirals at Johannesburg General Hospital. He estimated that one out of three patients who need the medicine refuse it. "They are just terrified of the side effects."
A program begun nearly two years ago by mining conglomerate Anglo American suggests the extent of the problem.
All 140,000 of the company's employees are eligible for free, easily accessible anti-retroviral treatment. Brian A. Brink, a physician who oversees the program, said 34,000 of those employees are infected with HIV and at least 8,500 have reached the point in their illness that they should be taking anti-retrovirals.
But only about 2,050 have so far taken advantage of the drugs. That means 75 percent of those in need of anti-retrovirals have not sought them. Brink attributes the gap to a combination of the stigma of AIDS, uncertainty about the effectiveness of anti-retrovirals and fear of their side effects.
"There's a lot of denial out there," he said. "I think there's a lot of ignorance."
Tshabalala, however, knows what anti-retrovirals can do. Her estranged husband started taking them in August, and already he has regained nearly all of the weight he had lost. He also has returned to his job as a taxi driver after not working for two years.
Tshabalala has also closely watched the side effects he has displayed. He grew frighteningly crazed and manic the first night after he began taking the medicine, she said, but he returned to normal the next day.
Yet something deeper is driving Tshabalala's reluctance to take anti-retrovirals, something that she struggled to explain.
Just seven months ago, she was a whirl of energy. But now a fatalism has settled over her. She finds herself suddenly and unexpectedly angry at her estranged husband and angrier still at one of his former girlfriends, now dead, who Tshabalala blames for introducing the virus into their family.
Tshabalala has come to regard AIDS, on some level, as the price of living in a world of sin.
"It's all about God," Tshabalala said as she stood outside the home of Radebe, the healer. "It's a punishment."