DURBAN, South Africa, seems an obvious choice of venue for this year鈥檚 world
AIDS conference. Sub-Saharan Africa is in the epicentre of the pandemic and
South Africa is the region鈥檚 most powerful nation. Ten per cent of the world鈥檚
AIDS population live within its borders.
So why are politicians, conference organisers and even the Joint United
Nations Programme on HIV/AIDS having to avert a boycott? Because national and
international criticism of South Africa鈥檚 AIDS policies is reaching boiling
point. The authorities stand accused of dismissing Western drugs as too toxic,
promoting home-grown products that are far more dangerous but don鈥檛 work, and
refusing to fund treatment that reduces rates of mother-to-child transmission.
And now, to the horror of the AIDS research establishment, the South African
government appears to be exhuming the theory hatched by 鈥渄issident鈥� US
scientists that says HIV isn鈥檛 the cause of AIDS.
Conference chairman Hoosen Coovadia, an AIDS researcher at the University of
Natal in Durban, issued a urgent plea last week: 鈥淚 wish to remind the world
that this is not a South African government conference. It is a meeting of
people concerned about HIV/AIDS, which will be held on South African soil . . .
while we as a conference organising body cannot influence the South African
government鈥檚 policies, AIDS2000 is a valuable forum for addressing many issues.鈥�
In reality, most concerned scientists think it would be better to go Durban and
protest rather than sulk on the sidelines.
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Researchers such as Coovadia and the country鈥檚 huge AIDS community hope such
discussion will help the country catch up. Until 1994, the year of South
Africa鈥檚 first democratic elections, it was perhaps inevitable that a creeping
epidemic should take a back seat to sweeping aside apartheid鈥檚 legacy of human
rights abuses. But now, after six years of democratic government, researchers
and people with HIV in South Africa say that the lack of progress against the
epidemic can no longer be excused.
Wild card
There has been no marked decline in the rates of infection. And according to
the national health department, patients with AIDS-related infections already
occupy 70 per cent of hospital beds.
This month, an army test of anti-malaria drugs in a unit of 33 men in
northern KwaZulu-Natal province had to be abandoned when tests revealed that 30
of the soldiers were HIV-positive. Reports suggest that infection rates are well
over 70 per cent in other army units.
According to World Health Organization economist Jeffrey Sachs, South Africa
could count on more international support in fighting AIDS if it had a clear,
sensible strategy to guide donors. But extraordinarily, the country is not even
spending its own resources properly. At least 40 per cent of the government鈥檚
AIDS budget wasn鈥檛 touched last year. Underspending has gone on since at least
1996. And the problem runs far deeper than poor planning. Over the past six
months, President Thabo Mbeki has become the single biggest wild card in the
country鈥檚 AIDS policies.
While Mbeki was still President Nelson Mandela鈥檚 vice-president, the
government provoked AIDS activists by refusing to fund AZT prescriptions for
pregnant women to prevent them passing on HIV to their children. The AZT
programme was deemed too expensive鈥攅ven though neighbouring Botswana
managed to scrape together the money for its pregnant mothers. Flying in the
face of evidence, Mbeki has since described AZT as too toxic.
Uproar followed last month when the government announced it would appoint a
special panel to reappraise its thinking on AIDS. According to Mbeki鈥檚
spokesperson, the reappraisal will include such fundamentals as 鈥渨hether there鈥檚
this thing called AIDS, what it is, whether HIV leads to AIDS, whether there is
something called HIV, for an example. All these questions鈥�.
Mbeki seems to have formed this opinion after encountering on the Internet
the views of US scientists Peter Duesberg, Charles Geshekter and David Rasnick,
鈥渄issidents鈥� who deny that HIV causes AIDS. Now both Mbeki and Health Minister
Manto Tshabalala-Msimang refuse to say they believe HIV causes AIDS, though they
will not deny it either. Their views have caused widespread dismay. Simon
Wain-Hobson of the Pasteur Institute in Paris, notes: 鈥淚f it impinges on
treatment and education then we have a real problem.鈥�
Professor Malegapuru Makgoba of the Medical Research Council of South Africa
warns that South Africa is becoming 鈥渇ertile ground for pseudo-science鈥�. Perhaps
the signs were there in 1996 at the start of the Virodene affair, when Mbeki and
a former health minister Nkosazana Zuma promoted a home-grown AIDS 鈥渢reatment鈥�
based on a toxic industrial solvent. When the country鈥檚 Medicines Control
Council refused permission to test the drug, the whole council was promptly
dismissed.
But financial considerations rather than scientific illiteracy seem to be
emerging as the real factors behind the government鈥檚 position. Last week, Zweli
Mkhize, health minister of KwaZulu-Natal and member of the ruling ANC鈥檚 National
Executive Committee, dismissed the issue of the AIDS dissidents as 鈥減eripheral鈥�.
Mkhize insists that South Africa is in line with conventional thinking: that HIV
causes AIDS.
Mkhize claims the uproar over the president鈥檚 chat with dissident scientists
misses the point. 鈥淭he [real] issue is that the cost of anti-retroviral drugs is
far too expensive for South Africa and other African countries to afford. It is
the pharmaceuticals industry and not the government that controls the price of
尘别诲颈肠颈苍别.鈥�
The US has only recently removed South Africa from a trade blacklist after it
threatened to bypass the drug companies鈥� monopoly on certain treatments by
passing drug patents to other companies so it could import cheaper drugs. Urged
on by US pharmaceutical interests, Vice-President Al Gore tried to force South
Africa to drop the legislation, but apparently changed his mind when pressure
from AIDS activists at home started to affect his campaign for the presidency.
At the moment both sides have agreed an uneasy truce that allows limited
compulsory licensing鈥攑rovided the patent owner is compensated and the
arrangement is open to judicial review.
But some treatments might end up costing less than originally estimated.
Coovadia and other researchers have tried to determine whether the relatively
inexpensive drug nevirapine effectively prevents mother-to-child
transmission. The results have been promising鈥攖hough more tests are needed
(快猫短视频, 24 July 1999, p 4). One dose of nevirapine given during
labour would cost just 拢3 per mother-child pair, whereas the more
extensive AZT treatment used in developing countries such Botswana, costs around
拢35.
Unfortunately, nevirapine is under fire after five South Africans who got the
drug in a clinical trial died of liver complications last month. The drug was
used in combination with stavudine and an experimental drug called FTC-302 from
the US firm Triangle Pharmaceuticals. Although nevirapine is widely used around
the world, liver-related deaths have never been linked to it before. Expert
observers believe the drug is highly unlikely to be the cause of death, and have
criticised the government for implying nevirapine was to blame.
But even if nevirapine treatment in pregnancy is eventually vindicated, some
fear the South African government will be loath to fund it. According to one
senior WHO source: 鈥淭hey鈥檙e terrified about the cost implications. Even if
short-course nevirapine doesn鈥檛 cost that much, they will then face the calls
for treating adults with drugs, at around $10 000 per person, per
year.
鈥淚t鈥檚 precisely because South Africa is so much more democratic than other
countries in the region and that it has well-organised AIDS activist groups that
can lobby parliament that makes this more likely. The government will grasp at
anything that casts doubt on these treatments.鈥�
Even more unpalatable, he says, is the possibility that preventing babies
being born with AIDS, isn鈥檛 deemed cost-effective. Babies don鈥檛 spread the
virus, they don鈥檛 live very long鈥攁nd they鈥檙e not economically productive.
There is a feeling that the money could be better spent elsewhere on prevention.
But if so, why are AIDS budgets being left unspent? Faced with the AIDS
nightmare, the South African government doesn鈥檛 have any easy options.
Unfortunately, it seems hell-bent on making life hard for itself.