More than 2,200 doctors, researchers and community activists have gathered in Durban for the first national South African AIDS Conference which opened on Sunday evening with speeches from Vice President Jacob Zuma and Health Minister Manto Tshabalala-Msimang. It does seem as though the South African government is edging towards announcing a programme to provide antiretrovirals (ARVs) in the public sector, but many questions still remain as to the depth of their commitment to doing so.
The Health Minister is deeply unpopular among AIDS clinicians and treatment activists for her unwillingness to face the need for antiretrovirals (ARVs) to reduce the daily death rate of 600 South Africans, in contrast to a number of her provincial counterparts. Treatment Action Campaign (TAC) activists held up posters listing people who had died in each province, a banner saying 'two pills a day save lives' (also a popular T-shirt slogan, referring to fixed dose combination ARV regimens) and 'AIDS treatment now', which some were chanting during the course of her speech. She has been ridiculed for suggesting, repeatedly, that viral load could equally well be suppressed and lives prolonged by diets including olive oil, onions, and the herb known as 'African potato'. As one South African put it, 'a good basis for a pasta sauce but not for an AIDS policy'. Nonetheless, these comments play to apparently widespread feelings among at least some people with HIV that better nutrition may be the best they can hope for.
The Health Minister did openly say, in the course of her speech, that antiretrovirals had a place in the management of HIV/AIDS, although she spoiled this by repeating her belief in nutritional alternatives too. She also maintained that the government had never even discussed a national ARV treatment programme with its multisectoral economic partners, which TAC complains they backed off from signing, prompting their recently renewed campaign of 'civil disobedience'. Adding to the insults, she said that some people believed ARVs were as simple to provide "as aspirins".
Dr Tshabala-Msimang won some support from the audience for observing that a great effort has been made to provide voluntary counselling and testing; to upgrade laboratory services for health care (including the development of cheaper CD4 testing); to ensure that essential drugs are consistently available without going out of stock; and to address huge inequities in standards of healthcare between different ethnic groups and between urban and rural areas. The government had acted to raise healthcare worker salaries to stem the 'brain drain' which had occurred since 1994, and was budgeting for extra healthcare staff in underserved rural areas. For all its problems, the health service was considerably better than the one the government had inherited from its apartheid predecessors.
Behind the scenes, preparations are well under way by the Department of Health to set up treatment guidelines for the introduction of ARVs in the public health sector, as part of the process that began with a working party between the Health and Treasury departments on the feasibility of such provision. Why she couldn't say this more positively and openly, and salvage at least some credit for herself and her department, is a mystery.
Vice President Jacob Zuma heads the South African National AIDS Council and delivered a low-key but still forthright defence of the government's record on AIDS. He stressed the continuing need for political leadership, community mobilisation, scientific research, resourcing the response to HIV and AIDS, preventing stigma and establishing partnerships. While being almost as defensive as the Health Minister in relation to calls for access to ARVs, he did say that the government was in the process of finalising agreements to ensure access to medication for people with HIV and AIDS. They wanted to ensure that the necessary infrastructure is in place, including laboratory networks and adherence support, before doing this. He also made a point of insisting that pharmaceutical companies should deliver on promises to make ARVs affordable to developing countries. This call would clearly make no sense unless he felt that at some stage the South African government would be in the market to buy them.
On political leadership, he claimed that “we never questioned the existence of HIV and AIDS, we only sought to understand causal factors beyond the virus” to explain away President Mbeki’s dalliance with “AIDS dissidents” which caused so much damage to the South African government’s reputation in this area.
Community mobilisation was essential at all levels of society, including businesses – large and small. There was much that a national government could never know and could never do, without active participation and partnerships with others.
On the scientific front, it was essential to keep a focus on what mattered most. The commitment to vaccine research was one such important priority, which would be maintained.
Resourcing the response had to include effective action to eliminate poverty, built the economy, address needs for sanitation, better nutrition, welfare grants and other measures. There would be increased external funding (a reference to the Global Fund, the US Presidential initiative and so on), but it will be essential to show results and be accountable for the use of funds, or these funds will not be sustainable.
“Stigma kills,” he said, and there must be measures to counter this. “People living with HIV must be afforded protection and dignity”, breaking down barriers in the same way that the society had brought down the barriers of apartheid. Finally, in relation to HIV prevention he noted that the awareness level is extremely high but the challenge to bring about actual changes in behaviour to limit risk remained to be met. He hoped the conference could contribute to finding solutions in this area.
Adding to the pressure on the South African government was UN envoy Stephen Lewis, who spoke at a pre-conference press briefing. Lewis observed that although South Africa had many problems it was still far better resourced to respond to AIDS than several of its neighbours which now have national treatment plans including ARVs. Lewis observed that treatment is an “obsession” throughout the continent, with Mozambique, Rwanda and Uganda all having advanced plans for ARV provision. Orphanhood was another equally massive issue, to which the response had still been inadequate. He expressed serious disappointment with the 16 July Paris meeting of donors to the Global Fund to fight AIDS, TB and Malaria and its failure to come up with substantial extra money.
Further reports from Durban will appear during the week.