[afro-nets] No ARV roll-out is better than a bad ARV roll-out (5)

[Dieter Neuvians MD <neuvians@mweb.co.za>]

No ARV roll-out is better than a bad ARV roll-out (5)
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[From the Moderator: To understand why emotions go so high in 
South Africa that subscribers call each other names("fool" etc.) 
you should read the "Special report on a decade of democracy - 
HIV/AIDS" from Integrated Regional Information Networks (IRIN) 
reproduced below.]

 
SOUTH AFRICA: Special report on a decade of democracy - HIV/AIDS
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JOHANNESBURG, 9 April (IRIN) - In May 1994, a month after being 
sworn in as the ruling party, the African National Congress 
(ANC) drew up a National Health Plan, with technical assistance 
from the World Health Organisation and the United Nations Chil-
dren's Fund.
 
The plan dealt at length with HIV/AIDS, pointing out that, "In 
view of the devastating implications of the epidemic for South 
Africa, it is mandatory to define prevention and control inter-
ventions, plus comprehensive care for those already infected, 
within the context of the Bill of Rights."
 
The ANC called for the development and implementation of an ef-
fective HIV/AIDS strategy by the end of 1995. 
 
Only now, a decade later, is a comprehensive treatment plan be-
ing rolled out.
 
By the end of 2002, an estimated 5.3 million South Africans, in 
a population of more than 42 million, were infected with the vi-
rus. 
 
As a result of HIV/AIDS, the South African Bureau for Economic 
Research predicted in 2001 that growth would decrease by half a 
percent for each year through to 2015, production costs could 
rise by up to 2.3 percent annually, and prime interest rates 
could increase to 2.9 percent per year between 2002 and 2015.
 
According to the Bureau, by 2015, South Africa's total labour 
force would decrease by 21 percent, including a 16.8 percent de-
cline in highly skilled workers, a 19.3 percent drop in skilled 
workers and a 22.2 percent decrease in semi-skilled and un-
skilled workers. 
 
Not only the work force is being affected: a recent survey re-
vealed that one in every five young South Africans aged between 
15 and 24 are infected, with the epidemic disproportionately af-
fecting women. 
 
The study, conducted by the University of the Witwatersrand's 
Reproductive Health Research Unit, found that nearly one in four 
women aged 20 to 24 were testing HIV positive, compared to one 
in 14 men of the same age. By the age of 22, one in four South 
African women has HIV.
 
The ANC had a "sound policy in place regarding its approach to 
HIV/AIDS. Unfortunately, other priority needs, such as educa-
tion, diverted our resources, and then the subsequent confusion 
about the causal link between HIV and AIDS delayed the process 
towards treatment of people living with HIV/AIDS," Sadiq Kariem, 
the secretary of the ANC's health secretariat, told IRIN. 
 
Critics point the finger of blame over the delays and "confu-
sion" at President Thabo Mbeki and his willingness to listen to 
the views of AIDS dissidents.
 
THE EMERGENCE OF TAC
 
In 1994, with Nkosazana Dlamini-Zuma at the helm of the health 
ministry, access to cheaper AIDS drugs was a priority. 
 
She moved for the amendment of the Medicines and Related Sub-
stances Control Amendment Act, allowing compulsory licensing 
that would enable the government to use a patent without the 
consent of the patent-holder in certain cases, and parallel im-
ports, which meant the government could shop around for patented 
drugs at cheaper prices from foreign suppliers of antiretrovi-
rals (ARVs), rather than sourcing them from the manufacturer's 
local subsidiary. The legislation came into effect in 1997.
 
The Pharmaceutical Manufacturers' Association (PMA) challenged 
the amendment in court. 
 
That year saw the emergence of the AIDS activist group, the 
Treatment Action Campaign (TAC). "Realising the need to lobby 
for cheaper (ARVs), TAC was formed in November 1998," recalled 
Mazibuko Jara, the organisation's spokesperson at the time. TAC 
stood with the government in the court case.
 
The organisation led a series of demonstrations outside several 
pharmaceutical companies that were party to the lawsuit. The PMA 
acquired an interdict in 1998, preventing the government from 
implementing the amended act until the court case had been re-
solved. 
 
"Dlamini-Zuma was a people's minister - her priority was to pro-
vide access to cheaper medicines. She came to our meetings, 
wanted to attend our demonstrations - we worked together," said 
Jara.
 
The trial dragged on for three years. In the meantime, power at 
the health ministry changed hands after the second general elec-
tion in 1999. Dlamini-Zuma moved on to take charge of the for-
eign affairs portfolio, with Manto Tshabalala-Msimang replacing 
her at the health ministry.
 
The relationship between TAC and the government began to dete-
riorate during that period, said Jara. "The president's [Mbeki] 
views on HIV/AIDS had become known by then. The government began 
dragging its feet on the court case involving the amendment to 
the Medicines Act - it was no longer a priority," he pointed 
out.
 
So TAC began lobbying the pharmaceutical companies nationally 
and internationally, sparking a series of global demonstrations. 
"The entire world community was watching the court case now," 
said Jara.
 
"Not since the campaign on breast milk substitutes has there 
been such a widespread mobilisation of international civil soci-
ety on a health issue. For the first time, one of the most pow-
erful multinational corporation lobbies became accountable to 
civil society, government and their shareholders, for profiteer-
ing at the expense of health and lives," recounted TAC chairman 
Zackie Achmat while addressing the UN Commission on Human Rights 
in 2002.
 
The relationship between the government and TAC soured. TAC's 
hand was strengthened when the labour federation, the Congress 
of South African Trade Unions (COSATU), joined its campaign. Fi-
nally, in 2001, the PMA dropped the lawsuit.
 
"Drug prices plummeted in South Africa and internationally. The 
majority of our people who are employed [40 percent are unem-
ployed] earn less than ZAR 2,000 (US$ 316.48) per month. In 
1998, when TAC started its campaign, a month's supply of ARVs 
cost between ZAR 2,500 (US$ 395.60) and ZAR 4,500 (US$ 712) per 
month. Now they cost between ZAR 700 (US$ 110.73) and ZAR 1,800 
(US$ 284.58) per month. The generic ARVs used by MSF [Medicines 
Sans Frontiers] in its pilot ARV project in Khayelitsha [infor-
mal settlement] in Cape Town, cost ZAR 450 (US$ 71.20)," Achmat 
told the UN body. 
 
AIDS DISSIDENTS
 
Meanwhile, in January 1999 Kariem launched the first of the 
sites dispensing Nevirapine for prevention of mother-to-child 
transmission (PMTCT) of HIV/AIDS outside Cape Town in the West-
ern Cape province. He had previously had Dlamini-Zuma's support, 
but said he now faced "resistance" within the ANC.
 
"I wanted to introduce at least two sites in each province as 
part of the [pilot] study. We battled with the resistance. Un-
fortunately, certain leaders of the ANC had come under the in-
fluence of the AIDS dissidents," Kariem said. 
 
The project was finally approved, and 18 sites dispensing Nevi-
rapine to pregnant mothers across the country were allowed.
 
The controversy over AIDS policy surfaced again in 2000, when 
Mbeki questioned the link between HIV and AIDS during an inter-
view with the news magazine, Time: "...you cannot attribute im-
mune deficiency solely and exclusively to a virus," he said.
 
In the same year, MSF and the TAC launched their first ARV trial 
in Khayelitsha. The two organisations wanted to prove to critics 
that ARVs could be dispensed and responsibily used by poor com-
munities.
 
After the success of the PMTCT pilot project, TAC began cam-
paigning for the rollout of anti-AIDS drugs in all hospitals. In 
KwaZulu-Natal an estimated 40 percent of women giving birth are 
HIV positive. The PMTCT project in the province managed to save 
more than half the babies born to infected mothers from the vi-
rus where Nevirapine was administered.
 
In August 2001, TAC launched a court case demanding that the 
government make Nevirapine more widely available. Later that 
year, the Pretoria High Court ruled in TAC's favour. 
 
However, the government decided to appeal the judgment in the 
Constitutional Court, while Tshabalala-Msimang continued to 
question the efficacy and safety of Nevirapine.
 
When asked during an interview on national television if the 
government would be prepared to follow the court order to roll 
out a Nevirapine programme, Tshabalala-Msimang was quoted as 
saying: "No, I think the courts and the judiciary must also lis-
ten to the authorities." In early 2002, an AIDS dissident lobby 
group within the ANC produced a document entitled, "Castro 
Hlongwane, Caravans, Cats, Geese, Foot & Mouth and Statistics: 
HIV/AIDS and the Struggle for the Humanisation of the African". 
According to the weekly newspaper, Mail & Guardian, the document 
cited studies that claimed ARVs killed people. 
 
Believed to have been co-authored by a senior ANC leader, Peter 
Mokaba, it claimed that the HI virus and AIDS were part of a 
conspiracy to dehumanise Africans. 
 
In April the Constitutional Court rejected the government's ap-
peal and ordered it to start distributing Nevirapine. 
 
Later that month, the South African cabinet issued a statement 
agreeing to a rollout of the PMTCT programme and promising to 
work to lower the cost of ARVs. It went on to recognise that 
ARVs could improve the health of people with HIV, "if adminis-
tered at certain stages... in the progression of the condition, 
in accordance with international standards."
 
TAC, COSATU, the government and other role players then sat down 
together to draw up the country's first comprehensive treatment 
and prevention plan for HIV/AIDS advocating the rollout of ARVs 
in all public hospitals.
 
However, the widely publicised dissident stance taken by Mbeki 
and Tshabalala-Msimang continued to stall the process.
 
A research paper by the Centre for Policy Studies, "Towards ef-
fective delivery: Closing the gap between policy and implementa-
tion in South Africa", identified "lack of political leadership" 
as one of the factors undermining the government's HIV/AIDS 
plan. 
 
Other factors listed by the study were "limited appreciation of 
the gravity of the problem and a general dismissal of the cost 
implications of the epidemic; confused authority lines among 
policy-making bodies; a lack of reliable statistics and data; 
ineffective consultation and communications with implementers; 
limited effective co-ordination between provincial and national 
government departments; a lack of resource and technical capac-
ity; and deficient management systems." 
 
While government seemed to dither, major private companies like 
Anglo American introduced their own treatment programmes for 
staff, aware of the epidemic on their balance sheets. Anglo 
American announced it would pay for ARVs for its workers as part 
of its expanded HIV/AIDS strategy.
 
Although some major firms took action, an International Business 
Owners Survey of 250 medium-sized companies by accounting firm 
Grant Thornton Kessel Feinstein (GTKF) showed that 69 percent of 
the respondents did not have an AIDS policy, while 85 percent 
had not even commissioned a risk assessment.
 
"Unfortunately, AIDS is not seen as a strategic issue and it ap-
pears companies will not act until the disease starts impacting 
on their bottom line," Clem Sunter, a strategist for Anglo 
American, was quoted as saying. 
 
In growing tension with the government, TAC threatened civil 
disobedience if business and government did not sign the earlier 
agreed framework agreement of the HIV/AIDS plan by December. 
 
Senior ANC officials responded by accusing the TAC of being 
anti-government. 
 
TREATMENT PROGRAMME AGREED
 
In early 2003, South African Finance Minister Trevor Manuel an-
nounced plans to almost double the amount spent on HIV/AIDS. 
Over the next three years, R3.3 billion (US $400 million) would 
go towards extending preventative programmes and finance "medi-
cally appropriate" treatment for HIV/AIDS. 
 
In March 2003, TAC activists laid charges of culpable homicide 
against Tshabalala-Msimang and the Minister for Trade and Indus-
try, Alec Erwin, holding them responsible for 600 HIV/AIDS re-
lated deaths a day.
 
In August that year, the cabinet issued a statement instructing 
the health ministry to develop an operational plan for the roll-
out of ARVS, as a "matter of urgency." According to news reports 
at the time, some members of the cabinet had put considerable 
pressure on Tshabalala-Msimang to develop the plan.
 
Finally, in November, after one false call, government announced 
it had the plan ready. It envisages that "within a year, there 
will be at least one [antiretroviral] service point in every 
health district across the country, and within five years, one 
service point in every local municipality." It aims to have 1.4 
million people on treatment within five years.
 
"Without the extent of democracy and tolerance that exists in 
South Africa today, TAC would not have been able to wage the 
struggle that we did against the unscientific stance on HIV/AIDS 
taken by the president and the minister of health. For that we 
are extremely grateful. Ten years ago, pre-1994, we would never 
have been able to achieve the victory we did, under the apart-
heid regime," commented Nathan Geffen of TAC.
 
In February this year, Tshabalala-Msimang announced that the 
government was still evaluating the health services before they 
could dispense the drugs. TAC then sent her a letter demanding 
the purchase of an interim supply of ARVs for dispensing.
 
Since cabinet approval of the Operational Plan for Comprehensive 
HIV and AIDS Care in November last year, very little has hap-
pened countrywide to implement the programme, TAC charged. Six 
months after the go-ahead, many provincial health departments 
are still unable to provide concrete information on their roll-
outs. 
 
At the beginning of March, the Mail & Guardian newspaper re-
ported that only patients living in Gauteng, the Western Cape 
and "at a push" the Free State would be assured of access to 
free ARV treatment within the year. At the time, only 13 sites 
had been accredited, all in the Western Cape Province. 
 
"We still have to continue our struggle, to ensure other prov-
inces follow suit," said Geffen. 
 
This month Gauteng, South Africa's most populous province and 
its business heartland, began dispensing ARVs in five selected 
hospitals. Provincial Premier Mbhazima Sholowa, a former COSATU 
office bearer, was quick to point out that a lot had to be done 
before an effective and sustainable rollout could occur and 
reach a planned 10,000 people within a year. 
 
"It is important to understand that there was a great deal of 
planning that had to happen," said Sholowa. "I know it is a be-
ginning, and I know that we are in for the long haul."
 
[ENDS]
 
IRIN-SA 
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Fax: +27-11-447-5472 
mailto:IRIN-SA@irin.org.za
 
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