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A fresh start: South Africa's war on HIV/AIDS
  1 December 2006
Source: Science Magazine
South Africa's approach to the HIV/AIDS epidemic has been criticised at home and abroad. In 2000 for instance, South Africa's president and health minister sparked outrage by openly questioning the link between HIV and AIDS.
So many scientists and activists have welcomed the country's long-overdue initiative to revamp its HIV/AIDS programmes, a draft of which is released today (1 December) by the South African government to coincide with World AIDS Day.
But the five-year plan has seen its fair share of controversy, reports Robert Koenig in Science.
A major area of criticism has been targets for antiretroviral treatment. Earlier drafts contained goals that lobby groups claimed represented only 20 per cent of those needing treatment.
They persuaded the government to delay announcing specific targets until a compromise is reached, probably early next year.
And many see current health minister, Tshabalala-Msimang - famous for promoting nutrition and traditional medicine in HIV/AIDS treatment - as an obstacle to progress.
South Africa Bolsters HIV/AIDS Plan, but Obstacles Remain
Robert Koenig
Science 1 December 2006:
Vol. 314. no. 5804, pp. 1378 - 1379
Ridicule at the Toronto AIDS Conference spurred South Africa's Cabinet to order a new plan to battle the epidemic
PRETORIA AND SOWETO, SOUTH AFRICA--When small baskets of garlic, lemons, and beets highlighted the South African exhibit at the XVI International AIDS Conference in Toronto last summer, many delegates were outraged. They viewed the display--intended to show the importance of nutrition in bolstering immune systems--as trivializing the response to the epidemic that now infects 5.5 million South Africans and kills an estimated 800 of them a day. As the meeting ended, Stephen Lewis, the United Nations special envoy for HIV/AIDS in Africa, lashed out at aspects of South Africa's AIDS policies as "wrong, immoral, [and] indefensible."
The ridicule in Toronto was followed by a sharply critical letter to President Thabo Mbeki from 82 prominent international scientists, including Nobelist David Baltimore, virologist Robert Gallo, and 11 South African researchers. Arguing that garlic and lemons "are not alternatives to effective medications," the researchers warned that "many people are c dying unnecessarily" in South Africa because they do not have access to antiretroviral (ARV) drugs to slow the progression of the disease. Although the country has the world's largest ARV program, it now reaches only about a quarter of the South Africans who are estimated to need the drugs.
Reflecting the outcry, some of South Africa's leading newspapers called in September for the resignation of the garlic-promoting health minister, Manto Tshabalala-Msimang. At about the same time, South Africa's ruling Cabinet, unhappy to again be the focus of international scientific scorn, decided to revive the near-moribund South African National AIDS Council. It named Deputy President Phumzile Mlambo-Ngcuka--rather than the controversial health minister--as the nation's point person for developing a more effective HIV/AIDS strategic plan for the next 5 years.
The deputy president planned to outline the framework of that new plan on 1 December, World AIDS Day. A draft of the wide-ranging plan, obtained by Science, features commitments to bolster prevention programs to sharply reduce the number of people being infected with HIV; better coordinate the government's often-fragmented response to the epidemic; support AIDS vaccine and antimicrobial research; and significantly expand ARV treatment--although the exact ARV target numbers were still being developed.
Many South African scientists, clinicians, and activists welcomed the long-overdue initiative to revamp HIV/AIDS programs. "For years, we had been confronted with obfuscation and confusion and a lack of leadership on HIV/AIDS," says Francois Venter, who heads the Southern African HIV Clinicians Society. But he and others cautioned that the devil is in the details, some of which were not available as Science went to press. And no one was expecting that the announcement of a new action plan would end the debate on South Africa's HIV/AIDS policies.
The need for more effective government programs is clear. Although a draft of the plan cited evidence that "HIV incidence has started to decrease," a November report by the Joint United Nations Programme on HIV/AIDS and the World Health Organization says that HIV prevalence--at nearly 19% of South Africa's adult population in 2005--"has not yet reached a plateau." The nation's 5.5 million infected people include a quarter of a million children under age 15, the report said. It also warned of "a continuing, rising trend in HIV infection levels" among pregnant women using prenatal clinics.
A history of controversy
International dissatisfaction with the country's HIV/AIDS policy is rooted in a series of government controversies and miscues over the past decade. In 1997, an attempt to fast-track clinical trials of a drug called Virodene ended in disgrace when a review panel found that the substance was toxic and had been prematurely tested on humans. Three years later, in early 2000, Mbeki sent a letter to the White House and to the U.N. Secretary-General suggesting that factors other than HIV could cause AIDS and asserting that it would be a "criminal betrayal" to "mimic foreign approaches to treating HIV/AIDS."
Later that year, delegates to the International AIDS Conference in Durban were stunned that Mbeki and his health minister continued to question the connection between HIV and AIDS and failed to support ARV therapy. "The government took a strange position opposed by well-established science," recalls the chair of the Durban meeting, pediatric AIDS researcher Hoosen Coovadia of the University of KwaZulu-Natal.
Meanwhile, as the epidemic worsened, the government came under increasing pressure to take decisive action. In 2002, Mbeki began to distance himself from the denialists and endorsed the concept of making ARVs available to pregnant women and rape survivors. Late in 2003, a panel developed an ARV rollout plan, which went into effect the following spring and now covers about 214,000 persons. Noting that the South African ARV program reaches more people than that of any other country, Medical Research Council (MRC) President Anthony MBewu contends that South Africa's recent initiatives on HIV/AIDS treatment and prevention have begun to blunt the epidemic.
Trying to rehabilitate the government's international image on HIV/AIDS policy, Cabinet officials are avoiding any public expression of AIDS denialism. Government spokesperson Themba J. Maseko told Science that "the position of the government is based on the understanding that HIV causes AIDS." Even South Africa's most outspoken AIDS activist, Zackie Achmat, credits the ruling African National Congress party with exerting pressure to suppress AIDS denialism within its ranks. Although Mbeki has not made a definitive statement of his own position, Maseko says the president fully supports the Cabinet's recent HIV/AIDS decisions on developing a new action plan.
A targeted approach
After the Toronto AIDS meeting, with the health minister hospitalized with a respiratory ailment, the Cabinet asked Deputy President Mlambo-Ngcuka to try to mend fences with interest groups and develop a stronger HIV/AIDS plan. Declaring that the nation's AIDS policy debate was at "a critical point," she held meetings this fall with leading clinicians, scientists, and activists to try to resolve "difficulties and misunderstandings" and forge a consensus.
The most difficult single issue in reaching such an agreement has been setting targets for ARV treatments. (The government bears most of the costs of ARV drugs at public clinics, but international organizations and donors pay for ARV costs at many private or religious facilities, and medical insurance covers other individuals.) The government originally planned to announce specific ARV targets on World AIDS Day as part of the new plan. Indeed, one draft listed a goal of tripling the current ARV numbers, to 650,000 adults and 100,000 children, by 2011. But as soon as the plan's early drafts began circulating, AIDS activists and clinician groups began lobbying for much higher numbers, and they persuaded the deputy president to delay announcing specific targets until a compromise could be worked out, probably early next year.
Four influential AIDS groups that sought the delay--the Southern African HIV Clinicians Society, the activist Treatment Action Campaign, the AIDS Law Project, and the University of the Witwatersrand's Reproductive Health and HIV Research Unit--delivered a 28-page critique in November of an early draft of the action plan. That response, obtained by Science, argued that the proposed ARV targets "represent approximately 20 percent of those requiring treatment, and should be revised upwards. All epidemiologic data suggests that there are approximately 800,000 people who need ARVs at the moment c and that an additional 500,000 people will require treatment annually going forward."
The critique also argues that the nation's research facilities are "largely uncoordinated when it comes to research on HIV" and recommends that a national health supervisory council find ways to improve coordination.
The draft HIV/AIDS plan did not address the coordination issue, but it confirmed that basic and clinical research into the epidemic were national priorities. Although shy on details, the draft specifically called for boosting research into microbicides and AIDS vaccines, a research strength of the country. MRC President MBewu told Science that "HIV/AIDS is the nation's top research priority."
Uphill battle
Although generally heartened by plans to boost HIV/AIDS prevention and treatment programs, South African scientists and activists caution that obstacles remain. For some, the chief problem is the recuperating health minister, Tshabalala-Msimang, who remains responsible for implementing the new HIV/AIDS plan. In November, she issued a statement lashing out at her critics and reaffirming her commitment to nutrition and traditional medicine in HIV/AIDS treatment.
University of Cape Town economist Nicoli Nattrass, an expert on the impact of the epidemic on South Africa, believes that HIV/AIDS activists "have won an important ideological battle," but--with the health minister still involved in implementation--" the counterinsurgency remains strong."
Clinicians and researchers are eager to see evidence that the government will back up its new HIV/AIDS commitments with more funding and improvements in health facilities. "Setting ambitious targets is good, but you have to have the resources and plans to meet those targets," says researcher Coovadia.
Complicating the challenge, tuberculosis is rife among South Africans infected with HIV, and new drug-resistant strains are threatening to spread rapidly. "We've got two epidemics clashing in a dangerous way. We can't carry on with business as usual," says immunologist Linda-Gail Bekker, co-director of the Desmond Tutu HIV Center in Cape Town.
Clinician Venter agrees that "a lot more needs to be done to get control of this epidemic." Still, he says, "it helps to have support at the top."
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