South Africa Says It Will Fight AIDS With a Drug Plan
New York Times - August 9, 2003
By Lawrence K. Altman
Bowing to regional and international clamor for a more vigorous at-
tack against the AIDS epidemic, the South African government yester-
day changed its stand on providing drugs to combat the virus, saying
it would develop a plan to offer them to infected people through its
public health system by Oct. 1.
"Government shares the impatience of many South Africans on the need
to strengthen the nation's armory in the fight against AIDS," the
South African cabinet said in a statement after a special meeting to
assess the financial costs of a national anti-H.I.V. drug plan and to
explore options for treating those with the infection.
South Africa has the largest number of H.I.V.-infected people in the
world, about 5 million, or over 11 percent of its population of 43.8
million, according to the United Nations AIDS program. The figures
are more staggering for the 23.7 million people aged 15 to 49; about
20 percent of them are infected.
The epidemic poses a major threat to the future of South Africa's
economy and security by primarily affecting young sexually active
adults and incapacitating the traditional extended family system that
cares for sick and orphaned relatives. So far, the epidemic has left
660,000 South African children as orphans.
Yet, for years, as the AIDS virus has spread, President Thabo Mbeki
and his top aides have resisted national programs to provide anti-
H.I.V. drugs, known as antiretrovirals, making him the target of in-
tense criticism at home and abroad.
The South African government said that because not every infected
person needed anti-H.I.V. drugs, its program would provide them ini-
tially to people with more advanced cases of AIDS. The drugs can ex-
tend life for many people but are not a cure. The government program
is also expected to provide prevention programs aimed at the tens of
millions of people who are not infected.
The change in policy comes in the same week that South Africa held
its first AIDS conference, and just a month after President Bush
pressed Mr. Mbeki during his visit to Africa to come up with a plan
that included both a drug regimen and prevention efforts. Mr. Bush
has pledged to provide $15 billion over five years in fighting global
AIDS, although it remains uncertain whether Congress will appropriate
"The White House welcomes any effort to address the AIDS pandemic,"
said Claire Buchan, a White House spokeswoman who was with the presi-
dent in Texas yesterday.
In the past, Mr. Mbeki and his aides have questioned the safety, ef-
fectiveness and costs of the drugs, as well as questioned the very
connection between H.I.V. and AIDS. Mr. Mbeki has also emphasized the
difficulties that many Africans experience in taking the complicated
regimens of multiple drugs every day.
He has stressed the importance of reducing poverty, calling it a ma-
jor factor in producing the AIDS epidemic, and urging improvement in
the diets of poor people.
The AIDS epidemic began to mushroom when Mr. Mbeki was vice president
in the administration of Nelson Mandela. That administration did lit-
tle to control the epidemic. But in recent years, Mr. Mandela has
spoken out on AIDS and exerted considerable pressure on the govern-
ment, and foreign countries, to do more to improve the quality of
life for infected South Africans.
The costs of treating those infected are difficult to calculate, but
are expected to run into billions of dollars.
The government said it would follow guidelines that the World Health
Organization issued in April describing the combinations of anti-
H.I.V. drugs that work best and the simplest acceptable laboratory
tests to monitor their use. The guidelines were intended to show doc-
tors in poor areas how to prescribe such drugs safely.
Of the 42 million people living with AIDS in the world, an estimated
30 million, or 70 percent, are in sub-Saharan Africa, which has a
population of 640 million. Women make up about 58 percent of them,
the United Nations says.
Dr. Peter Piot, the director of the United Nations AIDS program, said
AIDS had an even greater impact on the continent because about 60
million people throughout Africa were living with the disease, had
died of it, or had been made orphans by it.
The South African government's change of policy came after a four-day
national conference on AIDS earlier this week in Durban where demon-
strators jeered the government's health minister, Manto Tshabalala-
Msimang. It was the first major AIDS meeting in South Africa since an
international AIDS conference was held in Durban in 2000.
Zachie Achmat, the chairman of one advocacy group, the Treatment Ac-
tion Campaign, had led a growing grass-roots campaign to force the
government to make the drugs widely and cheaply available and had be-
come internationally known for refusing to take the drug cocktails
himself until the government changed its policies.
Although he welcomed the government's decision yesterday, Mr. Achmat
said his group "will wait to see the actual operational plan before
celebration." In an interview with the BBC, he also said, "For all of
us living with H.I.V. in South Africa, and our families, this is the
first sign of hope."
Dr. Piot told participants at the AIDS meeting in Durban this week:
"Throughout the world, the debate is not on whether to offer antiret-
roviral treatment in the public sector, but how to do it given the
numerous real constraints. For Heaven's sake, let us not wait to act
until we have the perfect solution because the era of perfect solu-
tions is still far away."
A major concern is how to use anti-H.I.V. drugs safely in developing
countries because they cannot be taken like aspirin and experts have
warned that injudicious use of the drugs could be seeds of a disas-
ter, possibly in spreading drug-resistant strains of the AIDS virus.
But a number of AIDS experts from the United States and elsewhere
have been teaching doctors in Africa in the proper use of such drugs.
The South African cabinet took note of such concerns and said AIDS
experts in the country and specialists from the William J. Clinton
Presidential Foundation would assist the government in developing an
operational plan. The foundation said it had worked with the govern-
ment in reviewing drafts of its plan.
The availability of generic or cheaper anti-AIDS drugs has been a
long-fought battle in developing countries. In April 2001, the phar-
maceutical industry dropped its legal fight against South Africa,
which the industry contended had been violating international trade
agreements and patent restrictions through the government's efforts
to buy brand-name drugs at the lowest rates available in the world.
On a visit to South Africa in June, Mr. Bush promised that it would
be among the first nations to receive new American financial assis-
tance to fight the disease.
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