After Apartheid: Reinventing South Africa?

AIDS Policy in Postapartheid South Africa

AIDS policy is one of the most notorious features of postapartheid South Africa. In 1990, when the ban against the African National Congress (ANC) was lifted and South Africa began the transition to democracy, HIV prevalence was less than half a percent, but rising rapidly. ANC military commander Chris Hani warned at the time that if left unattended, AIDS would “result in untold damage and suffering by the end of the century” (quoted in Thom and Cullinan 2004). Unfortunately, his dire prediction came true: by 2009 almost one in five adults was infected with HIV. Although it would have been impossible to prevent the already rampant African AIDS epidemic from crossing into South Africa over that country’s long and porous borders (Iliffe 2006), better policies could have saved hundreds of thousands of lives. Both the late apartheid government and the Mandela presidency (1994– 99) were slow to react to the AIDS epidemic, but these failures were dwarfed by those of the Mbeki years (1999–2008). The apartheid government assumed for too long that AIDS was an isolated gay epidemic, and neither it nor the Government of National Unity that followed confronted the heterosexual epidemic squarely or effectively. Mandela himself shied away from the topic when he was president, apparently having been told that to mention it was risky politically (Nattrass 2007, 40). To some extent, these early government failures are understandable, insofar as South Africa was in the throws of a democratic transition (complete with violent episodes) at just the time the AIDS epidemic was becoming visible. Furthermore, the power of antiretroviral drugs to help prevent new infections—especially the transAIDS Policy in Postapartheid South Africa Nicoli Nattrass 182 Nicoli Nattrass mission of HIV infection from mother to child—had yet to be demonstrated. Thus, the only weapon in the fight against AIDS at the time was AIDS awareness and safe sex campaigns—neither of which were compelling topics for politicians, given the stigmatizing nature of HIV disease and the difficulties inherent in addressing an epidemic that affected Africans more than other racial groups (Lieberman 2009). Mbeki, however, had more options. By the time he became president in June 1999, it was clear that a short course of zidovudine (AZT) or nevirapine for pregnant HIV-positive women could substantially reduce the risk of HIV transmission from mother to child (see review of early published studies in Brocklehurst 2002 and Volmink et al. 2007). Pilot mother-to-child transmission prevention (MTCTP) programs were already up and running in South Africa, and one of the first things the new health minister, Manto Tshabalala Msimang, did was visit Uganda, from where she returned enthused about that country’s cost-effective MTCTP programs (Coovadia 2009). This momentum , however, ground to a halt after Mbeki’s first address to the National Council of Provinces, in which he raised doubts about the safety of AZT, asked the health minister to find out “where the truth lies,” and advised the assembled ministers to access material about AZT through the Internet (Mbeki 1999; Nattrass 2007, 54–55). Mbeki and his health minister subsequently rejected reports from South Africa’s regulatory authority, the Medicines Control Council (MCC), about the safety of AZT. They also resisted the use of all other antiretrovirals, whether for MTCTP, for postexposure prophylaxis for rape victims, or for highly active antiretroviral therapy (HAART), citing discredited claims by AIDS denialists that antiretrovirals were “toxic.” It took sustained civil society mobilization, protest, and court action before their bizarre resistance to the use of antiretrovirals was broken (Nattrass 2007; Geffen 2010). Although MTCTP and HAART were rolled out nationally in the public sector only from 2002 and 2004, respectively, the Western Cape Province defied the national government by offering MTCTP services from 1999 in key hospitals, and by initiating in 2001 (in partnership with Médecins Sans Frontières) a pilot HAART project in Khayelitsha, Cape Town’s largest African township (Naimak 2006). Using the ASSA2003 demographic model, it is possible to estimate that if the national government had rolled out antiretrovirals for prevention and treatment at the same rate as the Western Cape Province, around 171,000 new HIV infections and 343,000 deaths could have been prevented between 1999 and 2007 (Nattrass 2007, 136–39, 2008a). This ballpark figure was supported by a subsequent study, performed using a dif- AIDS Policy in Postapartheid South Africa 183 ferent methodology, which found that...