Sanity has prevailed and the real war against Aids can begin, writes Belinda Beresford
The internecine strife within the government over the HIV epidemic appeared to swing towards the forces of orthodox science this week.
In what looks to outsiders to be a remarkable reversal but which government spin doctors suggest is just a matter of better communication the Cabinet this week publicly accepted the usefulness of anti-retroviral drugs.
And, in a move that took the Department of Health by surprise, the Cabinet announced that rape survivors should be able to demand anti-retroviral drugs from state hospitals to help protect them from catching HIV from their attackers.
Highly placed sources say that the government’s shift was the result of irresistible pressure from all quarters. Helping this reach a critical mass is said to be the increasingly vocal unhappiness within the African National Congress and the government about the state’s stance on HIV/Aids. Sources say this has involved threats by members of the government and the ruling party including the highly regarded Director General of health Ayanda Ntsaluba to resign over the government’s Aids policy. Ntsaluba has denied cutting short his three-year contract, which is approximately half run.
Former president Nelson Mandela recently added his immense moral authority to the calls for a more proactive government response, including anti-retroviral treatment.
On the propaganda front, the national and provincial departments of health have so far lost every stage of their epic court battle with the Treatment Action Campaign (TAC) over the speed at which the state nevirapine mother-to-child programme has been rolled out. In May they have their last-ditch appeal before the Constitutional Court. Win or lose, it has been a public-relations disaster.
Since President Thabo Mbeki mused about unanswered questions on HIV/Aids, including the link between the two, South Africa has seen a resurgence of Aids dissidents people who doubt in varying degrees the orthodox scientific view on HIV and Aids.
The ruling party came under strong internal and external criticism for the anonymously authored and virulent document, Castro Hlongwane, Caravans, Cats, Geese, Foot & Mouth and Statistics, which was submitted to the highest levels of the ANC last month.
A printed handout with the Cabinet statement acknowledged the acrimonious attacks on orthodox scientists but tried to distance the government from them: “As the government focuses its efforts and resources ever more intensively on the public policy challenges of HIV/Aids, it will draw whatever it can from science to use in this fight. As in all areas of science, research and debate will continue, but the government is not a protagonist in those debates.”
Additional pressure on the government may have come via the annual encounter between heads of all South Africa’s missions abroad and Mbeki and Foreign Affairs Minister Nkosazana Zuma at the weekend.
It is understood that the participants received a briefing from the International Marketing Council on foreign perceptions of South Africa. Although the diplomats did not challenge the government’s policy, they are understood to have raised the issue of lack of timely information and specifically the government’s slow reaction to the recent court judgements ordering it to provide nevirapine.
Senior ANC sources said many ministers, particularly those in the economic cluster, are worried about the adverse publicity South Africa has been receiving abroad on the Aids issue. The ministers have been particularly concerned over the impact of ANC chief electoral officer Peter Mokaba’s fiery Aids dissident remarks, which have been published in international publications including The New York Times, might have on investor confidence.
Mokaba told a Johannesburg newspaper last month: “The story that HIV causes Aids is being promoted through lies, pseudo-science, violence, terrorism and deception … We are urged to abandon science and adopt the religion and superstition that HIV exists and that it causes Aids. We refuse to be agents for using our people as guinea pigs and have a responsibility to defeat the intended genocide and dehumanisation of the African child, mother, family and society.”
Mokaba has also attacked the president of the Medical Research Council (MRC), William Malegapuru Makgoba, for his public stance on HIV/Aids.
This week a forensic audit cleared Makgoba of leaking an MRC document, the Impact of Aids on Adult Mortality in South Africa, to local newspapers last year.
The forensic investigation was ordered by the MRC board after it received a letter from the minister of health, which directly accused Makgoba of leaking the document.
Dated September 17 2001 before the report was officially released but after its contents had appeared in the media the letter says that the director general of health had advised that the report not be released until its contents had been digested by the Cabinet. “Instead the MRC President ignores the advice of the Director General and publishes the report anyhow, and this is also done while he is overseas.”
Although the minister did not call for an investigation into who leaked the document actually a widely distributed independent work of research neither commissioned nor owned by the government she told the MRC president: “I would like the MRC Board address themselves to the contents of this letter; to explain these action to me; and to inform me about the corrective actions they intend taking.”
For the first time this week the Cabinet also appeared to accept in principle the use of anti-retroviral drugs to treat people with HIV/Aids.
“On anti-retroviral treatments in general, Cabinet noted that they could help improve the conditions of PWAs [people living with Aids] if administered at certain stages of in the progression of the condition in accordance with international standards. However, because these drugs are too costly for universal access and because they can cause harm if incorrectly used and if the health systems are inadequate, government will continue to work for the lowering of the cost of these drugs.”
The announcement that anti-retrovirals would be offered to rape survivors marks a total reversal of previous ANC statements. Department of Health officials had been hoping for a go-ahead to run pilot studies on post-exposure prophylaxis for victims of sexual assault. Instead they were told to create the protocols and guidelines needed to roll out a national programme to help rape survivors.
Head of the Aids directorate Nono Simelela indicated that the guidelines could be drawn up within a week, and said the department would move as fast as possible. Women would have the right to be given Combivir a combination of AZT and 3TC after receiving counselling on the risks. Combivir is supposed to be available in state medical institutions to treat workers who become exposed to HIV during their work.
This one month of anti-retroviral therapy will form part of a package of care for rape, counteracting the inadequate treatment presently given to rape survivors.
A post-exposure prophylaxis regime helps curb the HIV epidemic. A woman is at greater risk of infection after a sexual assault because of the physical damage. Protect her from HIV and you prevent her from infecting partners or children.
By aiming to improve the overall treatment of rape survivors, this scheme has echoes of the government’s scheme to curb mother-to-child transmission of HIV. Both aim to use an anti-retroviral drug intervention as part of a holistic package of care, and both are largely targeted at women.
But this time the government looks set to avoid the debacle of the nevirapine mother-to-child programme, which has seen it dragged through the courts.
However, it continues to insist that it will only look at a national roll-out of the nevirapine programme after December this year. That is when the 12-month data from the pilots sites will be available.
Simelela was at pains to emphasise the efficacy of nevirapine in protecting children from HIV during the birthing process was not in doubt.
Additional reporting by Bongani Majola, Jaspreet Kindra, Drew Forrest