COUNTING THE COST
While South Africa's government feuds with AIDS researchers,
thousands are dying. But is science really the issue?
By David Le Page
New Scientist 29 April 2000
Durban, South Africa, seems an obvious choice of venue for this year's
world AIDS conference. SubSaharan Africa is in the epicentre of the
pandemic and South Africa is the region's most powerful nation. Ten per
cent of the world's AIDS population live within its borders.
So why are politicians, conference organisers and even the Joint
United Nations Programme on HIV/AIDS having to avert a boycott ? Because
national and international criticism of South Africa's AIDS policies is
reaching boiling point. The authorities stand accused of dismissing Western
drugs as too toxic, promoting homegrown products that are far more
dangerous but don't work, and refusing to fund treatment that reduces rates
of mothertochild transmission. And now, to the horror of the AIDS research
establishment, the South African government appears to be exhuming the
theory hatched by "dissident" US scientists that says HIV isn't the cause
Conference chairman Hoosen Coovadia, an AIDS researcher at the
University of Natal in Durban, issued a urgent plea last week: "I wish to
remind the world that this is not a South African government conference. It
is a meeting of people concerned about HIV/AIDS, which will be held on
South African soil . . . while we as a conference organising body cannot
influence the South African government's policies, AIDS2000 is a valuable
forum for addressing many issues." In reality, most concerned scientists
think it would be better to go Durban and protest rather than sulk on the
Researchers such as Coovadia and the country's huge AIDS community
hope such discussion will help the country catch up. Until 1994, the year
of South Africa's first democratic elections, it was perhaps inevitable
that a creeping epidemic should take a back seat to sweeping aside
apartheid's legacy of human rights abuses. But now, after six years of
democratic government, researchers and people with HIV in South Africa say
that the lack of progress against the epidemic can no longer be excused.
There has been no marked decline in the rates of infection. And
according to the national health department, patients with AIDSrelated
infections already occupy 70 per cent of hospital beds.
This month, an army test of antimalaria drugs in a unit of 33 men in
northern KwaZuluNatal province had to be abandoned when tests revealed that
30 of the soldiers were HIVpositive. Reports suggest that infection rates
are well over 70 per cent in other army units.
According to World Health Organization economist Jeffrey Sachs, South
Africa could count on more international support in fighting AIDS if it had
a clear, sensible strategy to guide donors. But extraordinarily, the
country is not even spending its own resources properly. At least 40 per
cent of the government's AIDS budget wasn't touched last year.
Underspending has gone on since at least 1996. And the problem runs far
deeper than poor planning. Over the past six months, President Thabo Mbeki
has become the single biggest wild card in the country's AIDS policies.
While Mbeki was still President Nelson Mandela's vicepresident, the
government provoked AIDS activists by refusing to fund AZT prescriptions
for pregnant women to prevent them passing on HIV to their children. The
AZT programme was deemed too expensive even though neighbouring Botswana
managed to scrape together the money for its pregnant mothers. Flying in
the face of evidence, Mbeki has since described AZT as too toxic.
Uproar followed last month when the government announced it would
appoint a special panel to reappraise its thinking on AIDS. According to
Mbeki's spokesperson, the reappraisal will include such fundamentals as
"whether there's this thing called AIDS, what it is, whether HIV leads to
AIDS, whether there is something called HIV, for an example. All these
Mbeki seems to have formed this opinion after encountering on the
Internet the views of US scientists Peter Duesberg, Charles Geshekter and
David Rasnick, "dissidents" who deny that HIV causes AIDS. Now both Mbeki
and Health Minister Manto TshabalalaMsimang refuse to say they believe HIV
causes AIDS, though they will not deny it either. Their views have caused
widespread dismay. Simon Wain-Hobson of the Pasteur Institute in Paris,
notes: "If it impinges on treatment and education then we have a real
Professor Malegapuru Makgoba of the Medical Research Council of South
Africa warns that South Africa is becoming "fertile ground for
pseudoscience". Perhaps the signs were there in 1996 at the start of the
Virodene affair, when Mbeki and a former health minister Nkosazana Zuma
promoted a homegrown AIDS "treatment" based on a toxic industrial solvent.
When the country's Medicines Control Council refused permission to test the
drug, the whole council was promptly dismissed.
But financial considerations rather than scientific illiteracy seem to
be emerging as the real factors behind the government's position. Last
week, Zweli Mkhize, health minister of KwaZuluNatal and member of the
ruling ANC's National Executive Committee, dismissed the issue of the AIDS
dissidents as "peripheral". Mkhize insists that South Africa is in line
with conventional thinking: that HIV causes AIDS.
Mkhize claims the uproar over the president's chat with dissident
scientists misses the point. "The (real) issue is that the cost of
antiretroviral drugs is far too expensive for South Africa and other
African countries to afford. It is the pharmaceuticals industry and not the
government that controls the price of medicine."
The US has only recently removed South Africa from a trade blacklist
after it threatened to bypass the drug companies' monopoly on certain
treatments by passing drug patents to other companies so it could import
cheaper drugs. Urged on by US pharmaceutical interests, VicePresident Al
Gore tried to force South Africa to drop the legislation, but apparently
changed his mind when pressure from AIDS activists at home started to
affect his campaign for the presidency. At the moment both sides have
agreed an uneasy truce that allows limited compulsory licensing provided
the patent owner is compensated and the arrangement is open to judicial
But some treatments might end up costing less than originally
estimated. Coovadia and other researchers have tried to determine whether
the relatively inexpensive drug nevirapine effectively prevents
mothertochild transmission. The results have been promising though more
tests are needed "(New Scientist", 24 July 1999, p 4). One dose of
nevirapine given during labour would cost just pounds 3 per mother/child
pair, whereas the more extensive AZT treatment used in developing countries
such Botswana, costs around pounds 35.
Unfortunately, nevirapine is under fire after five South Africans who
got the drug in a clinical trial died of liver complications last month.
The drug was used in combination with stavudine and an experimental drug
called FTC302 from the US firm Triangle Pharmaceuticals. Although
nevirapine is widely used around the world, liver-related deaths have never
been linked to it before. Expert observers believe the drug is highly
unlikely to be the cause of death, and have criticised the government for
implying nevirapine was to blame.
But even if nevirapine treatment in pregnancy is eventually
vindicated, some fear the South African government will be loath to fund
it. According to one senior WHO source: "They're terrified about the cost
implications. Even if shortcourse nevirapine doesn't cost that much, they
will then face the calls for treating adults with drugs, at around dollar
10 000 per person, per year. "It's precisely because South Africa is
so much more democratic than other countries in the region and that it has
well-organised AIDS activist groups that can lobby parliament that makes
this more likely. The government will grasp at anything that casts doubt on
Even more unpalatable, he says, is the possibility that preventing
babies being born with AIDS, isn't deemed cost-effective. Babies don't
spread the virus, they don't live very long and they're not economically
productive. There is a feeling that the money could be better spent
elsewhere on prevention. But if so, why are AIDS budgets being left
unspent? Faced with the AIDS nightmare, the South African government
doesn't have any easy options. Unfortunately, it seems hellbent on making
life hard for itself.