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 of AIDS.

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 sidelines.

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 questions".

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 problem."

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 review.

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 these treatments."

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.