Washington, DC — The South African government has relented, and some say completely reversed itself, with an unexpected April announcement that it would make anti-retroviral drugs available for rape survivors. In its statement, the government officially accepted the view that drug therapy can improve the quality of life of AIDS sufferers, walking away from President Thabo Mbeki's earlier statements that the drugs are "poison" or "a danger to health".
But the debate still rages. Two weeks ago, in a newspaper opinion piece, a member of President Mbeki's AIDS Advisory Panel, David Rasnick questioned the HIV-Aids link with a comment on the search for an Aids vacine: "If all South Africans are vaccinated and develop the hoped-for antibodies against HIV (which are currently dreaded by all), then the entire population will be HIV positive by definition." And even as he was dying, former African National Congress (ANC) youth leader Peter Mokaba, denied he was suffering from Aids.
The government's U-turn on drugs has been widely applauded inside and outside of South Africa. But the Director-General of Health, Dr. Ayanda Ntsaluba, says the government hasn't so much changed course as moving where the evidence takes it. Much of the world has misinterpreted his country's efforts, says Ntsaluba, who spoke with allAfrica's Charles Cobb Jr.
Would it be fair for us to conclude that the South African government has "flip-flopped" or is changing its mind about the link between HIV and Aids? It seems to have done so with respect to its decision about the use of anti-retrovirals by rape victims.
First of all, South Africa has always had a national strategy in a practical sense, in terms of what we have been doing on the ground. Our response has always been based on the relationship between HIV and Aids. The second point is, remember that South Africa about three or four years back took a decision to suppport - to be part - of the global effort that searched for an Aids vacine. That work is supported by government. And thirdly, I think when it comes to the issue of anti-retrovirals, it is important to remember that South Africa has been using anti-retrovirals. In the public health system we've always had policy guidelines that allow use of anti-retrovirals for occupational exposure by health workers if they happen, for example, to have needle stick injuries during the course of their work. In the private sector there has been use of anti-retrovirals for some time. What government has done is regulate that to make sure that the protocols followed lead to optimal results. So, I don't think there has been a division over that.
What we have seen, however, is a logical development of the policy. And that has developed in two ways. First, we have now come to the conclusion, looking at the body of evidence around use of anti-retrovirals for victims of sexual violence, that perhaps we have reached a point where we should allow women the option of using anti-retrovirals within the public health system if they so wish. The second point is, because we ran trials on mother-to-child transmissions beginning in May last year, we thought in April of this year that we've reached a point where we've got some body of evidence that enables our cabinet to make the statement that,barring major problems, we should roll out the program. So my point is that I think that some of the questions that have been raised in South Africa have sometimes been interpreted to mean, in effect, that South Africa does not believe that there is a causal relationship between HIV and Aids.
Well, that is certainly the criticism of your government that we are hearing in Washington, and it is criticism coming from inside South Africa as well as outside of South Africa, that the government has felt that there is no causal relationship. Not true?
It is an unfortunate situation, because as I say, if you look at what South Africa has been doing in terms of its programs, clearly everything that we have done, certainly since the first HIV/Aids national strategy in 1994, has been really based on that causal link. All these other things, like the work on the Aids vacine, we would not be talking about were we not basing that on the causal link. The problem that has arisen is that the questions at the beginning were not so much targeted at the issue of the causal link, they were much more questions that arose from the South African government which was saying, "We are doing all these things to deal with the HIV/Aids epidemic and we don't seem to be getting the results that we want. Is our response, therefore, comprehensive enough, or are there other issues that by following the narrow biomedical model that just looks at the virus and the disease we are missing out which are very central and critical for an effective response?" That was the issue.
For example?
The issues of underdevelopment, the issues of poverty, the issues of the status of women in society, which now increasingly many people are saying are fundamental to a comprehensive response to the challenge of HIV/Aids.
You almost seem to be saying, you're misunderstood. Is that how you feel?
I think if you look at what we have been doing, it becomes far more evident that quite a significant part of that was a failure to recognize, a failure to look at statements and a failure to look at what essentially has been happening on the ground in terms of programs driven and supported by government.
Right here will you give me a clear statement on just what the government's attitude and policy on HIV/Aids is?
I think the South African government's policy and attitude is that there is a causal link between HIV and Aids, and therefore our national strategy is based on that. And if you look at the recent cabinet statement, it is based on that.
I confess to some surprise here. This has not seemed to have been South Africa's position in the past. I am thinking of statements by President Mbeki.
That is why I raise the issue that there has been an approach [by critics] that interprets statements without correlating those statements to what, at a programmatic level, South Africa has been doing. If you look at the nature of our programs that we have been running throughout, and if you look at some of the interventions, those interventions are interventions that can only make sense in the context of a causal link between HIV and Aids.
So do you feel the criticisms of South Africa, one of which is that pregnant women in hospitals have been denied anti-retrovirals, is an unfair or inaccurate charge?
No. I don't think it's an inaccurate criticism. And also I don't want to say it is wholly unfair, because we ourselves have made the point that, perhaps in the way we have tended to deal with the issue, we have not dealt with it and understood some of the concerns people have raised consistently. On the issue of women not having anti-retrovirals, I think we have always said that the only option that we had before April 2001 was the use of AZT for four weeks. We've always raised difficulties about use of AZT in the South African public sector, and that is why we have always said that our first choice would be if the drug nevirapine would prove to be successful. Now as soon as nevirapine was registered in South Africa, which was in April last year, [we began developing treatment and research programs] at access sites through out the country - 250 of them now throughout the public health system. And now we are at a point where a year down the line, we can look and say that 63,000 women have gone through this program, and therefore we are able to make certain conclusions which have led to the decision about rolling out approval come December of this year.
Some people have criticized us about our stance on AZT. But rightly or wrongly, and I believe rightly, we held the view that given the nature of our prenatal services, for us to have taken a regimen that requires of the women to have four weeks of continuous treatment, when we know there are major problems with compliance around some of the programs that we have [such as for] tuberculosis, was not a realistic option. That is why we were pinning our hopes on nevirapine, because it's a single tablet and the issues of compliance become significantly reduced. We started those sites in May 2001. The recent cabinet statement is April 2002, and it is quite clear that the statement was made on the basis of some of the lessons that have been learned.
And perhaps some of the pressures on the government, particularly from someone as prominent as Nelson Mandela, or institutions as powerful as [the trade union movement] Cosatu as well as some regional ANC leaders, may have had something to do with this decision as well, wouldn't you say?
Let's put it this way: The decision for a review of the national program sometime early in 2002 was taken sometime very late last year. Initially that review was supposed to be in February. It's not the first review we've had of the national Aids program. In 1997 we had a detailed review. Having said that, I have no doubt that all the members of cabinet must have had in the back of their minds an understanding of what were the issues of concern to the South African public, to some members of the ruling party. There is no question in my mind about that. But the point I am making is that the idea of a review, and the need for it, was not an issue simply driven because sometime in 2002 there were suddenly these areas of concern, such as the intervention of former president Nelson Mandela.
Another way to look at it is to ask, "What should be the response of a democratic state and a democratically elected government, when clearly there is a particular approach being taken, and there is some unease among key sections of society. Clearly that is an issue that has to factor into the considerations. And while you will not support it if you think it is totally ridiculous, it must have a bearing on the decision-making process.
What has the generally negative view of the South African government's Aids stance cost you? Are there resources you might have gotten and have not? Materials? Money? Medicine?
I'm not sure. It has cost us a lot of time and effort. In a number of instances, when we could have spent time moving forward, we had to spend time trying to explain. Even basic things that people acknowledge South Africa has done well, people would not give South Africa that credit because there was this lingering doubt about whether South Africa was really committed to dealing with Aids. So if I were to look at what the cost has been, it has been much more in that direction, as opposed to saying resources have been withdrawn. The European Union supports significantly our HIV/Aids program. The United States through USAID and CDC (Centers for Disease Control) supports significantly our HIV/Aids projects. I don't think most of those people would put their resources in a program that is based on the wrong foundation.
When someone like yourself looks at other African countries where there have been fairly significant successes combating Aids, say Uganda, or Senegal, do you find things you can use? Do you ask: what are they doing that we're not doing? South Africa has so much more in the way of both human and financial resources.
Uganda's greatest success is in the prevention area. People in Uganda will tell you that what you see today in Uganda is a result of investments that happened 7, 8, 9 even 10 years ago in a significant way. In South Africa, unfortunately there is a slightly different issue. At the time of the democratic transition in 1994,there was virtually no HIV/Aids program to talk about. So invariably, the efforts of the current government of today, of last year, of the year before last, are going to show results in perhaps another two or three years. So I don't think it would be correct to simply say because those results are not coming yet, therefore there is no effort.
We've had a lot of people going to try to understand what has [been done] in Uganda. A lot of what they have done, we are doing in South Africa. But the Ugandans themselves will be the first ones to tell you one big difference between Uganda and South Africa. Because they did not have a good tracking system, a good monitoring system, it is difficult for Uganda to tell you, of the totality of things that they did, which were the critical ones that explain their success. Of course, we do know that there are some things that work - strong prevention programs, targeting an area. All of us are trying to do those things.
The second point I'd like to make is that I think when it comes to treatment of people with HIV and Aids for opportunistic infection, anybody can say that Uganda does it better than South Africa. Equally, I think when people look at some of the initiatives in some of the areas where there is beginning to be use of anti-retrovirals for treatment, we need to factor in that in South Africa, as we talk today, 13,500 people in the private sector are using anti-retrovirals. What we are talking about in South Africa is the appropriateness of anti-retrovirals for widescale use in the public sector, where the majority of patients who depend on the public sector are poor. It is those intricacies that compel us to say, looking at the reality of issues like compliance and support for those patients, that we are not sure we will get the results that are intended.
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Why not a regional initiative on Aids or other health issues for that matter, a SADC initiative?
We did submit a SADC-wide proposal [to the Global Fund for HIV/Aids], only to be confronted with the situation that the Fund had not anticipated that. There is no coherent mechanism to support regional initiatives. That has been raised by a number of countries because indeed, for most of these communicable diseases, it just makes sense to have far more in regional support. And it's not just SADC. If you look at the Nepad [African development initiative] health strategy, it is premised precisely on that. It sees regions that exist within the continent as the rallying point for coordination of the major offensive against communicable diseases.
Is the Global Fund going to commit resources to this approach?
Part of the pressure that we are putting is that it should.
But they haven't made that commitment yet?
They have taken a decision on the principle of providing support for regional initiatives. The problem that was raised in the last meeting of the board was that there is no clear mechanism for approving a regional proposal. Remember one of the philosophies of the Global Fund is that these proposals must not just represent governments, but must represent governments together with structures of civil society. Now in a [single]country it may be easy to create what they call a "country coordinating mechanism." But they have not conceptualized how that should be done for a regional proposal. In the case of SADC, the proposal that was put there, the governments had approved the proposal but the argument was that there had been no engagement at a regional level of the other elements, other structures of society. This is what the Global Fund was telling us.
And had you engaged those "other elements" in society?
I will concede that in terms of the regional proposal they had not been. But I will say the SADC proposal had literally been drawn out of the regional structures that had been canvassed.
What are we looking at in South Africa and the region in terms of health issues? We certainly hear the horror stories about HIV/Aids.
I think it is fair to say that if we were to look at the SADC region in its entirety, HIV/Aids would be the leading problem now. But certainly all of us know that TB and malaria are significant contributors to the burden of diseases in the region. And then there is still the problem that some of the major childhood illnesses, your measles, your polio, there are still countries in the region struggling with them.
