South Africa is the country with the highest number of Aids infections on the planet, according to a new UNAIDS report.
But how is it possible that we are struggling so badly, while the same report seems to indicate that much poorer countries such as Zimbabwe and Kenya are having significant successes in slowing the spread of the virus?
According to Eduard Grebe, researcher at the Aids & Society Research Unit at the University of Cape Town, the answer to this question is complex.
Lack of leadership
"First, in managing the epidemic, political will and leadership are just as important as good infrastructure and resources. Our national response has been characterised by severe neglect of the issue during the latter years of apartheid, a focus on other national priorities during the Mandela presidency and outright denialism during the Mbeki presidency," Grebe said.
"There certainly hasn't been a concerted and coordinated societal effort to respond effectively, with the government and civil society engaged in a long-running battle sparked by the president's scepticism about conventional Aids science, and the minister's hostility to the use of ARVs," he said.
Zim figures may mislead
Grebe also pointed out that it is not entirely clear how successful the response has been in other African countries. For example, the reported decline in HIV prevalence in Zimbabwe is difficult to explain.
"I am not entirely convinced that the figures are trustworthy, and even if they are, they are likely to be the result of migratory patterns and other demographic changes as much as of a successful prevention and response programme," he said.
Nathan Geffen, spokesperson for the Treatment Action Campaign (TAC) is also sceptical of Zimbabwe's supposed success in fighting Aids. "The figures must be treated with scepticism. What does a drop in sero-prevalence mean? Well it could mean that people with HIV are dying and the disease is naturally tapering off. It could also mean that there's a skewed HIV prevalence in Zimbabwean refugees. We just don't know," he said.
He went on to say that UNAIDS reports need to be treated with great caution. "South Africa has very robust data on HIV. We have three key institutions that estimate HIV prevalence: the HSRC, ASSA and the Department of Health. Their estimates are all very similar. However, the lack of good statistics as well as dysfunctional health systems in Sub-Saharan Africa, India and China mean that AIDS stats there are very difficult to estimate accurately."
In a similar vein, Sapa quotes Health Director General Thami Mseleku as saying that, "The focus on us being the highest is fine, but we should also focus on countries where they felt they have dealt with this problem and they are actually facing rising incidence."
5.5 million infected
Whereas infection rates may be questioned, there is general agreement that the actual numbers are staggering. An estimated 5.5 million South Africans are HIV-positive, according to government estimates.
In addition, a senior UN official said in October that South Africa is ignoring most of the 100 000 children born here every year with HIV infection.
"This is unacceptable," Ann Veneman, executive director of the United Nations Children's Fund (UNICEF), told Reuters in an interview. "The child really has been in some ways forgotten."
President Thabo Mbeki and Health Minister Manto Tshabalala-Msimang have come in for severe criticism – both internationally and locally – of their handling of the Aids pandemic and their rejection of the scientific consensus.
UN Special Envoy Stephen Lewis famously described the South Afican government's response to the pandemic as "more worthy of a lunatic fringe than of a concerned and compassionate state".
This followed the much publicised incident where Tshabalala-Msimang stirred controversy by touting garlic and beetroot as Aids cures at an international Aids conference in Toronto.
According to Grebe, the government's "main mistake" has been to "alienate its partners - civil society, health workers, the medical and scientific community, faith communities etc - instead of building a broad front for a coordinated response to the disease. Government denialism is one of the factors that contributed to this."
Grebe outlines what he sees as two key failures
- lack of seriousness about prevention; and
- the way in which the health system's human and physical infrastructure has been allowed to deteriorate.
"However, before condemning the Department of Health too harshly, we must recognise that both of these are serious challenges, the solutions to which are by no means obvious," he said.
"Even with strong leadership from government and a united front, the challenge would be great, and success is not assured. But without it, I believe failure is assured. This is why the dismissal of former Deputy Minister Madlala-Routledge was so disappointing. She had succeeded in building a new unity among all sectors around the new National Strategic Plan and her dismissal seems to indicate a return to the fractious approach of the past," Grebe said.
Can we turn it around?
At South Africa's third national Aids conference, held in Durban in June, the UNAIDS chief Peter Piot praised South Africa's new national strategic plan (NSP) for Aids.
Grebe agrees that the NSP is a good start, "in particular because it reflects a wide consensus. However, the unity and momentum that had been built up around it has recently seemed to be slipping away."
Geffen agreed, saying that the opportunity to use the NSP to improve the response to AIDS is at risk of being lost. "There has been very little movement since the NSP was endorsed by Cabinet. Mother-to-child transmission prevention is a good example. It would be straightforward for the minister of health to give the go-ahead to provinces to improve upon the single-dose nevirapine regimen. Yet she has not done this," he said.
Either way, it seems highly unlikely that the NSP will deliver on its stated aim of cutting new infections in half by 2011.
Amongst other things, the controversial firing earlier this year of Madlala-Routledge – a key figure in driving the NSP – has led many to doubt government's commitment to the new plan.
Still, Grebe points out that "we must recognise that there have been some successes. Despite how slowly the national antiretroviral treatment programme has been implemented, it is the world's largest and has reached a large number of people. So, despite all the failures, there is something to build on." – (Marcus Low, Health24, November 2007)