Sarafina, Virodene, unspent millions – in a country with one of the fastest growing AIDS epidemics in the world, it’s sobering to say the least that these are the predominant associations one makes with the fight against AIDS in South Africa.

The AIDS Review 2000, released yesterday (Thursday) by the Centre for the Study of AIDS at the University of Pretoria and written by Hein Marais, offers a fascinating overview of the South African response to HIV/AIDS since 1994.

It is no longer possible to dispute “the tragic fact that South Africa has failed to manage and control the spread of HIV,” states Marais in the review.

“The scale of South Africa’s failure to control its HIV/AIDS epidemic becomes clear when one notes that the HIV prevalence in both Thailand and South Africa was less than 1% in 1990; and eight years later it was 1,5% in Thailand compared to over 22% in South Africa.”

The five years between 1994 and 1999 were a crucial period for controlling the epidemic – a window of opportunity which, according to the review, has largely been squandered. What we have now is “a population that is manifestly aware of AIDS to the point of being bored, dismissive and fatalistic”, and very little else to show for our efforts.

The reasons for this failure as provided in the review are many. They include contextual factors, such as the restructuring of the public health sector, which hampered implementation and resulted in the government’s AIDS Programme consistently underspending on its budget.

But what has also marked and undermined the government’s AIDS campaign has been a consistent lack of consultation, a tendency towards centralised decision-making and a “siege mentality”. This has reached such proportions that not only relevant non-governmental role-players, but even the department’s own Directorate HIV/AIDS and STD’s has been left out of the consultative loop.

The review describes the resulting response to AIDS as having “all the features of a tabloid scandal”, with accusations and counter-allegations flying thick and fast. The net result, according to Dr Helen Schneider of the Centre for Health Policy at the University of the Witwatersrand, was “to externalise the problem as belonging to bumbling politicians rather than the nation as a whole.”

The first in a series of debacles and controversies was the ill-advised Sarafina II drama. Next to hit the headlines was the Virodene scandal. The crusade against AZT followed shortly thereafter.

The review suggests that attempts to extract accountability from the Department of Health were unsuccessful throughout. In fact, criticism regarding Sarafina is widely believed to have accounted for the funding cuts suffered by AIDS service organisations (from R19 million to R2 million in 1998).

Likewise, criticism by the Medicines Control Council of the fast tracking of Virodene on the grounds that the drug was dangerous were consistently ignored and the MCC was shut down and replaced in 1998.

The sum effect of these scandals has been consistently to distract both the public and politicians from the AIDS epidemic itself and to polarise those stakeholders who should have been allies in the fight against HIV/AIDS.

The review also points out that while the mistakes made around Sarafina and Virodene could be attributed to “misapplied zeal”, the late 1998 decision to withhold funding for AZT treatment to HIV-positive pregnant women defies such an understanding.

“Curiously, the same Cabinet that threw its weight behind a discredited vaccine initiative would later challenge a tried and tested drug treatment like AZT not only by disputing its effectiveness, but by claiming that it was dangerous,” says Marais.

According to the review, the tangle of official explanations given, none of which survived scrutiny, simply served to beg the question: What other calculations could account for this decision?

Marais suggests that it is the government stand-off with transnational pharmaceutical companies over parallel drug and medicine imports which is actually at stake. Using AZT would contradict the government’s bid to win the right to import or manufacture cheaper versions of the drug.

Apart from a few unfortunate blunders and mysterious interventions, the government’s response to AIDS has been largely invisible, states the review.

This is in sharp contrast to the ANC’s Maputo Statement on HIV/AIDS in 1990, warnings from Chris Hani on the epidemic’s potential “to ruin the realisation of our dreams”, and the adoption of the National AIDS Plan shortly after coming to power in 1994.

“The disease marked one of the few areas in which the ANC decided to work with an apartheid government department in the early 1990s while negotiations proceeded. All this indicates that key figures in the ANC had pinpointed HIV/AIDS as a priority for the organisation,” states the review.

Marais argues that nevertheless, there has been a reluctance to tackle AIDS which stems from a variety of factors. One of these is the fact that AIDS is an inherently divisive issue which comes at a time when the need to forge unity is a national priority.

This hesitation has also meant that those AIDS prevention campaigns we do have are too feeble to address or shift prevailing perceptions.

“Safe, sensible messages became the educational equivalent of muzak, a kind of background drone that was easy to ignore. They were the product of a reluctance to offend ordinary South Africans a curious reluctance, given the fate that awaited millions of people,” says Marais.

Overall, the review documents “a remarkable pattern of silence and evasion”.

“Indeed, if measured minute-by-minute, during his presidency Mandela probably spent more time with the Spice Girls and Michael Jackson than he did raising the AIDS issue with the South African public.” – Health-e News