It was mid-April when it first became evident that the South African government had had a change of heart regarding the use of anti-retroviral (ARV) drugs for the treatment of HIV/Aids in the public health sector.

On April 17 in a Cabinet briefing, government announced that survivors of sexual assault would be given ARVs in a bid to prevent HIV infection.

Interestingly, the decision went against the ANC’€™s National Executive Committee (NEC) declaration only a month earlier that ARV’€™s should not be offered as post-exposure prophylaxis (PEP) for healthworkers with needle stick injuries or survivors of sexual assault as “there was no proof that they worked”.

Political commentators speculated whether President Thabo Mbeki had really had a change of heart or merely taken a strategic decision to tone down his eccentric views on HIV/AIDS in an attempt to maintain the developed world’€™s support for the New Partnership for Africa’€™s Development (Nepad).

There was also a degree of skeptism about whether the statement would translate into action, given that the Treatment Action Campaign (TAC) had been forced to resort to the courts to get the ARV nevirapine offered to all pregnant HIV positive women.

Last year’€™s High Court decision ordering government to roll out nevirapine was upheld by the Constitutional Court in July, which pointed out that by restricting nevirapine to 18 pilot sites, government was violating the constitutional rights of women and their babies.

However, it seemed the big ship Cabinet had indeed turned in the water and was now heading in the same direction as other nations  fighting the disease. For in October, during the launch of its “Campaign of Hope” on AIDS, Cabinet issued an even more dramatic statement. It acknowledged that ARVs could “improve the condition of people living with AIDS” and said government was addressing challenges such as drug prices “to make it feasible and effective to use antiretrovirals in the public health sector”.

While TAC welcomed government’€™s announcement, its inspiring leader, Zackie Achmat ‘€“ wavering on the brink of clinical AIDS with a CD4 count of little more than 200 ‘€“ stood firm on his refusal to take the drugs until they are freely available to all in the public sector.

His principled stand drew personal visits from former President Nelson Mandela and from Dr Kgosi Letlape, the newly-appointed, outspoken chairman of the SA Medical Association (SAMA).

Cabinet’€™s statement came on the crest of a wave of momentum for ARVs to be more widely available.

In early August, Anglo American announced they would be giving the drugs to their employees. Old Mutual later announced the same thing.

Shortly afterwards, TAC and Cosatu had tabled a treatment plan with the National Economic Development and Labour Council (Nedlac), giving government and business until December 1 to react to the plan, which has ARVs in public health as one of its components.

SAMA proposed an R80-million project aimed at offering ARV treatment to 9000 patients countrywide. Letlape had earlier condemned “the country’€™s inhumane policy of no treatment for AIDS patients”.

But while support for ARVs in the public sector offered hope to the five million HIV positive South Africans, new scientific evidence at the 14^th International AIDS Conference in July painted a depressing picture of a retrovirus able to mutate fast and survive in the body.

“No amount of antiretroviral therapy will ever eliminate this (virus) reservoir,” said Robert Siliciano of Johns Hopkins University in Baltimore. “HIV is intrinsically incurable with antiretroviral therapy alone.”

A vaccine remains our only hope, but South Africa’€™s phase 1 vaccine trial, expected to start this year, has been delayed to late 2003. However, vaccine trials in the US and Thailand are more advanced and may offer some hope.

At present, ARVs ‘€“ which cannot prevent infection but can slow or block the virus from replicating rapidly and spreading throughout the body — are the best defence science has to offer to those infected with HIV.

Prevention is still the best possible hope for any nation, yet effective prevention involves trying to change behaviour that encourages the spread of HIV/AIDS . While offering ARVs to rape survivors is very good news, there is still no systematic government plan to address the rape epidemic in our country that is fuelling the spread of HIV.

Government also has yet to speak out or campaign against the widespread practice of men having multiple sex partners. Uganda attributes its success in halving its HIV prevalence rate over 10 years to people changing their sexual behaviour. Ugandan men reduced their sexual partners while teenagers started having sex at a later age.

In South Africa, the overwhelming message has been “C” (condoms) but the “A” (abstinence) and “B” (be faithful) have yet to be encouraged.

In addition, treatment, care and support for people living with HIV remains completely inadequate. In weaker provinces such as the Eastern Cape and Mpumalanga, many clinics lack drugs to treat opportunistic infections common to people with HIV. Home-based care in most parts of the country is ad hoc and run by volunteers, while support for AIDS orphans is also ad hoc.

Lack of strong vocal leadership at local, provincial and national levels is conspicuously absent in government’€™s AIDS campaign, with the exception of Gauteng.

Former President Nelson Mandela tried to fill this gap in part this year but no one from the present government joined him, while no local politicians made HIV/AIDS a priority.

The country still has no high profile HIV positive role models and instead ordinary people, supported by church leaders such as Archbishop Njongonkulu Ndungane ‘€“ have risked much to speak out about the devastation caused by AIDS.

Despite the lack of leadership, the release in June of the 2001 antenatal survey showed a minimal increase of 0,3% in the national HIV prevalence rate. There was a 5% decrease in HIV in women under the age of 20 and a 3% decrease in KwaZulu-Natal, the worst affected province (now at 33,5%). On the downside, there was a significant increase in HIV amongst women over the age of 30, while the infection rate leapt 5% to almost 16% in the Northern Cape.

A recent health department survey revealed that in the past two years there has been a massive increase (of up to 20%) in South Africans who see them as at risk of getting HIV. More responsible sexual behaviour can be expected to accompany such a perception.

The survey also found most citizens’€™ knowledge about HIV/AIDS was good, and that condom use among young people had also increased.

Sadly, improvements in government’€™s HIV/AIDS campaign seem to have come despite the conduct of a number of key health officials.

Health Minister Manto Tshabalala-Msimang continued to question the toxicity of nevirapine after the Constitutional Court upheld the High Court’€™s decision that to deny the drug was a violation of the Constitution.

She also hammered both Gauteng’€™s roll-out it’€™s prevention of mother-to-child HIV infection, and Anglo American’€™s offer of ARVs to its employees, saying neither had consulted with her.

Her most public blunder was the blocking of a $720-million grant from the Global AIDS Fund to KwaZulu-Natal because its granting “was unprocedural”, although procedures were set down very late and government officials in the province were an integral part of the grant application.

Mpumalanga Health MEC Sibongile Manana fired Dr Thys von Mollendorf, superintendent of Rob Ferreira Hospital, for allowing an organisation that offered ARVs to rape survivors to operate from the hospital. She has also failed to ensure nevirapine is widely available in her province, resulting in TAC demanding her dismissal for violating the Constitutional Court ruling.

Northern Cape Health MEC Dipuo Peters also condemned doctors who gave ARVs to Baby Tsepang, the child who became a symbol of child abuse when her violent rape was made public.

On the other hand, GCIS head Joel Netshitenzhe, Gauteng premier Mbhazima Shilowa, ANC secretary general Kgalema Motlanthe, Health Director-General Ayanda Ntsaluba and HIV/AIDS Directorate Chief Director Nono Simelela have brought quiet common sense to government’€™s AIDS debate.

The most inspiring HIV/AIDS leaders still remain outside government, a worrying trend when UNAIDS has identified leadership and political commitment as two critical factors in the fight against the disease.