Does anyone know the tune?

Confusion is the only certain ingredient in government’€™s approach to HIV/AIDS.

At times it feels as though there is a dance, but the tune is only audible to the Health Minister and the President.

We can watch their feet moving, but can never anticipate who is leading or which way they are going to turn next. And the dance twirls on from one public relations blunder to the next.

President Mbeki, his lapel no longer sporting an AIDS ribbon, said government would continue to implement its “comprehensive HIV/AIDS strategy” when he opened Parliament last week.

But his two dull sentences on the disease ‘€“ as over 10 000 people massed outside to demand treatment for people with HIV ‘€“ did little to convey the impression of a caring government committed to helping its 4,5 million citizens living with the disease.

Our president’€™s stubborn refusal to comment on HIV/AIDS ‘€“ a disease we are not even sure he believes in ‘€“ obscures the fact that there have been advances.

Phase one of our AIDS vaccine trial starts this year. Government is pouring resources into improving its cure rate for TB, the most common opportunistic infection.

There is a concerted effort by the “social cluster” of ministries ‘€“ particularly health and social development — to address poor nutrition. Although hunger and inadequate diet affects all poor South Africans, they cause those with HIV to get sick far quicker and succumb to various opportunistic infections.

Poor citizens are being given starter packs for food gardens. At some health facilities, free multivitamins and food parcels are also available, and those with HIV are given prophylactic drugs to prevent a range of common illnesses.

The compulsory fortification of bread and mielie meal, introduced last year, will also boost the immune systems of the sick.

The Treasury and health department are examining the cost of introducing anti-retroviral (ARV) drugs in public health and will report back within the next two months.

But there are still serious gaps in implementation, particularly as regards treatment and care.

Voluntary counselling and HIV testing (VCT) is internationally recognised as the door to both prevention and treatment. But most South Africans who take the test are not motivated by the desire to take control of their own destiny.

They are either pregnant, and being offered the anti-AIDS drug nevirapine, or have been sent to be tested by doctors. Yet VCT is a cornerstone of our national AIDS plan, and it is vital if people are to take individual responsibility for their own health and sexual practices.

“The gap between policy and implementation is at the heart of the problem of the AIDS crisis in the country,” says the HSRC’€™s Dr Olive Shisana, and the former director-general of health. “If all the elements of the [national HIV/AIDS plan] were implemented, South Africa would be well on its way to managing this epidemic.”

There is also no censure for those departments and provinces that are failing to implement the plan.

Mpumalanga is a perfect example. Mpumalanga’€™s once effective HIV/AIDS programme is in tatters and there is evidence of widespread abuse of funds, while its Health MEC, Sibongile Manana, has consistently obstructed the dispensing of anti-retroviral (ARV) drugs.

But instead of reprimanding Manana, Health Minister Dr Manto Tshabalala-Msimang recently said that she would “go to prison with her” if Manana were jailed for failing to roll out provision of the anti-AIDS drug nevirapine to pregnant HIV positive women and their babies, as ordered by the Constitutional Court.

However, within days of Tshabalala-Msimang’€™s irrational backing of the anti-ARV MEC, the minister had quiet, sober ‘€“ and by all accounts very positive — discussions with three universities about government input into an ARV study that they plan to conduct.

Last week, she met the vice-chancellors (VC) of the Universities of Natal, Cape Town and the Witwatersrand to discuss whether government concerns could be incorporated into planned research into providing ARVs to people with HIV/AIDS in resource-poor settings.

Wits acting VC, Prof Loyiso Nongxa, said government was keen for the research to be “expanded nationally” and wanted “co-ordination on some aspects”.

“If our principal investigators agree, they will thrash out more details with the department of health officials,” he said.

University of Natal VC Prof Malegapuru Makgoba added that government had raised important “constitutional and ethical issues”, including the need for the research to expand to rural areas.

The meeting was called after former US president Bill Clinton had contacted Mbeki about the funding proposal his foundation had received from the universities.

According to Makgoba: “It was correct for Clinton to contact Mbeki as our research initiative has enormous implications for government policy, and Clinton wanted to make sure that it was in line with our government’€™s policy.”

No doubt Clinton also wanted to ensure that his foundation was not embroiled in any AIDS controversy, which seems so common in our country.

Piggy-backing on the universities’€™ research, rather than conducting their own ARV “pilots”, offers many advantages for government. Aside from being able to draw on the country’€™s best scientists, government will avoid a possible court challenge to roll out ARVs, as it faced with the nevirapine pilots for pregnant women and their babies.

For the battle-lines have been drawn in this country over ARVs ‘€“ both because of government’€™s convoluted, secretive and slow approach to treatment issues and TAC’€™s ability to lobby.

TAC has now vowed to launch a “peaceful civil disobedience campaign” unless government announces an anti-retroviral treatment programme.

The organisation has been particularly angered by the breakdown in negotiations between business, government, labour and community organisations at Nedlac over a “national framework agreement on the prevention and treatment of HIV/AIDS”.

In November, the pace of negotiations was brisk. However, by the end of that month when agreement seemed imminent, business blinked and asked for more time to consult. Then government officials made a similar request.

Nedlac’€™s Jennifer Wilson says that while business has identified the changes it wants, the task team dealing with the framework agreement will only be reconvened “once government indicates it is ready to come back to the negotiations”.

Tshabalala-Msimang said this week that agreement could not be reached on treatment issues until Treasury had completed its report on costing ARVs in public health, expected in April.

TAC says it will wait, but wants the agreements reached on the treatment of opportunistic infections, sexually transmitted infections, nutrition and VCT to be “signed off”.

Government has shown clear preference for the SA National AIDS Council (SANAC) to be the clearing house for HIV/AIDS programmes and even decision-making ‘€“ rather than Nedlac or any other body.

Despite the fact that SANAC excludes key stakeholders such as TAC, it has become the organisation responsible for approving all South African applications to the Global Fund to Fight AIDS, TB and Malaria.

Responsibility for SANAC lies with Deputy President Jacob Zuma, who has been tied up for months with the Great Lakes negotiations. In reality, the Department of Health runs the day-to-day affairs of SANAC. Promises to make SANAC more representative and ensure it has dedicated staff have not yet materialised.

But unless a powerful body fills the leadership vacuum on HIV/AIDS, citizens are likely to continue to be bewildered, depressed and angered by leaders who don’€™t know how to share the tune with us.

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