HIV does cause AIDS but it's hard to prescribe the drugs, says South Africa's ANC

The highest decision-making body of South Africa's governing African National Congress (ANC), the National Executive Committee (NEC), has published a long statement on HIV and AIDS, saying that while it agreed HIV caused AIDS, antiretroviral drugs (ARVs) "could not be provided in the public health system because of prohibitive costs and the complexity of management".

The ANC also stressed that "socioeconomic conditions, particularly poverty, play a critical role in both the transmission and the progression of the disease". Both of these are defendable points, potentially taking some of the confusion out of the current political storm in South Africa over HIV/AIDS.

Meanwhile the latest ruling from the country's highest court — the Constitutional Court — has temporarily allowed hospitals and clinics to provide nevirapine to their pregnant HIV-positive patients, to reduce the risk of their infecting their babies.

The government's top HIV/AIDS official Dr Nono Simelela added that "what is possible in terms of antiretrovirals is continuously under interrogation", but "a real, honest analysis of the health service shows that we are nowhere near providing an antiretroviral service where we could be comfortable that no harm would be done."

This is a departure from President Thabo Mbeki's earlier more combative approach to HIV/AIDS, which led him to invite AIDS dissidents to sit on his advisory panel and refer frequently to the toxicity of ARVs.

In April, Mbeki said in a letter to ANC members: "Some in our society and elsewhere in the world seem very determined to impose the view on all of us that the only health matters that should concern especially the black people are HIV/AIDS, HIV, and complex antiretroviral drugs, including nevirapine."

Shortly after the court ruling, the influential ANC MP and former youth leader Peter Mokaba stirred up the fire further by stating publicly that HIV does not cause AIDS. He has since distributed a paper to ANC members in which he argues that ARVs themselves make people sick. But judging by the latest ANC statement this is not the majority view.

Significantly, it is the courts, not the government, that have opened the door to the first mass provision of ARVs in South Africa.

At present, a large number of health facilities are using the legal hiatus to give nevirapine to their patients. The hiatus has come about as a result of two government appeals against an earlier High Court execution order, made in December 2001. This order was granted after the Treatment Action Campaign (TAC), an AIDS activist group, took legal action against the government to force it to expand its 18 prevention of mother-to-child transmission (PMTCT) pilot sites. TAC's action succeeded and the High Court ruled that health facilities that had the capacity for it should be able to give nevirapine to patients.

The government appealed energetically against the order, as well as against the entire judgement, which it argued was inappropriate as it believes such policy decisions are its domain, not that of the courts. The Constitutional Court dismissed the government's application for leave to appeal against the execution order. However, at the time of going to press the Constitutional Court has yet to rule on the government's appeal against the entire judgement.

In the interim, hospitals and clinics that feel they have the capacity to run a PMTCT programme may simply order nevirapine from their provincial stores. The TAC is monitoring the drug supply and has threatened to take further court action if it believes the government is stalling.

Even if the court finally rules that health facilities should not have the power to prescribe nevirapine, it will be very difficult for the government to turn back the clock and deny patients access to the drug that can cut HIV transmission to babies by up to 50%. One of the stipulations of the court is that, in order for a health facility to be deemed ready, it must be able to properly test and counsel pregnant women. This is probably a bigger stumbling block to the expansion of PMTCT than the drug supply, as there is a lack of rapid HIV tests and trained counsellors.

Speaking on radio immediately after the Constitutional Court ruling, former president Nelson Mandela said he welcomed the ruling, and reiterated his call for the government to find a way to supply antiretroviral drugs to all citizens.

"That is not a question from which I can retreat," said Mandela. "When people are dying — babies, young people — I can never be quiet."

There is growing international support for ARV therapy for pregnant women and mothers to prevent HIV transmission to their babies, a position supported by WHO and UNAIDS. n

Kerry Cullinan, Durban

World Health Organization Genebra - Genebra - Switzerland