South Africa's 5th AIDS conference, held from June 7-10 this
year, marked a remarkable turnaround in the country's
efforts against the AIDS pandemic. Achievements noted
included bringing 400,000 additional AIDS patients into
antiretroviral treatment within the last year, raising the
total to 1.4 million; cutting the cost of antiretroviral
therapy in half over six months; and extending treatment
using trained nurses to more than 1,600 health facilities.
Most important of all has been a strong spirit of
collaboration among the government, medical specialists, and
This AfricaFocus Bulletin contains excerpts from the lead
article of the July 1 issue of HIV & AIDS Treatment in
Practice (HATIP), focusing on the South African AIDS
Conference. The article tells how South Africa, after years
of denial, is now taking on international leadership against
the pandemic. This is particularly striking at a time when
an 'AIDS backlash' among international donors threatens the
momentum of the global fight against AIDS, even in the face
of new scientific evidence of effective measures that should
and can be scaled up.
The 5th South African AIDS Conference, held from 7-10 June,
2011 in Durban, showcased the recent remarkable achievements
of the country's HIV/AIDS response.
Consequently, the conference was less concerned with
groundbreaking clinical research, and more with the work of
improving the care and health of the country's millions
living with and at risk of HIV.
Evidence was presented supporting the move towards nurseinitiated
management of ART (NIMART), and other taskshifting
measures to train lay staff and community
supporters. Meanwhile, a number of sessions focused on
service innovations or shared operational expertise to
improve the reach and quality of services for the prevention
of parent-to-child HIV transmission, HIV testing and
counselling and early infant diagnosis, the provision of ART
for children, adolescents and adults living with HIV, as
well as services to reduce the burden of TB in people with
South Africa takes its place as a global AIDS leader
The big story of the conference was how the country has
emerged from years of being an AIDS policy backwater to
become a global champion in the fight against HIV/AIDS. On
the international policy front, the country has become a
sophisticated voice, quite literally representing the
interests of millions of people living with HIV, one that
had been largely missing from the discourse on global public
Some of the sophistication may have been acquired through
interaction with human rights champions such as South
African Chief Justice Sandile Ngcobo, who gave a rousing
plenary address describing how South Africa's constitution
and legal system were used to push the government into
action on HIV. This unique history has helped to shape South
Africa's HIV policies, and place a greater emphasis on human
rights and equity than in many other resource-limited
settings, though there are clearly still gaps in delivery
and service uptake due to stigma, discrimination and
inequality that must be dealt with.
Nevertheless, the country's progressive policies and the
growing successes of its HIV programme are the result, after
years of discord, of a newfound collaboration between the
community, the medical and research establishment and the
government, which is now willing to listen.
The country's leadership now appears to view these resources
as strengths, and the HIV response itself as 'an opportunity
to invest in the quality of life of our communities.' In
fact, the government plans to leverage the HIV/AIDS and TB
response, and expertise acquired in dealing with those
diseases, to turn around the country's public health system.
Conference sessions were dedicated to engaging the HIV
establishment in re-engineering primary health care and
providing a forum for people from the communities to talk
about how health services could be designed to better meet
The conference chair Professor Francois Venter predicted
that if the country kept to this winning formula of 'having
all the right people in the same room' it would succeed
where academics and public health specialists have failed in
designing and delivering effective community health
services. In addition, with the West increasingly abandoning
its commitments, Dr Venter said South Africa would have to
increasingly come to the aid of the rest of the continent.
A very different kettle of fish
"You may have noticed," Prof. Venter said at the start of
the meeting's opening plenary, "that among all of the very
important dignitaries that we have here, we don't have the
At first this sounded like an all too familiar story - South
Africa's dignitaries have failed to show up at the South
African AIDS Conference before. But this time, it wasn't to
snub the conference organisers or to avoid being humiliated
by HIV/AIDS protesters.
"South Africa's Deputy President, Kgalema Motlanthe," Prof.
Venter went on to explain, "has been called away at the last
minute, due to an appeal for him to be in New York with the
Minister of Health, Dr Aaron Motsoaledi, at the United
Nations General Assembly Special Session (UNGASS) high level
meeting on AIDS."
The UNGASS meeting brings together many of the world leaders
and experts to take stock of the progress and challenges
fighting HIV/AIDS and to shape the future AIDS response.
When it was last held in 2006 the world finally seemed to be
moving towards responding effectively to HIV/AIDS.
The policy environment today is markedly different. With the
ongoing international financial crisis, and debates about
aid funding and global health priorities, the world has been
retreating from honouring its previous commitments to
support universal access to HIV prevention, testing, care
and treatment. In addition, governments and multilateral
organisations have failed to learn that an effective
HIV/AIDS response cannot be achieved without protecting the
human rights and meaningfully engaging populations most at
risk, and the communities of people living with HIV. Rather,
in many settings, HIV stigma and repressive laws are
It should be painfully apparent that whenever world leaders
get together to set global policy for HIV/AIDS, South
Africa, with over 5.5 million people living with HIV, the
world's largest infected population, ought to have a vested
interest. This was a lesson previous leaders had been slow
to learn, but it was clear that the Deputy President
understood what was at stake.
"The Deputy President was urgently needed," Prof. Venter
said, because neither of the two countries "which had been
appointed to represent Africa's interests at the assembly,"
had "stellar human rights records or particularly good HIV
programmes," he went on. "I think it's very important for
all of us that he is there; he needs to go and advocate on
behalf of the country. And we are delighted that South
Africa finally internationally is providing moral leadership
that we have been expecting for so long."
This was a remarkable thing to hear at a South African AIDS
Conference from a leading clinician and thought leader from
the HIV/AIDS community. As Prof. Venter would say at the
close of the conference, "this is a very different kettle of
The ghosts of South African AIDS Conferences past
South African AIDS Conferences have always been highly
politicised affairs. For readers who may be new to the field
or perhaps have just blotted it out of their memory, during
the Durban International AIDS Conference in 2000, which
served as the model for biannual national (regional)
conferences, former President Thabo Mbeki shocked the world
by questioning the role of HIV as the primary cause of the
AIDS epidemic during the opening plenary.
In response, over 5000 leading scientists signed the Durban
Declaration, which refuted AIDS denialism and called on the
government to pursue science and evidence-based policies to
combat the HIV epidemic.
But in addition to bringing scientists to South Africa to
confront denial, the conference chair Professor Jerry
Coovadia, now Emeritus Professor of Paediatrics and Child
Health at the University of KwaZulu-Natal (UKZN), had
another reason for bringing the conference to Durban - to
draw the world's attention to the very epicentre of the
pandemic, as well as the lovely people, and the promising
young nation, that it threatened.
In South Africa however, the conference was followed by
years of antagonism and mistrust between Mbeki's government
(whose Health Minister was infamous for promoting garlic and
beetroot to treat AIDS), and the country's HIV community -
made up of people living with HIV, treatment activists,
CBO/NGOs, doctors, nurses, caregivers and researchers. This
rift between the government and the HIV community, and the
resentment of 'outside interference', provided a constant
source of drama during the first three South African AIDS
"These conferences for me, and for many people, have marked
various terrible milestones in our fight with government,"
said Prof. Venter.
Despite denialism and neglect at the top of government, the
country's HIV research and medical establishment grew in
size and expertise.
HIV treatment, human rights and legal activists (the
Treatment Action Campaign and the AIDS Law Project - now
called "Section 27"), fought valiantly, and successfully,
for lower drug prices and to force the government into
action, paving the way for the country's evolving HIV/AIDS
There were also dedicated people in the Department of Health
who contributed to the effort, whenever their hands were
Finally, this response was assisted in no small measure by
the Global Fund and other bilateral and multilateral donors,
- in particular, the PEPFAR programme. (This was partly
because of a quality PEPFAR has often been criticised for -
it had few qualms about bypassing an inefficient national
The last South African AIDS Conference, held in 2009, marked
the start of a dramatic reversal in the direction of the
nation's HIV policies. Months earlier Mbeki had been forced
to resign (for reasons unrelated to his AIDS policies), and
the caretaker interim government (headed by the Deputy
President Motlanthe) had made a clear break from the HIV and
treatment denialism associated with the previous
administration. The government finally seemed to be on
board, but no one could be certain at that point whether the
spirit of collaboration would last after the next election.
When newly elected President Jacob Zuma announced his new
cabinet, he appointed a former student of Prof. Coovadia, Dr
Aaron Motsoaledi, to run the Department of Health - and he
has exceeded expectations.
"For the first time, I think we're in a situation where
we're trying to work out these problems together, where we
have a government that certainly wants to do the right thing
and is open to the fact that it respects us enough to listen
to what we have to say," Prof. Venter said.
"And we've got some successes to be proud of - they are
recent successes," he added.
South Africa's accomplishments
Professor Venter and the Deputy President highlighted some
of South Africa's accomplishments:
1) Just under 12 million South Africans got tested in the
last year for HIV - almost a quarter of the South African
population in less than a year.
2) The cost of antiretroviral therapy for the country has
been cut in half in the last six months.
Prof. Venter credited this to the Department of Treasury and
some hard bargaining by the Department of Health. "Bringing
down the cost of antiretrovirals just in the last six months
by more than half is no small achievement. It has meant that
treating HIV is getting to the stage where it's one of the
cheapest chronic diseases to treat, in the South African
system," he said.
3) South Africa's own public expenditure on HIV and AIDS has
increased by 40% per annum. "In the current financial year
we have allocated US$1 billion to HIV and AIDS programmes,"
the Deputy President said in an address to the UN.
4) The number of South African facilities providing ART is
now about 1668.
5) 1.4 million South Africans are now on ART, 400,000 of
whom started treatment in the last year. "That's 1.4 million
people who are alive and well on antiretrovirals who would
be either dead or sick. Four hundred thousand people who
would be dead in a year or two. Their families would be
burying them," said Prof. Venter. "There are not many things
in medicine that save this number of people. And we have to
thank a Department of Health, a donor, an NGO, an activist
nation who have got together and have collectively made this
As would later be reported at the conference, this number
includes around 100,000 children initiated on ART, which
appears to be associated with a drop or at least a
stabilisation in the national under-five child mortality.
"I really do think that is something to be proud of as a
country. Coming from a situation where we weren't doing
particularly well or benchmarking ourselves against
countries like Botswana and Namibia, we are starting to step
up and show the leadership that is required. It's going to
require a lot more. We need to almost double that number by
the end of 2012. It's going to require a lot of effort on
the part of all of us to actually get there," said Prof.
6) Reduction in mortality: ART appears to have had a clear
impact on survival. Several years back, before such rapid
scale-up of ART was considered possible, modelling by the
Actuarial Society of SA had predicted that, in 2010, there
would be 388,000 deaths due to the HIV epidemic, up from
257,000 at last count in 2005. However, the number of AIDSrelated
deaths has clearly dropping over the last couple
years. Last year, it is estimated to have dropped to around
194,000, about 60,000 less than in 2005 and half the number
projected. This sharp decline is attributable to the ART
programme, according to Professor Yunus Moosa, of the
University of KwaZulu Natal.
7) TB is finally receiving more attention: "TB has been the
orphan of the health world for decades. It hasn't been given
the resources it deserves but for the first time, it's being
regarded as the emergency that it actually is. For the first
time, we're seeing new drugs, new diagnostics. We need to
now start making sure that our healthcare system is one that
can tackle TB," said Prof. Venter. ...
8) Strengthened prevention: "We are making continuous
efforts to strengthen our prevention strategies," said the
Deputy President in his taped address, noting that more than
50,000 men have undergone medical male circumcision
nationally, along with an increase in the numbers of both
male and female condoms being distributed nationally.
Another highlight of the meeting was the performance of the
programme to prevent parent-to-child HIV transmission
(PPTCT), which has reduced the rate of transmission to 3.5%
at around 6 weeks of age - a profound improvement compared
to reports a few years ago.
Public policy and the law must remove barriers to access,
such as stigma and discrimination
"We've made significant progress in HIV and AIDS science.
That is why the tone of this conference rightly is different
from the many that have gone before," South African Chief
Justice Sandile Ngcobo said in a moving opening lecture at
the conference. "These are massive gains and they are worth
But he added that not everything that ought to be done is
being done, and the benefits of recent legal rulings do not
reach everyone who needs them.
"Why is that so? The answer I would like to suggest to you
is that the problem perhaps is no longer the virus, the
problem is us," he said. He added that the advances in
scientific knowledge over the past decades must be matched
by parallel advances in public health policy and law, in
order for the advances in the laboratory to translate into
better outcomes for affected communities.
South Africa has a particularly progressive constitution and
activists used the courts to force the government to provide
essential services such as PPTCT. Likewise, the courts have
played a critical role in dismantling statutory
discrimination against those with HIV and AIDS. For
instance, in a ruling against employment discrimination, the
Chief Justice said the courts reasoned that:
"People who are living with HIV have been subjected to
systemic disadvantage and discrimination. They have been
stigmatised and marginalised. Society's response has forced
them not to reveal their HIV status for fear of prejudice.
This in turn has deprived them of help they would otherwise
have received. People who are living with HIV are one of the
most vulnerable groups in our society. Notwithstanding the
availability of medical evidence as to how this disease is
transmitted, the prejudices and stigma against HIV-positive
people still persist," he said.
The court ultimately declared that people who are living
with HIV must all enjoy special protection in the law: "In
view of the prevailing prejudice against HIV-positive
people, any discrimination against them must be targeted as
the fresh instance of stigmatisation. And this is an assault
on their dignity," the justices wrote.
"The impact of discrimination of HIV-positive people is
devastating. It is even more so when it occurs within the
context of employment. It denies them the right to earn a
living. And for this reason the court said they enjoy
special protection in our law," said the Chief Justice.
He noted that criminalisation of people living with HIV
still presents significant challenges to the AIDS response.
"Even within the African Union where a compassionate and
rational approach to HIV and AIDS is so critical, there are
countries whose immigration laws either ban the entry of all
HIV-positive persons into their country, or include
restrictions on their eligibility to stay or work in their
country. Discriminatory policies and laws are often
motivated - at least in the field - by public health
concerns. Laws that discriminate on the basis of HIV status
are premised on a misunderstanding of where we are in the
science of HIV prevention, transmission and treatment."
While the courts may have needed to force the South African
government into action, its judgements have informed
activism and the development of public policy in the country
- which grounds the HIV/AIDS response more solidly upon a
human rights foundation than other countries in the region.
The regional AIDS response would benefit if South Africa
were to provide more leadership in protecting the human
rights of the most vulnerable groups and of people living
with HIV outside its borders.
One of the more recent goals of the South African health
system, which was discussed in at least one session of the
conference, was the re-engineering of primary health care so
that it effectively meets the needs of communities. This is
an indication of the ambition and growing self-confidence of
South Africa's Department of Health.
"It is probably one of the most profound changes that has
been proposed by a healthcare system in the last 20 years,"
said Prof. Venter. "This is something we all are going to
have to engage with and which is a very exciting communityled
development which I'm hoping is going to mean that it's
going to make healthcare much more available to the public."
But he also thinks the re-engineering of primary health care
is one area where South Africa may be able to succeed
precisely because of its experience with HIV/AIDS.
Prof. Venter also commented on the 'AIDS backlash': the
complaints from some academics and public health specialists
who claim that HIV/AIDS has received too much attention and
weakened health systems, and that funding should instead be
directed to other global health priorities.
Most of these complaints are unfounded, but Venter said the
HIV world should take ownership of some of the criticisms,
such as the need to increase efficiency - which is one of
the reasons why task shifting needs to be scaled up.
Additionally, HIV has received attention that other diseases
also deserve. But this should be seen as an opportunity to
apply the AIDS industry's experience to these other health
needs and the health system in general.
"Part of the challenge for us in the HIV world is to go and
repair the rest of the healthcare system. We've made some
real strides forward in terms of understanding health care
for chronic illnesses. Diabetes, hypertension, asthma are
crying out for the same sort of initiative," he said. "If
there's a preventable disease out there I would hope that
all of us will be out there to try and fight as hard for our
other patients with other diseases that are not HIV as we do
for HIV. And I think that that's what this primary health
care re-engineering is about - it is an opportunity to take
those lessons out."
While the backlash against AIDS funding is less prevalent
within South Africa, it has contributed to weakening global
commitment to the HIV response and must be confronted. A
very real consequence of the AIDS backlash might require
another kind of leadership from South Africa.
"I think in every country, except South Africa and Botswana,
whose entire antiretroviral programme is funded from their
tax payers, the fact that the donors are starting to say:
"Enough already!", is something that should make us all
very, very scared. Because it's all very well to handle this
in South Africa but I think we recognise the obligation we
have to the rest of Africa, to try and help them dig
themselves out of the sand pot we were in at the beginning,"
South Africa's lobbying at the UN
This was the sort of situation the Deputy President was
trying to prevent with his trip to New York. At the close of
the conference, Prof. Venter gave a glowing report of how
the Deputy President had acquitted himself at the meeting in
"The first thing he did, which is a direct firing across the
bows, on everyone who thinks that we should inhibit and use
our culture to oppress women, to oppress gay men, to oppress
sex workers -- he went out and he asserted that this is
what's in our constitution," said Prof. Venter. In addition,
the proceedings from the conference informed the Deputy
President's testimony to the UN. "It's something we do need
to report, that it came straight out of this conference,
straight through his lips and straight into the UN.
The Deputy President also told the UN meeting that South
Africa is currently considering how it might introduce
treatment for all at a CD4 count of 350, and plans a social
mobilisation strategy to get people to access treatment
before they get very ill. South Africa's mass testing and
counselling campaign will continue, and efforts to reengineer
primary health care will be stepped up.
He emphasised: "Global solidarity is critical and as we
continue to explore alternative ways of resourcing this
major crisis, we must work in partnership with communities,
development partners and civil society. An AIDS-free world
is an attainable goal: let us remain committed to this
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