South Africa finds 1 billion Rand to treble HIV budget, after Mandela confronts Mbeki

10 April 2002. Related: Treatment access.

Graham McKerrow, HIV i-Base

The South African government has announced a trebling of spending on HIV prevention and treatment to 1 billion Rand (£62m) next year, and a further rise to R1.8bn (£111m) the following year.

The announcement in the finance minister’s give-away budget in February represents a turnaround in government thinking on HIV, and follows a high profile intervention by former president Nelson Mandela.

However, several organisations have said the money is still far too little, and that the government has yet to seriously address the issue of treatment for people with HIV.

The cash announcement coincides with a decision to launch a programme of treatment with nevirapine to cut mother to child transmission of the virus. South Africa has been the target of international condemnation for refusing to adequately combat HIV, and central to the controversy have been statements by President Thabo Mbeki questioning whether HIV is the cause of AIDS and quoting in evidence AIDS dissidents such as Professor Peter Duesberg.

Political pressure inside the country for a change of policy became unstoppable as several provincial governments, including the Western Cape and KwaZulu Natal, announced nevirapine programmes to combat vertical transmission of the virus.

The latest wave of pressure started in January when treatment activists illegally imported generic drugs from Brazil. In early February The Nelson Mandela Awards for Health and Human Rights 2002 were awarded to Prof James McIntyre and Dr Glenda Gray of Chris Hani Baragwanath Hospital “in recognition of outstanding contributions to the medical science and practical implementation of drug therapies for the prevention of HIV transmission to newborns”.

A week later the ANC’s flagship province, Gauteng, which surrounds Johannesburg, announced that all its public hospitals would dispense nevirapine by the end of the year — a move seen as wrecking national government policy on HIV. This was followed on 18 February by a well-publicised meeting between Mr Mandela and President Mbeki to discuss the health crisis. Both men are on record as having sharply different views on the issue but an ANC statement said the two had reached an understanding “and reaffirmed the correctness of the positions taken by the ANC and the government.”

However, the ANC leadership was reported in local media as accusing Mr Mandela of basing his criticism on media reports that did not accurately reflect the Mbeki government’s position on AIDS.

Finance minister Trevor Manuel said in his budget speech at the end of the month: “The Budget contains significant measures to strengthen the national HIV/AIDS programme. In addition to an estimated R4bn currently spent by provincial health departments on AIDS-related illnesses, funding for prevention programmes in schools and communities, hospital treatment and community care programmes will amount to R1bn next year, rising to 1.8bn in 2004/5.”

“This includes a progressive roll-out of a programme to prevent mother to child transmission at the conclusion of the current trials.”

Most of the new money will pay for life skills education in schools, voluntary testing, home-based care and community-based support for people with HIV, as well as paying for antiretrovirals. Some of it will be used to provide medication to prevent TB and pneumonia in people with HIV.

Mr Manuel’s department said widespread use of triple combination therapy is still considered unaffordable but “continues to be the subject of various research projects”.

There is evidence that South Africa’s prevention programmes are beginning to work, but have a long way to go. Government statistics show that HIV infection rates in the under-20s declined from 21% in 1998 to 16.1% in 2000. The health department distributed 310 million condoms last year, and that figure will rise by 16% this year, said Mr Manuel.

Non-governmental bodies welcomed the announcement of new money as a step in the right direction, but said that a budget that included huge tax cuts and increases in spending could have done more to pay for anti-HIV treatment. The budget included R15bn (£1bn) in tax cuts.

Mark Heywood of the South African Treatment Action Campaign told journalists that the increase in the AIDS budget should be seen as a serious commitment to tackling the epidemic, but that it was insufficiently aimed at improving the lives of people with HIV.

He said: “The question is, do we spend our resources to keep our people well, or just to pay the price of creating facilities where they can die? It will be much more cost-effective to invest in health services and medicines so that people can stay alive and be productive.”

He called for an urgent investigation by the government into the cost implications of the health crisis, and said: “We need to work out how we can cut expenditure through a more effective targeting of treatment resources.”

A recent study showed that providing home-based care alone would cost the country about R1.8bn a year, Mr Heywood said. He urged the government to issue compulsory licences to cut the cost of combination drug therapy.

Dr Saadiq Kariem, of the Networking AIDS Community of South Africa, said that while this new budget was an improvement, people with HIV had hoped more would be allocated for treatment. He said more money was needed to care for children orphaned by AIDS, and called for more to be spent on home-based care for people with HIV.

The scale of South Africa’s AIDS crisis has been illustrated in many ways and has caused major skills shortages and thousands of orphans. The latest measure of the disaster is that the country now has a crisis in its cemeteries, which are having to turn away the dead because there is no more room to bury them. There is now a problem caused by the number of so-called “informal burials”. One province alone, KwaZulu Natal, is recording nearly 200 HIV-related deaths every day.

Comment

The new South African AIDS budget may be too small and it may be too late for many of that country’s citizens – but it represents an important change of direction by the South African government and is to be welcomed as a sign that official policy is at last moving in the right direction.

The government must now be urged to cooperate closely with NGOs working in the field to find effective ways not only to expand prevention programmes but also to provide vital treatment and care. South Africa is not a rich country but it is one that can afford a R15bn give-away budget, and in that context it is not impossible to find R1.8bn for a proper home-care programme for people with HIV. This virus does not discriminate but it does attack the economically productive section of the population and such a programme would keep vital workers well: it would allow those who make the wealth to continue to do so, it would allow teachers to continue training the next generation, it would keep parents fit enough to raise their children. In short, antiretroviral treatment is an investment, not an expenditure — and the tax cuts in this latest budget show that South Africa is one African nation that can afford the bill.

Then, in association with Europe and North America, that country can turn its attention to the long-awaited ‘Renaissance of Africa’ — in the form of Mr Mbeki and Mr Blair’s joint project to boost aid to the continent and encourage democracy and stability — which must also prioritise the fight against HIV.