Lost in Faith

Anthony Butler

4 May 2009

Johannesburg — But there are three reasons to caution against complacency. First, opinion makers’ belief that the government is on top of the epidemic is in part a product of their own privileged circumstances and the characteristic “invisibility” of HIV/AIDS.

Implicit rationing of ARVs has resulted in the privately insured — public servants, politicians, journalists, employees of nongovernmental organisations and skilled workers — being shielded from the full effects of AIDS. Poor and voiceless women have absorbed most of its costs, both as victims and as carers.

Second, prevention programmes are failing. Prevalence is flattening out, but mostly because deaths are increasing fast enough to cancel out new infections. The structural causes or “drivers” of HIV’s spread, such as poverty, biological vulnerability to infection, and gender inequality, remain deeply entrenched.

Although Africans are less promiscuous than their European or Latin American peers (who, in the language favoured by researchers, specialise in “rapid serial monogamy”) the migrant labour system, the “sugar daddy” syndrome, and polygamy predispose many of the continent’s citizens to “concurrent sexual partnerships” — the maintenance of more than one longer-term relationship at a time.

For this reason among others, prevention programmes are difficult in Africa. It is relatively easy to discourage promiscuity or to promote condom use in casual sex. It is far harder to discourage concurrent relationships, to remove the fundamental causes of concurrency such as migrant labour and polygamy, or to encourage safe sex within long-term partnerships.

Finally, SA has yet to experience the third “wave” of its HIV/AIDS epidemic. Wave one, the rapid infection phase, came as early as 1998 when there were perhaps 800000 new infections in one year. Wave two, the high point of HIV-prevalence, did not occur until a decade later, when HIV began “running out of people to infect” and deaths began outstripping new infections. We are now heading for wave three — an extended surge in AIDS deaths — and it is this tsunami of mortality that will truly test the country’s social and political fabric.

Policy makers can expect a collision between two trends. On the one hand, the epidemic is now producing rapidly growing numbers of people with advanced HIV infection who require ARVs to stay alive. Deaths are running at about 350000 a year, but in the absence of adequate ARV programmes these numbers could quickly double.

On the other hand, there is no way to scale-up the ARV roll-out fast enough to keep pace with surging demand. In smaller countries such as Botswana, it has been shown that rapid increases in treatment can sometimes be achieved even where resources are scarce. The health infrastructure and skills SA requires to deliver ARVs beyond the towns and cities, however, are profoundly constrained and cannot sustain accelerated availability of drugs.

The more successfully an ARV programme is implemented, moreover, the larger the number of HIV-infected people who will remain alive — and so require continued ARV treatment for the rest of their lives.

South Africans in rural areas and former bantustans are today more or less totally excluded from ARV programmes, and treatment reaches just 30% of those who need it across the country as a whole. In the next five years, the unavailability of life-prolonging treatment to millions of citizens will almost certainly become a burning political issue.

Under former president Thabo Mbeki, a continuous diet of obfuscation and evasion from the government encouraged the majority of advanced HIV- infected citizens to die silently and often stigmatised, with their treatment limited to traditional medicines.

The incoming administration will no doubt try rapidly and sustainably to scale up the public ARV programme. At the same time it will need to manage significant political fallout.

Overwhelmed treatment facilities could soon become recognised as sites of exclusion, and ARV rationing may quickly fuel an intense new protest politics about what is unavoidably a matter of life and death.

Butler teaches public policy at UCT.

Copyright © 2009 Business Day. All rights reserved. Distributed by AllAfrica Global Media (allAfrica.com).