South Africa's New Enemy

Jon Cohen*

Photos by Malcolm Linton

Many South Africans long dreamed of the day when the oppressive apartheid system would end. That day has come, but now the country faces a new disaster: one of the world's worst HIV epidemics--and most confusing government responses

Since the beginning of this year, an estimated 320,000 South Africans have become infected with HIV, accounting for fully half the new HIV infections in sub-Saharan Africa. During that time, South Africa's president, Thabo Mbeki, has been publicly questioning whether HIV is the cause of the AIDS epidemic that is ravaging his nation. He has established a four-person panel to come up with tests to prove whether the virus causes the disease, although virtually every AIDS researcher believes the cause was proven beyond any reasonable doubt in the 1980s. The panel plans to report its findings in time for the international AIDS meeting to be held in Durban next month. Mbeki himself is scheduled to deliver the keynote address, which should guarantee that his skepticism will continue to get headlines around the world.

Figure 1

Figure 2
Shocking sentinels. Pregnant women (above) dramatically indicate how HIV prevalence has soared in South Africa. Young men and women in this mining town (bottom) have been particularly hard hit.


Mbeki describes his interest in discredited ideas about HIV as a search for a better way to deal with the epidemic in Africa. Outsiders may see it as a flirtation, but many AIDS researchers here see it as irresponsible. While HIV infection rates soar in South Africa, the government has stumbled from controversy to controversy, undermining confidence in its public health strategy. Although the Mbeki administration has supported AIDS prevention efforts and research, it has ignored its own experts' advice to provide AZT to HIV-infected pregnant women. It has become mired in scandals, like a former health minister backing a supposed wonder drug for AIDS that turned out to have no scientific worth. And last year, it even failed to spend nearly half of its AIDS budget. "It's not a good time to be a researcher in South Africa if your pursuit is science and truth," says epidemiologist Mark Lurie of the Africa Centre for Population Studies and Reproductive Health, a Wellcome Trust-funded effort in Mtubatuba.

Fertile ground
Salim Abdool Karim, head of the HIV Prevention and Vaccine Research unit in Durban that's sponsored by the Medical Research Council (MRC), says the government's confused response to the epidemic, combined with a large migrant workforce, high rates of sexually transmitted diseases, a thriving sex worker industry, and widespread poverty, provided a perfect breeding ground for HIV. "You couldn't ask for anything else," says Karim, who chairs the scientific program for the upcoming Durban meeting. "If I were going to design an infection that was going to ravage this country, I could not do better than HIV and AIDS," says Karim, a large man who goes by the nickname "Slim."

South Africa has had two HIV epidemics. The first took place in the 1980s and remained largely restricted to homosexual men; the second, much larger one took off in the 1990s and spread rapidly among heterosexuals. Studies from prenatal clinics across the country, which form the basis for national estimates, show prevalence skyrocketing from 0.76% in 1990 to 22.4% by 1999 (see left-hand graph). South Africa's Ministry of Health estimates that HIV now infects 4.2 million children and adults in the country, about 10% of the population--and more than 10% of the total infections in the world. A strain of the virus called subtype C accounts for almost all South Africa's infections.

Figure 3
HIV haven. "Slim" Karim clarifies why the virus thrives in his country.

A key factor in the disease's spread here is the country's large migrant workforce. Epidemiologists have evidence, for example, that migrant gold miners are the link between high infection rates in the mining town of Carletonville, near Johannesburg, and sharp increases in infection rates in KwaZulu-Natal across the country. Preliminary data from studies by epidemiologist Lurie and colleagues show that HIV has infected one or both partners in 33.7% of "migrant couples" in KwaZulu-Natal--nearly double the prevalence in nonmigrant couples.

In Carletonville, according to epidemiologist Brian Williams, who works with the nonprofit Council for Scientific and Industrial Research, he and his co-workers have found that a staggering 60% of 25-year-old women are infected, as are 50% of 32-year-old men (see right-hand graph). Says Williams: "It's completely terrifying."

Learning to govern
In response to this mounting crisis, the government has organized AIDS counseling and training centers, promoted the use of condoms, led the international campaign to pressure pharmaceutical companies to lower drug prices, and boosted the AIDS research budget. But as MRC president Malegapuru William Makgoba pointed out in a 19 May Science editorial (p. 1171), the best chance to control the HIV epidemic in South Africa was when the apartheid era was ending in the early 1990s, but at the time the country "had no effective government." Makgoba wrote: "In the midst of the heroic efforts to build a new, pluralistic South Africa, the HIV epidemic simply became one challenge too many."

Compounding the problem, the postapartheid government that took over in 1994 and which Mbeki now heads has sown confusion and anger with its HIV/AIDS policies. "You have a government that's learning to govern," says Karim. "It's a government learning that liberation is more than good ideas."

First came the scandal over Sarafina II, a 1995 AIDS musical commissioned by the Health Department that cost $14 million rand (US$2 million today)--a substantial chunk of the AIDS budget--and triggered an official investigation of then-health minister Nkosazana Zuma and others. Zuma, with support from then-deputy president Mbeki, next helped promote Virodene, a supposed anti-HIV wonder drug that turned out to be worthless. A team appointed by Zuma then recommended abolishing the government-appointed Medicines Control Council, which had criticized the testing of Virodene. The council, the equivalent of the U.S. Food and Drug Administration, also has written two reports detailing how AZT benefits outweigh risks, but the Health Ministry has not accepted either report.

Since taking office in June 1999, Mbeki has further baffled AIDS researchers and advocates. Under pressure to provide AZT to HIV-infected pregnant women and rape victims, Mbeki last October told his Parliament that doing so would be "irresponsible" because "the toxicity of this drug is such that it is in fact a danger to health." Then Mbeki began questioning whether HIV causes AIDS (Science, 28 April, p. 590). This spring, the South African Parliament also learned that the health department had not spent 40% of its AIDS budget. "It's a very difficult situation we're in," says Quarraisha Abdool Karim, the former head of the National AIDS Program (and Slim's wife), who now studies HIV infection in women. "Every few months we have this case that undermines all the good work that's been done."

AIDS researchers in South Africa become most exercised about the country's refusal to provide drugs to HIV-infected pregnant women. South Africa participated in the PETRA study, which showed in February 1999 that a short course of AZT combined with the anti-HIV drug 3TC could cut infection rates at birth in half. Health Minister Mantombazana Tshabalala-Msimang, an obstetrician gynecologist, says the treatment is impractical in South Africa: "AZT/3TC is beyond what this country can afford." She notes that nine sites in South Africa now are evaluating the much cheaper regimens of nevirapine (see p. 2160). "Researchers advise governments," says Tshabalala-Msimang. "They're doing studies. They said we should wait."

Quarraisha Karim bristles at this. "Research is being used as an excuse not to make policy," she says. Makgoba adds that the MRC has presented the government with studies that prove the cost-effectiveness of providing AZT/3TC. He thinks part of the reluctance to follow the advice of scientists comes from the government's antipathy toward pharmaceutical companies. "It's an unhappy relationship," says Makgoba. "And the science is caught in the middle of it."

Parks Mankahlana, Mbeki's spokesperson, confirms a widespread rumor that providing treatment to infected pregnant women worries the government because of the number of surviving orphans this policy would create. "A country like ours has to deal with that," insists Mankahlana. "That mother is going to die, and that HIV-negative child will be an orphan. That child must be brought up. Who's going to bring the child up? It's the state, the state. That's resources, you see?"

Obstetrician James McIntyre, who co-directs the Perinatal HIV Clinic at Soweto's Chris Hani Baragwanath Hospital, says this cynical argument doesn't even make sense. "Drug treatment doesn't create the orphan problem," says McIntyre. "If we do nothing, seven out of 10 kids will be uninfected, and they'll be orphaned. And we have to consider what happens to orphans. It's a whole lot easier for the family to take care of uninfected children."

When asked how Mbeki feels about embarrassing his country's AIDS researchers, Mankahlana responds, "People are just being foolish." He adds: "You know, Mbeki wants to wake up in the morning and see the South African economy grow. He wants to see jobs being created. He wants to see crime levels coming to zero. He wants to see lodgings of people improve. OK, there's this problem of HIV/AIDS, but you see scientists must work. They must do what they have to do, which is to find a cure for this thing. They must. If they want government assistance, they will get it. End of story."

Of course that's not the end of the story. When thousands of AIDS scientists and hordes of journalists flock to Durban in July for their weeklong international meeting, they will focus the world's attention on South Africa's response to HIV and AIDS. Makgoba suspects the conference may go a long way toward helping his government develop a sound strategy for confronting the epidemic. "When South Africa was tearing itself apart with apartheid, the world came to South Africa and solved the problem," says Makgoba. "When South Africa is tearing itself apart with AIDS, it may just provide another opportunity for the world to help."

* Jon Cohen was accompanied by photographer Malcolm Linton. For a gallery of additional photos and the stories behind them, see

Volume 288, Number 5474, Issue of 23 Jun 2000, pp. 2168-2170.
Copyright © 2000 by The American Association for the Advancement of Science.