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South Africa Looks to Set New Course in HIV/AIDS Fight

March 23, 2009 at 12:00 AM EDT
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South Africa's new health minister is promoting testing, treatment and frank dialogue about HIV. But many challenges lie ahead in managing the epidemic, as Ray Suarez reports in the first of his three-part series of reports from South Africa.

RAY SUAREZ: It’s Saturday morning at Avalon Cemetery in Soweto, time for a week’s worth of funerals.

The enormous ghetto called Soweto was created by the legal segregation of South Africa’s apartheid years. It’s far bigger than most American cities, so the normal cycles of life and death would bring mourners here, but not this many, not the endless parade of living for the dead, not the graves dug in row after row and filled in a morning’s work, not the number of headstones marking the deaths of hundreds in their 20s and 30s.

Africa has been fighting AIDS for decades, but the scale of HIV infection and death from AIDS is different in South Africa. There are some 7.5 million HIV-positive people here, 1 out of every 6 people in the country, 1 out of every 4 working age.

AIDS is pushing down life expectancy rates in South Africa below 50 years and filling whole sections of this cemetery with the graves of children.

While the dying goes on at a breathtaking pace and this country continues to cope with the staggering losses in its most productive generation, there is at long last some good news, some hope in South Africa’s struggle against HIV and AIDS.

Three-quarters of a million South Africans are now living with HIV instead of dying of AIDS because the country has begun distributing life-saving antiretroviral drugs, or ARVs.

For years, South Africa’s president, Thabo Mbeki, and his health minister questioned whether HIV causes AIDS and wouldn’t make antiretroviral treatment available. His health minister, Dr. Manto Tshabalala-Msimang, recommended herbal remedies, earning her the sarcastic nickname “Dr. Beet Root.”

Last fall, a scathing study by Harvard University blamed Mbeki for AIDS deaths of over 300,000 South Africans.

New health minister

RAY SUAREZ: In September, AIDS activists everywhere welcomed the arrival of a new health minister, Barbara Hogan, a former political prisoner who spent eight years in prison for opposing apartheid.

BARBARA HOGAN, minister of health, South Africa: Did we ever think that we would have to face death in this kind of way after we got liberation? You know, we thought we got liberation, now we could move on. And now this deadly thing comes along and kind of mows us down. It's frightening.

RAY SUAREZ: Hogan welcomes the support of AIDS activists.

BARBARA HOGAN: The goodwill has been very good for me, because it's just given me the encouragement to continue and to open up resources and open up the conversation again in the country around HIV and AIDS.

RAY SUAREZ: And to move forward as quickly as the country can afford with more antiretroviral treatment.

This clinic in Johannesburg's tough Hillbrow neighborhood now has thousands of regular patients on the life-giving drugs, like Tbaho, who says her restored health has helped her convince others to get tested.

TBAHO: Can you see I'm well? I go to parties. I'm a young person. I do things. I have a partner. And I'm able to -- I've got two kids. I'm able to raise my kids, and I'm living positively. And then I thank God for the ARVs.

RAY SUAREZ: Antiretroviral therapy doesn't only stop the progress of an individual's disease; it can also slow the spread of HIV. In this medically underserved country, often the only time a woman sees a doctor is when she's pregnant. An HIV test is now routine. And if the mother-to-be tests positive, antiretrovirals are prescribed.

DR. VIVIAN BLACK, maternal HIV expert: And that's where the use of antiretrovirals comes in, because you give antiretrovirals, you bring down the amount of virus in the blood, which means that, during the birthing process, there's less virus in the blood that the baby gets exposed to. So that is the most effective way of reducing mother-to-child transmission.

RAY SUAREZ: Putting this mother on ARVs when she was pregnant kept her new son safe from infection.

DOCTOR: Have you been tested for HIV yet?


DOCTOR: When did you the test?

PATIENT: Last -- last year.

DOCTOR: And what was the result?

PATIENT: It was also negative.

DOCTOR: Congratulations. Very well done.

Treating pregnant women

RAY SUAREZ: For a long time, HIV-positive pregnant women had to visit two separate clinics in this vast public hospital to get their prenatal care and to treat their HIV, and they found that up to 40 percent didn't make it to both. Now that they've combined the facilities, all the women get all the treatment with tremendous results. The number of HIV-positive children drops from roughly 1 in 3 to 1 in 25.

DR. HELEN REES, HIV-AIDS expert: The drugs will have pushed the virus down, down, down, down, down.

RAY SUAREZ: But one of the world's foremost AIDS fighters, Dr. Helen Rees, says outside these hospital walls the numbers are still alarming.

DR. HELEN REES: Unfortunately, the numbers and the epidemic are moving in the wrong direction. We found that maternal deaths have increased instead of decreased, infant deaths have increased instead of decreased, and childhood deaths have increased, instead of decreased. So we have actually gone as a country in the wrong direction.

RAY SUAREZ: Professor Rees oversees this program for HIV-infected pregnant women, partially funded by the U.S. Agency for International Development. Rees is a big believer in antiretrovirals, but she says the scale of South Africa's new efforts hasn't yet matched the size of the threat.

DR. HELEN REES: To give you an analogy from a U.S. perspective, if you had an epidemic like this, I think the U.S. would be on a war footing. If 1 in 3 of all of your pregnant women were coming in infected and you were seeing this bulge in mortality of young people, you would be on a war footing. And we haven't done that as a country, but I think we're beginning to do it now.

BARBARA HOGAN: I think the country has learned that we made a mistake. The graph shows that it's the young who are dying, and the graphs show consistently that that echoes what happens when a country is at war.

What more can I say? You know, what more can I say? But now we are committed. We are going to do our damnedest.

RAY SUAREZ: This year, 500,000 South Africans will contract HIV. For all the different ARVs make every day, the fighters on the front lines insist this country can't medicate its way out of the AIDS crisis.

Despite a new emphasis on prevention, HIV infection has skyrocketed. Condoms are given away free in clinics and clubs. Still, more than a thousand South Africans a day are infected.

Winnie Moleko directs the largest HIV clinic in South Africa.

Challenges for women's health

WINNIE MOLEKO, Women's health advocate: People do have information. But when we look at also the people that are being infected, mainly women, you know, they still don't have power, you know, to take control of themselves, you know, the reason being that, you know, most of the women are not working. They are depending on, you know, men to provide.

RAY SUAREZ: Eva Mashua, married, 36 years old, agrees with Moleko's assessment.

Women don't feel like they have the power to say no. Do you think that's true?

EVA MASHUA: It is true. According to our culture, we were raised up like that. A man is always the head of the family.

RAY SUAREZ: Twenty-six-year-old Carrabo Carbella says this is the way of African men.

CARRABO CARBELLA: They don't believe in condoms, you know. They are living a true African. As I'm an African, I won't use a condom.

RAY SUAREZ: Even if it will save your life?

CARRABO CARBELLA: Yes, I won't. I say I won't. I'm safe. I was still having sex more and more and more. Even if I have AIDS, I will still have more.

RAY SUAREZ: And can women say no?




RAY SUAREZ: They cannot say no?

CARRABO CARBELLA: No, they can't.

RAY SUAREZ: Health experts now say that government must not only tackle prevention, but also the unique sexual culture that's evolved from South Africa's history of segregation. Apartheid pulled a huge black male workforce away from their families.

BARBARA HOGAN: This feature of men being migrant workers has been a feature of the Southern African region because of the mining industry that set up over a hundred years ago. The mines employed people who are migrants. They never set up for families.

When apartheid came along, women and families were refused access to the urban areas, even though a man might have been working. And that was the apartheid pass laws.

So deeply entrenched for over a century there has been a pattern in which families have been forcibly separated. And men in town often took on another lover or another family there and at home. And that has become part of our way of our cultural lives. You know, whether we want to admit it or not, that is part of our cultural lives.

Promoting healthy choices

RAY SUAREZ: Mining executive Dr. Brian Brink remembers a decade ago when AIDS began to destroy the workforce at the mining giant Anglo American. It got to the point where the company began to train two men for every skilled job just in case.

DR. BRIAN BRINK, Anglo American Corporation, South Africa: It's very difficult to watch your employees getting sick and dying and going on early ill health retirement in their 30s and 40s and dying. You just can't tolerate that. And as a business, we realize that we couldn't wait for this thing to get sorted out.

RAY SUAREZ: At Brink's urging, Anglo went way out ahead of South Africa's government, offering ARVs to its workers, 15 percent of whom are HIV-infected, and encouraging but not requiring annual testing. Now the testing rate is high, and the new infection rate is slowing.

Fifteen hundred dollars a year per worker for ARVs turns out to be a bargain.

DR. BRIAN BRINK: The savings that we get from having somebody on treatment through reduced absenteeism, through improved productivity, from not having to pay out other benefits because they're getting sick, all of those savings add up to quite significantly more than the cost of providing the treatment.

RAY SUAREZ: The company wants to demolish the old apartheid-era dependence on migrant labor and discourage multiple sex partners by keeping men with their families.

The government is also trying to achieve that. A new national campaign called "One Love" encourages marital faithfulness or one-partner relationships. Health Minister Hogan was serenaded at the launch.

RAY SUAREZ: And the hit television drama, "Soul City," has joined up with "One Love."

Soul City's John Molefe told me it wasn't charitable or even patriotic to use a hit show to support national goals.

JOHN MOLEFE, marketing manager, Soul City: We are not preaching. We are not telling people. We are just making people aware of what are the challenges and showing them what other people are doing, but also giving the challenge back to them and saying, "You have to take the responsibility to actually bring about the change."

RAY SUAREZ: With elections just weeks away, AIDS activists will be watching closely to see if Jacob Zuma, the favored presidential candidate, will keep Barbara Hogan and her new vision for South Africa's HIV crisis.