Global Policy Forum

By Lawrence K. Altman

Owing to regional and international clamor for a more vigorous attack against the AIDS epidemic, the South African government yesterday changed its stand on providing drugs to combat the virus, saying it would develop a plan to offer them to infected people through its public health system by October 1.

"Government shares the impatience of many South Africans on the need to strengthen the nation's armory in the fight against AIDS," the South African cabinet said in a statement after a special meeting to assess the financial costs of a national anti-H.I.V. drug plan and to explore options for treating those with the infection.

South Africa has the largest number of H.I.V.-infected people in the world, about 5 million, or over 11 percent of its population of 43.8 million, according to the United Nations AIDS program. The figures are more staggering for the 23.7 million people aged 15 to 49; about 20 percent of them are infected.

The epidemic poses a major threat to the future of South Africa's economy and security by primarily affecting young sexually active adults and incapacitating the traditional extended family system that cares for sick and orphaned relatives. So far, the epidemic has left 660,000 South African children as orphans.

Yet, for years, as the AIDS virus has spread, President Thabo Mbeki and his top aides have resisted national programs to provide anti-H.I.V. drugs, known as antiretrovirals, making him the target of intense criticism at home and abroad.

The South African government said that because not every infected person needed anti-H.I.V. drugs, its program would provide them initially to people with more advanced cases of AIDS. The drugs can extend life for many people but are not a cure. The government program is also expected to provide prevention programs aimed at the tens of millions of people who are not infected.

The change in policy comes in the same week that South Africa held its first AIDS conference, and just a month after President Bush pressed Mr. Mbeki during his visit to Africa to come up with a plan that included both a drug regimen and prevention efforts. Mr. Bush has pledged to provide $15 billion over five years in fighting global AIDS, although it remains uncertain whether Congress will appropriate that much. "The White House welcomes any effort to address the AIDS pandemic," said Claire Buchan, a White House spokeswoman who was with the president in Texas yesterday.

In the past, Mr. Mbeki and his aides have questioned the safety, effectiveness and costs of the drugs, as well as questioned the very connection between H.I.V. and AIDS. Mr. Mbeki has also emphasized the difficulties that many Africans experience in taking the complicated regimens of multiple drugs every day. He has stressed the importance of reducing poverty, calling it a major factor in producing the AIDS epidemic, and urging improvement in the diets of poor people.

The AIDS epidemic began to mushroom when Mr. Mbeki was vice president in the administration of Nelson Mandela. That administration did little to control the epidemic. But in recent years, Mr. Mandela has spoken out on AIDS and exerted considerable pressure on the government, and foreign countries, to do more to improve the quality of life for infected South Africans.

The costs of treating those infected are difficult to calculate, but are expected to run into billions of dollars. The government said it would follow guidelines that the World Health Organization issued in April describing the combinations of anti-H.I.V. drugs that work best and the simplest acceptable laboratory tests to monitor their use. The guidelines were intended to show doctors in poor areas how to prescribe such drugs safely.

Of the 42 million people living with AIDS in the world, an estimated 30 million, or 70 percent, are in sub-Saharan Africa, which has a population of 640 million. Women make up about 58 percent of them, the United Nations says. Dr. Peter Piot, the director of the United Nations AIDS program, said AIDS had an even greater impact on the continent because about 60 million people throughout Africa were living with the disease, had died of it, or had been made orphans by it.

The South African government's change of policy came after a four-day national conference on AIDS earlier this week in Durban where demonstrators jeered the government's health minister, Manto Tshabalala-Msimang. It was the first major AIDS meeting in South Africa since an international AIDS conference was held in Durban in 2000.

Zachie Achmat, the chairman of one advocacy group, the Treatment Action Campaign, had led a growing grass-roots campaign to force the government to make the drugs widely and cheaply available and had become internationally known for refusing to take the drug cocktails himself until the government changed its policies. Although he welcomed the government's decision yesterday, Mr. Achmat said his group "will wait to see the actual operational plan before celebration." In an interview with the BBC, he also said, "For all of us living with H.I.V. in South Africa, and our families, this is the first sign of hope."

Dr. Piot told participants at the AIDS meeting in Durban this week: "Throughout the world, the debate is not on whether to offer antiretroviral treatment in the public sector, but how to do it given the numerous real constraints. For Heaven's sake, let us not wait to act until we have the perfect solution because the era of perfect solutions is still far away."

A major concern is how to use anti-H.I.V. drugs safely in developing countries because they cannot be taken like aspirin and experts have warned that injudicious use of the drugs could be seeds of a disaster, possibly in spreading drug-resistant strains of the AIDS virus. But a number of AIDS experts from the United States and elsewhere have been teaching doctors in Africa in the proper use of such drugs.

The South African cabinet took note of such concerns and said AIDS experts in the country and specialists from the William J. Clinton Presidential Foundation would assist the government in developing an operational plan. The foundation said it had worked with the government in reviewing drafts of its plan.

The availability of generic or cheaper anti-AIDS drugs has been a long-fought battle in developing countries. In April 2001, the pharmaceutical industry dropped its legal fight against South Africa, which the industry contended had been violating international trade agreements and patent restrictions through the government's efforts to buy brand-name drugs at the lowest rates available in the world. On a visit to South Africa in June, Mr. Bush promised that it would be among the first nations to receive new American financial assistance to fight the disease.

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