A détente has emerged on the battlefield of HIV/AIDS in South Africa. The appointment of Barbara Hogan to minister of health and her subsequent adoption of an orthodox approach to the HIV/AIDS epidemic has been greeted with emotions of joy and relief by activists and practitioners alike. If Hogan’s decisive action to address the life-threatening shortage of antiretroviral drugs in the Free State and her focus on limiting the cholera outbreak in Limpopo are any indication, effective leadership may have finally arrived in the Department of Health. Edwin Cameron’s recent appointment to the constitutional court has brought about a similar response amongst HIV/AIDS activists, as the visible presence of a person living with HIV/AIDS on the country’s highest court will ostensibly undermine AIDS stigma. While these developments are in part outcomes of consistent political pressure by activists and practitioners in the fields of public health and HIV/AIDS, they may not go far enough in addressing the legacy of AIDS dissidence in South Africa.

Amongst the various analysts who have commented on Mbeki’s questioning of the link between the HIV virus and AIDS, the focus has ranged from discursive analyses of Mbeki’s dissidence to detailed narratives of the struggle between social movements (such as the Treatment Action Campaign and the ANC) and purveyors of alternative treatment for HIV/AIDS with dubious medical value. In Mortal Combat, Nicoli Nattrass builds upon these strands of research to argue that the primary effect of Mbeki’s AIDS dissidence is that it undermines the scientific basis of medical knowledge (and consequently the Western scientific canon). While much weight should be afforded to this analysis, it may neglect another legacy of AIDS dissidence moving forward: its lingering effects with the state and social institutions.

DISSIDENCE AND INTRANSIGENCE

With respect to state institutions, the first year of the South African National Aids Council was marked with obstinacy by Manto Tshabalala-Msimang’s Department of Health in a number of areas. The South African National AIDS Council (SANAC) was particularly negatively affected. The SANAC secretariat, the body assigned to administratively assist SANAC structures and housed within the Department of Health, did little to support the institution, according to several SANAC delegates. The Resource Mobilization Committee, or RMC, responsible for the acquisition of funds to propel the joint government–civil society response forward was also undermined by foot-dragging on the part of the Department of Health. Chaired by the former Minister of Health Tshabalala-Msimang, the RMC mismanaged the Global Fund tender process, blocking an important funding stream for the state as well as civil society (as all South Africa based organisations applying for funding must work through the country coordinating mechanism, the RMC, to apply for support from the Global Fund).

At the national level, it appears the legacy of Mbeki’s AIDS dissidence will not be long lasting. If the turnover in leadership within the Department of Health leads to the prioritisation of SANAC and the joint civil society–government response envisioned in the National Strategic Plan for HIV/AIDS and STIs (2007–2011), we may come to see Mbeki’s influence on national-level institutions as limited to his tenure in office. While the failed Global Fund tender process is a significant challenge, the recent £15 million grant from the UK to support SANAC and the implementation of the National Strategic Plan will significantly offset the organisational failure that typified Tshabalala-Msimang’s leadership.

However, it remains to be seen whether refurbishing national-level institutions will fundamentally alter the character of the HIV/AIDS epidemic in South Africa. While national-level politicking over HIV/AIDS has become the cause célèbre of researchers and journalists alike, restructuring the leadership of national-level institutions will not solve many of the more intractable problems in addressing the epidemic. Key problems the current wave of institutional upheaval will not address are those of understaffing and funded vacancies. Although strong leadership and a new political directive will do much to improve the quality of the work environment in the public health sector, it will not change the wage differential that exists between the public and private sector, both within and outside of South Africa.

While the provincial legacy of AIDS dissidence will be particular to each province, the recent charges filed against the KwaZulu-Natal Health Member of the Executive Council (MEC) Peggy Nkonyeni bode well for the future of the public sector response to HIV/AIDS. Charged with leading the response to HIV/AIDS in the global epicentre of the HIV/AIDS and XDR Tuberculosis epidemic, Nkonyeni is well known for her support of alternative HIV/AIDS therapy. If Nkonyeni’s indictment is any indication, Hogan and the ANC leadership may cull AIDS dissidents from state institutions by any means necessary.

What is perhaps the more pressing issue is that of testing. The HIV/AIDS pandemic will never be brought under control unless testing becomes widespread and de-stigmatised. As long as those who are infected do not know their status, particularly men, initiatives such as the extension of dual therapy prevention of mother-to-child transmission (PMTCT) will only stem the tide of new infections in children rather than protecting their mothers. One should not underestimate the efforts of current communication strategies that emanate from nationally based civil society organisations such as Soul City. However refined their messaging, the efficacy of these efforts are difficult to quantify outside of testing rates, which have remained relatively static.

So while we should all welcome a new era of ANC leadership on HIV/AIDS, expectations of progress should be tempered by the fact that this shift will not change the fundamental problems faced in the public health sector or in public perceptions of HIV/AIDS.

AIDS DISSIDENCE ‘GOES LOCAL’

During the course of a year of research in South Africa, I spent a significant amount of time in Khayelitsha, a terrain littered with foreign researchers attempting to assist the South African response to the HIV/AIDS epidemic. A central issue that I encountered was a lack of cooperation between two of the key organisations in the community relative to HIV/AIDS: the Treatment Action Campaign (TAC) and the South African National Civics Organisation (SANCO). This was driven primarily by the contentious politics between the ANC and the TAC, concerning which SANCO sided with the ANC given the close relationship between the two organisations. Furthermore, according to various media reports and community activists, the homes of SANCO members in Khayelitsha and Nyanga served as distribution points for the Rath Foundation’s unproven vitamin-based ‘AIDS treatment’.

While this localisation of national-level politics should not in itself shock anyone who has followed the contentious politics of HIV/AIDS, it is highly significant for gauging the legacy of AIDS dissidence in South Africa. SANCO, the contemporary manifestation of the civic movement during the anti-apartheid struggle, is a significant presence in townships throughout South Africa. While its national membership might not be the 5 million that it has claimed, it is nonetheless a significant organisation in that its local antecedents operated as the de facto local government in many townships during the 1980s.

In Khayelitsha, SANCO is an important organisation given its central role in community development forums and the dominance of its members in street committees. The implication of SANCO in Mbeki’s project complicates the common depiction of AIDS dissidence as an ideology which solely inhabits the corridors of power. Instead it should be viewed as having filtered into the communities which, according to the statistics, are most at risk: the former townships which are predominately black and poor.

Khayelitsha is one such community, and given that nearly one in three pregnant women are HIV positive, clear messaging is an absolute necessity. While there are many organisations working in the community to project clear messaging on HIV/AIDS, my time in Khayelitsha reinforced one of Jonny Steinberg’s central insights in Sizwe’s Test. Organisations such as the Treatment Action Campaign (TAC) or Médecins sans Frontières operate within communities and can significantly change the resources and level of care available in that context, but outside of a handful of devoted members, the organisations tend to operate in relative isolation from the community, outside of their presence at clinics.

This point was brought home in Khayelitsha when activists in Harare were targeted by gang members following their testimony in the trial over the rape and murder of Nandipha Makeke. While TAC activists were threatened and attacked in their community and at their branch office in Site B, other local organisations did little to support the TAC. The community stood aside while activists were forced to remove their singular ‘HIV positive’ t-shirts for fear of attack. While the TAC is active in townships across South Africa, it remains an organisation that is only in the early stages of planting roots in communities that have received decidedly mixed messages concerning HIV/AIDS.

This is highly significant for the issue of increasing testing in South Africa. While the TAC may have significant intellectual resources and footholds in various communities around the country, the breadth, depth and reach of the organisation does not match that of SANCO. Thus while the TAC continues to work to spread orthodox scientific knowledge of HIV/AIDS treatment in affected communities, its efforts have been circumscribed by the legitimation of AIDS dissidence by SANCO. That the ANC leadership utilised SANCO as a means of disseminating the ideology of AIDS dissidence is significant due to the fact that SANCO retains ‘struggle credentials’ that few other organisations can claim and gives further legitimacy to the ideology of AIDS dissidence at the local level.

While this situation is without question a challenging one, it is not without hope. By challenging MPs to disclose their HIV status and thus challenge stigma, National Assembly Speaker Gwen Mahlangu-Nkabinde has clearly articulated the ANC’s post-Polokwane position on HIV/AIDS. While this gesture is significant, it will not un-weave the complex web of political contestation that has resulted from the ANC’s support of Mbeki’s AIDS dissidence. While the ANC leadership may have begun to work towards undermining the legacy of AIDS dissidence at the national level, it is unclear whether this strategy will filter down into the communities most in need of a clarifying message.

THINKING THROUGH THE WAY FORWARD

One potential avenue the ANC could pursue would be to cajole SANCO into backtracking on its support for alternative AIDS therapy. This is not as unrealistic as it may sound, as the post-Polokwane ANC leadership has already re-animated the street committee structure as part of its new anti-crime platform. In speeches by Jacob Zuma, Cyril Ramaphosa and Kgalema Motlanthe, street committees figure prominently as a community-led strategy for fighting crime. Is it unimaginable that these same structures could be utilised to clearly articulate an orthodox position on HIV/AIDS as part of a broader initiative to empower communities with knowledge of their bodies and environment that could have significant implications for public health?

This is not only a possibility but a necessity. The research of Elke Zuern and Patrick Heller emphasises that while SANCO branches do vary in their politics and policies, the ‘corporatist’ structure of SANCO means that the organisation’s national executive can exert significant influence on local branches. Therefore, if the ANC is willing to take decisive action on HIV/AIDS as part of a national effort to increase community education on public health, it is only a matter of exerting the political will to ply SANCO into organising its branches and their street committee members into working with public health organisations or HIV/AIDS activists.

While this strategy might appear sound on paper, it is predicated on organisations working together that have been involved in intense political struggle over the past decade. The TAC in particular has challenged SANCO’s support of unproven ‘alternative therapies’ and their role in spreading mixed messages to communities on HIV/AIDS. It is beyond the scope of this short piece to examine TAC’s organisational strategy over the past decade, but clearly it would be difficult, if not impossible, for many TAC activists to work with those who have undermined their efforts to expand treatment literacy and testing. However, the reality the TAC faces is that it lacks the organisational capacity to reach far enough fast enough to meet the ambitious targets of a 50 per cent reduction in infections and 80 per cent treatment coverage by 2011, as set out in the National Strategic Plan for HIV/AIDS and STIs.

At the same time, the TAC is not acting alone in the struggle against HIV/AIDS. The many other organisations working locally, provincially or nationally would need to be included efforts at coordinating a joint government–civil society response to the HIV/AIDS pandemic that reaches down to the most local of South Africa’s social structures, the street committee. And it will take more than the ANC and a few civil society organisations to bring about the sea change necessary to keep the HIV/AIDS pandemic under control. The private sector, frequently left out of the discussion on HIV/AIDS, is particularly important in this process. Whether it is utilising the vast private medical infrastructure or extending medical coverage for people living with HIV/AIDS to their families, all social sectors must actively engage with one another if the pandemic is to be brought under control.

CONCLUSION

That South Africa must face an epidemic in the infancy of its democratic age is perhaps one of the great injustices of our time. However the manner in which the Mbeki administration managed the situation has transmogrified this dimension of the AIDS epidemic and shifted the collective focus away from issues such as price gouging by global pharmaceutical corporations. Facing up to the legacy of AIDS dissidence must do more than simply substitute a heterodox discourse of HIV/AIDS with an orthodox scientific position. A sustained and localised response that aligns politically opposed social organisations and state institutions while utilising existing social institutions is not only cost-effective, but creates a united front in support of improved public health and orthodox science.

Given the monopoly pricing system for life-saving drugs that currently structures the global response to HIV/AIDS, practical solutions that work in low-resource settings such as South Africa’s townships should be given heavy consideration. This is particularly the case given that much of the promising research presented at the 17th International Aids Conference utilises antiretroviral drugs in microbicides or in tandem with traditional barrier methods such as the diaphragm. It is clear that HIV/AIDS must be de-politicised and de-stigmatised if progress is to be made. In order to address the party’s complicity in creating the legacy of AIDS dissidence, the ANC must take decisive and grounded political action that unifies all relevant organisations around a coherent response to one of the great challenges of our time.

* Theodore Powers has conducted doctoral research on the relationship between HIV/AIDS, social development and informal urban settlements in South Africa.
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