HIV treatment in South Africa: overcoming impediments to get started.

I n South Africa, the euphoria of the peaceful transition from apartheid to democracy has been dulled by the devastation of HIV/AIDS. The epidemic has had a disproportionate effect on poor, previously disenfran-chised groups, in which the apartheid migrant labour system had destroyed family life and created conjugal instability. South Africa is now in the midst of a maturing epidemic, and AIDS dominates almost all aspects of medical care. HIV-1 prevalence reached 24·5% in pregnant women attending public health services in 2002. 1 Highly active antiretroviral therapy (HAART) symbolises hope for many communities. But access to these life-saving drugs was severely restricted until the 2000 International AIDS Conference in Durban, South Africa. This defining moment 2 in global solidarity and advocacy for treatment access changed the discourse on AIDS treatment in poor countries from " if " to " when ". The change was largely due to rapid price reductions and funding made available by, among others, the Global Fund to fight AIDS, Tuberculosis, and Malaria. Although there have been many events to celebrate in postapartheid South Africa, the government's response to the AIDS epidemic was, until very recently, not one. Before 1994, the apartheid government's approach to dealing with AIDS was insufficient and lacked credibility. The Mandela government set about redressing this in 1994 by establishing AIDS as one of the 23 presidential lead projects and one of the 12 reconstruction and development programmes. This initial period of hope was, however, short lived. The biggest setback came when President Mbeki (who took office in 1999) expressed doubt about whether HIV causes AIDS. Mbeki also questioned the safety and efficacy of antiretrovirals. Subsequently , a presidential AIDS panel was created with equal numbers of AIDS denialists and orthodox AIDS scientists, but it is yet to report recommendations. In 2001, advocacy groups challenged the government's decision not to provide two-dose nevirapine treatment to reduce the risk of mother-to-child transmission of HIV-1. The Constitutional Court's ruling against the government was a landmark, and it showed that the country's constitution could hold the government accountable for its actions (or in this case inaction). Under increasing pressure to address treatment access, the government adopted the national treatment plan, which recognised that by mid-2003 about half a million South Africans were in need of anti-retroviral treatment. The plan established a commitment to measure CD4 counts in about 200 000 people with HIV infection; starting 53 …