Aids and AZT

South Africa's policy on prescribing anti-retrovirals has attracted the attention of the international scientific community.

PRESSURE on the government to make AZT or nevirapine available to pregnant women with HIV/Aids is bound to mount. The World Conference on Aids in Durban in July will turn the spotlight on the South African stance and could well be the scene of demonstrations by local activist groups, as well as critical attack by experts attending the conference. Secondly, the HIV/Aids Treatment Action Campaign (TAC) plans to launch legal action very soon.

"I believe there is a very strong legal case under the Constitution for giving AZT to pregnant women, both as regards the rights of children to health care and the reproductive rights of women," says Mark Heywood of the Wits Aids Law Project, which is co-operating with TAC. Although constitutionally the right to health care can be limited in certain circumstances on grounds of cost, Heywood does not think this argument would apply: "AZT can be shown to be cost effective and affordable," he says. "The government knows it’s on weak ground when it comes to AZT for pregnant women."

In fact the Aids Law Project was about to initiate legal action last year and only decided to hold back following a meeting with health minister Dr Manto Tshabalala-Msimang in which she gave them what turned out to be "false reassurance". The government changed its ground after President Thabo Mbeki claimed that a large body of scientific literature showed that AZT — a medication on the World Health Organisation’s essential drug list — was potentially toxic and that it would be irresponsible to prescribe it for HIV patients until its safety was established.

As Dr Ian Roberts, special adviser at the department of health, said in a recent interview: "Good political decisions are underwritten by good science." (see interview below). But Mbeki’s information has been derived from individuals who, although undoubtedly sincere, are not members of the mainstream scientific community. They include Charles Geshekter, a lecturer in African history at California State University, and Anthony Brink, a Pietermaritzburg lawyer, both of whom contributed opinion page articles to a debate on Aids in the Citizen. Brink is believed to have referred the president to a South African website promoting the discredited theories of Professor Peter Duesberg, the Californian molecular biologist — that HIV does not cause Aids and that it is the drug AZT that destroys the immune system.

The puzzle remains why the president and his health minister should be guided by them rather than expert bodies such as the Medicines Control Council and the Medical Research Council. One answer lies in the specifically African perspective on the disease that they offer. In his article, "The Epidemic of African Aids Hysteria" (Citizen, September 16, 1998), Geshekter argues that Africans have long suffered the symptoms of Aids — weight loss, chronic diarrhoea, fever and persistent coughs — but that these symptoms are due to the environmental risks caused by poverty not to a sexually transmitted virus. Researchers have wrongly redefined these symptoms as HIV/Aids and then assumed that, as in the West, the epidemic of immune deficiency was driven primarily by sexual promiscuity. As a result, he says, health professionals have fixated on condom distribution or evangelistic demands for behaviour modification instead of concentrating on improving water quality, sanitation and diet.

Geshekter also suggests a more sinister agenda: "Having millions of Africans threatened by Aids makes it politically expedient to use the continent for vaccine trials or for distribution of severely toxic drugs like AZT that radically affects the liver and kidneys, causes muscular diseases and destroys red blood cells."

For Mbeki, a committed Africanist, who is trying to keep public spending under control in a country facing the onslaught of Aids, there must be multiple attractions in this kind of "theory". It sets Africa apart from the West, downplays the weak points of sexual behaviour and exploitation of women, highlights poverty — which no one can deny is the essential social context of the epidemic — and thus increases moral leverage on the developed world for debt relief. And finally it demonises Western researchers, drug companies and, of course, AZT.

An interview with Dr Ian Roberts

HEALTH DEPARTMENT watchers on the look-out for any hints of change in government policy on Aids and its treatment have noted that Dr Ian Roberts popped up at the Conference on Retroviruses and Opportunistic Infections in San Francisco in February. Roberts is a special adviser in the department, and his socialist perspective was a crucial influence on former health minister Dr Nkosana Zuma. While in America, Roberts gave an interview to Emily Bass, a specialist writer on HIV/Aids, for the internet magazine, Salon. The interview is not just significant because it gives insight into Roberts’ thinking, but also because it indicates the intense interest that international specialists are taking in South African policy — especially on the issue of mother to child transmission of the disease. Refocus reprints some of the key passages below. (The full text is available on

Bass: Vaccines are a huge priority right now. Where do you see progress coming from in this area?

Roberts: It has to be global effort. All relevant people need to come together one way or another and lose protectionism and desire to leverage themselves and just focus on what we need. It’s not a question of do we have the budget. It’s that if we don’t solve it, the ramifications are going to be enormous. In a sense, it’s a shame we don’t have complete, total global dictatorship for a year where one individual says, "Either you do it or you die."

Bass: Do you see this global involvement happening?

Roberts: On the flight here, I flew next to someone from Shell — it could have been anybody, from any company. I always ask people the same question, partly because it gives them a level of discomfort: "What are you doing about Aids? What is your company doing about Aids?" He said, "Well it’s not Shell’s problem." If I had a company, or was managing director of Shell now, I would be very focused on what I could do. Not only because my market place is going to change tremendously, but also because there’s a responsibility when a continent is facing what we are. Three or four months ago, I didn’t have the same sense of urgency I have now, so I can understand if Shell doesn’t have that urgency. Still, it seems surprising to me that it’s not there.

Bass: So, something’s changed for you recently. Where has your sense of urgency come from?

Roberts:It’s hard to say exactly. One thing may be that there are very few people that I’m close to, or that I like, and one of them died recently of non-Hodgkin’s lymphoma [an Aids-related illness]. He was a fashion designer and worked for Missoni with my wife.

Bass: What about something like nevirapine or AZT for stopping pregnant women from passing the virus on to their babies? Last year a Ugandan study found that a $4, two-pill regimen dramatically reduced the levels of transmission. Will you move forward with that?

Roberts: Often, the easiest answer is for policy advisors to just roll out a [new policy]. So you can say, "We’ll roll out nevirapine," and then Aids activists can congratulate themselves and say, "We pushed the government into this"; researchers can congratulate themselves and say, "Wonderful initiative — we did all the work." Government can stand up and say, "We’re really doing something in Aids now" — and at two years old, the kiddies are still dying, and everyone’s lost hope. That’s not saying we shouldn’t intervene. Once we know the results [of South African trials of this regimen], we’ll go back to the minister for her policy decision, which may be that we need more clinical trials, or it may be that we’ll roll out a new policy.

Bass: That almost seems to be in conflict with the urgency of what’s happeningin terms of infections.

Roberts: What I want to avoid is self-perpetuating publication of papers. Science can either produce more publications or it can impact on the social reality of people infected. You have to have some solid evidence about what you’re doing. The danger of rolling out public health policies based on anecdotal evidence is that they’re very difficult to reverse. I think we can be quite loose and make best guesses, but good political decisions are underwritten by good science.

Bass: Still, at this conference, some researchers have been surprised by your hesitation to recommend ideas, like the $4, two-pill nevirapine regimen, that might work, that have been proven to work in other African countries.

Roberts: They’re entitled to their opinion. We’re waiting for the SAINT [South African Intrapartum Nevirapine Trial] study, which will provide important information specific to South Africa. In addition, we’re looking at the total picture — trying to understand reducing transmission in the South African context. I don’t dispute that nevirapine lowers transmission, but we have to deal with the problem from a holistic perspective. Treatment might be important, it might not be. Perhaps it’s more important to improve the child’s quality of life [such as clean water, food, shelter].