How activism reshaped South Africa's fight against HIV/Aids over a quarter century of change

In July 2000, then president Thabo Mbeki opened the International Aids Conference in Durban with a speech that ignored well-established facts and doubted that HIV caused Aids. With the world watching, he walked out on 11-year-old HIV activist Nkosi Johnson, who from the stage was pleading with him for access to antiretroviral (ARV) treatment.

At the time, a month’s supply of ARVs cost about R2,400, an amount out of reach for most people who needed medicine — like Johnson. Experts estimate the Mbeki administration’s Aids denialism and delayed response unnecessarily cost roughly 330,000 people their lives between 2000 and 2005.

But the government’s HIV dissidence at that fateful meeting achieved exactly the opposite of what Mbeki intended: instead of leading to delegates casting doubt on HIV science, it started a “treatment revolution”, with experts vowing to get treatment to everybody. 

Twenty-five years later, after long-standing activism and a famous 2002 court case that forced the government to provide HIV-positive pregnant women with medicine that stopped them from infecting their unborn babies, and which in the process mobilised access to treatment for everyone, we’re there.

South Africa now has the biggest HIV treatment programme in the world, with about six million people on anti-HIV medication — and it’s free. New HIV infections have dropped by 75%, from about 1,463 a day in 2000 to roughly 370 daily infections now.

In a quarter of a century, our understanding of HIV science has evolved — and along with it our toolbox to fight the epidemic. 

Learning about different ways in which the virus attacks the body meant newer, better drugs with fewer side effects could be developed. ARVs became cheaper as generic licences were issued to companies that started to compete for the market.  

U=U — having undetectable levels of virus in your body because of sticking to treatment, and it therefore being untransmittable — became a thing. Medical male circumcision helped to slash infections in men (because it removes tissues with the cells the virus loves to invade). And medicine to prevent HIV-negative people from getting infected became available — first a pill, a monthly ring, then a two-monthly jab and now a six-monthly shot that’s in the process of being registered with regulators. 

But the epidemic is not over, Mitchell Warren of the international HIV advocacy organisation Avac told Bhekisisa this week. 

“HIV is still an issue,” he said. Despite three-quarters of people with HIV being on treatment, “we still have 1.3-million new infections (worldwide) every year”. Although that’s about half of what it was 15 years ago, “the worry is that the declines in the past five or so years have begun to plateau”, so the number of new infections isn’t coming down fast enough to end Aids as a public health threat by 2030 — and that’s “a cause for great concern”. 

That’s why, said Warren, the six-monthly anti-HIV injection needed to become widely available. The world could not afford to squander this chance, he said.

For World Aids Day 2024, we’ve put together a timeline of how South Africa’s HIV response has evolved over the past 25 years — and 15 years since the government vowed to “start to turn the tide in the battle against Aids”.

DM