cape town

At risk: but one week's AZT treatment would cut maternal transmission of HIV by 37 per cent. Credit: AP/DENIS FARRELL

South Africa's minister of health, Nkosazana Zuma, has refused to alter her decision not to pay for a pilot programme administering the antiviral agent AZT to HIV-positive pregnant mothers. This is despite increased threats of a boycott of the World AIDS Congress in Durban next year.

New findings released in Chicago last month by UNAIDS, the joint United Nations programme on HIV/AIDS, and based on trials with 1, 357 mainly breastfeeding women in Uganda, South Africa and Tanzania, indicate that a one-week treatment of mother and child with both AZT and 3TC (lamivudine), beginning at the start of labour, could reduce transmission by 37 per cent.

The president of the International AIDS Society, Mark Wainberg, visited South Africa at the end of January in what seems to have been a futile attempt to persuade Zuma to reverse her earlier decision.

Although he left the country “confident and encouraged” that the new information would cause a change of mind, Zuma has now confirmed that the government will not change its mind on a pilot study for AZT treatment, which it refused to fund last October (see Nature 396, 504; 504; 1998).

The ministry has argued that the pilot programme would create unmeetable expectations if funds were not available to follow it up with full implementation. But the annual base cost of implementing a short-regime programme nationally would be around R14 million (US$2.3 million), from a R20 billion annual health budget.

Additional costs arise from counselling and the provision of formula milk for mothers to feed their babies in lieu of breastfeeding. Glaxo-Wellcome is offering AZT to the South African government at 75 per cent below the price for developed countries, and has offered to hold that price for five years.

Along with replacing a four-week regime (which reduces transmission by 50 per cent) with a one-week one, this has reduced the initial cost estimates by a factor of five.

“We are disappointed. We cannot understand why Zuma is ignoring the data, ” says Glenda Gray, director of the Perinatal HIV Research Unit at Chris Hani Baragwanath Hospital in Johannesburg, one of the sites of the UN trials.

The ministry has continued to argue that it cannot find the funds for AZT treatment, despite counter-arguments that it is more cost-effective than treating HIV-positive babies. Babies born with HIV account for about 20 per cent of new infections in South Africa each year, and the daily cost of paediatric care in a state hospital is R400.

Wainberg also called on South Africa's president, Nelson Mandela, its deputy president, Thabo Mbeki, and its minister of finance, Trevor Manuel, to recognize that perinatal treatment is the most cost-effective approach, and to make funds available for this. “South Africa must consider itself to be at war, ” he said. “Its number one enemy⃛ is not some neighbouring country threatening its borders. It is HIV.”

This is a thinly veiled reference to the country's decision last year to spend R30 billion on upgrading its defence force. But Vincent Hlongwane, Zuma's press secretary, replies that Zuma's position is fully supported by the cabinet, which has apparently made a policy decision to channel all disposable funds into preventative measures.

The International AIDS Society met with South African and international AIDS researchers in Chicago last month to discuss growing calls for a boycott of the 13th World Aids Conference, scheduled to be held in Durban next year.

Wainberg said they had agreed to oppose a boycott at this stage, but warned that if there were no signs of a change of policy by April (when he is to visit South Africa again) “it may be time to consider another course of action”.

Local AIDS activists have not yet come out in support of a boycott because the conference is still 18 months away. But AIDS Consortium representative Mark Heywood has indicated that they will reconsider their position later in the year.

Meanwhile, the Centre for Applied Legal Studies and the National Association for People with AIDS are planning legal action to challenge Zuma's decision.

The Western Cape provincial government, which is controlled by the National Party, went ahead with the pilot programme in defiance of Zuma's policy. The programme was launched in January in the township of Khayelitsha, Cape Town, with the reported support of the African National Congress's leader in the province, Ebrahim Rasool.

But Zuma's handling of the issue does not seem to have affected her popularity within her party at national level. She is third on their national list for this year's general election, outranked only by party president Thabo Mbeki and deputy president Jacob Zuma, her former husband.

There is even speculation that she might be appointed deputy president in Mbeki's new government, ahead of both Jacob Zuma and the leader of the Inkatha Freedom Party, Mangosuthu Buthelezi.