By Michael Grunwald
Washington Post Staff Writer
Tuesday, January 28, 2003; Page A01

CAPE TOWN, South Africa -- Nelson Mandela visited an AIDS clinic here last month and declared that South Africa's government was finally getting serious about the epidemic. "They are coming around," said the former president, wearing a T-shirt emblazoned HIV POSITIVE in bold purple letters. In the presence of the hero, a local health official compared the nation's battle against AIDS to its earlier struggle against apartheid: "We are as determined as you were when you said in 1961 that you would not surrender!"

With one in every nine citizens now infected with HIV, the virus that causes AIDS, the outcome of the AIDS crisis could shape South Africa's future as dramatically as apartheid's demise nearly a decade ago. And once again, a reluctant South African government is gradually being pressured into action from below: by advocacy groups, churches, courts, media outlets, unions and businesses, as well as the nation's most respected institution, Mandela himself. Political leaders -- including Mandela's successor, Thabo Mbeki, who in the past had questioned the well-established medical link between HIV and AIDS and suggested that life-saving antiretroviral drugs were part of a genocidal campaign to poison blacks -- have been forced to follow.

"It's obviously happening slower than we'd like, but civil society is forcing the government to act," said Michael Sinclair of the Kaiser Family Foundation, which funds a nationwide HIV prevention program for youth that is the largest in the world. "When you think about it, that's the history of South Africa."

For example, after Mbeki's government refused to pay for antiretrovirals -- first suggesting they were lethal, then too expensive -- AIDS-ravaged firms such as DaimlerChrysler, DeBeers and Anglo American recently began giving them away to employees. The HIV-positive leader of the nonprofit Treatment Action Campaign, Zackie Achmat, has ratcheted up the pressure by refusing to buy antiretrovirals for himself until the government offers them to the poor. And when studies proved that a drug called nevirapine could block the transmission of HIV from mothers to babies, the Treatment Action Campaign filed a lawsuit, and a judge ordered the government to distribute the drug to pregnant women with HIV.

"People are dying," said Brian Brink, the medical director at Anglo American, where one-fourth of the miners are HIV-positive. "Increasingly, you have to say: Why on Earth are we delaying?"

South Africa has more people infected with HIV than any other country, yet its approach to AIDS is still much less aggressive than those of less economically advanced African nations such as Uganda, Senegal and Botswana. Mbeki mentioned the disease only twice -- and only in passing -- during a two-hour state-of-the-union-style address last month. His government has refused to distribute antiretrovirals to AIDS patients in public hospitals, and even blocked the province of KwaZulu-Natal from accepting a $75 million grant from the United Nations to start distributing the drugs on its own.

Mbeki's party, the African National Congress, was slow to deal with AIDS after the end of white rule in 1994, focusing its energies on economic development and even shutting down clinics that could have helped fight the disease. In many ways, South Africa's medical system still operates in a state of denial.

At Johannesburg Hospital, for instance, there is just one four-hour AIDS clinic a week, with only one salaried doctor, Clive Evian, even though 80 percent of the hospital's patients are HIV-positive. A diabetes clinic is open twice a week.

"Our AIDS patients have a better chance of getting a kidney transplant than they have of getting antiretrovirals," Evian said. "The government has sent the message that AIDS doesn't matter."

But the government's intransigence has been softened by local and international outrage, and there are signs that it could soften more.

Mbeki's finance minister recently announced that the national AIDS budget would triple, and next month officials expect the government to announce a new AIDS strategy that would include at least one pilot program to distribute antiretrovirals to patients in need. The government has also pledged to work out a deal that would let KwaZulu-Natal accept its U.N. grant and has begun providing emergency anti-AIDS drugs to rape victims in public hospitals. Mbeki's aides have talked about setting national targets for reducing HIV rates and creating national awareness days to promote HIV tests.

A recent survey found that HIV prevalence among pregnant women under age 20 had declined for the third straight year.

"Let us join hands so that we can together build on the progress that has been made in the fight against the epidemic, to intensify the campaign of hope," Mbeki's cabinet said in its most recent statement on HIV/AIDS.

"The president is very serious about this," said Tshepo Mazibuko, a government spokesman.

Still, the overwhelming consensus here is that the changes reveal less about Mbeki than they do about South Africa's vibrant democracy. The media have banged away at Mbeki's health policies, lampooning his health minister as "Dr. No" and "Dr. Do Little." Rival political parties have exploited the issue, and Mbeki has even faced criticism within the ANC. At 84, Mandela, who mostly ignored AIDS during his presidency, has adopted the cause as his final crusade, politely but pointedly rebuking his successor.

There have been countless pressure points: Adam Habib, director of the Center for Civil Society at the University of Natal, notes that there are 100,000 unfettered private organizations in South Africa.

"The government isn't the only source of power around here," he said. "It's a sign of maturity. It means that when the government mucks things up, as it has with AIDS, other sectors can rise to the challenge."

It is a monstrous challenge in a country with about 5 million infected people, and with only about 600 of them receiving free antiretroviral drugs from nonprofit groups. (About 20,000 more pay for antiretrovirals through private insurers.)

More than half the country's free antiretrovirals are distributed here in the gritty township of Khayelitsha, at the Doctors Without Borders clinic that hosted Mandela's visit last month.

The clinic began giving away the "AIDS cocktail" -- three antiretrovirals taken in combination -- in May 2001, and like a much larger antiretroviral program in Botswana, the therapy yielded immediate results.

About 90 percent of the patients have improved dramatically. More than 80 patients would have been expected to die within a year without treatment; only eight did. In just six months, the treatment tripled the average patient's CD4 count, a key indicator of the disease's progress, and produced an average weight gain of nearly 20 pounds. Meanwhile, the cost of the drugs has decreased by about two-thirds, to $1.55 per patient per day, and the clinic's HIV tests have increased from 500 to 14,000 per year.

"You can see how the patients with drugs are the patients with hope," said Tempisa Nkompela, an HIV counselor at the clinic.

But there is also a five-month waiting list for the therapy at the Doctors Without Borders clinic -- and it would be much longer if everyone who needed antiretrovirals in Khayelitsha were on it.

Valerie Asselman, a doctor at the clinic, does not even tell patients about the drugs until she feels sure they will get them. "I don't want to build up false hopes," she explained. "We just don't have enough for everyone."

This is true throughout southern Africa: About 30 million people are infected with HIV, and less than one-tenth of 1 percent have access to antiretrovirals. Without hope of treatment, people have little incentive to find out their HIV status. So the tragic cycle has continued, with an estimated 1,700 new infections every day in South Africa alone. Stephen Lewis, the U.N. special envoy to Africa for HIV issues, said the worst epidemic in history was leaving him "emotionally unhinged."

"I don't know how you can see what's happening on this continent and not mobilize as if humankind depended on it," Lewis said. Sometimes, he said, he starts to think that South Africa, the economic and intellectual engine of its region, could steer its neighbors toward more progressive AIDS policies. But then his doubts come back: "They're making changes, but much too late, and it's taking much too long."