CAPE TOWN, South Africa — The abused and orphaned children in Pastor Julius Bonani's church are the face of an AIDS epidemic that is killing nearly 1,000 South Africans a day and infecting even more.
And yet, the 18 children who live in Bonani's heartbreak home, in a shanty town filled with dust and despair, also personify a tortuous journey toward hope in the country most affected by the AIDS crisis. After a decade of denial under a president who has disputed the cause of AIDS and a health minister who thinks garlic is a remedy, there is growing political will to tackle the crisis.
The challenges are overwhelming. An estimated 5.4 million of South Africa's 48 million people have the virus — the highest total of any country. But after years of pressure from activists, South Africa now boasts the world's biggest AIDS treatment program.
The number of people receiving therapy has more than tripled in just two years, from 143,000 in March 2006 to 456,000 at the end of February, according to government statistics. That's still only half the estimated 900,000 who have developed full-blown AIDS and need treatment, but a national plan launched a year ago aims to provide care and treatment to 80 percent by 2011 and halving the number of new infections.
Abandoned after birth
Some 40,000 children nationwide are receiving AIDS drugs, including the 18 in Bonani's church — children such as Thandiswa, who was found sucking at the breast of her dying mother, her dead twin at her side. And Abina, who still bears the scars of cigarettes her drunken father extinguished on her skin in fury that she had HIV. And Siphosethu, who was abandoned just after birth, smothered in rags, crawling with ants and reeking of festering sores.
They are being transformed into bubbly, bossy 6-year-old Thandiswa; giggling, wriggling Abina; and Siphosethu, whose name means "our gift." They are given their medicine every day with a helping of porridge and a big dollop of love.
"Not one child in our care has died," says Bonani, with a smile. "We are so very, very proud of them."
Bonani and his wife, Lulama, who have looked after their 13-year-old HIV-positive grandson since their own daughter died of AIDS, hope the children in their care will be the last generation infected with HIV through their mother's womb or breast milk.
Mortality rates rise
More than 90 percent of pregnant women with HIV in the Western Cape province around Cape Town now receive drugs to prevent the virus from passing to their unborn children. But in poorer areas like the rural Eastern Cape, the number of women on medication is nearer half.
Health professionals and activists say the biggest test of the government's commitment will be what it does to reduce mother-to-child transmission.
Mortality rates for women and young children are higher now than they were in 1990, before the end of apartheid, according to a study by the Medical Research Council, which said South Africa was one of only 12 countries suffering such increases.
The report, titled "Every Death Counts," said at least 260 mothers, newborns and children under 5 die every day in South Africa, with HIV, AIDS and related infections like tuberculosis and pneumonia responsible for about two-thirds of the deaths.
After four years of delay, Health Minister Manto Tshabalala-Msimang in February issued guidelines that comply with World Health Organization recommendations: Doctors should give two drugs, nevirapine and AZT, to pregnant women, not just nevirapine, because the dual therapy is much more effective than the single drug. It is now up to individual provinces to implement the new strategy.
The Western Cape didn't wait for the official go-ahead. It broke free of the national health ministry's straitjacket in 2004 and prescribed both drugs, slashing mother-to-child transmission to less than 5 percent — compared with more than 20 percent in some other provinces.
Gauteng, home of Johannesburg and the most populous province, and KwaZulu-Natal, the worst affected, started using both drugs at the start of April. KwaZulu-Natal authorities say they hoped to cut the rate of mother-to-child transmission from the current 32 percent to about 10 percent.
Francois Venter, a doctor who heads the Southern African Clinicians Society, said the dual therapy guidelines had "rejuvenated" prevention efforts. "There's quite a vibe about clinics trying to do better than each other," he said. "People are getting excited about trying to fix the problem."
But doctors often have to battle bureaucracy. A clinic in rural KwaZulu-Natal suspended two doctors for giving women dual therapy ahead of its local authorization and other "misdemeanors." The health chief in the province, which is also suffering sky-high rates of TB which feeds off AIDS, makes no secret of her dislike of conventional treatment.
Much of the blame for South Africa's AIDS disaster is laid at the door of its health minister, Tshabalala-Msimang, and President Thabo Mbeki, who gained notoriety after he came to office in 1999 by questioning the link between HIV and AIDS.
Mbeki for years supported Tshabalala-Msimang, dubbed "Dr. Garlic" for her mistrust of AIDS drugs and her espousal of garlic, olive oil and lemon. Instead, he axed her respected deputy, Nozizwe Madlala-Routledge, whom he accused of being insubordinate, but who was a driving force behind the new AIDS strategy launched last year.
Mbeki has said nothing to indicate he has reversed his position on the causes of AIDS, and Tshabalala-Msimang continues to advocate nutritional remedies, although she now extols the virtues of the new national campaign.
"The sustained and expanded national response to HIV and AIDS is beginning to pay some dividends," she wrote in the foreword of a report to the U.N. General Assembly.
Events may simply be overtaking the controversies. Mbeki has only one more year in office. His deputy heads the revamped South African National AIDS Council and has mended fences with activists, and the Treasury has announced a massive increase in spending on HIV.
Jacob Zuma, who is first in line to succeed Mbeki as president, says taming the epidemic is a top priority.
But there is a snag. Zuma was in 2006 acquitted of rape in a trial in which he confessed to having knowingly had unprotected sex with the woman, who had the AIDS virus. His defense: He showered afterward, believing it reduced the risk of infection. He has since apologized and AIDS activists hope he will try to silence his critics by getting tough on AIDS.
'Prevention is just a disaster zone'
Prevention is the weakest link in South Africa's shaky chain.
The Human Sciences Research Council estimated that there were 1,500 new infections per day in 2005.
"For every two people put on treatment, five get infected. It's just unbelievable. You are chasing the tail the whole time," exclaims Venter, the doctor. "Prevention is just a disaster zone."
South Africa is not alone. Major initiatives like the WHO's "3 by 5" campaign, which aimed to put 3 million people worldwide on AIDS drugs by 2005, and much of the Bush administration's AIDS funding, are criticized by experts for focusing on treatment rather than building up the health system, condom distribution or HIV testing.
Male circumcision is the only new tool in the prevention armory. But unlike other African health ministers, Tshabalala-Msimang is skeptical. She says there is not enough information available about its effect on AIDS infection — this despite its endorsement by WHO and UNAIDS, based on "extensive and convincing" evidence that the procedure cuts the risk for infection for men by about 60 percent.
The government says education campaigns among the young are beginning to pay off. The prevalence rate among girls aged 15 to 19 fell to 13.5 percent in 2006, down from 16 percent two years previously.
South Africa still lacks extensive public anti-AIDS publicity, too many of its men still shun condoms, and the biggest obstacle remains the stigma associated with the virus. But Bonani believes that, too, is beginning to change, at least in his community.
When Bonani first took in AIDS orphans, his church congregation vanished. One of his workers was accused of being a witch. But now AIDS is discussed openly in the community, he said, and his congregation is back up to 70, of whom 17 have revealed they have the virus.
"It took them three years to come back and to rebuild the trust," Bonani says, smiling. "Now they apologize, and they accept us."
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