Fighting for treatment: A history of HIV care in South Africa

Twenty years ago, MSF was involved in a revolution in South Africa that would save thousands of lives and forever change the way the world saw and treated HIV.

MSF staff, alongside activists and people dying from AIDS, used mass protests and legal action, first against profiteering pharmaceutical companies and then against the South African government, to fight for free HIV treatment for all.

From clandestinely bringing medicines into the country to providing large-scale treatment, this is the story of a healthcare revolution.

In 1994, as South Africa celebrated its hard-won freedom from apartheid, the country descended into a chilling new crisis. An incurable disease called HIV – which destroys the body’s immune system – was sweeping across the country.

As late as 2001, prominent people maintained that ARV treatment in poorer countries was impossible: that year, Andrew Natsios, director of the United States Agency for International Development (USAID), told the US House of Representatives’ Committee on International Relations: “Rural Africans do not know what watches and clocks are. They use the sun.” Since they wouldn’t be able to take medicines properly, it was pointless trying to provide treatment.

The MSF team were anxious to prove to the scientific community that, contrary to accepted wisdom, ARVs could be safely administered to a poor African community, even outside a hospital setting.

Against opposition, in February 2000, MSF and partners opened a clinic in Khayelitsha township, Cape Town, to treat infected mothers and their partners. The clinic was soon overflowing with patients.

“By the middle of 2000, a few months after we had opened, we had registered several hundred people as HIV-positive,” says Dr Goemaere.

“We were only seeing the sickest of the sick – those who were absolutely desperate. People were brought in on stretchers or in wheelbarrows. The waiting room was packed. Stigma dropped very rapidly because suddenly people realised – it’s not only me…”

But thousands of people were ill. Clinic staff were forced to choose who would live and who would die.

Desperate for generic ARVs, MSF struck an undercover deal with the Brazilian government. MSF Brazil would buy generic ARVs from the Brazilian government and then ship them to their colleagues in South Africa.

However, MSF couldn’t wait for the generics to arrive. Goemaere’s clinic had been running for a year by this time and the situation was dire.

To buy enough drugs to keep patients on treatment, Goemaere visited one of the few pharmacies in Cape Town that supplied them.

The dozen treatments he purchased that day cost more than the second-hand Toyota he was driving. However, it was enough to tide them over until the first consignment of Brazilian ARVs arrived secretly via DHL in November. The first group of patients was switched to generic drugs.

In 2002, the MSF team presented results from the Khayelitsha project at the Barcelona AIDS Conference. The findings were explosive: 91 percent of patients were still on treatment and healthy.

The denialists could no longer ignore scientific fact. In early 2003, a landmark court case brought by the Treatment Action Campaign (TAC) found that two pharmaceutical companies had abused their dominant positions in the ARV market.

Four Indian companies that produced generic ARVs were finally allowed into South Africa.

On 8 August 2003, the South African government made the longed-for announcement that they were going to roll out free ARVs. The battle had been won.

“Looking back at these events, I am struck by how far HIV care has progressed,” says Dr Goemaere, who still works for MSF in South Africa.

“What sounded like medical utopia in early 2000 is now the norm rather than the exception in most sub-Saharan countries. Once we struggled to treat 400 patients and faced the terrible dilemma of selecting who would live and who would die.

“What a relief for clinicians now to initiate any new patient on ARVs, some at their first visit, without having to worry about limited resources.

“This must be among the greatest-ever public health achievements in the history of humankind. It was a struggle in which the best of science joined forces with the best of political will to change the course of the pandemic.

“It was a grassroots victory, with people fighting for their rights and for human dignity, first against pharmaceutical companies and then, unexpectedly, against their own government.”