Leadership determines AIDS performance

As South Africa prepared to swear in a new president on 25 September after the dramatic ousting of Thabo Mbeki four days before, attempts by commentators to summarise the former president's mixed legacy have not failed to mention his controversial stance on AIDS.

AIDS activists and civil society groups have long argued that government commitment and leadership are crucial to the success of national AIDS programmes; in countries like Uganda and Thailand, HIV prevalence declined steeply after leaders made combating the disease a priority.

At the other end of the spectrum, they have linked Mbeki's questioning of HIV as the cause of AIDS and his suspicion of antiretrovirals (ARVs) to a slow and inadequate AIDS response in South Africa. The health department has responded by pointing to its ARV treatment programme, which it describes as the largest in the world.

Nicoli Nattrass, director of the AIDS and Society Research Unit at South Africa's University of Cape Town, decided to test the assumption that having the largest ARV programme in the world demonstrated good leadership in the context of the country's HIV burden, also the largest in the world.

"My suspicion was that South Africa had the resources and institutional capacity to do much better," she told IRIN/PlusNews. "The only way to resolve the issue was to conduct a cross-country analysis to find out what level of [ARV] rollout one would expect for a country with South Africa's characteristics."

Using ARV treatment coverage as a key indicator of commitment to combating AIDS, Nattrass compared 82 AIDS-affected developing countries, taking into account the impact of socio-economic and institutional factors beyond the control of governments.

My suspicion was that South Africa had the resources and institutional capacity to do much better

She found that when it came to implementing effective AIDS policies, good leadership could overcome resource constraints, health system weaknesses and other limitations.

According to an article by Nattrass in the September issue of the Journal of Public Health, a British publication, "The study provides empirical support for much of the conventional wisdom about AIDS leadership at country level."

The reputation of countries like Uganda, Brazil and Thailand as "poster children for good AIDS leadership", for example, was found to be well deserved; considering their relative AIDS burdens and available resources and capacity, their ARV treatment programmes were exceeding expectations. On the other hand, South Africa, Uruguay and Trinidad and Tobago were performing well below expectations.

Commenting on the study, Justin Steyn, a researcher at the Governance and AIDS Programme of the Institute for Democracy in South Africa (IDASA), an independent non-profit public interest organisation, pointed out that a country's ARV rollout was only one indicator of political leadership on AIDS. "It's very difficult to measure leadership; it's a very abstract concept," he told IRIN/PlusNews. "Measuring it through rollout is only one way."

Nattrass responded that although ARV coverage only indicated one aspect of a national AIDS policy, it was the one on which data was most readily available, and also the basis on which South Africa's AIDS leadership was being defended.

"It would have been good to have data on what kinds of drug regimens were being used, on how much treatment literacy there was," she said, "but my study was limited to the available international statistics."

Godknows Giya, another researcher at IDASA, noted that there are many important variables that affect a country's ARV programme, such as weak infrastructure or the affect of stigma on uptake, which the study did not take into account because they have not been captured through data.

In 2007, Nattrass published "Mortal Combat: AIDS Denialism and the Struggle for Antiretrovirals in South Africa", in which she chronicled the alleged influence of dissident AIDS theories on Mbeki and his health minister, Manto Tshabalala-Msimang, and their reluctance to roll out ARV therapy.

She was optimistic that the government's leadership on HIV and AIDS would improve in the wake of Mbeki's resignation this week. "But it depends crucially on who they put in place as the new Health Minister," she said. "Anyone is better than Tshabalala-Msimang."

On 25 September, new President Kgalema Motlanthe stripped Tshabalala-Msimang of her post, reassigning her to a lesser cabinet position.

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