As economist Dr Nicoli Nattrass argues in this article first published in Business Day, the burning question is not the compexity of rolling out antiretroviral therapy, but how much money government will allocate to AIDS interventions. Dr Nattrass is a professor in the School of Economics at the University of Cape Town and Director of the AIDS and Society Research Unit.

The cabinet has given the Health Minister until the end of September to develop a ‘€˜detailed operational plan’€™ for rolling out antiretroviral drugs.   This announcement has been welcomed with jubilation and the Treatment Action Campaign has called off its programme of civil disobedience.    

To the extent that the government’€™s announcement represents a genuine shift in policy, such delight and relief is understandable.   At least the cabinet appears to have accepted that antiretroviral treatment is an important weapon in the fight against AIDS.     Not only do antiretrovirals prolong life, but they also save lives by preventing new infections.   This is because people on antiretrovirals have lower viral loads (and hence are less infectious) and will have been counselled about safer sex.   AIDS treatment is thus an important dimension to an AIDS prevention strategy.    

 What is puzzling about the general response to the government’€™s announcement is the lack of critical commentary.   No one seems to be asking the obvious question:   why do we need a detailed operational plan to start providing treatment?   As the experience of Brazil, and now Botswana, shows very clearly, there is only one way of rolling-out a treatment plan: start where capacity exists and expand outwards from there.     South Africa already has the capacity in many places.   In the Western Cape alone there are fifteen sites which could start dispensing antiretrovirals tomorrow.   They have the doctors, the infrastructure and the monitoring systems.   All they need is the drugs.   Similar sites are available in Gauteng and Kwa-Zulu Natal.

 Botswana, which has a similar per capita income to South Africa and much higher HIV prevalence levels, started providing treatment in the major urban hospitals after three months of planning.   Yes, they recognised that providing antiretroviral treatment is not as simple as dispensing asprin (as our Health Minister once famously said).   And, yes, they recognised that by starting with the large hospitals, people living with AIDS in rural areas were relatively disadvantaged.   But they did not let these challenges freeze them like a rabbit in the headlights.   Instead of calling for a ‘€˜detailed operational plan’€™, they simply did their best.   Now, after 18 months of experience with treatment, the results are encouraging.   Eighty-five percent of patients have experienced complete viral load suppression.   By delaying the roll-out of treatment in South Africa, we are denying many people the same life-prolonging (and life saving) benefits.

According to the Health Minister, South Africa cannot move forward because government is ‘€œnot happy with the costing yet’€.   What is her problem?   Not only are there more costing studies available here than in any other developing country, but the South African studies are the most sophisticated available.   Unlike in Brazil and Botswana, South African researchers (including the government’€™s own Health and Finance Task Team) had access to top-quality demographic modelling work, as well as cost data from hospitals and antiretroviral pilot treatment sites.   We already know far more about costs than Brazil or Botswana did before they started treatment.  

Part of the reason we have so many costing studies (including my own) is in response to the government’€™s long-standing discourse of ‘€˜unaffordability’€™.   For the past two years, government has been arguing that antiretroviral treatment is complex, problematic and, above all, ‘€˜unaffordable’€™.   The various costing studies ‘€“ including that of the government’€™s own task team ‘€“ show that this argument has no basis: antiretroviral treatment is expensive, but within the bounds of the feasible.   It is affordable if society wishes to make the necessary sacrifice in terms of forgoing spending on other priorities and/or accepting an increase in taxation.  

Public debate is needed over the level of resource allocation for combating AIDS. The government’€™s discourse of unaffordability effectively forestalls such debate.   Now, it appears, there is a danger that government may be using a different silencing discourse.   Instead of being told that antiretrovirals are ‘€˜unaffordable’€™, the public is now being spun the line that providing treatment is a very complex exercise which requires a high-level ‘€˜detailed operational plan’€™, sophisticated monitoring systems, etc before we can act at all.  

 National planning and co-ordination is obviously required to provide a sustained supply of low-cost drugs and to ensure that the supply of testing services grows in line with the treatment roll-out.   But the bulk of the required planning and capacity-building needs to be done on a case-by-case basis at hospital, district and provincial levels.   If government is serious about a roll-out, then medical practitioners need to take ownership of the treatment programme in their areas and to start thinking how to integrate it with other health services (including, most obviously, TB).    

The extent of the treatment roll-out will ultimately be constrained by the amount of money that government chooses to allocate to AIDS interventions.   This is the burning issue ‘€“ not the complexity of the roll-out per se.   And it is this issue which needs far more social deliberation than it has yet received.   We must not let this new discourse of complexity silence public debate on how South Africans, as a society, should respond to the AIDS pandemic.  

Nicoli Nattrass is a professor in the School of Economics at UCT and Director of the AIDS and Society Research Unit.