AIDS treatment activists have long criticized the South African government for its AIDS policy, especially the limited availability of medicines that can potentially save many lives. The drugs are only accessible at a few sites around the country, and some government leaders continue to express doubts about whether they should be offered at all.
In a small, dusty marketplace in Khayelitsha Township, workers unloading a truckload of vegetables know only too well what AIDS can do.
"This thing of HIV now, it is all over, and I think everyone now knows about it because they see people are dying of it," said Gerard Tshoko.
Gerard Tshoko says the situation might be bad here in Khayelitsha,but it is even worse in his home village in the rural Eastern Cape province. There, he says, there are no HIV clinics like the one less than a block from here, which distributes the AIDS-fighting drugs known as anti-retrovirals.
"And you see that thing is only here, Khayelitsha Site-B, not all over South Africa. You go to Eastern Cape, nothing like that, and people are dying all over!" he said.
Mr. Tshoko lowers his voice to barely a whisper as he tells two reporters that he knows many people who attend the special AIDS clinic around the corner, where they receive anti-retroviral therapy and other treatments for HIV-related illnesses. Two other clinics provide the same services to patients in other parts of Khayelitsha.
The program's administrator, Emi MacLean, says that when it opened three years ago, skeptics said nobody would be willing to attend clinics just for AIDS patients, because they would not want to admit they were HIV positive. The stigma is just too strong. But more than two years later, she believes the program is working.
"People are definitely coming. They know that specialized care is something that is beneficial for them," she said. "And they have heard now not just from people who are HIV positive and dying, which people had heard from before, they have also heard from people who are HIV positive and living, and benefiting from anti-retroviral therapy. So definitely word of mouth is the best advocacy tool."
The difference, she says, is the drugs. Anti-retroviral therapy can reduce the amount of HIV, the virus that causes AIDS, to almost undetectable levels in a patient's bloodstream.
Ms. MacLean says some patients who are near death when they start the treatment recover to an extent that seems almost miraculous. They gain weight, an average of 8.8 kilograms, and almost entirely stop suffering from opportunistic infections such as tuberculosis and thrush.
She believes having treatment available for AIDS patients gives people an incentive to get tested for HIV, and therefore should help stop the spread of the virus.
The Khayelitsha clinics are run by the international charity, Doctors Without Borders, sometimes known by its French initials, MSF.
Ms. MacLean says the group established the clinic in part to prove to the government that the drugs really do work, and that they can be administered effectively in impoverished communities.
"It is not necessarily a question of how long we can keep doing it, it is how long we need to keep doing it," she said. "Obviously the end goal of this is not to have MSF developing HIV clinics that provide anti-retroviral therapy throughout South Africa, but to be demonstrating that it can work, so that the government will be providing them throughout South Africa. That is what we really want and need to happen, and that is what the people of South Africa want and need to happen."
The South African government was reluctant to begin widespread distribution of anti-retrovirals, and only began doing so after a group of activists took officials to court. President Thabo Mbeki is seen as the skeptic-in-chief, having said repeatedly that he believes the drugs are toxic, and having expressed doubt about whether HIV even causes AIDS.
Mr. Mbeki's main objections relate to the side effects experienced by some patients taking anti-retrovirals. Ms. MacLean says among the Khayelitsha patients, most side effects have disappeared after about three-months of treatment.
The president has also complained that the drugs are too expensive for the South African government to afford. When the clinic opened two years ago, the treatment cost about five dollars per person per day. But since then, the drugs have gotten much cheaper, a little more than a dollar a day. The clinic was set up to treat 80 patients with anti-retrovirals, and is now able to treat about 350 with the same funding.
Finally, the president feared the anti-retroviral regimen was too complicated to be properly administered in impoverished, largely illiterate communities. But Khayelitsha is one of the poorest communities in the Western Cape province, and more than 85 percent of their patients have recovered well enough to lead relatively normal lives. Only 13 patients have died, mainly because they were already too sick when they started the treatment.
Analysts say the government's AIDS policy, and especially its reluctance to support anti-retroviral therapy, is helping fuel a growing sense of dissatisfaction among its own staunch supporters.
At the vegetable market near the clinic, Gerard Tshoko's uncle, Joseph Tshoko minces no words when asked whether he thinks the government is doing enough about AIDS.
"I do not think so. I do not think so," he said, and answered: "I can not comment on that," when asked if the president, Thabo Mbeki doing enough.
Joseph Tshoko and President Mbeki both come from the Eastern Cape province. They speak the same language, Xhosa, and belong to the same political party, the African National Congress. In the South African political culture, it is very unusual for ANC members to criticize their leaders, at least in front of outsiders.
The clinic administrator, Emi MacLean, says at first, the president's stance kept people away from the clinic. She believes solid positive results are helping change their minds.
"There are a lot of people, I think, within the ANC who believe and know that anti-retroviral therapy can be effective for themselves, for their country, for their constituency," she said. "But they have been quieted by the strong oppositional stance that the Ministry of Health and national leaders have taken. And I think in order for the policy to change in South Africa, the people within the ANC who know what is right need to take a [stand]. And I think they are going to have to before too long."
Former President Nelson Mandela is not bound by the ANC's rules of political decorum. He is a legend in South Africa, and has become increasingly outspoken on the AIDS issue. Ms. MacLean says Mr. Mandela, who visited the Khayelitsha clinic last year, has opened a window for other ANC members to break with the president.
Doctors Without Borders is hoping to force that window open even wider. The group is in the process of opening up a new clinic in the Eastern Cape, the ANC stronghold from where the Tshoko family hails [comes]. The co-sponsor of the Eastern Cape clinic is the Nelson Mandela Foundation.