Zackie Achmat, once at the centre of South Africa’s push for lifesaving HIV treatment, has come out of retirement as US funding cuts and his own government’s inertia revive old fears.
Twenty-five years ago, Achmat co-founded what became the most powerful social movement in post-apartheid South Africa, leading a showdown against the government that won lifesaving medical treatment for millions of people with HIV.
Until just a few months ago, Achmat (63), thought those days were well behind him, reports The New York Times. He was spending time on a pomegranate farm, caring for rescue dogs and watching Korean telenovelas. He made a failed bid for Parliament on an anti-corruption platform, but was enjoying watching new generation of activists lead.
As for HIV, the issue that once dominated his life, he hardly thought about it. He didn’t need to, so robust was the national treatment programme that grew out of the victories he and his colleagues won two decades ago.
Then came January, and the Trump administration’s decision to slash its foreign assistance, including funding for the President’s Emergency Fund for Aids Relief, or Pepfar. As part of an overall reduction in funds sent overseas, which Trump has called wasteful and a misuse of taxpayer dollars, Pepfar’s budget has been sharply reduced.
South Africa received $440m from Pepfar each year, paying the salaries of thousands of nurses, data managers and others who worked on the HIV programme. All of it was eliminated. The clinic in Cape Town where Achmat collected his medication closed overnight.
If any country is able to maintain HIV services without US help, it is South Africa. It has the continent’s most developed economy, and its government purchases most of its own HIV treatment.
But in an eerie echo of history, the government has been near-silent about its plans, an approach that has stirred an old anxiety in Achmat and others, and spurred them into action once again.
In the first days after the cuts began, Health Minister Aaron Motsoaledi said that the government was making a plan, and that there was no cause for panic.
“Nobody must stop taking ARVs,” he said. “We will do everything in our power, because that will be dangerous for the individual and the country as a whole.”
But weeks passed, and Motsoaledi said little else.
Achmat and others waited to hear if the government would step in and reopen the closed clinics, create jobs for 15 000 health care workers who were paid by the United States, and put back on the roads the vans that dispensed medication to sex workers and drug users. They expected a task force, like the team the Health Ministry assembled during the Covid-19 pandemic.
Doctors, researchers and activists wrote open letters and demanded meetings with the government.
Dr François Venter, a veteran HIV clinician in Johannesburg, wrote a widely circulated article titled, South Africa’s HIV programme is collapsing – and our government is absent.
Motsoaledi responded with a lengthy statement laying out reasons the country’s HIV programme was not at risk. The US funds were just 17% of its budget, he said, and people who received health services from a US-funded clinic could proceed to their local public one.
So ended Achmat’s retirement.
In May, he gathered a small crew of veterans of his movement, the Treatment Action Campaign (TAC), to confront health officials holding a public meeting on tobacco policy.
They filed into a hotel conference room and found seats among Members of Parliament and bureaucrats. Dr Sibongiseni Dhlomo, a senior Health Department official, opened the proceedings, and as he began to speak, Achmat rose to his feet.
“Mr chairperson,” he interrupted. “We sent you a letter asking for a meeting. We haven’t heard from you.”
Dhlomo was affronted. “Enough,” he said. “We won't allow this. You won’t disrupt this meeting.”
Achmat erupted. “People are dying! If you had any respect you would listen to us.”
Dhlomo scoffed. “Those days are over.”
The meeting became a melee and parliamentarians bellowed for security.
Achmat trembled with a rage that seemed to have transported him back 20 years.
Seeking justice
An early veteran of the fight against apartheid, who was first jailed and beaten for protesting white rule at 14, he became a zealous organiser for the ANC.
In 1990, as the country was beginning its transition to multiracial democracy, he learned he had HIV. The news landed like a death sentence, but it turned out he was among the rare people whose bodies control the virus naturally for some time, so he threw himself into the work of building the new country.
It was a heady time, but the impact of HIV was increasingly visible: 600 people a day were dying of Aids.
In high-income countries, HIV had become a chronic, not fatal, illness managed with medications.
But in South Africa, treatment cost at least $15 000 a person a year, a king’s ransom, so Achmat announced the launch of the TAC, a movement to get access to affordable drugs.
It swelled with black women from poor communities, who were galvanised out of secrecy and shame at their HIV diagnosis. They targeted protests at multinational pharmaceutical companies, which blocked South Africa's attempts to bring more affordable Asian-made versions of the medications into the country.
Achmat was, by then, weakened by the disease, but he announced a drug strike: he would not take ARVs until everyone in South Africa could get them.
After much bad publicity, the drug companies began to lower their prices in 2001. But the government refused to buy the medicine.
Then-President Thabo Mbeki questioned whether drugs produced by big foreign companies were actually lifesaving, and surrounded by conspiracy theorists who said that HIV did not cause Aids, refused to provide the treatment through the public health system.
Achmat and the TAC turned to civil disobedience tactics and were arrested in the thousands at sit-ins. And, using a tool of the new South Africa, they sued the government for access to lifesaving treatment.
Achmat continued his drug strike, growing sicker and sicker, before Nelson Mandela came to his bedside and entreated him to end his strike, donning the “HIV positive” T-shirt Achmat had made famous, and aligning himself with the protesters.
The Mbeki Government lost in court and finally capitulated in the face of mass public pressure. In 2003, the national treatment programme began. Achmat took his medication and within weeks had shed the chronic infections in his lungs and gut.
Over the next 20 years, South Africa's treatment programme became the world's biggest and one of the best run. In the first 11 years that the drugs were widely available, life expectancy rose by more than a decade. The activists of the TAC put away their signature T-shirts and moved on.
Until the announcement by the Trump administration.
As public criticism mounted, Motsoaledi said that there were drugs on the shelves in public clinics – people needed only to go and collect them.
Public health experts were exasperated. They heard, in the government’s response, an echo of the Mbeki days.
“Why are we so embarrassed to say we need help?” said Professor Glenda Gray, CEO of the South African Medical Research Council (SAMRC), who oversees a major HIV research centre that had lost a huge hunk of its budget from the United States.
Last week, Motsoaledi announced emergency funding of $33m for the HIV programme, about a tenth of what Pepfar gave the country.
It is difficult to know exactly what is happening to that programme, partly because the ministry has not explained its plans and partly because so much of the data collection was US-funded.
Some people who used Pepfar-run services have transitioned to the public system, which reported a rise in users, but it’s not clear how many. Tens of thousands of people have lost access to HIV prevention as a result of the cuts. Testing rates have fallen, according to the National Health Laboratory Service.
Most clinics are still dispensing drugs, and while lines are long, and nurses are overworked, the programme has not collapsed.
And yet the Health Ministry and activists are once again fiercely at odds.
Achmat said he suspected they would need to use the courts – as they did 20 years ago – to force the government to engage.
His home is scattered with memorabilia, including framed newspaper cuttings of huge TAC demonstrations; he looks at them ruefully now.
“I can't believe we’re doing this again,” he said. But he reckons he has a reputation for relentlessness that this moment requires. “If they see me,” he said of government officials, “they’ll shake in their bloody boots.”
The New York Times article – A Venerable AIDS Activist Returns to Battle (Restricted access)
See more from MedicalBrief archives:
Urgent action needed to reduce ARV clinic stockouts – Treatment Action Campaign
Activist Zackie Achmat to receive honorary doctorate from UCT
HIV testing drops after aid cuts, but Minister denies system collapse