Dazed and confused: the reality of Aids treatment in South Africa

Ian Hodgson
11 January 2006

HIV has always been more than simply a virus: wherever it strikes there is controversy, panic and confusion. In 2005, heated debate around aid allocation policy, and the morality of certain HIV prevention strategies were prominent in the discourse. As always, access to Aids treatments was also high on many agendas, not least because December 2005 marked the end of the World Health Organisation’s “3x5” initiative: a two-year campaign to provide 3 million people globally with anti-retroviral medication (ARVs).

The campaign fell short of its target by about 1.8 million, and this deficit highlights another major controversy that continues to blight Aids care provision and treatment in South Africa. The country with the most people infected with HIV is paradoxically also the place where there seems to be most controversy. In 2000, President Thabo Mbeki publicly questioned links between HIV and Aids, aligning himself with a small group of largely United States-based Aids denialists. Now, Dr Matthias Rath, perhaps the most controversial nutrition-specialist since Robert Atkins, seems to have the ear of South Africa’s health minister, Mantombazana Tshabalala-Msimang.

Also in openDemocracy on the global challenge of HIV/Aids:

Bill Bowtell, “HIV/Aids: global policy after Bangkok” (August 2005)

Jeremiah Norris, “Misleading the poor isn’t a policy: a response to Bill Bowtell”
(August 2004)

Donna M Hughes, “The ‘ABC approach’ to global HIV/Aids: good for women and girls” (August 2004)

If you find this material valuable, please consider supporting openDemocracy by sending us a donation so that we can continue our work for democratic dialogue

Who is Matthias Rath?

Matthias Rath is a German-born medical researcher who over the years has gained increasing prominence as one of a growing number of scientists who challenge orthodox views of the HIV epidemic and the treatment of affected people. According to Rath, anti-retroviral medications (ARVs) for Aids are harmful and essentially ineffective; their endless promotion by drug companies and international agencies is simply a product of economics and corporate greed.

Instead, he promotes a nutritional alternative through which, the Rath Foundation website claims, “millions of lives can be saved now – naturally”. This “natural” approach is a cocktail of vitamin supplements, amino acids, minerals and trace elements that the Rath Foundation claims are able to reverse the symptoms of Aids. Rath cites empirical evidence supporting his view of ARVs and of the benefits of a nutritional approach. Through 2005 has been putting on show people with Aids who have apparently eschewed ARVs in favour of the Rath approach, with dramatic results. In a country where the demand for ARVs outstrips supply by a factor of four, news of an alternative is for some miraculous.


Rath has attracted a firestorm of criticism from scientists, activists, and academic institutions whose work he claims justifies his theories. The Harvard School of Public Health for example, famously distanced itself from Rath in May 2005, after he cited findings from a study in Tanzania published by the school as confirming his views. Harvard, in a press statement, said: "We condemn these irresponsible and misleading statements as in our view they deliberately misinterpret findings from our studies to advocate against the scale-up of antiretroviral therapy."

On various fronts, Rath has been accused of opportunism, hypocrisy, of being a charlatan, and trading on Aids misery. The Treatment Action Campaign (Tac), a highly vocal and influential NGO in South Africa, which for years has advocated that the 600,000 or so affected people still without medication gain more access to ARVs, accuses Rath of promoting pseudo-science.

At the end of November 2005, in an action supported by the South African Medical Association, Tac sued the government for not taking a more robust stance against Rath’s activities in the country and demanded a report from the health minister, Mantombazana Tshabalala-Msimang. This action is a clear indication of increasing concern not just over the theories promoted by the Rath Foundation, but also over allegedly unethical trials in Cape Town’s townships, and unscrupulous recruitment of treatment recipients. This accusation was given some credibility recently when, according to one news report in October 2005, two people with Aids whose improving condition had been attributed by the Rath Foundation to nutritional supplements, had been on ARVs all along.

Science, relativism and South Africa

The refusal of the South African government to condemn Rath outright has caused widespread consternation: indeed, the health minister has appeared with Rath, and seems to go out of her way to promote the benefits of nutrition – food “just like our grandmothers used to make” – to maintain the health of people living with HIV/Aids.

Why has this situation come to such a point? Two considerations are important in understanding and learning from this debacle: the possibility that the issues at stake may simply be a matter of perspective (that, in other words, Rath could have a point), and that the controversy could be the product of political and economic expediency.

The first consideration may on the surface have some merit. Science and the community have never been easy bedfellows. The “transitional truth” of science – an assumption that today’s theories may be discounted tomorrow, and that “truth” is generally in a state of flux – never rests easy with a public who desire certainty, especially in a context so sensitive and charged as HIV/Aids.

The nutrition versus ARV debate could be an example of the usual rough and tumble of the adversarial world of scientific discourse, taking place in the public domain instead of behind the closed door of a laboratory. Overt criticism of Rath – beyond the context of scientific debate – could therefore be premature, and contribute towards a situation similar to the debate in Britain over the alleged side-effects of the MMR (measles, mumps and rubella) vaccine, where public disagreement amongst scientists has stoked public confusion.

Rath’s accusation of the predatory behaviour of the drug companies that manufacture ARVs also has a kernel of truth. Drug companies are often responsible for maintaining high prices, and holding onto drugs patents for as long as possible: Brazil’s government went head-to-head with the pharmaceutical company Abbott in July 2005 in a bid to wrestle the patent of ARV Kaletra from the company, in order to provide a cheaper generic alternative.

The year also saw vigorous spats at the World Trade Organisation and G8 over proposed (though not as yet fully realised) flexibilities on trade-related intellectual property rights (Trips) in relation to ARVs, confirming that rules of trade are not readily eschewed for public-health imperatives.

Also by Ian Hodgson on openDemocracy:

“ Loaded but lonely: the moralisation of US aid policy”
(November 2005)

However, the credibility of the notion that Rath is simply a victim of an inflexible and over-bearing scientific community breaks down over his foundation’s recommendation that people with Aids use nutritional support in place of ARVs, rather than the more orthodox view that the two can be part of a holistic package of care. The sheer number of studies – from a range of sources – that demonstrate the benefit of ARVs, suggest that any position that does not include these must be challenged; and by the criteria of the “transitional truth” notion, Rath has produced no substantial data yet to justify outright rejection of ARVs. Rath therefore cannot and should not make the claims he does.

The second consideration in this drama, that the sluggishness of the South African government in condemning Rath may have ulterior political and economic motives, also has evidence to draw on. A policy that implicitly supports a nutritional alternative to ARVs could distract attention from the appalling lack of progress in access to Aids-medications. The roll-out of ARVs in South Africa is painfully slow: this is the wealthiest and one of the most stable nations on the continent, yet of the 840,000 people who require ARVs, estimates for the end of 2005 suggest that only around 200,000 (up from 104,000 in September 2004) will have access.

The “dash” for ARVs that started in the 1990s has created immense problems for South Africa economically. But is has also become a matter of national pride: why should developed countries dictate to South Africa about how it should tackle HIV? The health minister, speaking of “3X5” in June 2005, stated that “nobody had asked South Africa” what they thought of the proposal; instead it was imposed from Geneva. Seeking an African solution to an African problem has for South Africa been implicit in a number of policy developments: and the emphasis on nutrition could be one example.

The politics of confusion

Political motives or not, the serious faultlines across the landscape of South African public policy are of concern; foremost among them a lack of cohesion and clarity in information for the millions of people currently affected by HIV, and a worrying tendency to align with views that are at best unorthodox, at worst a threat to public health.

Andrew Feinstein, chair of the London-based NGO Friends of the Treatment Action Campaign (FoTAC), says the South African government must take more responsibility, for its “refusal to encourage people who need them to take ARVs, confusing public messages, and the slow pace of the roll out of treatment are significant contributory factors in the death of Aids-related causes of over 800 South Africans every day”.

The government’s 2003 “Operational Plan for Comprehensive Care and Treatment for people living with HIV and AIDS” was hailed by many as the most radical on the continent, but this potentially rational approach is being obfuscated. The result will be what FoTAC most fears – hundreds of thousands of people with Aids but without immediate access to ARVs, attracted to the as yet unproven Rath solution.

As always with such confrontations, it is the HIV-affected person who is disenfranchised, caught in the crossfire of political rhetoric, and forced to wait for experts to come up with a solution for a fatal disease. Since the fall of apartheid, South Africa has made remarkable progress politically: but it is sad that in the greatest threat to the nation’s health, there remains a level of confusion and lack of cohesion that could yet be its nemesis.

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