VERVENA, South Africa — A fading roadside ad for Selala Funeral Service here captures what was, until recently, the essence of South Africa’s AIDS epidemic: “Tombstones Are Available,” it reads. “Buy One, Get One Free.”
Not long ago, even places like Vervena, a blip on the roadside northeast of Pretoria, supported several funeral parlors.
But in the last few years, “we’ve managed a miracle,” said Dr. Salim Abdool Karim, one of the country’s leading AIDS researchers. “Undertaking is not a business you want to go into anymore.”
As recently as 2008, the AIDS epidemic in South Africa was out of control, hampered by the indifference of President Thabo Mbeki, Nelson Mandela’s successor. Death was everywhere.
Now the country has won high praise from world AIDS experts for its response, especially at a time when the Ebola virus has spread in West Africa.
South Africa has 2.4 million people on antiretroviral drugs, far more than any other country, and adds 100,000 each month. Five years ago, 490 clinics gave out those drugs; now 3,540 do. Only 250 nurses were trained to prescribe them then; now 23,000 are. (The figures, from the end of 2013, are the most recent available.)
Mother-to-child transmissions have dropped by 90 percent, new infections have dropped by a third, and life expectancy has increased by almost 10 years.
“South Africa takes this very seriously and has made major, major progress,” said Michel Sidibé, the executive director of Unaids, the United Nations agency fighting the disease.
But experts say much of that progress is now in jeopardy.
Though few Americans or even South Africans realize it, the nation owes much of its success to a single United States program, the President’s Emergency Plan for AIDS Relief, or PEPFAR, started in 2003 under President George W. Bush. It has poured more than $3 billion into South Africa, largely for training doctors, building clinics and laboratories, and buying drugs.
Now that aid pipeline is drying up as the program shifts its limited budget to poorer countries, so the South African government must find hundreds of millions of dollars, even as its national caseload grows rapidly.
The country has 6 million infected and 370,000 new infections a year. That is seven times as many new infections as in the United States, which has six times the population. Condom use is dropping, according to a new survey, and teenage girls are becoming infected at alarming rates.
Still, Dr. Aaron Motsoaledi, the national health minister, says he is confident South Africa will find the money and the political will to fight on.
“It’s a logistical problem,” he said. “Any country in the world would be shaken by putting 2.4 million people on treatment quickly. But it’s not as if we have any choice. If we don’t, they fill up the hospital beds and ICUs. It’s becoming easier for Treasury to give me what I ask.”
Dr. Ian Sanne’s Right to Care chain of clinics, which treats 203,000 patients in five provinces, is an example of the fruits of American largess.
In a country where public hospitals use hand-scribbled paper records and are infamous for long waits, Right to Care’s Johannesburg headquarters has an electronic medical records system so fast that a nurse can read a tuberculosis test result delivered by a $17,000 GeneXpert machine and click a box that types a prescription directly into the patient’s record. Within 17 seconds, a German-made robotic arm in the clinic’s pharmacy can pluck that drug from the shelf, print a label, and drop it down a chute to be handed to the patient.
“We opened in 2004, with 100 percent PEPFAR money,” Sanne said.
Right to Care, like many other AIDS treatment programs here, owes its existence to a decision that year by PEPFAR to help South Africa quietly, almost clandestinely, while the Mbeki administration was still in power.
In poor countries with broken health care systems, PEPFAR paid American medical schools to run its programs. South Africa, by contrast, had excellent doctors and hospitals, but Mbeki’s health minister, who claimed garlic, beetroot and lemons could cure AIDS, forbade public hospitals to give out AIDS drugs.
Mbeki was finally ousted in an internal African National Congress power struggle in 2008; by that time, Harvard researchers calculated, his policies had cost 365,000 lives.
In the interim, PEPFAR had supported private practitioners like Sanne, Dr. Hugo Tempelman of the Ndlovu Care Group and Dr. Helen Rees of the Wits Reproductive Health Institute in Johannesburg.
“It was a gracious, unpretentious and right thing to do,” said Justice Edwin Cameron, a judge on the country’s highest court who began taking AIDS drugs back when they cost him a third of his salary. “You empowered us and let us get on with it.”
Because South Africans are sensitive about needing any foreign help, the aid is still given with little fanfare. Many clinics have only one sign of their roots: a modest brass plaque with PEPFAR’s globe-and-red-ribbon logo.
“I’ve had visiting congressional delegations upset that America gets no recognition for saving lives while China gets visibility for building an airport in Mozambique,” Rees said.
The country received $350 million from PEPFAR last year, according to Dr. Eric Goosby, who ran the program until last November. That figure will shrink to $250 million by 2016.
“We need to move on to places like Burundi and Cameroon,” Goosby said.
While very poor countries rely almost entirely on donors, South Africa now pays 83 percent of its own costs. But it struggles to do so. Patients overwhelm understaffed public clinics. And as evidence mounts that it is best to put patients on drugs as soon as they test positive rather than waiting until their immune systems falter, the national caseload will triple.
Sanne complained bitterly about cutbacks, Goosby said, and got “bridge money” to prevent layoffs from his well-trained staff.
“Our stay of execution,” Sanne said, laughing.
‘Corruption and Pilferage’
Closing private clinics can have dangerous consequences. When one Durban hospital abruptly went bankrupt after its PEPFAR grant expired, its 4,000 HIV patients were told to report to public clinics near their homes — places that many HIV patients avoid for fear of being spotted and shunned by their neighbors.
A Harvard-sponsored survey found that nearly 20 percent of those 4,000 patients did not renew their prescriptions at their local clinics.
In theory, because PEPFAR pays for the care of about a million South African patients, a similar dropout rate nationally would mean that 200,000 patients were not in care and were at risk of developing drug-resistant strains, said Matthew M. Kavanagh, the author of a study of South Africa for Health GAP, an American medical advocacy group.
Motsoaledi, South Africa’s health minister since 2009, has won high praise from AIDS experts and even from advocacy groups that are often at odds with him.
Asked if there was any chance that the United States, having received little credit for helping from 2004 on, would now be vilified for pulling out, he said: “No, I personally will never allow that. Because this would never have happened without America.”
How well the country can do on its own remains to be seen. It has world-class doctors; the first heart transplant was done in Cape Town in 1967. But public hospitals and the drug supply chain are overseen by local governments, where corruption and incompetence are common.
The country was recently scandalized by the death of “Baby Ikho,” a chubby 1-year-old who was hospitalized with simple pneumonia but died slowly because the hospital administrator ordered oxygen only after it ran out.
The doctor who reported the death, blaming the administrator, was fired for doing so.
Last year, Section 27, a health advocacy group, surveyed South Africa’s pharmacies and found that 20 percent had sometimes run out of drugs for AIDS or tuberculosis.
Mark Heywood, Section 27’s executive director, said the problem was theft from government warehouses by local officials. Some of those officials stayed in office even while facing criminal charges because they supported President Jacob Zuma’s wing of the deeply factionalized ANC, he said.
Motsoaledi agreed that those warehouses were sites of “corruption and pilferage” and said that he was making hospitals order directly from manufacturers or from one national warehouse. Corrupt officials would not be protected by connections, even to the president, he said.
“My hands are not tied by any faction,” he said. “We will destroy them.”
His greater worry, he said, was that forces outside the country would push up the prices of newer AIDS drugs by preventing the import of generic versions. Some South Africans still receive older drugs no longer prescribed in wealthier countries.
In January, Doctors Without Borders released documents it obtained outlining a secret campaign planned by a Washington lobbying firm hired by the pharmaceutical industry. It proposed forming a fake grass-roots organization called “Forward South Africa” advocating stronger patent laws against generics.
Motsoaledi publicly denounced the plan as “satanic” and “genocidal,” and the pharmaceutical lobby dropped it after some of its members quit in protest.
Motsoaledi said he was confident that he would eventually be able to pry enough money out of government to treat everyone.
“If we don’t,” he said, “we make TB worse, cervical cancer goes up, even leprosy returns. From whatever angle you look at, it’s cheaper to treat people early. The treasury minister understands that. It’s becoming easy for him to agree.”