Almost a year after announcing that he would withdraw from the AIDS controversy in South Africa (SA), President Thabo Mbeki has returned to the fray. He wrote a letter to Health Minister Manto Tshabalala Msimang asking her to reconsider government spending on AIDS because it was not the country's major cause of mortality. The letter was leaked to the SA newspaper Business Day in September.

Mbeki had used out-of-date (1995) figures from the World Health Organization's website to question the view that AIDS had become the major cause of death in the country. According to these figures, “external causes” such as violent deaths or accidents, were the major cause of mortality, while AIDS ranked only 12th. “Needless to say, these figures will provoke a howl of displeasure and a concerted propaganda campaign among those who have convinced themselves that HIV/AIDS is the single biggest cause of death in our country,” Mbeki wrote.

Two weeks later this was followed by the leak of a SA Medical Research Council (MRC) report showing that AIDS has indeed become the leading cause of mortality in the country, having caused the deaths of 40% of people aged between 15 and 49 last year. For the past five years, the MRC has been assessing patterns of HIV mortality for the period 1985–2000. A draft summary of its findings was distributed to government departments in May.

“I do not want to fuel the controversy and I am sure President Mbeki did not see it before writing the letter,” MRC President Malegapuru Makgoba told the Financial Times. Makgoba has confirmed that the MRC decided subsequently not to release the report publicly until it has been distributed among policy-makers.

Despite this, Tshabalala Msimang has made veiled threats to the MRC. She was reported as saying that council workers, “who themselves are government employees, have chosen to act in ways which place themselves in a hostile position vis-à-vis the government, and it will be necessary for this serious situation to be attended to.” The MRC is a statutory council that relies on state funding for two-thirds of its income.

Opposition Democratic alliance leader Tony Leon has criticized the government for not using “information it has commissioned,” and said last month in a speech that “Most disturbing of all is that deaths of children under 5 years is expected to triple by 2010.”

The MRC's figures are supported by independent reports of the increasing prevalence of HIV in the country. Last month, the company Anglo American, which employs 160,000 people in sub-Saharan Africa, declared that it could not afford to supply anti-retroviral drugs to all its HIV/AIDS-infected workers, as 21% of its employees in SA are HIV-positive. Treatment costs around R1,500 (US$164) a month, and most large employers have shied away from commitments to providing drugs.

Neither are AIDS drugs being made available by the government despite its legal victory over the Pharmaceutical Manufacturers' Association six months ago to obtain cheaper drugs (Nature Med. 7, 390; 2001), and the substantially reduced cost of treatment. A new report issued by the aid group Medecins sans Frontières states, “Only one year ago prices of antiretroviral drugs put them out-of-reach of the vast majority of people living in developing countries. But as a result of international pressure and generic competition, prices are being reduced considerably” (see http://www.accessmed-msf.org/index.asp).

And although nevirapine, which is used to prevent mother-to-child transmission, has been available at no cost since July last year, the government continues to refuse to provide it throughout the public health system. As Nature Medicine went to press, the government was due to respond to a lawsuit brought by the activist group Treatment Action Campaign and over 250 health workers for failing to do so.

Some pharmaceutical companies have taken their own initiatives and signed drug-licensing agreements within SA. For example, GlaxoSmithKline concluded a deal last month allowing the country's largest generic manufacturer, Aspen Pharmacare, to produce zidovudine and lamivudine, which compose the most widely used anti-retroviral combination in SA.