In South Africa, only the funeral industry is booming

Seven-year-old Xolile is trapped inside on a rainy morning, cutting paper hearts in art class. The student at Cotlands Baby Sanctuary, an AIDS orphanage in Johannesburg's dodgy south side, is receiving oxygen but remains dedicated to his task. “I'm going to cut 2 hearts,” he vows.

More heart is exactly what many commentators suggest South African President Thabo Mbeki needs to straighten out his befuddled stance on HIV/AIDS. Mbeki recognizes that his credibility has been harmed by his stance, and this year he is trying to turn things around by injecting more money into handling the crisis. The government has promised to more than double spending on AIDS to one billion rand (about Can$150 million).

Meanwhile, in a population of 44 million, 4.8 million to 5.3 million people are now estimated to be HIV positive. By 2010, a quarter of all South Africans will likely be HIV positive, and up to 6 million will have died. But is an infusion of cash enough to cope with the growing pandemic and salvage Mbeki's reputation?

The president tarnished his and his country's image by questioning the causal link between HIV and AIDS, restricting the use of key drugs and listening to the advice of dissidents.

The government's jaw-dropping attitude reached a new low earlier this year when it refused to comply with a court decision that it had a constitutional duty to offer nevirapine to pregnant women at state clinics and hospitals. In South Africa, it is estimated that a quarter of all pregnant women are infected with HIV. Nevirapine dramatically lowers the transmission rate between mother and child.

“We have our hands tied,” said one hospital's AIDS therapy coordinator, who declined to give his name. “No state institutions are able to offer triple therapy. We treat the complications due to high viral count, but not the cause.”

Now the government says it will provide nevirapine for HIV-positive pregnant women and other antiretroviral drugs for sexual assault victims by year's end. It stopped short of a policy of universal access to antiretroviral drugs for all people living with AIDS. So far, nevirapine use has been restricted to pilot projects, despite Boehringer Ingelheim's offer to provide it for free for 5 years.

But drugs won't solve all problems. Nevirapine might have prevented Xolile's declining health, but it would still have left him an orphan. “If we save the child but don't treat the mother, it just leads to more orphans,” said one doctor.

A report released in January by the University of Natal at Durban states: “The failure to introduce a widespread intervention to reduce the transmission of HIV from mothers to their children is a clear example of how poor leadership in South Africa is contributing to the violation of children's rights — in this case the right to life.” It says the number of children under age 15 whose mothers have died of AIDS is expected to rise from 300 000 to 3 million by 2011.

The country's HIV-related problems are mind-boggling.

· at least 120 000 South African children under age 13 are HIV positive;

· about 1700 people are infected every day, two-thirds of them between the ages of 15 and 20;

· 7000 babies die of AIDS-related illnesses every month;

· AIDS will be the leading cause of death in South Africa within 3 years;

· half of adults can expect to contract the virus during their lifetime;

· life expectancy will plummet from 60 years in the early 1990s to about 40 years in 2010.

AIDS is already a highly visible disease in South Africa, where undertakers bar mourners' cars from cemeteries because they are too crowded, 7 days a week.

Rural villages that depend on migrant labour are rife with the disease, but HIV is not always understood to be an infection. Witch doctors and tribal lore abound — a belief that sex with a virgin can cure AIDS has caused a horrific spike in child-rape cases across the country. Meantime, economists predict that AIDS will cut South Africa's GDP by 2% a year for the next decade.

Few dispute that the country needs more testing facilities that also offer counselling, distribute drugs and train staff. “But do you wait?” said Maureen Kirkman, spokeswoman for the Pharmaceutical Manufacturers Association of South Africa. “Or do you start with a plan where there are [already] facilities?”

With 80% of the population relying on the government for health care, most people are waiting for a government program. Unfortunately, many public hospitals are already in dire financial straits. At least half of admissions to internal medicine and pediatric departments are AIDS related. At the same time, the academic and tertiary care hospitals that house these departments are facing cuts as the government restructures primary care. The Johannesburg General Hospital is operating on a 20% budget reduction for the next year despite facing mounting caseloads because patients are voting with their feet against the new primary care clinics.

But can South Africa ever provide the care that is available in the West? Even health workers acknowledge that universal access to triple therapy in South Africa could cause an influx of desperate refugees from other parts of Africa. “Drug access has to be coordinated across southern Africa,” said one doctor.

Back at Cotlands, director Jackie Schoeman is at a loss to understand government policy. “I don't think anyone knows what's behind the stance on antiretrovirals, unless it is to generate really bad publicity around the world.”

Meantime, young Xolile concentrates on his hearts, oblivious to the turmoil swirling around the disease that is killing him. — Colin McClelland, Johannesburg