A new study estimates that more than 330,000 HIV-positive South Africans lost their lives between 2000 and 2005 as a direct result of government delays in rolling out a treatment programme.
The report by researchers at the Harvard School of Public Health was published in November in the Journal of Acquired Immune Deficiency Syndromes (JAIDS).
The researchers attributed the deaths to government policies that blocked the distribution of life-prolonging antiretroviral (ARV) drugs long after neighbouring countries had launched such programmes.
Using data from UNAIDS and the World Health Organisation to estimate how many people would have benefitted from ARVs, the authors compared the number of people who actually received the drugs either for treatment or for the prevention of mother-to-child HIV transmission (PMTCT).
Compared with what neighbouring Botswana and Namibia, with similarly severe epidemics and resource constraints, managed to achieve in rolling out treatment over the five-year period, they concluded that South Africa fell far short of what was "reasonably feasible".
Botswana and Namibia were rolling out PMTCT and ARV treatment programmes at a time when former President Thabo Mbeki was still questioning the link between HIV and AIDS, and his health minister, Manto Tshabalala-Msimang, was describing ARVs as "poisons".
The authors pointed out that the South African government declined the offer of free nevirapine from pharmaceutical manufacturer Boehringer Ingelheim in 2000 and delayed the disbursement of a 2002 grant from the Global Fund to Fight AIDS, Tuberculosis and Malaria to fund treatment in KwaZulu-Natal Province.
Botswana's national PMTCT programme had been underway for four years when South Africa finally launched its PMTCT programme in 2003, after a protracted legal battle with the Treatment Action Campaign (TAC), a local lobby group.
A 2001 High Court decision ordering the state to roll out nevirapine was upheld by South Africa's Constitutional Court, which ruled that by restricting the availability of the drug to just 18 pilot sites, the government was violating the constitutional rights of women and their babies. The study authors estimated that the delay resulted in 35,000 babies being born with HIV.
By 2005, South Africa had achieved 30 percent coverage of PMTCT services, compared to 70 percent in both Botswana and Namibia; its ARV treatment rollout had only been underway for a year and had reached 23 percent of those in need of the drugs, compared to 85 percent in Botswana and 71 percent in Namibia.
The authors of the Harvard study suggested that South Africa could have started its ARV programme four years earlier and scaled up coverage as the drugs became cheaper to achieve 50 percent coverage by 2005.
Using UNAIDS estimates of the number of deaths resulting from AIDS in South Africa, they projected that the availability of ARV therapy could have added 2.2 million years to the lives of HIV-positive people over the five-year period. They calculated that a further 1.6 million years were lost due to delays in implementing a PMTCT programme.
Should leaders be held accountable?
South Africa has the highest HIV caseload in the world: of approximately 5.5 million people living with the virus, 350,000 are accessing ARV treatment via the public health sector, while a further 524,000 are still in need of the drugs, according to the TAC.
"Access to appropriate public health practice is often determined by a small number of political leaders," the authors of the Harvard study concluded. "In the case of South Africa, many lives were lost because of a failure to accept the use of ARVs to prevent and treat HIV/AIDS in a timely manner."
Commenting on Friday in The Times, a local newspaper, Zachie Achmat, former chairperson of the TAC, called on South African President Kgalema Motlanthe and the government to hold Mbeki and Tshabalala-Msimang liable for the deaths of thousands of HIV-positive people.
"They should be called to address an independent judicial board so that justice can prevail for those who lost loved ones at their hands," he said. "They must be held accountable."
Dr Francois Venter, president of the Southern African HIV Clinicians Society, noted that Mbeki and Tshabalala-Msimang were not alone in bearing responsibility for deaths resulting from the delay in rolling out treatment.
"I think the Cabinet as a whole needs to account, our leaders need to understand the implications of their decisions; they are very culpable," he told IRIN/PlusNews.
"But everybody should have been out at the forefront challenging this: the churches, the trade unions, civil society," he said. "If it wasn't for a few brave activists and people living with HIV, there would have been a lot more people dead."
Neither Mbeki nor Tshabalala-Msimang, who is now the minister in the Presidency, have responded to the study's findings.