Why are we asking this now?
The South African leader has just announced a barrage of new HIV and Aids commitments that he bills as "the opening of a new era" in the fight against the disease.
Jacob Zuma used World Aids day on Tuesday to make a rhetorical break with the denialism of his predecessor Thabo Mbeki and meet what most health experts agree are the major policy commitments needed to arrest the crisis and start to diminish the impact of the pandemic in the country it hits harder than any other.
What did he say, and how can we be sure he meant it?
While it is obviously important what he said and the detail of the policies, it matters politically how he said it and what he chose to emphasise. The new policies call for earlier treatment for all patients diagnosed with Aids or tuberculosis, the biggest killer of HIV positive people; a huge expansion of HIV testing; for pregnant women to receive anti-retroviral drugs (ARVs) to reduce the number of infected babies being born; and for all babies who test positive to receive drug therapy.
In rhetorical terms the normally macho Mr Zuma made moves to remove the stigma which still clings to the country's biggest killer of young adults. In the audience for the address was the daughter of Gugu Dlamini, a woman stoned and stabbed to death in 1998 after revealing on a radio show that she had HIV. "To families looking after sick relatives, we wish you strength," Mr Zuma told a live television audience.
"We understand what you are going through. To those who have lost their loved ones to the epidemic, we share your pain and extend our deepest condolences." The showman president's very public embrace of those living with the disease may be as powerful as policy changes.
How bad is the HIV/Aids crisis in South Africa?
So bad the statistics are almost impossible to digest. The country of 50 million has some 5.3 million people infected with HIV, by far the highest number of any country in the world. There have been an estimated 413,000 new infections this year alone. Someone dies of HIV-related illness every two minutes in South Africa.
There are still nearly 1.5 million people with HIV not getting ARVs, of whom more than 100,000 are children. This despite the fact that South Africa has more patients on AR drug therapy than any other country, a massive burden on a developing country with a chronically stressed national health system.
If you spotlight almost any demographic, horrifying figures emerge: one third of all South African women between ages 25-29 are HIV positive; there are 1.4 million Aids orphans and experts believe that one third of all children in the country will have lost one or both parents to the disease by 2015. Practically the only bright spot is that the rate of new infections has plateaued. But the number of HIV-related deaths will continue to soar for the next five years.
How does this change things?
Hugely. At present life-prolonging anti-retro viral drugs that have transformed the life expectancy of HIV sufferers in the industrialised world are only available to HIV positive South Africans whose immunity levels have already fallen dangerously low. The latest accepted diagnosis for identifying the point where HIV becomes full blown Aids is with a count of white blood cells. When the CD4 or T-cell counts are lower than 200 or 14 perent of total white blood cells, it's Aids.
Currently, this is the mark public hospitals wait for before they will dispense ARVs. From April 2010, pregnant women and patients with both tuberculosis and AIDS will receive treatment if their CD4 or T-cell counts are 350 or less.
This is in line with WHO guidelines for reducing the number of fatalities from the pandemic through earlier treatment.
How was Zuma's talk of a new era received?
With near universal acclaim. Sharing the stage with the president was Mark Heywood from the highly respected Treatment Action Campaign, an independent group that has challenged the South African government on Aids. He said the speech would have a global impact: "It was a very good speech in all its aspects — the empathy he showed, what he said about prevention and the need to test for HIV was all very positive."
Britain's Department for International Development said: "South Africa has turned a corner and is embarking on a new and bold drive to take responsibility for tackling HIV and Aids." UNAIDS executive director Michel Sidibe, who was also on the podium shortly before Mr Zuma, told the president: "What you do from this day forward will write, or rewrite, the story of Aids across Africa."
Can South Africa actually afford to keep its new promises?
This is the biggest question mark remaining. South Africa is emerging from its first post-Apartheid recession; the Zuma government came to power promising to deliver on jobs, healthcare, infrastructure and a wealth of other commitments that look increasingly hard to afford. Spending on HIV and Aids will, in this context, have to increase by 20 per cent each year until 2014.
The detailed answer to this question is hindered by the absence of reliable statistics – a consequence of the disastrous Mbeki years in which the richly incompetent Tshabalala-Msimang presided over the health ministry.
The South African mantra of "service delivery" that has been struck up in response to corruption, incompetence and the perception that taxpayers don't get their money's worth, chimes with the management of the HIV and Aids crisis. Despite adequate funding for the purchase of ARVs there are chronic shortages in many areas and long queues everywhere. Even if the money is there it's not clear that it's being spent effectively.
Why is there so much scepticism about Zuma in relation to Aids?
Jacob Zuma is an unlikely Aids hero. He will forever be marked by his disastrous testimony during his rape trial – a charge on which he was acquitted – in which he admitted to having unprotected sex with a woman he knew to be HIV positive and then showering to avoid catching Aids. Many feared that the macho, polygamous Zulu elder would make a poor role model for a society facing an existential threat from an often sexually transmitted disease.
However, his vow to go and get tested, although he claims to already know his status, was a departure from the Mbeki approach and a step in the direction of the more magnanimous Nelson Mandela. In the depiction of Zapiro, the country's legendary cartoonist, Mr Zuma almost always has a shower attached to his head. In a recent cartoon where he is seen trying desperately to cut it off, he is advised to start acting more "presidential" and it may fall off by itself. Perhaps he was listening.
Have we seen the worst of Aids in South Africa?
* New plans for extended and earlier treatment for pregnant women and babies will save lives
* The inclusion of tuberculosis in broader treatment acknowledges its impact on Aids deaths
* It decisively breaks the denialism of Mbeki and compares Aids with (the ultimately defeated) apartheid
* It remains unclear how South Africa is going to pay for such an ambitious programme
* This doesn't address the current failures in the health system which are unrelated to policy or funding
* Zuma is still standing in the way of fully accounting for past failures demanded by trades union leadersReuse content