When President Donald Trump mused recently about injecting household disinfectants as treatment for Covid-19 in the White House briefing room, South Africans were reminded of their own dark past.
Two decades ago, the country’s health minister announced that beetroot or garlic could treat HIV/AIDS.
South Africa’s president Thabo Mbeki at the time falsely believed that HIV treatments could be poisonous, so he kept proven, lifesaving antiretrovirals (ARVs) from those in need.
In all, South Africa’s official AIDS denials and misinformation cost the lives of more than 300,000 people, according to several studies.
“We can’t have a large number of people dying,” Dr. Yogan Pillay, a senior official at the Department of Health, said. “We came from a period where we had large numbers of South Africans dying from HIV. We can’t repeat that now and we shouldn’t.”
An ambitious initiative
It is the memory of that past failure, South African health officials say, that is driving their fight against this new virus and it is the considerable resources they have since built up against HIV, that could provide their best weapon in fighting Covid-19.
After years of dithering under Mbeki, the South African government drastically changed course against HIV because of civil society lawsuits and a change in leadership.
They put millions of people on ARVs and recruited an army of community health workers to inform the public of the dangers of AIDS and the importance of testing.
They were able to mount this fight, in large part, because of an ambitious initiative launched by another US Republican president.
Former President George W. Bush’s President’s Emergency Plan for AIDS Relief (PEPFAR), announced in 2003, is arguably the single most successful international US public health response.
More than 14 million people are on ARVs because of PEPFAR. When it began, fewer than 50,000 people in sub-Saharan Africa could access the life-sustaining drugs.
“Quite frankly, without the PEPFAR investment in South Africa, we wouldn’t have more than a million people on treatment, a significant reduction in the number of deaths from HIV and TB, or the significant increase in our life expectancy,” Dr. Pillay said.
Pillay said that there are currently roughly eight million HIV positive people in South Africa, with more than two million infected people not on antiretrovirals.
A sweeping lockdown
Those numbers mean that South Africa has the world’s largest HIV burden, which helped to convince South African scientists and officials to recommend a sweeping lockdown as Covid-19 struck the country.
Countries around the world are under lockdown, but South Africa’s is one of the strictest and it was instituted before a single confirmed Covid-19 death and in a country already in an economic recession.
“This was a very tough decision for the government to take,” Dr. Pillay said, “but they took it because they didn’t want to repeat the mistakes of … our early response to HIV.”
In a middle-income country with the world’s greatest levels of inequality, South Africa has managed to drastically flatten its infection curve early while much richer countries like the UK and the United States have struggled to do so.
South Africa has distinct disadvantages to those wealthy nations. Millions live in townships and informal settlements across the country where the lockdowns make sense in principle, but not really in practice.
Townships like Thokoza, in the southeast of Johannesburg, are a nightmare scenario for combating a respiratory disease.
But here, too, the country’s experience with HIV is helping its battle.
Around 35,000 government and PEPFAR supported health workers are now actively screening for the disease in communities they already work, conducting routine health checks, according to Pillay.
They have already screened nearly six million people for Covid-19, according to the latest figures from the country’s Department of Health.
Community health worker Anito Pato said that the trust she has built up with the community allows her to address fear of the new virus right away. She goes door-to-door in Thokoza to check for symptoms of Covid-19 and refer the sick for testing.
“They didn’t know much about Covid-19 and they think it is affecting the rich people, not them,” Pato said. “We try to explain to them why we are screening and what corona is.”
A man in a blue work shirt called Pato over during her visit. He wanted a test. Pato explained that there aren’t enough tests right now and that he should go to the clinic or the mobile testing center they have set up if he gets the symptoms.
“AIDS is better because we have got treatment,” the man, Salvin Tawananda, told CNN, “But corona, people are just scared.”
The government and US Centers for Disease Control (CDC) are closely monitoring efforts in Thokoza and other townships, where social distancing is all but impossible, and failure could be disastrous.
“It is very hard for people here to adhere to those lockdown rules and that is even more reason why we should be out there looking for the disease before it takes over these communities,” said Dr. Meredith McMorrow, a CDC official based in South Africa.
“South Africa was certainly the hardest hit by HIV and it concerns us that it will be the hardest hit by Covid-19 as well that is why we are doing everything we can to get ready right now.”
Covid-19’s effect on HIV patients
McMorrow’s concern comes from not yet knowing Covid-19’s effects on HIV positive people.
To date, studies in China and elsewhere are inconclusive, but Megan Doherty, the head of the WHO’s global HIV program, said it pays to be extremely cautious with any emerging disease.
“Because this is an unprecedented pandemic, we just don’t know how it reacts in all situations,” she said. “We just don’t know enough about the interactions between HIV and Covid-19 and how patients with both infections will do.”
ARVs are being tested as possible therapeutics for COVID-19 in clinical trials.
Dr. Larry Corey, now president and director emeritus of the Fred Hutchinson Cancer Research Center in Seattle, helped develop the first effective ARV treatment.
He said he is skeptical that ARVs designed for HIV will become a broad-based treatment for Covid-19.
“The best ARVs that are discovered are highly specific to each virus,” he said.
Corey, who now leads the global HIV-vaccine trial network, said regardless of the results of ARV trials in Covid-19 treatment, South Africa is well placed to play a critical part in the next phase of this pandemic, because of its HIV infrastructure and experience with HIV vaccine trials.
“I feel proud of my communities,” said Pato, as she moved down a narrow path leading to another section of corrugated iron shacks. “I feel like I am a bullet to shoot this disease. It must not control us. We must control this corona.”