nting Mother-to-child Transmission of HIV
in South Africa:
e Study of Civil Advocacy & Policy Change
Melanie E. Campbell, M.Sc.
melanie.campbell@utoronto.ca
University of Toronto, with academic support from the University of Cape Town
Funded by the Canadian International Development Agency
Photo courtesy of the Treatment Action Campaign, http://www.tac.org.za/
Background:
South Africa (SA) is home to the greatest number of HIV+ people in the world.
Studies suggest that the second leading mode of transmission, from mother-tochild during pregnancy and birth, could be reduced by 50% through a
prevention program using a two-dose Nevirapine regimen. The SA
Government initially stalled full rollout of such a program, opting for an 18-site
pilot program instead. In response, an advocacy group, the Treatment Action
Campaign (TAC), successfully challenged and overturned the government’s
policy in court.
Description of Study:
This case study relied primarily on qualitative interviews with 21 policy
stakeholders to understand the historical, political, social and cultural legacies
and beliefs that shaped the Nevirapine policy process. In particular, it
examines the role and activities of the TAC and physicians/researchers in
challenging the government’s initial prevention of mother-to-child transmission
(PMTCT) policy. It further explores the motivations behind this initial
piecemeal policy.
 Macro-sociological factors such as a culture of loyalty within the African
National Congress (the governing party in SA), which seemed to limit most
party members from expressing public dissent against the government’s initial
limited-access policy.
 Resources. First, there are large gaps in the distribution of resources among
and within provinces, particularly for the training of health care providers and
the provision of health services. Second, although the cost of a universal
PMTCT program was partially offset by manufacturer Boehringer Ingelheim’s
5-year Nevirapine donation, the cost of acquiring and training staff, providing
milk formula*, and in some cases refurbishing clinic sites would have to come
from a limited pool of money, already barely able to cover the country’s other
health needs.
ii. Understanding the
Response to Government
This study’s exploration of the roles of two key groups in advocating for
improved access to PMTCT interventions yielded the following insights:
 The Treatment Action Campaign
 The TAC’s strategies were particularly effective for a number of reasons: the
TAC was skilled in grassroots mobilization, honed by some key members’
experiences in the anti-Apartheid struggle, and the TAC was adept at legal and
political maneuvering or “elite” activism, its roots being in the successful
AIDS Law Project.
Results: i. Understanding
the Government’s Role in
PMTCT Policy Development
Based on the data collected for this study, a number of themes emerged which
shed some light on why the South African Government initially adopted a
piecemeal, 18-site pilot program rather than a nation-wide, universal
program, despite evidence that Nevirapine was safe and effective*.
The themes include:
 A post-Apartheid policy environment of relative inaction with respect to
AIDS. One concrete example of this is the limited adoption of the 1994
NACOSA plan for AIDS – the innovative plan was developed through a series
of consultative processes with local stakeholders but only implemented in part.
 Micro-sociological issues such as the disposition of certain key governmental
actors – namely President Mbeki and Health Minister Tshabalala-Msimang.
These two actors were seen as central to the PMTCT policy issue.
 Grassroots mobilization: With public education strategies and programs
for school children, the TAC is seen as a visible community member and
voice for many people living with HIV/AIDS.
 Elite activism: The TAC’s court case demonstrated their political savvy,
high level understanding of scientific and technical detail, as well as their
ability to engage NGOs and researchers internationally.
 Physicians/Researchers
 Physicians and researchers advocacy efforts included writing affidavits for
the TAC court case, educating patients, creating income-generation
projects for patients and their families, as well as more covert forms of
advocacy.
 Covert activism: A number of physicians had found ways to subvert the
government’s “official” limited-access program, for example, by getting
donations to purchase drugs or by setting up research programs with drug
provision as part of the protocol.
*This issue, as well as ALL of the results listed on this poster are far more complex than implied here. For more details and further analysis a
summary paper with the same title as this poster, as well as the full text thesis (from which both the summary and poster are derived) are available
for public access at:
http://individual.utoronto.ca/melaniecampbell
Please contact the author at melanie.campbell@utoronto.ca if you have trouble downloading these files, or with any questions or comments.

The author would like to thank Peri Ballantyne, Solomon Benatar, Richard Lee, Bev Chalmers, Terry Sullivan and
especially the participants of this study, for providing valuable input and making this research possible.