PILLS, POWER, AND HISTORY: SITUATING THE SOUTH AFRICAN HIV/AIDS EPIDEMIC

The South African HIV/AIDS epidemic has retained a unique position within the academic literature due to its late emergence and the political dynamics that arose in response to demands for HIV/AIDS treatment. While the HIV/AIDS epidemic developed in Central and West Africa during the 1980s, it was not until the late 1990s that HIV prevalence rose to comparable levels in South Africa (Iliffe Reference Iliffe2006). The confluence of internal migration, social violence and high levels of social inequality led some to characterise it as an epidemic ‘waiting to happen’ in South Africa (Marks Reference Marks2002). However the extent to which the autoimmune syndrome spread within the country was undoubtedly facilitated by slow government action to implement HIV/AIDS treatment and prevention initiatives based on ART. By some measures, the government's lack of decisive action with the provision of HIV/AIDS treatment prematurely ended the lives of some 330,000 South Africans (Chigwedere et al. Reference Chigwedere, Seage, Gruskin, Lee and Essex2008).

The politics of HIV/AIDS in South Africa has garnered extensive attention from academic analysts, primarily due to the circumspect position taken by leading members of the ANC on the relationship between HIV and AIDS. During the administration of former President Thabo Mbeki (1999–2008) several senior party officials – including the Minister of Health – delivered public messages that questioned the scientific link between HIV and AIDS. The analyses that have ensued have characterised the AIDS dissident position as an extension of President Thabo Mbeki's personal beliefs (Comaroff Reference Comaroff2007; Gevisser Reference Gevisser2007; Nattrass Reference Nattrass2007), as a refraction of apartheid's racial ideology (Fassin Reference Fassin2007), as a means of securing the support of traditional leaders (Susser Reference Susser2009), and as a rejection of transnational biomedical norms (Youde Reference Youde2004, Reference Youde2007). While these perspectives elucidate the elements that constitute AIDS dissidence, they have often correlated the actions of a specific faction of the ANC with the party as a whole. In investigating how power is exercised and/or maintained in South Africa, the focus here will be on the ways that members of the ANC's AIDS dissident faction utilised – and the HIV/AIDS movement interacted with – the institutions of the South African state.

The case of HIV/AIDS in South Africa necessitates recasting the analysis of power beyond the scope of internalised discipline and ideology to include those infected and affected by the epidemic. More specifically, power can also be understood here to involve access to life-extending medical treatment and control over the resources that enable individuals to make educated decisions about their health and sexual relationships. While government officials delivered obfuscating messages on the epidemic, non-state and community-based organisations educated infected and affected communities via HIV/AIDS outreach programmes. This focus on education and treatment has served as the central pillar of the South African HIV/AIDS movement since the early 1990s.

While these activities have gravitated towards state-controlled public health infrastructure, they have been not under the direct control of the ruling party. In contradistinction to these programmes, orthodox HIV/AIDS treatment is based upon antiretroviral drugs (ARVs), which are controlled substances in South Africa. Given this status, the availability of ARVs is contingent upon control over state institutions. Key state institutions in this regard include the Medicines Control Council, Medical Research Council and the Department of Health. It is to these and other state institutions that this analysis will turn in its investigation of the power dynamics of HIV/AIDS in South Africa between 1999 and 2008.

INSTITUTIONAL DYNAMICS AND THE RISE OF AIDS DISSIDENCE, 1999–2004

The 1999–2004 period in South Africa was marked by the impact of neoliberal macroeconomic policies, the emergence of the AIDS dissident faction of the ANC, and a series of legal victories by the South African HIV/AIDS movement that forced the ruling party to implement ART in the public health sector. During the ANC's first years in power, policy decisions were restricted by the inheritance of apartheid debt, the transnational economic orthodoxy of the Washington Consensus, and the ability of unfettered finance capital to undermine the fragile politico-economic consensus that had emerged out of the transition. In this context, members of the ruling party espoused a circumspect view of international economic forces, including the political economy of the global pharmaceutical industry (Schneider Reference Schneider2002: 152). These views became associated with a political platform that enabled the ANC to mobilise its core constituency through appeals to nationalist sentiment and a critique of the unequal impact of globalisation on the Global South: AIDS dissidence (Gevisser Reference Gevisser2007).

The development of the AIDS dissident position began shortly after the ascension of Thabo Mbeki to the position of President and his appointment of Dr Manto Tshabalala-Msimang to the post of National Minister of Health. Soon after her appointment in 1999, Tshabalala-Msimang introduced a key dimension of the ideology of AIDS dissidence: the toxicity of ARVs. Visiting a clinical trial of zidovudine (AZT) in Uganda, Tshabalala-Msimang declared that no programme using the drug for the prevention of mother-to-child transmission (PMTCT) would be initiated in South Africa before the Department of Health had run its own trials (Fassin Reference Fassin2007: 54). President Mbeki further questioned the toxicity of AZT during an address to the National Council of Provinces in October 1999 (Fassin Reference Fassin2007: 54). These statements from the leadership of the ANC came despite the fact that AZT had been proven to significantly cut the rate of mother-to-child transmission of HIV five years earlier (Musoke Reference Musoke2004).

However by February 1999 the Western Cape Department of Health had gone ahead with its own PMTCT programme. With the province's health department under opposition political control, it had tested nearly six hundred women for HIV and given AZT to ninety-six women who were close to giving birth (Fassin Reference Fassin2007: 53). The National Department of Health intervened to stop this ‘experimental’ programme. The Minister of Health then called upon the Medicines Control Council to review the safety of AZT for the prevention of mother-to-child transmission of HIV (PMTCT) in November 1999. In halting the implementation of PMTCT in the Western Cape, the AIDS dissident faction of the ANC utilised the jurisdictional hierarchy of national institutions to prevent or limit the use of ARVs in the public health sector to prevent HIV transmission.

The rise of the AIDS dissident faction of the ANC also influenced the composition of national institutions. The South African National AIDS Council (SANAC) was formed in January 2000 when the Inter-Ministerial Committee on AIDS was amended to incorporate broader societal representation. This was due in part to revised guidelines for international donor funding that required the inclusion of additional civil society representatives (Papadakis Reference Papadakis2006). While this appeared to be a step towards a more open approach on HIV/AIDS policy, the newly formed SANAC did not include any medical practitioners, scientists, representatives from the Medicines Control Council, members of the Medical Research Council, or prominent HIV/AIDS activists (Butler Reference Butler2005: 594). The omission of biomedical practitioners underscored the role of noted AIDS dissident and Minister of Health, Dr Manto Tshabalala-Msimang, in the establishment of SANAC (Butler Reference Butler2005: 594). As is evidenced by the composition of its personnel, SANAC operated within the confines of AIDS dissident political control and thus did not break with party leadership on the issue of ART.

However the clearest manifestation of the formal institutionalisation of AIDS dissidence came with the establishment of the Presidential Advisory Committee on HIV/AIDS in March 2000. This committee was comprised of international HIV/AIDS experts and individuals espousing dissident views on the scientific link between HIV and AIDS. Orthodox AIDS scientists found the process to be demeaning, as it was an opportunity for AIDS dissidents to have their views represented in official state documentation (Susser Reference Susser2009). The ‘inconclusive’ findings of the Presidential AIDS Advisory Panel Report (2001) reinforced the reality that the panel – purportedly comprised of international experts – included members who did not see a causal link between HIV and AIDS. In this case, the office of the Presidency enabled the AIDS dissident faction of the ANC to establish an institutional mechanism that furthered a scientifically questionable viewpoint on HIV/AIDS.

The increasingly public profile of the AIDS dissident position came to international attention at the 13th International AIDS Conference held in Durban, South Africa in July 2000. Through international networks of AIDS activists, the Treatment Action Campaign (TAC) organised a march of 5,000 people at the conference (Geffen Reference Geffen2010: 54). The protest action railed against the obfuscation of HIV/AIDS science by the South African government and demanded access to ART in the South African public health sector. The TAC had emerged as the leading non-state organisation in the South African HIV/AIDS movement following its inception in 1998. Expanding the base of HIV/AIDS activism by organising poor and working class Black South Africans, the TAC took a strategy of direct action in demanding HIV/AIDS treatment and prevention programmes.

As the South African HIV/AIDS movement grew in strength from the Durban conference, the ANC dissident faction's dependence on state institutions to counter orthodox responses to the epidemic intensified. In the aftermath of the conference, the President of the Medical Research Council came under attack for an analysis of the effect of HIV/AIDS on mortality rates in South Africa. Statistics South Africa critiqued Dr William Makgoba's utilisation of apartheid-era statistics in this study, while President Mbeki characterised the Medical Research Council as ‘irresponsible’ (Fassin Reference Fassin2007: 64). The ANC leadership's furore over the mortality statistics continued with an attempt by the Minister of Health to block the publication of the Medical Research Council report in September 2001 (Schneider Reference Schneider2002: 150). These events led to the dismissal of Makgoba and the appointment of Dr Anthony Mbewu as President of the Medical Research Council. Mbewu was an Mbeki ally who purportedly supported his views on HIV/AIDS (Geffen Reference Geffen2010: 129).

While national institutions were transformed to limit the influence of the South African HIV/AIDS movement on national policy, the TAC focused on making the antiretroviral drug, nevirapine, available in the public health system. This was a feasible goal given that the German pharmaceutical company Boehringer Ingelheim had offered the drug to developing countries free of charge since late 2000 (Boehringer Ingelheim Reference Boehringer2008). Despite this the South African government announced that it would not expand the use of nevirapine for PMTCT beyond a pilot programme at two public hospitals per province in April 2001 (Annas Reference Annas2003: 750; Jones Reference Jones2005: 439–40). This stance galvanised the South African HIV/AIDS movement because the efficacy of nevirapine in preventing mother-to-child transmission of HIV had already been established in the scientific community by 1999 (Guay et al. Reference Guay, Musoke and Fleming1999).

The ANC's decision to exclude nevirapine from the public health sector's PMTCT protocol led the TAC and Aids Law Project to take legal action against the government. The leading organisations of the South African HIV/AIDS movement argued that the unequal provision of nevirapine violated the right to health in South Africa. In July 2002 the Constitutional Court ruled that the limited use of nevirapine ‘violated the health care rights of women and newborns under the South African constitution’ (Annas Reference Annas2003: 751). However the ruling party had relented prior to this ruling and Tshabalala-Msimang announced that nevirapine would be made available in the public health sector in April 2002 (Thom Reference Thom2002).

The legal challenge to ensure that all South Africans could benefit from the efficacy of nevirapine-based PMTCT led to the expansion of the HIV/AIDS alliance. Particularly significant was the support the TAC received from members of the ruling party and the Congress of South African Trade Unions (COSATU), the labour federation that constitutes one third of South Africa's governing alliance. This alliance reflected an acceptance of the TAC's demand for ART among members of government and began a process of isolating the President, Minister of Health, and other members of the AIDS dissident faction within the party (Geffen Reference Geffen2010: 58). While these events highlighted growing divisions within the state regarding HIV/AIDS, they also presaged the rejection of AIDS dissident views by the leadership of the ruling party.

In May 2002, ANC Cabinet members publicly broke rank with the President by announcing that HIV caused AIDS. While some analysts have pointed to the ‘cabinet revolt’ as a sign of democratic processes with the ruling party, this decision also concretised the fissures within the ANC on AIDS dissidence (Butler Reference Butler2005). Around this time leading TAC activist Zackie Achmat claimed that half of the cabinet was sympathetic to the demand for ART by the HIV/AIDS movement (Friedman & Mottiar Reference Friedman and Mottiar2005). In addition, both COSATU and the South African Communist Party publicly criticised Mbeki's position on HIV/AIDS (Fourie Reference Fourie2006). While it has been postulated that the TAC used its relationships with the members of the tri-partite alliance ‘instrumentally’ to achieve mass mobilisation, this interpretation neglects that these organisations represented South Africans whose socio-economic rights were violated by the ANC's intransigence in implementing ART in the public health sector (Jones Reference Jones2005: 434–5).

Despite a growing tide of resistance, the AIDS dissident faction of the ANC was still able to limit the availability of ART in the public health sector. Under the leadership of noted AIDS dissident, Tshabalala-Msimang, the National Department of Health acted slowly in implementing the Constitutional Court decision to provide nevirapine in the public sector. Thus, while the TAC had scored a victory in the legal sphere, institutional control of the Department of Health by AIDS dissidents limited the impact of this event. This lack of action led the South African HIV/AIDS movement to pressure the government to draft a comprehensive AIDS treatment programme that included ART. In late 2002, HIV/AIDS activist and Aids Law Project member, Mark Heywood, announced a deal had been reached on such a policy within the National Economic Development and Labour Council (NEDLAC). However the ANC denied that an agreement had been reached and business leaders sided with the ruling party in backing out of the draft agreement (Geffen Reference Geffen2010: 62).

Frustrated by the slow pace of implementation for nevirapine and the failure of the NEDLAC HIV/AIDS agreement, the TAC planned a series of protest actions that grew into a civil disobedience campaign against the government. This process began with the ‘Stand up for our Lives’ march led by the TAC and COSATU at the opening of parliament on 14 February 2003 (TAC 2003). This protest received the support of former President Nelson Mandela, had the participation of trade unions COSATU and the Federation of Unions of South Africa, and numbered between 10,000 and 15,000 people (Geffen Reference Geffen2010: 63). At the conclusion of this march, COSATU and the TAC handed a memorandum to government officials to demand that they re-initiate the policy negotiations that had been derailed in NEDLAC by the end of the month (TAC 2003). When this deadline passed, the TAC began its civil disobedience campaign to pressure the ANC to adopt a comprehensive HIV/AIDS treatment plan.

The civil disobedience campaign consisted of the TAC leading several marches to police stations and public events where they demanded the arrests of the Minster of Health and other leading ANC figures for culpable homicide (Geffen Reference Geffen2010: 64). The campaign tested the TAC's alliance with COSATU, as the trade union body saw these actions as a threat to overthrow the state (Ranchod Reference Ranchod2007: 13). Following the decision by the TAC to suspend the civil disobedience campaign at the end of March 2003, COSATU negotiated with the Ministry of Health to restart talks for the NEDLAC plan (COSATU 2003). While the NEDLAC draft agreement was not implemented at that time, it did serve as a precursor to a comprehensive HIV/AIDS treatment plan adopted later in the year.

The adoption of the HIV and AIDS Care, Management and Treatment Plan (Comprehensive Treatment Plan) was predicated on negotiations between the TAC, COSATU and a moderate faction of the ANC led by then Deputy President Jacob Zuma. Acting as an intermediary between the HIV/AIDS movement and the government, Zuma met with the TAC's leadership and promised to commit the government to a treatment plan if the organisation ended its civil disobedience campaign (Geffen Reference Geffen2010: 68). Zuma kept his promise; the South African cabinet instructed the Department of Health to draft an operational plan for ‘rolling out’ ART in August 2003 (PlusNews 2004). Along with the adoption of the Comprehensive Treatment Plan, the ANC leadership agreed to restructure SANAC to allow for more representation from civil society in December 2003 (SANAC 2010). While this in part was to align the institution with revised guidelines for international donor funding, the influence of HIV/AIDS activists is rumoured to have played an important role in this process (Papadakis Reference Papadakis2006: 61–2).

As senior members of the ruling party opened space for HIV/AIDS activists in national policy and incorporated ART into state institutions, the AIDS dissident faction intensified their dissemination of heterodox views on HIV/AIDS. This process had begun with the circulation of the ‘Castro Hlongwane’ document at an ANC National Executive Committee meeting held from 15–17 March 2002. This document, whose authorship has been attributed to Mbeki by some, elaborated the AIDS dissident position at length and blamed the death of presidential spokesperson, Parks Mankahlana, on the consumption of ARVs (Kenyon Reference Kenyon2006). The document was reportedly posted to the ANC website and distributed within ANC branches around this time (Marais Reference Marais2005: 22).

During the same year, the Minister of Health offered her public support for an alternative HIV/AIDS treatment called ‘Africa's Solution’. Thus, a vitamin-based nutritional supplement accompanied by the consumption of garlic, lemons and olive oil was deemed to be an appropriate HIV/AIDS treatment by a key state figure (Cullinan Reference Cullinan2005). Director General of Health, Thami Mseleku, confirmed that the creator of ‘Africa's Solution’ – nutrition nurse Tine van der Maas – had been invited by provincial health ministers to conduct voluntary work with HIV/AIDS patients at public hospitals in five provinces (Cullinan Reference Cullinan2005). Van der Maas's nutritional approach to HIV/AIDS was validated by the participation of provincial health ministries and the backing of senior officials in the National Department of Health.

ART ROLLOUT AND THE TRANSFORMATION OF AIDS DISSIDENCE, 2004–2008

During the 2004–2008 period, the TAC and its allies faced continued resistance from the Ministry of Health despite renewed international support and a joint government–civil society mechanism for overseeing the provision of AIDS treatment. While the HIV/AIDS alliance continued to create space within national institutions to influence policy decisions, the ANC dissident faction's control over the organs of the South African state proved to be decisive in limiting the ‘rollout’ of ARVs. In addition, the AIDS dissident faction of the ruling party supported non-state organisations in developing initiatives that tested and distributed scientifically unproven HIV/AIDS treatments in communities infected and affected by the epidemic. Through this, the AIDS dissident faction of the ANC effectively outflanked the South African HIV/AIDS movement's attempts to control the national public health response to HIV/AIDS.

Despite the success of the HIV/AIDS alliance in pressuring the government to adopt an orthodox AIDS treatment policy, this period began with the Department of Health initiating patients on treatment at a rate far below than what the Comprehensive AIDS Plan had required. As the April 2004 national elections loomed the South African HIV/AIDS movement threatened legal measures to speed up the government's ‘roll out’ of ARVs (Geffen Reference Geffen2010: 69). Following this, the Ministry of Health agreed to purchase antiretroviral drugs. The apparent need for oversight on policy implementation led non-state and community-based organisations to form the Joint Civil Society Monitoring Forum (JCSMF) in June 2004 (TAC 2005). This umbrella organisation exerted pressure on the government to speed up the slow accreditation process, purportedly the key factor slowing down implementation (IRIN 2004; Geffen Reference Geffen2010: 70).

By the end of 2004 only 15,000 patients were on ARVs nationally, and by March 2006 less than one-third of the projected patients were on treatment (Susser Reference Susser2009: 167; Wouters et al. Reference Wouters, van Rensberg and Meulemans2010: 178). The issue was not funding, as the National Treasury supported the treatment initiative. The funds allocated for HIV/AIDS rose from R213 million in 2001 to R1·439 billion in 2004/5 (Wouters et al. Reference Wouters, van Rensberg and Meulemans2010). The incorporation of ARVs into the public health system was undermined by a health minister who ‘dragged her heels’ in addressing a human resource crisis, problems with the drug procurement process and a slow accreditation process for the distribution of ART (Nattrass Reference Nattrass2008: 166–7). The exercise of institutional power was also evident with the expiration of the HIV/AIDS/STD Strategic Plan (2000–2005). This left the planning for HIV/AIDS treatment separated from the medium-term budgeting framework upon which future allocations for the epidemic would be based.

Concurrently, the AIDS dissident faction of the ANC developed alliances with non-state organisations that disseminated alternative views on HIV/AIDS treatment. Senior ANC figures developed ties with organisations such as the Dr Rath Health Foundation Africa (Rath Foundation), founded by German vitamin salesman Dr Mattias Rath. In March 2004, the president of the Medical Research Council, Dr Anthony Mbewu, reportedly met with Rath and suggested building ties with the National Association of People Living with AIDS (NAPWA) to ‘counterattack’ against the HIV/AIDS movement (Geffen Reference Geffen2010: 129). It should be noted that this meeting closely coincided with the government ceding the fight on the inclusion of ART in the public health sector.

The Rath Foundation instead developed an alliance with an organisation that had long-standing ties to the ANC, the South African National Civics Organisation (SANCO). This partnership set out to test and distribute a micronutrient-based vitamin regime. SANCO was arguably the preeminent organisation in South Africa's black townships during the anti-apartheid struggle, acting as a de facto local government in these areas during the 1980s. After having faced financial difficulties following the political transition, SANCO has emerged as an intermediary between the ANC and communities in resolving issues such as service delivery (Seekings Reference Seekings1996, Reference Seekings1997; Zuern Reference Zuern2002, Reference Zuern, Ballard, Habib and Valodia2006; Heller Reference Heller, Tomlinson, Beauregard, Bremner and Mangcu2003). This partnership between a respected civics organisation and a foreign non-state organisation was represented to the residents of Khayelitsha – a township located on the outskirts of Cape Town – as providing alternative treatment that could cure HIV/AIDS.

SANCO members staffed Rath's clinics, circulated pamphlets through its branch office, and recruited patients to stop taking ARVs in order to adopt the untested vitamin regime in early 2005 (Geffen Reference Geffen2010: 142). The Rath Foundation asserted that the vitamin-based pills it had distributed were a cure for AIDS and subsequently published these claims in newspaper advertisements in May 2005 (Cullinan & Thom Reference Cullinan and Thom2005, Nattrass Reference Nattrass2008: 169). The results of Rath's vitamin-based treatment were also presented to provincial ministers and the national Minister of Health over the course of 90 minutes at a meeting of the National Health Council in September 2005 (Cullinan & Thom Reference Cullinan and Thom2005; Geffen Reference Geffen2010: 144). When questioned about Rath's trials in parliament by the political opposition, Tshabalala-Msimang agreed to distance herself from the vitamin-based treatment only if it turned out to be ‘poisonous’ (Cullinan & Thom Reference Cullinan and Thom2005).

While the Rath Foundation had the backing of a powerful faction within the ruling party, it had not received official sanction for conducting a clinical trial in Khayelitsha.Footnote ¹ The Rath Foundation's activities were never registered with the Medicines Control Council, but a government investigation of the Rath Foundation's activities was discontinued (Cullinan & Thom Reference Cullinan and Thom2005). The TAC responded to these events by filing a complaint with the Medicines Control Council and the Department of Health in February 2005 (TAC 2008). The organisation then mobilised broad public support for government intervention to stop the Rath Foundation's actions, including the South African Medical Association (SAMA), COSATU and public health workers from the Western Cape (Cullinan & Thom Reference Cullinan and Thom2005). The lack of state action to stop the distribution of Rath's vitamins led the TAC and SAMA to take legal measures in November 2005. The court case focused on the false claims of the Rath Foundation and the Western Cape Department of Health's inaction in preventing these activities (Nattrass Reference Nattrass2008: 170). The legal case continued until June 2008, when the Cape High Court ruled in favour of the TAC and SAMA (Gray & Jack 2008: 43).

Despite the South African HIV/AIDS movement's legal challenges, the AIDS dissident faction of the ANC continued to utilise its control of state institutions to limit the influence of HIV/AIDS activists on policy. After having been re-elected as the President of South Africa in 2004, Mbeki had named Nozizwe Madlala-Routledge as the Deputy Minister of Health. A member of the South African Communist Party with a history of social activism, Madlala-Routledge had begun holding meetings with the TAC in 2005 (Ministry of Health 2005). As HIV/AIDS activists made inroads into the state institution that had previously served as a roadblock to the dissemination of ARVs, the Minister of Health blocked Madlala-Routledge from holding further meetings with TAC leaders (Geffen Reference Geffen2010: 71). Barring the TAC from meeting with the Deputy Minister of Health proved to be a short-sighted decision as it led then Deputy President Phumzile Mlambo-Ngcuka to become involved with the political struggle between the Department of Health and the TAC (Geffen Reference Geffen2010: 71–2). The support of a powerful new ally in the Deputy President led to the HIV/AIDS movement participating in the drafting of a new national AIDS plan.

The process of drafting the National Strategic Plan for HIV/AIDS and STIs (NSP) was accomplished through the restructuring of SANAC. This process began in May 2006, when Mlambo-Ngcuka initiated an internal review of the council to transform the institution to include HIV/AIDS activists and scientific researchers (Wouters et al. Reference Wouters, van Rensberg and Meulemans2010). The process of changing SANAC gained pace following the International AIDS Conference, with an assessment of the previous National Strategic Plan (2000–2005) undertaken in August (SANAC 2010). From this point, leading HIV/AIDS activists worked closely with the Department of Health until a draft of the new National Strategic Plan was presented to non-state organisations and HIV/AIDS activists in March 2007 (SANAC 2010). After this consultation, SANAC re-convened and adopted the National Strategic Plan as national policy (SANAC 2010). Critically, Aids Law Project activist, Mark Heywood, was nominated to serve as deputy secretary of SANAC the following month (SANAC 2010).

With the support of the Deputy President and Deputy Minister of Health, the HIV/AIDS movement was able to fundamentally change the national institution that provided oversight for HIV/AIDS policy. SANAC was transformed into a joint civil society–government institution that would oversee the implementation of the National Strategic Plan and advise the South African cabinet on developments in HIV/AIDS science and policy. The restructured SANAC created a formal institutional space within the state for the HIV/AIDS movement to ensure that the South African government could no longer drag its feet on policy implementation and fulfil the goals of the National Strategic Plan: to extend the lives of people living with AIDS and limit the spread of HIV.

While it displayed great promise, this period of productive interaction between the government and the TAC-led HIV/AIDS movement did not last. In June 2007, Tshabalala-Msimang returned from nine months of sick leave. With the Minister restored to office, the exercise of institutional power by the ANC's dissident faction resumed. Despite the restructuring of SANAC and the existence of a new national AIDS policy, the AIDS dissident faction of the ANC was able to slow the implementation of the National Strategic Plan and undermine its oversight. The dissident faction was able to accomplish this because the details of SANAC's restructuring had only been discussed in general terms prior to the return of the Minister of Health (Powers 2012). When SANAC's institutional roles were finalised, the Minister of Health held the chair of the Resource Management Committee while the Director General of Health occupied the chair of the Programme Implementation Committee. These positions of power enabled the ANC dissident faction to control the flow of donor capital for HIV/AIDS and the oversight of policy implementation for the National Strategic Plan from within SANAC (Powers 2012).

However the National Department of Health was perhaps the most significant domino to fall with the Minister's return to office. Given its prominent role in implementing the National Strategic Plan, the removal of the HIV/AIDS movement's key ally shortly after Tshabalala-Msimang's restoration was a devastating blow for the policy. The AIDS dissident faction's reassertion of power was highlighted by the Deputy Minister of Health's dismissal for not working as part of the ‘collective’ (Mail & Guardian 2007). While Madlala-Routledge was formally recalled from office for bringing her son to a conference without state approval, the conditions under which she was removed from office pointed to political factors (Nattrass Reference Nattrass2008: 159). With her removal from office, the HIV/AIDS movement had lost the primary source of support for their efforts within the Department of Health.

The dynamics that had marked the end of the 1999–2004 era continued into the 2004–2008 period, with the HIV/AIDS movement expanding its influence on state policy and the AIDS dissident faction attempting to limit the availability of ART in the public health sector. The process of extending the AIDS dissident position intensified during this era, with ANC leaders cultivating links between non-state organisations aligned with the ruling party. The South African HIV/AIDS movement challenged these developments through the legal sector of the South African state while expanding support for its activities within the ANC. The progress made in changing South African national policy was undermined by the Minister of Health's reappearance, which marked a return to the institutional dynamics that had marked the 1999–2004 era. However, what is critical for this discussion of power are the methods by which the AIDS dissident faction of the ANC changed the political trajectory that had taken hold during the Minister of Health's absence.

STATE INSTITUTION, NON-STATE ORGANISATIONS AND THE PARA-STATE

Much ink has been spilled over the response of the ANC's AIDS dissident faction to the epidemic in South Africa. A significant portion of these narratives has addressed the question of why the AIDS dissident faction of the ANC adopted their heterodox position on the relationship between HIV, AIDS and ART (Mbali Reference Mbali2002; Nattrass Reference Nattrass2004; Fassin Reference Fassin2007; Gevisser Reference Gevisser2007; Susser Reference Susser2009). Other scholars have attended to the question of how HIV/AIDS activists responded to the actions of the AIDS dissident faction (Robins Reference Robins2004, Reference Robins2006; Nattrass Reference Nattrass2007; Steinberg 2008; Geffen Reference Geffen2010). Given the shallow historical depth of this phenomenon, work has turned its attention to the social effects of AIDS dissidence only recently (Nattrass Reference Nattrass2012). In contextualising this period, analyses have often described the politics of HIV/AIDS via historical narrative rather than a series of tactical decisions taken by groups with opposing interests. While institutions have often figured prominently in these discussions, they have been understood as a framework for political activities rather than as a means of exercising power.

Despite the lack of emphasis on institutional analysis in the literature, two accounts have taken up this aspect of the South African HIV/AIDS epidemic as their central focus. Makino (Reference Makino, Shigetomi and Makino2009) contends that the success of the South African HIV/AIDS movement was predicated on the openness of formal political institutions to policy input from civil society organisations. This factor then allowed the HIV/AIDS activists to decisively alter post-apartheid HIV/AIDS policy through formal political engagement. Strode & Grant (Reference Strode and Grant2004) analyse the institutional composition of the governmental response to the epidemic from a normative perspective oriented around ‘good governance’. This account offers a fine-grained overview of the issues within SANAC, arguing that the institution lacked sufficient representation and input from civil society.

Despite their institutional focus, these accounts do not adequately consider the role of the anti-apartheid movement and early HIV/AIDS activists in creating the institutional conditions necessary for the subsequent success of the South African HIV/AIDS movement. Makino (Reference Makino, Shigetomi and Makino2009) does acknowledge that the development of NEDLAC grew out of the political transition. However there is inadequate attention paid here to the role of the civil rights lawyers and HIV/AIDS activists in setting a rights-based approach to HIV during the political transition (Heywood & Cornell Reference Heywood and Cornell1998). A rights-based approach to the epidemic became part of national policy with the National AIDS Plan (1994) and was critical to the ability of the South African HIV/AIDS movement to utilise the legal sphere to expand access to treatment. From this perspective, the South African HIV/AIDS movement created – rather than benefited from – the institutional conditions that led to its success.

In both of these accounts, SANAC is characterised as a response to the dictates of transnational donor capital and not as a national institution that was transformed to serve the goals of the HIV/AIDS movement. This perspective overlooks the post-2006 restructuring of SANAC by the South African HIV/AIDS movement. While the success of the restructured institution was limited by the AIDS dissident faction of the ANC, it was nonetheless an important event in the political history of this period. Finally, the question of power is left largely unattended in these narratives. This is a critical factor to consider in the institutional dynamics of HIV/AIDS in South Africa, as it offers a means of understanding the broader significance of this process. More specifically, this period offers a revealing case study for theories that seek to explain the relationship between state and society in Africa.

The analysis of political systems and authority in Africa has produced a wide range of conceptual approaches from which to analyse the political dynamics of HIV/AIDS in South Africa. From notions of ‘failed’ states to those operating with ‘warlord’ politics or ‘neopatrimonial’ regimes, the case of Africa has been largely characterised as operating outside of the normative parameters of governance (Tull Reference Tull2005). Building upon the normative conceptions of governance developed by Max Weber, the particularity of African states in these accounts highlights the corollaries between colonial and post-colonial perspectives on the continent (Mbembe Reference Mbembe2002). Rather than analyse socio-political phenomena by describing what it is not, here the institutional dynamics of HIV/AIDS will be compared with other examples of non-state political formations operating alongside – and at times supporting – the imperatives of a ruling party.

The concept of a ‘para-state’ has been utilised to describe parallel or competing political formations in a particular society. The para-state has been described in one instance as ‘a force that may act against, within or in place of a nonfunctioning state’ (Liotta Reference Liotta1998: 61). The concept has been predominantly used to describe ‘states within states’ or ‘sub-states’ that act in place of the formal state (Kingston & Spears Reference Kingston, Spears, Kingston and Spears2004). As such, the majority of case studies focus on the emergence of autonomous regions, often as part of a civil war or extended social conflict.

Gill (Reference Gill2009) applies the concept in this manner to describe the development of a political region controlled by paramilitary forces in Colombia at the turn of the twenty-first century. This process was initially supported by the ruling party as it targeted the city of Barrancabermeja, a stronghold of leftist guerillas leading a civil war against the Colombian state (Gill Reference Gill2009: 315). This para-state was then reincorporated into the formal state alongside neoliberal economic reforms, underscoring the relationship between capital, accumulation and violence.

Gill's application of the para-state concept incorporates several meanings that can be ascribed to the concept. The predominant usage of the term focuses on the first definition of the prefix ‘para’ in the Oxford English Dictionary (2005): ‘analogous or parallel to, but separate from or going beyond’. This utilisation of the ‘para’ prefix correlates to the use of the para-state concept to describe an autonomous political formation. However the para-state in Barrancabermeja was always predicated on official and regional acceptance of its activities. This underscores that this para-state may be complementary to – rather than autonomous from – the formal Colombian state.

Gill's research highlights the need to incorporate elements of state dependency into the concept of a para-state. This can be found in the etymology of the ‘para’ prefix, in which the original Greek use points to a ‘subsidiary relation’ (Oxford English Dictionary 2005). This framing is often used to describe how non-state armed groups act to achieve the political ends of the state, or para-military groups. In this usage, the activities of a militarised non-state organisation serve the larger goals of an elite or ruling party. If one strips this example of its context of armed conflict, it describes a para-state in which state and non-state social formations operate in concert to produce a mutually desirable outcome. The emergence of an alliance of non-state organisations working with the ANC dissident faction to disseminate alternative HIV/AIDS treatment is proposed here as an example of this latter definition of a para-state.

Central to the emergence of a para-state related to the HIV/AIDS epidemic in South Africa was the direct action taken by the HIV/AIDS movement to counteract the exercise of institutional power by the AIDS dissident faction of the ANC. This was achieved by the coordination of international and domestic political pressure with a series of legal challenges to government intransigence on treatment. Through this process the South African HIV/AIDS movement forced the hand of the ruling party to adopt orthodox treatment guidelines and disseminate ARVs via the state's health institutions. With the institutional power of the ANC's AIDS dissident faction limited, an alliance of non-state organisations emerged to carry forward its political agenda. This constituted the AIDS dissident para-state. The activities of this para-state were then utilised as a basis for the formal recognition of its ‘research findings’ by their presentation within state institutions. This attempt to place ‘African solutions’ to the epidemic on equal footing with ARV-based treatment grew directly out of the AIDS dissident para-state that emerged during Thabo Mbeki's second term as President of South Africa.

This AIDS dissident para-state was not an autonomous socio-political formation, nor did it attempt to develop zones of sovereign authority. Rather, the organisations producing this para-state operated in concert with elements of the ruling party to push forward a political project. In essence, this subsidiary or supporting activity expanded the scope and reach of a political initiative that had been limited by the South African HIV/AIDS movement.

The example of the AIDS dissident para-state in South Africa highlights the necessity of expanding the para-state concept to incorporate a wider array of activities and alliances. Rather than conceptualising of the para-state as a set of ideal types with different relationships to state authority, it may be more accurate to theorise para-states as operating across a spectrum from those attempting to establish ‘states within states’ to others that extend the goals of an elite or ruling party. This perspective allows for the particularity of each case to be examined without recourse to abstract ideals and their Eurocentric bias. Further, it can also allow for the influence of historically particular factors to be considered in the analysis of how and why a particular para-state emerged.