Sitting in her cramped but tidy home in the Soweto area of South Africa, Mercy Makhalamele points to a painted portrait of her daughter and laments the AIDS-related death of the baby girl. "If there was a mother-to-child transmission program in South Africa, she could be alive today," says Makhalamele.

But the country, one of the hardest-hit by the AIDS pandemic, does not have a mother-to-child transmission (MTCT) drug program. Antiretroviral medications used in perinatal HIV prevention are unaffordable for most South Africans, and the government does not offer them through its health system, despite figures showing one in four pregnant women in the country have the virus.

"WE NEED TO CHALLENGE OUR GOVERNMENT WITH EXACTLY WHAT THEY'VE GIVEN US: A HERITAGE OF ACTIVISM. —Mercy Makhalamele

Makhalamele is striving to change that. She is a first-string player in the burgeoning AIDS activist movement making daily headlines in South Africa. She is a founding member of Treatment Action Campaign, a bold and savvy activist organization with a mission to secure lifesaving treatment and affordable health care for HIV-infected South Africans, something of an uphill battle in a developing nation that has one of the world's fastest-growing rates of new HIV infections, with an estimated 1,700 daily.

During the past year South African president Thabo Mbeki has steepened the battle's incline by refusing to firmly acknowledge that HIV causes AIDS—although new government treatment guidelines issued in late October recognize a link between the two—thereby skirting governmental responsibility for the procurement of antiretroviral treatment. Minister of Health Manto Tshabalala-Msimang has responded to activist demands for an MTCT program with heel-dragging and broken promises.

TAC's efforts to dismantle these governmental hurdles through public demonstrations, community mobilization, and use of the media to spotlight its message has led to its comparison with the direct-action group ACT UP. Some believe TAC's work is serving as a catalyst in reinvigorating and redirecting U.S. activists toward a global campaign for AIDS treatment.

"I think the push and energy for AIDS activism is really coming from countries like South Africa," says Eileen Hansen, former public policy director of the AIDS Legal Referral Panel in the United States. "Their need for information and assistance is pushing people to rethink their commitment to activism and reactivate."

"THE MINUTE PEOPLE HEARD ABOUT TAC, EVERY- BODY BECAME INVOLVED." —Mercy Makhalamele

The Making of a Movement
It was less than three years ago, in March 1998, that Makhalamele and a handful of other HIV-positive activists organized the first Toyi Toyi (the Zulu phrase for demonstration) in the province of KwaZulu-Natal, where HIV rates are among the highest in South Africa and the site where a young woman, Gugu Dlamini, would be stoned and knifed to death by a mob in December 1998 after she revealed publicly she was HIV-positive. About 80 people took to the streets to demand AZT for pregnant HIV-positive women and an end to discrimination against people who have AIDS.

Through similar demonstrations and community outreach, TAC— joined later by the National Association of People Living With HIV and AIDS, South Africa—began slowly unwrapping the nation's shroud of silence surrounding HIV and AIDS. "It was quite clear that people who mobilized were people living with HIV who were in need of treatment. The minute people heard about TAC, everybody became involved," Makhalamele recollects.

Fast-forward to summer 2000. With world attention building for the 13th International AIDS Conference, held in South Africa, activists decided to up the stakes. TAC, working with members of the AIDS Law Project, is planning to file an unprecedented lawsuit against the South African government, demanding that a nationwide program be put forth to treat HIV-positive pregnant women, through antiretrovirals to prevent transmission of the virus to their unborn children.

It is estimated that in South Africa an MTCT program using nevirapine alone could prevent 14,000 seroconversions a year and would cost an amount equal to only 0.3% of the national health budget. Other short-course treatment options could employ the drugs AZT and 3TC.

Many deem MTCT programs to be vital steps in slowing the spread of HIV in developing countries. Agencies of both the World Health Organization and the United Nations endorse MTCT programs as a feasible and cost-effective means of curbing transmission of HIV from mother to child. Since 1994, in the United States and Europe, the use of antiretrovirals during pregnancy has reduced the number of perinatal infections by at least half.

Pharmaceutical company Boehringer Ingelheim in July offered a five-year supply of nevirapine to developing countries free of charge. But the South African government declined the offer.

Constitutional Challenge
TAC believes its lawsuit will force the implementation of antiretroviral therapy for pregnant women because such a program would fall under the country's constitutional health care guarantees. The South African constitution says that all women have a right to make choices about bearing children and that the government has a duty to provide everyone with access to health care if this is within its budget. The government also offers free health care to pregnant women and children under 6.

"So to deny one group of women access to a drug that is on the essential-drug list and that is affordable could be argued to be a case of unfair discrimination," says Mark Heywood, a lawyer and head of the AIDS Law Project. "The government is resisting because implementation and widespread knowledge of efficacy [of MTCT programs] would create a demand for improved access to decent treatment."

A NEW REVOLUTION?: Although now backpedaling on previous statements by acknowledging a link between HIV and AIDS, the South African health ministry, led by Manto Tshabalala-Msimang, and President Thabo Mbeki himself are not doing enough to help expectant mothers to prevent passing HIV on to their unbo0rn children, says Mercy Makhalamele, a founding member of the activist group Treatment Action Campaign.

At that time, Makhalamele hopes "women will get up and speak up for these issues," she says. "There would be a need to complement MTCT programs. The first would be providing women with treatment, not only [antiretrovirals] but with basic medications."

Armed with the lawsuit, activists are enlisting the broad support of trade unions and political parties. The Congress of South African Trade Unions—1.8 million strong—and the South African Communist Party, both alliance partners in Mbeki's ruling African National Congress, are important TAC allies.

TAC also has been working with activists in the United States to step up pressure on pharmaceutical companies and governments on both sides of the equator. "We need to construct a popular international alliance," says Heywood. "What happens in the third world is about defending the profit margins of the first world."

Through this kind of collaboration, AIDS activism in the United States has begun to shift from a domestic movement to a global one. For example, ACT UP members blitzed Pfizer headquarters in New York City several times in 2000, demanding an end to what the group says is price gouging, so that poorer nations could afford the antifungal drug fluconazole (Diflucan), used to treat certain AIDS-related opportunistic infections, including deadly cryptococcal meningitis. ACT UP also made news during the Republican national convention in Philadelphia by displaying banners calling for AIDS drugs for Africa.

AIDS activists here and abroad are also beginning to link up with the larger antiglobalization movement. "If we hope to fight AIDS effectively on a global scale, we must ally ourselves with the groups on the front lines fighting the World Trade Organization, the International Monetary Fund, and the World Bank," says Asia Russell, a member of the Philadelphia chapter of ACT UP.

In keeping with that goal, U.S. activists joined in protests against unfair AIDS drug pricing at the World Trade Organization Ministerial Conference Meeting in late 1999 in Seattle.

In South Africa, where struggle is something of a way of life, the battle for HIV treatment continues. "We need to challenge our government with exactly what they've given us: a heritage of activism," Makhalamele says.

Will the activists of South Africa apply the lessons learned in the fight to end apartheid and emerge as leaders in the global movement? Makhalamele is hopeful that they will. And knowing that other HIV-infected women throughout the world are preventing their babies from being born with HIV and are getting the proper treatment to stay alive to raise their children helps keeps her on her mission.