The Treatment Action Campaign (TAC) is a leading voice for access to treatment for people living with HIV/AIDS (PLWHAs) in South Africa and one of the louder voices in the worldwide battle. This is not necessarily a tribute to TAC's success: despite the publicity that has followed the movement during the last year, there is a long way to go in the struggle for access to treatment.

Only about 20,000 of South Africa's 5 million PLWHAs have access to antiretroviral medicines. Only about 10% of pregnant women living with HIV have access to a clinic that offers a programme to reduce the risk of perinatal transmission. Few rape survivors have access to post-exposure prophylaxis. Only a handful of South African businesses offer treatment to employees who cannot afford medical aid. There is still too much treatment illiteracy and stigma associated with the disease. A tragic anecdote: recently, a doctor in one of the largest private HIV/AIDS practices in Cape Town asked all his patients living with HIV/AIDS how many of their friends and family members they had informed of their status: most of them had not told a single person!

Activism and leadership: crucial for change

TAC can only be judged to be successful once these problems have been largely overcome. Each day without resolution implies a day of failure. For hundreds of thousands of South Africans and the estimated 19 million people who have died of AIDS worldwide, TAC and its allies have not succeeded.

Nevertheless, TAC has had some considerable achievements. In early 2001, fewer than 10,000 South Africans could afford antiretroviral treatment. TAC's litigation and mobilisation against pharmaceutical profiteering resulted in substantial decreases in drug prices, so that many middle-class people and workers on medical aid can afford them. TAC's treatment literacy workshops and outreach programmes have improved knowledge about these issues for tens of thousands of South Africans. Furthermore, access to treatment has become a central focus of the political debate in South Africa.

TAC is often asked why it has achieved a position of leadership on these issues. What strategies and operational mechanisms has it used? TAC has been fortunate in having access to low-cost, high-quality, legal, video and computer resources, as well as the expertise to make optimal use of these. All these resources have been essential for organising and enhancing activities. Most developing world community-based organisations (CBOs) do not have easy access to any of these. In South Africa and probably most other countries, there is a need to pool these resources in the activist community. Furthermore, most NGOs in the developing world lack management capacity to deal with the complexity and range of issues effecting their work, as well as a lack of resources. These are threats to TAC as well. Solutions to these problems are not easy to find, especially in a country where educational standards under the apartheid regime were appalling and continue to struggle under the new one. To complicate matters, donors have warned that with a looming global recession, money will be harder to come by. A reasonably well-established organisation like TAC may overcome such obstacles, but many smaller CBOs doing good work will struggle to carry out their programmes.

Keys to success

Keys to TAC's success are sound political analysis, rigorous research and massive community-based and working-class mobilisation. Without any one of these, TAC as an organisation would be irrelevant.
Political analysis and scientific research drive TAC's strategy. An understanding of the workings of the World Trade Organisation (WTO), the Trade Related Aspects of Intellectual Property Rights (TRIPs) Agreement, intellectual property law, human rights and constitutional law, the science and medicine of HIV/AIDS, and research into South Africa's health-care system are all necessary for informing our actions. We need such knowledge, not only to form advocacy positions but also to be able to answer our adversaries adequately and to convince the public of the correctness of our advocacy and actions.

Perhaps the most controversial action TAC has taken was to import generic fluconazole, an essential medicine, into South Africa in breach of the manufacturer's patent. This action generated enormous press coverage and controversy, as well as the still present risk of being prosecuted for breaking some laws. TAC emerged from this event a stronger, more respected organisation. In hindsight, however, if TAC had not researched the quality of the imported drug, the price differences between the generic and patented versions, the use of this drug in curing two common opportunistic infections in PLWHAs, as well as a legal argument for why TAC's action was justified, the action probably would have backfired. An organisation cannot break the law and expect public support without being able to argue its case convincingly.

Maintaining strong communities linkages

To make an impact, activist organisations must develop a strong community-based membership, formal or informal, and establish links with organisations representing those primarily affected by the issues at stake. The "corporatisation" of many NGOs over the last decade has left their management with greater salaries but less relevance. TAC began as a small group of people, some living with HIV/AIDS, who developed community branches in poor areas. Substantial effort has also gone into working with the labour movement, as well as faith-based organisations. The Congress of South African Trade Unions (COSATU), the country's biggest union conglomeration, is one of TAC's key allies.

The one serious criticism of TAC's first fluconazole importation action is that it was done before community support was developed. Upon realising this mistake, TAC took remedial action and a subsequent fluconazole importation was done with hundreds of TAC supporters greeting a local television celebrity at Cape Town International Airport, who offered to bring medicines back from Thailand.

As a result of this work, TAC's membership has grown considerably, though not enough, over the last 18 months. TAC is now able to organise protests of a few hundred people at short notice. With slightly greater effort, it can organise massive marches with over 5000 people, such as the protest at the 13th International AIDS Conference in Durban and outside Pretoria High Court during the case between the pharmaceutical industry and the South African government. TAC's involvement in this court case as a friend of the court and its subsequent legal action against the minister of health for not implementing a country-wide prevention of mother-to-child transmission (PMTCT) programme, helped reduce drug prices, improved PMTCT and highlighted inequities in access to treatment. However, the success of these actions would be greatly diminished without the accompanying mass mobilisation. In TAC, committed members, with a strong sense of occupying the moral high ground, play a crucial role in leading and organising the struggle for treatment access.

This contrasts starkly with the "corporate" model of running NGOs, where the organisation's management has little association with the people most affected by their objectives. Mass-based organisations cannot be developed along these lines. An example of where this leads can be seen in South Africa in the unsatisfactory job done by the country's larger organisations involved in HIV prevention. The country's best known and largest prevention organisation has developed a reputation for producing unintelligible roadside billboards, removed from ordinary people. Mass mobilisation is not an obvious part of their agenda and their sexual behaviour modification messages are couched in innuendo. This is irresponsible in the middle of the worst health crisis in recent history. Without brave, committed, uncorrupted leadership, based and involved in its target community, no activist or community outreach organisation can succeed.