JOHANNESBURG, South Africa - When a South African provincial leader promised this week to make AIDS drugs available to all HIV-positive pregnant women to protect their babies from becoming infected, it hardly sounded like a rebellious act.
But here in South Africa, where AIDS is as much a political as a medical issue, the announcement was a challenge to the government's much-criticized policy on limiting public access to drugs that fight AIDS.
It also made the premier of the province that includes Johannesburg and Pretoria the latest hero in a nationwide movement of politicians, doctors, church leaders and activists to stir the government to take action against its AIDS crisis.
Even former President Nelson Mandela has stepped into the fray, highlighting the government's weak response to an epidemic that has infected about 4.7 million people, about 11 percent of the population.
"This is a war. It has killed more people than has been the case in all previous wars and in all previous national disasters," Mandela said in an interview with Johannesburg's Sunday Times. "We must not continue to be debating, to be arguing, when people are dying."
South Africa has drawn worldwide criticism for its often tortured AIDS policies. President Thabo Mbeki has openly questioned the link between HIV and AIDS, and has dabbled in fringe scientific theories about the disease.
Critics have condemned South Africa's reluctance to expand public access to nevirapine, the anti-retroviral drug that Premier Mbhazima Shilowa vowed this week to make available in every public hospital and clinic in Gauteng province, where 29 percent of all pregnant women are HIV positive.
A single tablet given to a mother during labor - and another dose given to the newborn - can reduce the risk of passing on infection to the child by as much as 50 percent, studies show.
Although the drug is widely used in other parts of the world, South Africa is restricting its availability, arguing it is too expensive and perhaps unsafe. Last year, the government began a pilot project to test the drug at 18 sites, two in each of the nine provinces. The program reaches about 10 percent of all the pregnant women who are HIV positive.
In December, AIDS activists won a major court battle against the government when a judge ruled that public health officials must supply nevirapine to all HIV-infected pregnant women.
The Health Ministry has appealed the court's decision, arguing that its public hospitals and clinics do not have the resources to manage such a large distribution program. But critics suggest that the government is delaying a national roll-out program because of Mbeki's misgivings about AIDS drugs.
Now the government is faced with a mounting chorus of protest from all quarters of the country. So-called "rebel doctors" have provided nevirapine to pregnant women in defiance of the government. Hospitals have also joined in the protests, assuring the government that they have the resources to manage nevirapine. Complaints about the drug's cost have also been rebuffed. The drug's German manufacturer, Boehringer Ingelheim, is offering it for free.
The pressure appears to be working. One by one, politicians have been breaking from the national government. Two opposition-held provinces have announced that they will ignore the Health Ministry's policies.
Home Affairs Minister Mangosuthu Buthelezi - leader of the opposition Inkatha Freedom Party - also lashed out at the country's AIDS policies.
"Our nation is dying of AIDS. We can no longer hesitate or falter," Buthelezi said in parliament this month. "This is the time to act in the full measure of our capacity, leaving no stone unturned."
But the latest shock to the government came from the premier of Gauteng, a province of 7.8 million people. Shilowa is the first leader who is a member of the ruling African National Congress to say that his province will defy the government policies.
Shilowa played down his announcement, emphasizing in his speech that expansion of the AIDS drug program in his province was not in conflict with national government programs.
But yesterday, the national government disagreed. Health Minister Manto Tshabalala-Msimang issued a statement declaring that Shilowa had breached government policy by moving ahead to distribute the drugs. Health officials said it is unclear whether the minister will take any steps to stop Shilowa from pursuing his plans.
After the statements by Mandela, the ANC quickly tried to end dissent within its ranks. On Monday, the party leadership called for a meeting between Mandela and Mbeki. Party officials later issued a statement saying that the party had reached a common understanding on AIDS and "reaffirmed the correctness of the positions taken by both the ANC and government."
Despite the government's attempts to rein in dissent, AIDS activists view the growing rebellion against the government's policies as a welcome and inevitable development.
"The position of the ANC is unsustainable for many people," said Zackie Achmat, chairman of the Treatment Action Campaign, a national group fighting for access to AIDS drugs. "On the ground the social pressure is so enormous that they know what they need to do."
Steven Friedman, director of the Center for Policy Studies in South Africa, said that faced with a public outcry for change, the government is slowly backing away from its stance - not unlike how the apartheid government once grudgingly conceded ground to its critics.
"It is a retreat that is carefully packaged," he said.
But the changes do not necessarily reflect a shift in the thinking of Mbeki, who has been skewered by health workers and activists for his unconventional views on AIDS.
During his state of the union address this month, Mbeki made little mention of the AIDS epidemic, showing no signs of dedicating himself to the aggressive national AIDS program that many observers say is needed, Friedman said.
"He's got himself in a corner. It's making his retreat a lot more difficult," Friedman said.