When Jacob Zuma, now poised for an almost certain second term as South Africa’s president, faced criminal rape charges in 2006 stemming from sexual relations with a woman that he knew to be HIV positive, he later remarked that he didn’t use a condom and claimed that he took a shower afterwards to reduce the risk of contracting HIV. 

So when he emerged in 2007 as the heir apparent in the ruling African National Congress (ANC), there wasn’t much hope that Zuma would necessarily bring an incredible amount of sophistication to HIV/AIDS policy in a country that’s long suffered from health policy failures.

Yet almost immediately after becoming the country’s third post-apartheid president in 2009, Zuma effected nearly a 180-degree turn on HIV/AIDS policy. There was little doubt that his HIV/AIDS policy could be any worse than that of his predecessors.

Notwithstanding the triumph of Nelson Mandela’s historic presidency, Mandela himself admitted in the 2000s that he didn’t do enough to acknowledge the growing threat of HIV/AIDS infection, which would ultimately kill Mandela’s youngest son Makgatho, a fact that Mandela made public upon his son’s death in 2005.

His successor, Thabo Mbeki, was even worse. A proponent of aberrant medical theories that HIV, in fact, might not cause AIDS, Mbeki stalled as the rest of sub-Saharan Africa embraced new treatments and prevention strategies, leading to what some studies claim to be over 300,000 premature deaths in South Africa.

South Africa, like the rest of southern Africa, has one of the world’s highest HIV/AIDS rates. Like many issues in South Africa, race plays a significant role — a recent survey showed that the HIV rate among black Africans is around 15%, with a 3% rate among the ‘coloured’ (the South African term for mixed-race persons) population and a 0.3% rate for whites. The highest risk is for black females, aged 15 to 49, who are affected at a rate of 23.2%.

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Zuma is almost certain to be reelected as president after the May 7 parliamentary elections that will, once again, return the ruling ANC to power.  But amid widespread unhappiness over South Africa’s economic performance and its government’s record on everything from individual rights to corruption, Zuma’s policy turn on HIV/AIDS could ultimately become the strongest policy accomplishment of an otherwise disappointing presidency.  

Under the leadership of Aaron Motsoaledi, Zuma’s minister of health since 2009, a medical doctor and a longtime ANC party official in Limpopo province, the current administration has struggled to make up for lost time from the days of Mbeki-era denialism.

For a government that’s faced charges of economic mismanagement, is responsible for lethal police crackdowns and is accused of corruption on gargantuan levels, from Zuma downward, Motsoaledi is one of the ANC’s unsung heroes — and the health policy that he’s carried out over the past four years one of the few clear bright spots for a political machine now headed into its third consecutive decade in power. Manto Tshabalala-Msimang, the previous minister of health for nearly a decade during the Mbeki administration, had recommended that South Africans combat HIV/AIDS with a combination of garlic and beetroot, among other traditional remedies.

Whereas South African health officials were once on the periphery of the international fight against HIV/AIDS, Motsoaledi (pictured above) is now one of the loudest voices criticizing multinational pharmaceutical companies for the high price of HIV medications, and he is waging a global fight to weaken patent protections for those companies to reduce the cost of anti-retroviral therapy in South Africa and elsewhere.

Almost immediately upon his election four years ago, Zuma introduced a new HIV/AIDS policy for South Africa, the most critical aspect broadened the use of drug therapy for HIV-positive pregnant women. The rate of mother-to-child transmission has dropped to just 3.5% as of 2011, and South African and international health officials hope to reduce that rate to nearly zero over the next four years.

In the first two years of the Zuma administration, South Africa scaled up the number of South Africans on anti-retroviral therapy from less than 900,000 to nearly 2 million, spending billions of its own money in addition to funds from the United States, the World Health Organization and other international organizations.

Moreover, Zuma launched a national campaign for greater HIV testing, and subjected himself to a test in 2010 (pictured above), breaching what had been, even today, a taboo in conservative South African society. He’s even started championing male circumcision, which has been shown in some studies to reduce the risk of HIV transmission during sexual intercourse, and Zuma’s government is working to make circumcision more prevalent in KwaZulu-Natal, the Zulu heartland (Zuma himself is a Zulu, and he’s worked with the Zulu king Goodwill Zwelithini to reverse a Zulu trend away from circumcision), where HIV rates are among the highest in the world. Above all, Zuma’s approach has attempted to reduce the stigma surrounding HIV infection, a major impediment to testing and treatment.

Unfortunately, that still hasn’t turned the tide, and HIV infections rose from 10.6% in 2008 to 12.2% in 2012, according to a new survey by the country’s Human Sciences Research Council, bringing the total number of South Africans living with HIV/AIDS up to 6.4 million. The rise is partially explained by a leap in new reported cases, however, indicating that the government’s push for more widespread HIV testing is working. It’s also a sign that South Africans with HIV are living longer — though new HIV cases are on the rise, life-saving drugs mean that fewer South Africans are progressing to full-blown AIDS.

South Africa still has strides to make, especially in treating the tuberculosis that kills many HIV/AIDS patients with compromised immune systems, and it’s becoming a laboratory for even deadlier strains of drug-resistant TB. In an era of shrinking budgets, South Africa is also facing a shortage of HIV drugs in the future. That’s on top of inefficiencies in a bifurcated health care system split between public and private health-care providers, even as Motsoaledi hopes to implement a national health care insurance program over a 14-year horizon:

Health Minister Motsoaledi talks a good game and seems to possess a degree of recognition of the poison chalice that is now in his hands….

But hope lives on in Motsoaledi. He has forced medical schools to take on more students, is building more hospitals and has given himself five years to complete some of the improvements he recognises that the national health service so desperately needs.