Khayelitsha- Every Monday morning, patients infected with the AIDS virus come to the red-brick clinic in this impoverished community of dilapidated shacks. In the waiting room, babies wail, nurses hustle and some young women fidget on wooden benches as their earrings dangle and their chipped pink toenails gleam.
The clinic looks like one of the hundreds of medical centers overwhelmed by South Africa's AIDS epidemic.
Yet there is little talk of depression or dying here. In this clinic, patients are getting stronger, not weaker, and they chatter about gaining weight, returning to school and searching for jobs. They are taking part in an ambitious program that offers the poor what was once unthinkable: free AIDS medicine and a chance to live.
Akhona Jazi, who once relied on a wheelchair, now walks on her own. Doris Matanda, who weighed 86 pounds, has gained 37 pounds in three months. Pumza Charlie no longer worries about dying from tuberculosis before her 30th birthday.
These days, she dreams of finding a job and buying her own house. "I thought I was going to die, but now I'm fresher than ever," said Ms. Charlie, 28, who shares a two-room house with her mother. "People here are dying of AIDS every weekend, every weekend. But I'm gaining weight.
I've got no problems. So far, so good." This clinic offers a rare glimmer of hope in South Africa, which has more people infected with H.I.V. than any other country. The vast majority of AIDS patients die here because they cannot afford the lifesaving medicines common in the West.
But over the last two years, the number of private initiatives offering free or low-cost AIDS drugs has slowly but steadily increased. In this gritty township near Cape Town, the relief agency Médecins Sans Frontières (MSF) provides free triple-therapy treatment to about 330 people and reports remarkable results.
Doctors treat even the sickest of the sick, patients who can barely walk or swallow. After six months of treatment, most people show dramatic improvements, gaining as much as 20 pounds and the strength to fight off killer diseases. MSF, which runs the largest free program, started treating the poor here in 2001.
In August, Anglo American and De Beers, the mining giants, announced that they would provide AIDS drugs to their employees, joining companies like DaimlerChrysler, which already offered such treatment. Meanwhile, the number of patients receiving AIDS drugs through their health insurers has doubled in the last two years as drug prices have begun to fall.
Only about 25,000 of the 4.7 million people infected with H.I.V. in South Africa are believed to have access to lifesaving medicines, and most of those are covered by health plans. But when President Bush announced in his State of the Union address on Jan. 28 that the United States would finance AIDS treatment for two million more people, most of them Africans, he gave an unexpected lift to a continent where 2.5 million people died from the disease last year.
News of the American initiative inevitably focused attention on the groups in South Africa that have started providing free AIDS drugs, frustrated by the national government's reluctance to provide the medicines in public hospitals and clinics.
President Thabo Mbeki has expressed concern about the safety of AIDS drugs commonly prescribed in the United States and Europe. Senior members of his political party have called the medicines "poison" and accused drug companies of trying to use Africans as guinea pigs.
Other officials insist that providing AIDS drugs in the public sector is too costly. But critics note that the prices of brand-name AIDS drugs have fallen sharply in the face of stiff competition from makers of inexpensive generic equivalents.
The pressure on the government to soften its position is rising as doctors, ministers, trade unions and prominent officials, including Nelson Mandela, the country's revered first black president, demand distribution of the drugs. Skeptics, including some national government officials, argue that the strict triple-therapy regimen, so successful in the West, is too complicated and costly for Africans.
Patients must take several pills a day at specific times, which can be difficult in rural communities. Failure to adhere to the regimen, which must be taken for life, may produce strains of the virus resistant to medication.
The challenges facing new patients are evident even in successful programs like the one here. In its first year, MSF found that three-quarters of its patients suffered mild reactions to the drugs, including nausea, rashes and low white blood cell counts during the first three months of treatment.
Interviews suggest that some patients struggle to maintain the regimen in the early days. Of 159 participants, three dropped out of the program during the first year. Thirteen people, very sick at the onset of treatment, died that year from illnesses including chronic diarrhea and Kaposi's sarcoma. The condition of the vast majority, however, improved greatly.
The mild reactions to the drugs, which never resulted in hospitalization, diminished sharply after three months. And adherence to the regimen has been excellent, doctors say.
Within three months, the virus was undetectable in 90 percent of patients. They also got sick much less often. Patients on the drugs, known as antiretrovirals, suffered an average of one illness a year instead of four. The struggle to recruit doctors and nurses remains an enormous problem.
Right now, the clinic has three full-time doctors, down from six last year. But provincial officials, who have their own health budget, have been eager to help. MSF pays for the generic AIDS medicines from Brazil - which cost about $1 per patient per day - and the provincial government covers the costs of other drugs, laboratory tests, and 50 percent of staffing costs and allows the group use of three clinics here.
"We're very pleased with the results," Dr. Fareed Abdullah, the deputy general in the Western Cape Province's health department, said of the program. "We're confident that it will be regarded as a best-practice model for all of South Africa."
But the demand for AIDS drugs far exceeds supply. The United Nations estimates that four million Africans need AIDS drugs right now. The Bush administration initiative would halve that figure, but nearly two million people would probably die for lack of medicine.
Dr. Eric Goemaere, who runs the MSF project here, estimates that about 1,000 people still need treatment in Khayelitsha. The lucky few visit the nurses and doctors regularly to collect their pills and get checkups. They must also attend monthly support group meetings.
At one such meeting of 14 people this week, a man in a plaid shirt confessed that he had forgotten to take his tablets. Another man said he had learned to take his tuberculosis medicine and AIDS medicine at different times to avoid nausea.
An older woman in a silky white shirt admitted that she had not told her children the true purpose of her new pills. "I tell them it's treatment for high blood pressure," she said, and the group laughed. Some talked about the guilt they felt at having access to lifesaving drugs.
Others said they were still nervous about the drugs, fearing they might be poisonous. Most fears evaporate after the patients see the startling improvements. Many people say they feel ready to disclose their disease to friends and relatives.
Nobantu Kwinana, for instance, invited two foreign visitors to see her four-room house and her precious tablets. She started taking them six months ago - one in the morning and four at night - and keeps them on her night table in a bedroom wallpapered with supermarket fliers. "At first, I was just hoping to die," said Ms.
Kwinana, 54, describing her reaction to her first AIDS test two years ago. "I thought: `What are my children going to say? What are my sisters going to say?' Now, I'm not scared. I know that I have H.I.V. and I know how to save myself. I have these pills. They are good for my life."