發佈日期：2025 年 7 月 14 日 / 更新日期：2025 年 7 月 16 日/ 紐約時報
扎基·阿赫馬特 (Zackie Achmat) 曾是南非拯救生命的愛滋病防治運動的核心人物。由於美國削減治療經費以及其本國政府的惰性再次引發人們的擔憂，他已結束退休生活。
二十多年前，史蒂芬妮‧諾倫 (Stephanie Nolen) 第一次採訪扎基‧阿赫馬特 (Zackie Achmat)，當時他剛成為愛滋病毒活動家。她從開普敦報導了這個故事。
活動人士聚集在開普敦市中心大教堂的台階上。大多數都是上了年紀的婦女，頭巾下佈滿了臉龐。他們聚集在一個身穿大號外套的灰髮男子周圍，他聳著肩膀抵禦清晨的寒意。
他們手挽手，準備潛入街對面的會議。
「準備好？」，男人說道，聽起來有點疲倦，有點緊張。
扎基·阿赫馬特 (Zackie Achmat) 已經有一段時間沒有就生死攸關的問題與政府對峙了。
二十五年前，阿赫馬特先生與他人共同創立了後種族隔離時代南非最強大的社會運動。他領導了一場與政府的對決，為數百萬愛滋病毒感染者贏得了挽救生命的醫療。 ——卻差點害死他。
直到幾個月前，63 歲的阿赫馬特先生還以為那些日子已經過去了。他花時間在石榴農場，照顧救援犬並觀看韓國電視劇。他曾以反腐敗為綱領競選議員，但失敗了，但他很高興看到新一代積極分子發揮領導作用。
至於愛滋病毒這個曾經主宰他生活的問題，他幾乎沒怎麼想過。他不需要這麼做，因為國民治療計畫是如此強大，這是阿赫馬特先生和他的同事二十年前取得的勝利的結晶。
到了一月份，美國川普政府決定削減對外援助，包括美國總統防治愛滋病緊急救援計畫（PEPFAR）的經費。川普先生稱，美國政府對海外援助資金進行了全面削減，認為這是浪費和濫用納稅人的錢，因此，PEPFAR 的預算也大幅削減。
南非每年從總統防治愛滋病緊急救援計畫獲得 4.4 億美元，用於支付數千名護理師、資料管理員和其他從事愛滋病防治工作的人員的薪水。所有這些都被消除了。阿赫馬特先生拿藥的開普敦診所一夜之間關門了。
如果沒有美國的幫助而任何國家能夠維持其 H.I.V.醫療服務就只有非南非莫屬。它是非洲大陸最發達的經濟體，大部分的本國愛滋病毒治療係政府購買支付。
但在歷史的詭異迴響中，政府對其計畫幾乎保持沉默，這種做法激起了阿赫馬特先生和其他人的焦慮，並再次促使他們採取行動。
在削減開支的最初幾天，南非衛生部長亞倫·莫佐阿萊迪博士表示，政府正在制定計畫，沒有理由感到恐慌。
他表示：「沒有人必須停止服用抗反轉錄病毒藥物」。「我們將竭盡全力，因為這對個人和整個國家來說都是危險的」。
但幾週過去了，莫佐阿萊迪博士仍未發表任何言論。
阿赫馬特先生和其他人都在等待政府是否會介入並重新開放已關閉的診所，為 15,000 名由美國支付薪水的醫療保健工作者創造就業機會，並讓那些向性工作者和吸毒者發放藥物的貨車重新上路。他們期待一個工作小組的成立，就像衛生部在新冠疫情期間組建的團隊一樣。
醫生、研究人員和活動人士撰寫公開信，要求與政府會面。約翰尼斯堡的文特爾 (François Venter) 醫師是一位資深愛滋病臨床醫生寫了一篇廣為流傳的文章，題為「南非的愛滋病計畫正在崩潰——而我們的政府卻缺席」。
莫佐阿萊迪博士發表了一份長篇聲明，闡述了南非愛滋病毒問題的原因。該計畫沒有面臨風險，他說道，美國的資金僅佔其預算的 17%，在美國資助的診所接受醫療服務的人可以前往當地的公立診所。他將批評者與「非洲論壇」的成員進行了比較——後者是南非廣受詬病的極右翼非洲人活動分子。
阿赫馬特先生的退休生涯就此結束。
五月的那個早晨，阿赫馬特先生召集了他的「治療行動運動」（簡稱 TAC）的一小群資深運動人士，與舉行公開會議討論菸草政策的衛生官員對峙。
他指示道：「不准張貼標語」，「我們會做得很好」。
五月，阿赫馬特先生與議會衛生事務委員會對峙。 「有人正在死去！如果你還有點尊嚴，就應該聽我們說。」他說道。 圖片來源：莎曼珊·雷德斯為《紐約時報》拍攝
對峙結束後，阿赫馬特先生和治療行動運動成員被護送出大樓。
他們魚貫進入飯店會議室，在議會成員和官僚中間找到座位。衛生部高級官員西邦吉塞尼·德洛莫 (Sibongiseni Dhlomo) 博士宣布會議開幕，當他開始發言時，阿赫馬特先生站了起來。
「主席先生」，他打斷道，「我們給您發了一封信，要求舉行會議，但我們還沒有收到您的回復」。
Dhlomo 博士感到受到了冒犯。「夠了」，他說道。「我們不會允許的，你別打擾這次會議」。阿赫馬特先生猛地一震，就像被人推了一下，他爆發了。「有人正在死去！如果你還有點尊嚴，就應該聽我們說」。
Dhlomo 博士嗤之以鼻，「那些日子已經過去了」。
女人們開始舉起拳頭，高喊「阿曼德拉！」— 種族隔離時代的人民力量口號。會議變成了一場混戰。議員們高聲呼籲保全。阿赫馬特先生在房間裡踱步，全身顫抖，憤怒讓他彷彿回到了 20 年前。
當時，阿赫馬特先生是一位反對種族隔離鬥爭的老兵，他發現自己陷入了一場意想不到的新鬥爭。
他在一個黑人小鎮長大，14 歲時因抗議白人統治而首次入獄並遭到毆打。他成為了非洲民族議會（the African National Congress，反對種族隔離的主要力量）的熱心組織者。
1990 年，當該國開始向多種族民主過渡時，阿赫馬特先生得知自己感染了愛滋病毒。這則消息聽起來就像是死刑判決書。但事實證明，他是少數能夠在一段時間內自然控制病毒的人之一，因此他全心投入新國家的建設工作。
那是一個令人興奮的時代，但愛滋病毒的影響卻不容忽視。愛滋病日益明顯：每天有六百人死於愛滋病。
在高收入國家，愛滋病毒已經成為一種慢性疾病，但不是致命的，可以透過藥物治療。但在南非，每人每年的治療費用至少為 15,000 美元，這筆錢是一筆巨款。阿赫馬特先生在一位朋友的葬禮上宣布成立「治療行動運動」( TAC )，這是一項旨在讓人們獲得負擔得起的藥物的運動。
這項活動由來自貧困社區的黑人女性發起，他們因為愛滋病毒診斷的保密和羞恥而受到激勵。她們的抗議活動針對的是跨國製藥公司，這些公司阻礙了南非將更便宜的亞洲產藥品引入該國。那時，阿赫馬特先生已經因感染愛滋病毒而虛弱。但他宣布停止使用抗愛滋病毒藥物：除非南非每個人都能獲得抗愛滋病毒藥物，否則他不會使用這種藥物。
在經歷了大量負面宣傳之後，製藥公司於 2001 年開始降低價格。
但政府拒絕購買該藥品。
1999 年接替納爾遜·曼德拉出任總統的塔博·姆貝基倡導用非洲方案解決非洲問題。他開始質疑外國大公司生產的藥物是否真的能救命。他周圍都是陰謀論者。他們說愛滋病毒，不會導致愛滋病，並且他拒絕透過公共衛生系統提供治療。
阿赫馬特和 TAC 感到困惑和憤怒，於是他們開始使用他們在非洲民族議會 ( ANC ) 擔任步兵時學到的公民不服從策略 (civil disobedience tactics)。 ——現在正用它們來對付非洲民族議會本身，數千人在靜坐抗議中被捕。並且，他們利用新南非的工具起訴政府，要求獲得救命的治療。
阿赫馬特先生繼續停止使用藥物，病情越來越嚴重，他不得不強迫自己再發表一次演講或領導另一場集會。曼德拉先生來到阿赫馬特的床邊，懇求他結束停止用藥，並穿上了阿赫馬特先生使之聞名的「愛滋病毒陽性」T卹，與抗議者站在一起。
姆貝基政府在法庭上敗訴，最後在在公眾壓力面前屈服。 2003年，國民治療計畫開始實施。阿赫馬特先生服用了藥物，幾週之內就擺脫了肺部和腸道的慢性感染。他精力充沛。
在接下來的20年裡，南非的治療計畫成為世界上規模最大、運作最好的治療計畫之一。在這些藥物廣泛應用的最初11年裡，人們的預期壽命增加了十多年。 TAC 的活動人士收起了他們的簽名 T 卹並繼續前進。
直到川普政府宣布這項消息。隨著公眾的批評聲浪越來越高，莫佐阿萊迪醫生表示，公立診所的貨架上就有藥，人們只需去取就可以了。
公共衛生專家對此感到憤怒。從政府的回應中，他們聽出了姆貝基時代的迴響。
「為什麼我們不好意思說我們需要幫助？」，負責監管一家大型愛滋病防治機構的格倫達·格雷 (Glenda Gray) 博士說道。該研究中心失去了來自美國的一大筆預算。
衛生部長辦公室沒有回應採訪要求。
週三，莫佐阿萊迪博士宣佈為愛滋病防治緊急撥款 3,300 萬美元。該計畫提供的資金約為美國總統防治愛滋病緊急救援計畫 (PEPFAR) 向該國提供的資金的十分之一，他沒有具體說明如何使用它。
很難確切知道該計畫的具體進展情況，因為該部尚未解釋其計畫，而且大部分的數據收集工作都是由美國資助。一些使用 PEPFAR 服務的人已經轉向使用公共系統，公共系統報告了用戶數量增加，但具體數量尚不清楚。削減措施帶來數以萬計的人無法獲得愛滋病毒預防上的效果。根據國家衛生實驗室服務中心的數據，檢測率已經下降。
然而，阿赫馬特先生向政府委員會憤怒地宣稱「有人正在死去」的說法有些誇張。大多數診所仍在配藥，儘管排隊很長，護士也勞累過度，但該計畫並未崩潰。
然而，衛生部和活動人士再次發生激烈爭論。
加拿大外交官 Stephen Lewis 曾擔任聯合國非洲愛滋病問題特使，試圖遊說姆貝基先生，但未能成功，因此成為了「治療行動」( TAC ) 運動的擁護者。路易斯表示，阿赫馬特先生和其他人的反應有其歷史淵源。
他說：「活動人士誇張的讓人想起姆貝基，這並不奇怪，因為他們非常焦慮——『天哪，這種事還會再發生嗎？』」，「半夜時分，他們被噩夢所困擾——夢到他們把死者從病房里拉出來時床架發出叮噹的聲音」。
阿赫馬特先生說，他懷疑他們需要利用法庭——就像 20 年前做的那樣——來迫使政府參與。
他的家裡擺滿了紀念品，包括裱框的大型 TAC 示威活動的剪報；現在他懊悔地看著他們。
「我不敢相信我們又這樣做了，」他說。但他認為，他以堅持不懈而聞名，而此刻正是需要他這樣做。 「如果他們看到我」，他談到政府官員時說道，「他們會嚇得渾身發抖」。
史蒂芬妮‧諾倫（Stephanie Nolen）是《紐約時報》的全球健康記者。
全球健康記者報導藥品和醫療保健取得的情況
「我工作的指導原則是『去到那裡』。我希望直接傾聽那些受疾病困擾或無法獲得新藥的人們的心聲。我從事全球健康報導已有30年，足跡遍布80多個國家」。
本文的印刷版刊登於 2025 年 7 月 15 日的紐約版 A 區第 4 頁，標題為：重新投入到確保愛滋病毒藥物安全的鬥爭。
A Venerable AIDS Activist Returns to Battle
Published July 14, 2025 / Updated July 16, 2025 / The New York Times
Zackie Achmat, once at the center of South Africa’s push for lifesaving H.I.V. treatment, has come out of retirement as U.S. funding cuts and his own government’s inertia revive old fears.
Stephanie Nolen first interviewed Zackie Achmat more than two decades ago in his first years as an H.I.V. activist. She reported this story from Cape Town.
The activists gathered on the steps of the cathedral in the center of Cape Town. Most were older women, faces lined beneath their head wraps. They converged around a gray-haired man in an oversized coat, his shoulders hunched against the morning chill.
Linking arms, they set out to infiltrate a meeting across the street.
“Ready?” the man said, sounding a little weary, a little nervous.
It had been a while since Zackie Achmat confronted his government about matters of life and death.
Twenty-five years ago, Mr. Achmat co-founded what became the most powerful social movement in post-apartheid South Africa. He led a showdown against the government that won lifesaving medical treatment for millions of people with H.I.V. — and nearly killed him.
Until just a few months ago, Mr. Achmat, 63, thought those days were well behind him. He was spending time on a pomegranate farm, caring for rescue dogs and watching Korean telenovelas. He made a failed bid for parliament on an anti-corruption platform, but he was enjoying watching new generation of activists lead.
As for H.I.V., the issue that once dominated his life, he hardly thought about it. He didn’t need to, so robust was the national treatment program that grew out of the victories that Mr. Achmat and his colleagues won two decades ago.
Then came January, and the Trump administration’s decision to slash its foreign assistance, including funding for the President’s Emergency Plan for AIDS Relief, or PEPFAR. As part of an overall reduction in funds sent overseas, which Mr. Trump has called wasteful and a misuse of taxpayer dollars, PEPFAR’s budget has been sharply reduced.
South Africa received $440 million from PEPFAR each year, which paid the salaries of thousands of nurses, data managers and others who worked on the H.I.V. program. All of it was eliminated. The clinic in Cape Town were Mr. Achmat collected his medication closed overnight.
If any country is able to maintain H.I.V. services without U.S. help, it is South Africa. It has the continent’s most developed economy, and its government purchases most of its own H.I.V. treatment.
But in an eerie echo of history, the government has been near-silent about its plans, an approach that has stirred an old anxiety in Mr. Achmat and others, and spurred them into action once again.
In the first days after the cuts began, South Africa’s health minister, Dr. Aaron Motsoaledi, said that the government was making a plan, and that there was no cause for panic.
“Nobody must stop taking ARVs,” he said, referring to antiretroviral medications. “We will do everything in our power, because that will be dangerous for the individual and the country as a whole.”
But weeks passed, and Dr. Motsoaledi said little else.
Mr. Achmat and others waited to hear if the government would step in and reopen the closed clinics, create jobs for 15,000 health care workers who were paid by the United States, and put the vans that dispensed medication to sex workers and drug users back on the road. They expected a task force, like the team that the health ministry assembled during the Covid-19 pandemic.
Doctors, researchers and activists wrote open letters and demanded meetings with the government. Dr. François Venter, a veteran H.I.V. clinician in Johannesburg, wrote a widely circulated article titled “South Africa’s H.I.V. programme is collapsing — and our government is absent.”
Dr. Motsoaledi responded with a lengthy statement laying out reasons South Africa’s H.I.V. program was not at risk. The U.S. funds were just 17 percent of its budget, he said, and people who received health services from a U.S.-funded clinic could proceed to their local public one. He compared his critics to members of AfriForum — far-right Afrikaner activists who are widely reviled in South Africa.
So ended Mr. Achmat’s retirement.
That morning in May, Mr. Achmat gathered a small crew of veterans of his movement, the Treatment Action Campaign, known as TAC, to confront health officials holding a public meeting on tobacco policy.
“No placards,” he instructed. “We’ll do it nicely.”
They filed into a hotel conference room and found seats among members of Parliament and bureaucrats. Dr. Sibongiseni Dhlomo, a senior health department official, opened the proceedings, and as he began to speak, Mr. Achmat rose to his feet.
“Mr. Chairperson,” he interrupted, “We sent you a letter asking for a meeting. We haven’t heard from you.”
Dr. Dhlomo was affronted. “Enough,” he said. “We won’t allow it. You won’t disrupt this meeting.”
Mr. Achmat jolted as if he had been shoved. He erupted. “People are dying! If you had any respect you must listen to us.”
Dr. Dhlomo scoffed. “Those days are over.”
The women began to raise their fists, calling out “Amandla!” — a power-to-the-people chant from the apartheid era. The meeting became a melee. Parliamentarians bellowed for security. Mr. Achmat paced the length of the room, trembling with a rage that seemed to have transported him back 20 years.
Back then, Mr. Achmat was a veteran of the fight against apartheid, who had found himself in an unexpected new struggle.
He grew up in a colored township, first jailed and beaten for protesting white rule at 14. He became a zealous organizer for the African National Congress, the leading force against apartheid.
In 1990, as the country was beginning its transition to multiracial democracy, Mr. Achmat learned that he had H.I.V. The news landed like a death sentence. But it turned out that he was among the rare people whose bodies control the virus naturally for some time, so he threw himself into the work of building the new country.
It was a heady time, but the impact of H.I.V. was increasingly visible: Six hundred people a day were dying of AIDS.
In high-income countries, H.I.V. had become a chronic, not fatal, illness managed with medications. But in South Africa, treatment cost at least $15,000 a person a year, a king’s ransom. Speaking at a friend’s funeral, Mr. Achmat announced the start of the TAC, a movement to get access to affordable drugs.
It swelled with Black women from poor communities, who were galvanized out of secrecy and shame at their H.I.V. diagnosis. They targeted protests at multinational pharmaceutical companies, which blocked South Africa’s attempts to bring more affordable Asian-made versions of the medications into the country. Mr. Achmat was, by then, weakened by H.I.V. But he announced a drug strike: he would not take ARVs until everyone in South Africa could get them.
After a lot of bad publicity, the drug companies began to lower their prices in 2001.
But the government refused to buy the medicine.
Thabo Mbeki, who succeeded Nelson Mandela as president in 1999, championed the idea of African solutions for African problems. He began to question if drugs produced by big foreign companies were actually lifesaving. He surrounded himself with conspiracy theorists who said that H.I.V. did not cause AIDS, and he refused to provide the treatment through the public health system.
Bewildered but furious, Mr. Achmat and the TAC turned to civil disobedience tactics they had learned as foot soldiers for the A.N.C. — now using them against the A.N.C. itself. They were arrested in the thousands at sit-ins. And, using a tool of the new South Africa, they sued the government for access to lifesaving treatment.
Mr. Achmat continued his drug strike, growing sicker and sicker, and had to drag himself to give another speech or lead another rally. Mr. Mandela came to his bedside and entreated him to end his strike, and donned the “H.I.V. positive” T-shirt that Mr. Achmat had made famous, aligning himself with the protesters.
The Mbeki government lost in court and finally capitulated in the face of mass public pressure. In 2003, the national treatment program began. Mr. Achmat took his medication and within weeks had shed the chronic infections in his lungs and gut. He brimmed with energy.
And over the next 20 years, South Africa’s treatment program became the world’s biggest and one of the best run. In the first 11 years that the drugs were widely available, life expectancy rose by more than a decade . The activists of the TAC put away their signature T-shirts and moved on.
Until the announcement by the Trump administration. As public criticism mounted, Dr. Motsoaledi said that there were drugs on the shelves in public clinics — people needed only to go and collect them.
Public health experts were exasperated. They heard, in the government’s response, an echo of the Mbeki days.
“Why are we so embarrassed to say we need help?” said Dr. Glenda Gray, who oversaw a major H.I.V. research center that had lost a huge hunk of its budget, which had come from the United States.
The health minister’s office did not respond to interview requests.
On Wednesday, Dr. Motsoaledi announced emergency funding of $33 million for the H.I.V. program, about a tenth of what PEPFAR gave the country. He did not specify how it would be used.
It is difficult to know exactly what is happening to that program, because the ministry has not explained its plans and because so much of the data collection was U.S.-funded. Some people who used PEPFAR-run services have transitioned to the public system, which reported a rise in users, but it’s not clear how many. Tens of thousands of people have lost access to H.I.V. prevention as a result of the cuts. Testing rates have fallen, according to the National Health Laboratory Service.
However, Mr. Achmat’s angry declaration to the government committee — that people were dying — was exaggerated. Most clinics are still dispensing drugs, and while lines are long, and nurses are overworked, the program has not collapsed.
And yet the health ministry and activists are once again fiercely at odds.
Stephen Lewis, a Canadian diplomat who, as the United Nations’ special envoy on H.I.V./AIDS in Africa tried and failed to lobby Mr. Mbeki and became a champion of the TAC, said the response from Mr. Achmat and others was rooted in history.
“It’s not surprising that the activists are hyperbolic, harkening back to Mbeki, because there is tremendous anxiety — ‘My God, is it all going to happen again,’” he said. “In the middle of the night they’re haunted by the nightmare — the clinking of the bed frames as they pulled the dead out of the hospital wards.”
Mr. Achmat said he suspected they would need to use the courts — as they did 20 years ago — to force the government to engage.
His home is scattered with memorabilia, including framed newspaper cuttings of huge TAC demonstrations; he looks at them ruefully now.
“I can’t believe we’re doing this again,” he said. But he reckons he has a reputation for relentlessness that this moment requires. “If they see me,” he said of government officials, “they’ll shake in their bloody boots.”
Stephanie Nolen is a global health reporter for The Times.
Global health reporter covering access to medicines and health care
“The guiding principle of my work is ‘go there.’ I want to hear directly from the people who are affected by disease, or lack of access to a new drug. I’ve been writing about global health for 30 years and have reported from more than 80 countries.”
A version of this article appears in print on July 15, 2025, Section A, Page 4 of the New York edition with the headline: Wading Back Into the Fight To Secure H.I.V. Drugs.
