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Mbeki's stance was all the more puzzling because his country had appeared to be leading the international crusade to bring down the price of AIDS drugs in the developing world. American AIDS activists, energized by the success of the anti-retroviral drug cocktails, thought they were joining that campaign. Last year, they badgered the Clinton administration into reversing a little-known policy to impose trade sanctions on any nation that sidestepped patent protections on AIDS drugs.

As it turns out, all this official questioning of basic AIDS science, and all this talk of toxic drugs, is just dissembling for domestic consumption. The real issue with anti-retroviral drugs is that leaders honestly believe South Africa can't afford them, even at a discount. The government also doesn't want to craft a health policy that favors some people over others, let alone a policy that allows multinational drug manufacturers to call the shots.

"The guiding principal is access to health care ... Equal access to health care," Tshabalala-Msimang said.

That attitude has angered AIDS doctors, researchers and activists who believe that millions of people in South Africa could benefit from anti-retroviral drugs. "South Africa is becoming paralyzed by the issue of equity,'' said Dr. James McIntyre, director of the HIV Research Unit at Chris Hani Baragwanath Hospital, the sprawling public medical center in Soweto.

As the international furor over Mbeki's public slap at AIDS researchers carried on this month, his ministers were slowly owning up to the real issue. Forget about the questions about the cause of AIDS, and the toxicity of AZT. Mbeki is grappling with a horrible choice: pay for the drugs or pay to bring running water to remote villages in KwaZulu-Natal. "We just can't afford AZT,'' Tshabalala-Msimang said.

The preference of the South African government, a 6-year-old democracy built from the wreckage of apartheid, is to fight AIDS with a lower-cost, lower-tech approach. Instead of anti-retrovirals for the infected, the Mbeki administration wants education-oriented AIDS prevention programs. The government is demanding deeper discounts on lower-cost antibacterial and antifungal drugs to treat the opportunistic infections that occur when -- yes -- HIV wears down the body's natural defenses.

Stripped of the "HIV may not cause AIDS" arguments, the strategy makes more sense. It acknowledges that trade-offs may be necessary. The government, moreover, uses arguments against anti-retrovirals that the pharmaceutical industry itself has made. Until South Africa has the clocks, running water and refrigerators needed to maintain 24-hour combination drug therapies, the industry lobby has said, it makes little sense to sink resources into such medications.

"Drugs are not going to help because we won't be able to use them properly,'' said Sean Drysdale, the Hlabisa doctor. "While they are feeling well, we'd be asking them to take a concoction that would make them feel terrible.''

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