"Some of the patients find it pointless," Ebrahim Variava, a physician at the hospital, said. "What can we do for them?"
But now AngloGold is prepared to offer hope. The company, like some other major employers in South Africa, is planning to do what the government will not - supply the life-sustaining drugs that can suppress AIDS.
Soon, AngloGold will begin to provide some of its ill workers with antiretrovirals, the expensive drugs that have revolutionized AIDS treatment in rich countries. Employers here are struggling to save workers in a country where AIDS is so widespread that it is a labor nightmare as well as a medical tragedy.
About 20 percent of South Africa's working-age population is HIV-positive.
"The provision of antiretrovirals changes the whole mind-set," Variava said. "Once you start treating this, it changes the whole dynamic."
AIDS medicines are unaffordable for most of the 4.7 million infected South Africans. President Thabo Mbeki's government has declined to provide the drugs to patients of the public-health system, including pregnant women and rape victims, who could benefit from brief preventive treatments.
But the price of the drugs is falling following the failed lawsuit by pharmaceutical companies to block generics in South Africa. And private employers such as AngloGold and its majority owner, natural-resources conglomerate Anglo American PLC, are moving to provide the treatment to their rank and file.
AngloGold's pilot project initially would focus on but a few hundred miners. The trials will help determine whether the company can administer the drugs on a broad scale to a workforce made up largely of migrant laborers.
The company also hopes to learn how miners who blast rock two miles underground while hunched over in four-foot seams in 90-degree heat can bear up under the added stress of antiretroviral drugs.
Company officials say the chief beneficiary of the introduction of AIDS drugs won't be those who are sick but the 70 percent of its workforce not infected. Such antiretrovirals as GlaxoSmithKline's AZT are regarded as the key to improving AngloGold's HIV-prevention programs.
"The principal benefit of voluntary testing is not to identify HIV-positive but to identify the negatives and keep them negative," said Gavin J. Churchyard, who heads AngloGold's health-research unit.
Most workers don't know their HIV status because only those employees who are sick get tested. By offering the antiretrovirals, AngloGold hopes to persuade apparently healthy workers to also get tested.
Those testing negative will be taught how to avoid AIDS. Those testing positive but found to be asymptomatic will be taught how to slow the onset of the disease and will be given antibiotics to prevent opportunistic infections.
"If we're going to ask people to volunteer, we've got to offer something substantial," Colin Eisenstein, head of AngloGold's health services, said. "If they test negative, they get counseling. If they're positive, they'll be directed into the wellness program."
The voluntary counseling and testing program and the antiretroviral pilot project underpin the industry's position that AIDS is a "manageable" problem and not the financial catastrophe that some investors fear for South African business.
"Everybody is saying, 'Wow, here comes this wave that will make us unviable in South Africa,' " Eisenstein said. "We're not saying there aren't additional costs, but it's manageable. It's not going to bankrupt companies."
AngloGold, which operates 27 mines, mostly in Africa, says the additional $7 million that it spends on AIDS treatment amounts to 0.1 percent of the company's revenue. By 2011, the cost is expected to rise to 0.4 percent.
"We need to send out the message: Live better; live longer," said Brian Brink, Anglo American's medical director, who will coordinate AngloGold's antiretroviral project with seven others at Anglo American's timber and coal- and platinum-mining divisions.
"There's a possibility of turning AIDS into a chronic disease, like diabetes," he said. "One can work with HIV."
Managing AIDS on a grand scale - most American or European workplaces don't have to deal with any health problems of this magnitude - is a daunting and complex undertaking. AngloGold has run a voluntary testing service at Welkom for eight years, but few workers have participated, fearing that the information would be used against them.
The source of this distrust goes back to 1986, when the mining companies conducted their first AIDS surveys and found 0.5 percent, an alarming rate at the time, to be HIV-positive.
Mining companies banned workers from Malawi, identified as the chief source of the virus. The miners' unions protested, and legislation was enacted prohibiting discriminatory action and making AIDS a reportable illness.
Despite assurances that those who submitted to tests would be protected, hospital workers sometimes leaked the results to the community, undermining confidence in the program.
This year, the company reorganized the service to ensure confidentiality. No names, only numbers, appear on medical files. The program also switched to an AIDS test that delivers same-day results. Before, most patients didn't bother to return for their results.
AngloGold is also organizing teams of peer educators - many of them HIV-positive - to encourage workers at the mine shafts to get tested.
Still, the patients sometimes confound. Fewer than half speak functional English. Some believe that condoms dispensed are themselves contaminated with AIDS. Others are frightened of giving blood for testing.
"They fear we're infecting them with AIDS or selling their blood," wellness-project manager Jeeva Munsamy said.
Those with reduced immune levels receive cotrimoxazole antibiotic as a prophylaxis. Everyone gets training and watches videos that teach how to improve one's diet and prevent the spread of the virus.
Despite the education, many HIV-positive patients drop out of the wellness program to seek alternative treatment from traditional healers. On a recent clinic day, about half of 113 patients missed their appointments.
Such shortcomings illustrate the challenges facing the doctors who will run the antiretroviral pilot project. The drugs require a rigorous schedule to administer, and lapses can reduce their effectiveness and lead to the development of drug-resistant strains. Even among the hospital's tuberculosis patients, urine tests found that only 85 percent were actually taking their medicine.
"You can't just throw drugs at the problem and create a super-resistant strain," Brink said. "That would be a disaster, an unprecedented disaster."
Anglo American is seeking help from drug firms to conduct the pilot projects. Inevitably, the decision about whether to provide antiretrovirals on a wide scale will be based on a mathematical equation: How cost-effective is it?
"There's no quick fix here, but I do think we can turn it around," Churchyard said. "It's my opinion the cost of treatment is less than the cost of not intervening."
Brink said it would be easier for companies such as Anglo American to justify the cost than for governments, which must serve a broad population.
"The cost of the drugs has come down five times or more," he said. "Drugs in the context of Africa are still unaffordable. In the business sector, where we're talking about people who are employed, the cost-benefit factor is easier to justify."
But even at the discount rate of $2 a day - a miner earns about $10 a day - the cost factor is difficult to model.
"How much longer are people going to live?" Brink asked. "I can't find anyone who will give me an estimate. Let's say two, three years of extra life. You spend a hell of a lot of money to get that additional time, and then you still have to treat it."
Anglo American is also considering whether to treat the families of mine workers in rural areas. After all, the miners and their wives who die will leave lots of orphans. (South Africa is expected to have two million AIDS orphans by 2010.)
Such a program might affect not only the company's bottom line but also the welfare of the nation upon which it has built its fortunes.
"If we can extend a mother's life for five years," Brink said, "it changes the orphan problem immensely."
Andrew Maykuth's e-mail address is amaykuth@phillynews.com.
