The recent publication of a Kenyan government study that shows a lower infection rate than previously thought in that country (6,7% versus 9,4%) and misleading articles by Rian Malan in noseweek and The Spectator have caused some concern over the accuracy of South African HIV statistics.
But the evidence is overwhelming that the HIV epidemic is immense and that South African statistics are plausible. We know this from a vast number of sero-prevalence surveys in pregnant women, communities and hospitals, as well as analyses of death data by the Medical Research Council (MRC) and Statistics SA.
The Department of Health, the Actuarial Society of South Africa (Assa) and the Human Sciences Research Council (HSRC) have all separately used the results from some of these surveys to estimate the size of the epidemic.
This is a difficult task and there is quite a large margin for error. The estimates range from 4,8-million to 6,6-million South Africans with HIV in 2002. The differences are significant, but they all imply the same conclusion: the South African HIV epidemic is massive. There is sufficient evidence to reach the same conclusions about Botswana, Zambia, Malawi, Zimbabwe and Tanzania, countries, which Malan disputes have large epidemics.
Of course, no one can know precisely the size of HIV prevalence, but as more research is done, estimates will be revised and become more accurate.
Malan offers a number of ill-informed criticisms of Assa’s estimates and argues that too much money is being invested in Aids. These have since received wide media coverage both locally and internationally. Space permits only a brief rebuttal here.
Malan’s most serious error pertains to a report released by Stats SA in 2002. It analysed a sample of death-registration certificates from 1997 to 2001. By 2001 tuberculosis had become the disease with the most number of recorded deaths, followed closely by HIV; in women HIV is the leading cause of death. Furthermore, the proportion of deaths due to TB rose dramatically from 1997 to 2001.
Since TB is the opportunistic infection most commonly associated with HIV, much of the proportion of deaths attributed to TB would also be HIV-related. The same trends for the same reason can be observed for influenza and pneumonia, as well as other diseases. The only rational explanation is an HIV epidemic. The reason not all Aids deaths are recorded under the HIV category is that doctors frequently do not write anything to do with HIV on death certificates, either because the patient was not tested or to protect the family from stigma and lost funeral benefits.
The report, coupled with an analysis of mortality produced by the MRC in 2001, offers the clearest evidence yet of a sustained growth in mortality in young people and points to HIV being the country’s biggest single cause of death. The government has just released the Towards Ten Years of Freedom report, which argues that delivery of social services, such as clean water and housing, has improved. These are major factors in vulnerability to poverty-related disease. Yet more people are dying younger. How can proponents of the view that we do not have a massive epidemic explain this?
Yet Malan leads his readers to believe that the Stats SA report calculates far fewer Aids deaths in 2001 than Assa’s computer models (47 000 versus 195 000). But Stats SA neither says nor implies any such thing. The so-called Stats SA calculations are entirely Malan’s and he has made a mess of them, which raises questions about his number-crunching abilities.
He only counts deaths in the HIV category and ignores the HIV-related deaths in the other illness categories. If he read the report properly, he would know that it makes it clear this cannot be done.
Malan also argues that demographers overestimate HIV prevalence in medical-scheme members. He offers a quotation from an old newspaper article and his own whimsical perceptions to back up his argument. Our knowledge of HIV prevalence in the middle class is much worse than among poor people, so medical-scheme estimates are a poor argument to support his thesis that countrywide prevalence estimates are grossly exaggerated.
Nevertheless, data from the country’s biggest HIV-management programme for medical schemes and a study conducted by the HSRC demonstrate that Malan’s perceptions are unsupported and that the demographers’ estimates are plausible.
Malan argues against the politicisation of Aids, which he claims is commandeering disproportionate amounts of limited health resources away from other diseases. But, it is precisely because of the politicisation of HIV that there is a growing awareness globally of the inequities in health care between rich and poor countries that go far beyond this disease.
There have been concrete results of this raised awareness. The Global Fund to Fight Aids, TB and Malaria was established in 2001 as a result of the efforts of Aids activists. The fund means that there is now the real prospect of substantial money being invested in combating the infectious diseases related to the most number of deaths in the developing world after HIV.
Malan complains that ”spending on Aids research exceeded spending on TB by a crushing factor of 90 to one”. But this real problem he refers to has nothing to do with estimating HIV prevalence in Africa. Pharmaceutical companies have spent big money researching new HIV drugs because of profitable markets in the United States and Europe. There is no lucrative market for treating TB in these countries. The failure of drug companies to develop enough medicines for high-mortality diseases in developing countries is because the current research and development incentive system does not encourage developing medicines for the poor.
This is something that Aids activists have consistently highlighted, which is why the global pharmaceutical industry is under unprecedented pressure. Ultimately though, we should ask Malan if it is worth quibbling over whether 15-million or 30-million people in sub-Saharan Africa are HIV-positive, when governments are still so far from an adequate response to the epidemic. Undoubtedly we need more research into HIV prevalence and mortality, but what we already know is sufficient to reach the conclusion that there is a moral imperative to improve treatment and prevention efforts.
Nathan Geffen is the national manager and Eduard Grebe is a volunteer for the Treatment Action Campaign . A detailed rebuttal of Rian Malan’s arguments is available on www.tac.org.za