The recent controversy about the allegation that HIV/Aids statistics are inflated has created the perception that the United Nations Programme on HIV/Aids (UNAids) estimates should be viewed with caution. Can you comment?
I don’t think this is true. It is not just about taking computer modelling and churning out estimates. Our estimates are based on real-life studies, and the methodology is straightforward. UNAids and the World Health Organisation [WHO] publish estimates of the number of people living with HIV, which are based on all available data, including surveys of pregnant women, community-based surveys such as household surveys, and other information.
We work with countries to assess how strong the data is and to help them do their own estimates. We need to know if what we do about HIV/Aids has any impact, because the amount of money available in any country — certainly in poor countries in Africa — is very limited. We need to make sure the money is well used.
So we should not view them with caution?
The real question is whether we have any interest in inflating the estimates and, if so, would the Aids industry get more money? I can guarantee you that UNAids would not have more or less money with one or two or five million more or less people infected in the world. That is not how it works. Also, our estimates are on the conservative side. Now we are accused of inflating figures, whereas three or four years ago we were accused of playing down figures.
I would claim that there is no other health problem in the world where we have such reliable estimates, but I would like to see them improve. For South Africa and most countries, the estimates are quite good, but there are countries where we have problems, such as Nigeria. Overall, I would say that the estimates we have for Africa are reliable, and we are investing a lot in working with countries to improve their estimates.
Why is there so much focus on estimates? If we are going to have a debate only on statistics, that is diverting attention from the real agenda — what we are doing to fight the epidemic.
The allegation says UNAids gets its estimates from antenatal statistics, which are not always reliable.
There is no gold standard. Antenatal statistics give you a good view of what is going on with sexually active women. They do not tell you what is going on with men. That is a problem. In community-based surveys, like in Mali and Zambia, we have seen a better view of the epidemic in rural areas — because rural areas are under-represented in antenatal surveys.
The problem in community-based surveys is that men have a low participation rate. They do not want to be tested, or they are absent from the household. I think community-based surveys do underestimate the epidemic, but the results of women in community-based surveys and ante-natal surveys are more or less the same. We don’t say the community-based surveys are bad: they are complementary.
Leading South African commentators have in essence agreed with criticisms of UNAids figures, but defended the South African models used by local actuaries. If local actuary models are more reliable, why not disregard UNAids statistics?
The irony is that that is what we do. Five years ago we met with them because we were seen to be over-estimating the figures. For us, the ideal scenario is that each country generates its own statistics, and we focus on quality assessment control.
We constantly ask ourselves whether the quality of our data is good enough. But we are very confident that the current estimates are solid and this is confirmed by community-based surveys.
Are we throwing all our resources into Aids and disregarding other diseases?
Our estimates on Aids are far better than any other disease. If anything, we do not spend enough on Aids. I think we still underestimate the burden of Aids. But as much as I think not enough is being spent on other services, certainly there is still not enough being spent on Aids.
Does UNAids exert political pressure on countries?
One of the problems with Aids is that it is so politically and culturally loaded, and part of the problem with the estimates has to do with that. We make sure we have strong evidence. In South Africa the debate has been so polarised, more than in any other country in the world.
What are your impressions of South Africa’s capacity to implement the new Aids plan effectively? Do we need more political leadership for it to be effective?
What I look for in political leadership is budget and the commitment to institutional arrangements. I am confident that South Africa will soon have the largest HIV treatment programme in the world, certainly in Africa. If there is one country that can do it, it is South Africa.
I know there is much inequity regarding access to health services. I applaud the concern of your government about this inequity, and the fact that strengthening the health-care sector is part of the plan. When I look at the budget and the decision last year to roll out the treatment plan I definitely applaud that.
I am also frustrated that it is not going faster. In terms of leadership, we need to look at the provinces as well. I am confident that the leadership will be there to sustain [the plan], and this is not a one-off budget — people will need treatment for the rest of their lives. Aids will be important for a whole generation of people.
The roll-out of the plan will require much more senior-level engagement. The speeches are right, the budgets are there. Now it is about getting it done — and that will require a different form of leadership. You have to roll-out these strategies, but also to monitor the impact. That is why the integrity of the information is so important.
How does UNAids engage with governments? Does it exert pressure? Are you neutral?
You cannot be neutral and say “Here are statistics Mr President” then hope they will act on it. It is a political strategy. Our credibility is that we are the world’s reference on Aids. Not just on statistics, but what works and what does not work. We have regional and global gatherings. It is about a balance, but we do speak out, as we have in this country.