Nokhwezi Hoboyi never imagined she would live to see her 25th birthday. The petite woman’s playful smile masks memories of her life slipping away just two years ago, when she lay in a hospice on the brink of becoming yet another South African Aids death statistic.
”I had given up … I would say to my parents, ‘Please, tell my friends to come to my funeral,”’ the 26-year-old says, recalling her battle with a virus that has infected an estimated one in nine South Africans.
Hoboyi’s survival, made possible by anti-retroviral (ARV) drugs, makes her a new South African HIV statistic — reflecting the growing number of people with the virus living normal lives in one of the countries worst hit by the Aids disaster.
But it also represents a maturing stage in the epidemic, bringing new policy dilemmas for officials seeking to track Africa’s expanding Aids crisis and to make long-term plans to treat millions of infected people.
Experts on the disease are discussing these challenges and other issues at the 16th International Aids Conference in Toronto this week, billed as the biggest global Aids meeting.
South Africa’s Department of Health said new data released last month shows the rise in the percentage of people testing positive for the virus has slowed down over the past year — an indication that the epidemic is stabilising.
From its annual survey of pregnant mothers attending public ante-natal clinics, the department estimates about 5,4-million of a population of about 45-million are HIV positive, a slight decrease from earlier projections.
This is largely due to government prevention strategies, officials said.
Some health experts, however, say the picture is not that clear-cut, or that optimistic.
The fact that HIV prevalence — the proportion of the population estimated to be infected — is no longer rising or is even declining may merely mean that deaths from Aids are equal to or outstripping new infections, researchers say.
”We need to start understanding the epidemic differently now,” says Olive Shisana, director of the state-funded Human Sciences Research Council (HSRC). Experts say authorities need to find new ways of measuring and tracking the disease.
”The levelling off does not necessarily mean that we don’t have a problem,” she said. ”What it may mean is that infections are continuing to rise and at the same time more people are actually dying.”
Drugs skew data
The distribution of ARVs in South Africa from 2004, after an about-face by President Thabo Mbeki’s government that had refused for years to fund a state programme, is prolonging tens of thousands of lives.
As more people receive treatment, the number of those infected with HIV will rise, as fewer people die.
”In the long run, if we see more people start using anti-retrovirals we will probably see an increase in the prevalence of HIV. I think this is something we need to clarify … this is a very complex issue,” Shisana says.
The government needs to take this complexity into account as it looks at the future of its ARV programme. While it may be congratulating itself on a stabilisation of the epidemic, in fact it may need to prepare for an expensive expansion of one of the world’s largest public Aids-drugs programmes as people live longer and need continuous treatment for the incurable disease.
The government’s ante-natal survey — a standard method of measuring HIV prevalence in Africa — shows an infection rate among the pregnant women of 30,2%, compared with 29,5% previously.
But other data also shows Aids deaths are soaring, hinting that the percentage of new infections would be even higher if the epidemic was truly being brought under control.
A Statistics South Africa study of mortality between 1997 and 2002 found death increased by 62% among people over the age of 15. The study looked at a period before Aids drugs were publicly distributed and showed a massive rise in deaths from diarrhoea, TB and pneumonia — diseases typically associated with HIV.
Activists say deaths in South Africa are still rising, with up to 900 people succumbing to the epidemic every day as the drugs still only reach a small proportion of people.
‘Not a good thing’
The Treatment Action Campaign, the country’s most influential Aids lobby group, says there is little evidence to support the government’s statement that its prevention efforts are cutting into Aids prevalence.
”A decline in prevalence may not be a good thing,” national manager Nathan Geffen said in a statement.
”Infected people are living, [so] if the number of people with HIV is declining, it could be because [people who do not have access to ARVs] are dying of Aids instead of getting treated,” he said, adding greater emphasis should be placed on the rate of new infections.
The debate over the figures may also have lessons for other countries at the centre of the global Aids epidemic.
South Africa’s neighbour Botswana is battling stubbornly high prevalence of about 24%, possibly a consequence of one the best ARV programmes in the world that reaches up to 85% of those infected with the virus.
For HIV-positive South Africans like Hoboyi — who herself lost two infants to Aids — the debate over South Africa’s Aids data is of secondary importance, even though it may influence how government and, ultimately, global Aids funds are allocated.
”Here I am today, I am able to wake up in the morning,” she said. ”I never thought I would ever be able to wake up and go to work again.” — Reuters