/ 21 November 2008

A steady erosion

HIV is thought to have a kill rate of close to 100%, higher than even the notorious haemorrhagic diseases such as Ebola. But, unlike such virulent attackers, HIV kills its hosts through a steadily attrition of the immune system, giving ample time for new infections to occur. The result is a slow-burning epidemic steadily destroying lives and eroding South Africa’s development potential.

HIV/Aids was regarded as effectively untreatable in South Africa. The drugs were too expensive: Supreme Court of Appeal Judge Edwin Cameron had to have financial help to afford the antiretrovirals that have now kept him alive for so many years. Effectively, antiretroviral therapy (ART) was seen as something for the wealthy elite — and, so the argument went, even if it were affordable, then poor and unsophisticated people were unlikely to be able to take it properly.

This prejudice has been turned on its head because antiretroviral programmes in South Africa, and other developing countries, have shown adherence and success rates at least as comparable as those in the developed world.

With the numbers of people likely to be infected with HIV escalating, attention has turned to the economic impacts. Economically HIV/Aids impacts in many ways. Sickness and death in the workforce result in falling productivity both as people become sick, and when they need to be replaced.

Households with an individual sick with HIV/Aids divert resources to aid the sick person through payments for healthcare and through the diversion of individual time and effort to caring for the sick.

Households also need to find replacements to take over the work done by the sick, or dead, person, leading frequently to children taking on added responsibilities and increasing the chances that they will drop out of school. This is particularly true of girls, who tend to be regarded as the natural caregivers. The result is a decline in opportunities for people and households to develop educational or physical resources to pull themselves out of poverty

The macroeconomic impact has been relatively mild compared with these microeconomic issues. Predictions of economic collapse have failed to come true, with even the number of HIV-positive people having to be revised downwards.

These predictions were borne of ignorance — the transmission mechanisms of HIV are still slightly obscured, people over-estimated the number of those infected, and the strength of human and community coping mechanisms were underestimated.

Alan Whiteside, professor at the University of KwaZulu-Natal, says that is possible the economic impacts were overestimated. ”Maybe we talked it up to get people to react, that’s quite possible. When we looked at the economics of HIV we overstated what it was going to do in terms of GDP. We underestimated the coping mechanisms. If a person who dies is not a voter, not a contributor, then government doesn’t care, and it doesn’t matter in economic terms. But it does really matter in social and developmental terms. Aids takes away people and cuts across what we need in society, it erodes our abilities.”

Recently, with some exceptions, macroeconomic predictions about the impact of HIV/Aids on the economy have dropped away. Several economists point to an unpalatable reason: the people in South Africa most likely to get sick and die from HIV have been either the informally employed or lower skilled workers.

In the case of the former they didn’t — and still don’t — impact on the country’s formal growth statistics. In the case of the latter, the huge unemployment levels in South Africa mean that unskilled labour could be fairly rapidly replaced.

But while some researchers were predicting economic gloom, others were using economics to motivate for hope. Nicoli Nattrass from the University of Cape Town, and Sidney Rosen from Boston University in the United States, used economic analysis to show that giving ART to workers made financial as well as ethical sense.

A preliminary economic impact assessment carried out by Aurum Institute for Health Research for Anglo American showed that that the first 12 months on ART represented a net cost of R51 per patient when treatment costs and absenteeism and healthcare savings were taken into account. By 36 months this figure had grown to a saving of R13 71 per patient, and this data excludes the costs of deaths, ill health, and improved productivity once on treatment.

One of the difficulties in treating a currently incurable disease such as HIV is that both the virus and its interactions with humans are very complicated. HIV uses one of the fundamental human drivers, sex, as a route of transmission. Unfortunately this is one of the human activities that cause illogical and moral responses. For example the abstinence programmes once so beloved of the Bush administration have repeatedly been shown not to work.

Nor is the link between income and risk of HIV as directly clear as was once thought. Poverty, particularly among women, can lead to higher-risk sexual behaviour such as transactional sex, and sex with older men who, simply by virtue of their age, have a higher chance of having the virus. One study looking at 3 000 girls at school found 3% had HIV but that not one boy was infected. But in some cases HIV prevalence rises along with income to a particular level. People who have more disposable income may have more chances to find sexual partners, either paid or unpaid.

Research by Aids doctor and consultant Clive Evian among several large companies in Botswana, Swaziland, and South Africa found that people tend to believe HIV is someone else’s problem: in the more than 5 000 participants, levels of HIV prevalence were highest — over 29% — among those who didn’t know or weren’t sure of their HIV status. This compared to an overall average prevalence of 24,5%, and prevalence of 22,4% among those employees who knew their status.

Evian’s study found that a third of all HIV-positive patients did not trust the confidentiality promises of either employers or health services. But this resistance to testing can be overcome by workplace programmes. Research from Anglo American found that in 2003 less than 10% of employees took up voluntary counselling, a figure which has risen steadily to 72% by 2007, with a target of 75% for 2008.

South Africa’s response to HIV has been abysmal: the latest National HIV and Syphilis Prevalence Survey (2007) estimates that between 26,9% and 29,1% of pregnant women had HIV. In 2006 it was between 28,3% and 29,9%, while in 2005 it was between 29,1% and 31,2%.

Even if the annual number of new infections peaked in the late 1990s, the long period during which HIV apparently lies dormant — averaging between seven and 10 years — means that the number of deaths resulting from the virus will continue to rise.

Modelled estimates by Rob Dorrington, professor of actuarial science at UCT, and his colleagues are that by the middle of 2006 almost 600 000 people were Aids sick, and during that year 479 000 people had moved from being HIV-positive to having Aids.

Methods of collecting and analysing data have changed, and that makes direct comparisons over time difficult. However, according to Statistics South Africa in 1997 there were 33 000 registered deaths among children under the age of five. In 2005 this was 62 000. Again this is likely to be due to infectious diseases — and in South Africa this means HIV/Aids.

Without effective interventions to preserve the health of mother and child as much as possible, approximately one-third of children would become infected with HIV during late pregnancy, birth or breastfeeding.

Pregnancy is an additional risk to a woman with a compromised immune system, especially if she is not provided with the levels of nutrition she needs. Researchers are gathering greater understanding of the strains put on the body by sub-clinical or apparently invisible HIV infection. The depletion of nutrients and micronutrients is even more problematic for a woman whose body has to feed a foetus or baby.

Few children infected with the virus during pregnancy, birth or breastfeeding survive to their fifth birthday without antiretroviral drugs.

The same study estimates that in mid-2006 there were more than 527 000 new infections, and that 11,2% of the population were HIV-positive. Among adults aged 20 to 64 HIV prevalence was estimated at 19,2%.

As with other sexually transmitted infections, HIV is most common among teenagers and adults who are sexually active. This is also the age group that tends to be most economically productive, as well as producing their own families.

In South Africa and many other hard-hit countries and communities, HIV, as one of the newest of humanity’s scourges, has particular synergy with one of the oldest, tuberculosis. The result is an even greater strain on the health system as it copes with the diagnosis and treatment of increasing levels of TB, while rolling out an antiretroviral programme that is simultaneously the biggest in the world and yet too small. The majority of people with active TB also have HIV, requiring active treatment of both.