IN THE HIGH COURT OF SOUTH AFRICA (TRANSVAAL PROVINCIAL DIVISION) In the matter between TREATMENT ACTION CAMPAIGN AND OTHERS Applicants MINISTER OF HEALTH AND OTHERS Respondents AFFIDAVIT: PROFESSOR QUARRAISHA ABDOOL KARIM I, the undersigned QUARRAISHA ABDOOL KARIM hereby make oath and state as follows: 1. I previously deposed to an affidavit in this matter. 2. The facts deposed to in this affidavit are again within my personal knowledge except where I indicate otherwise. To the extent that I rely on information supplied by others, I believe that such information is true and correct. 3. I respond to the affidavits filed on behalf of the Respondents to the extent that they deal with epidemiological matters pertaining to the reduction and prevention of mother-to- child transmission of HIV. 4. The HIV/AIDS epidemic is one of the largest public health emergencies to face South Africa. I understand that this is not in dispute. 5. Regrettably, Dr Makubalo denies the relevance of facts that show the growth and extent of the epidemic in this matter (paragraphs10.5 &10.6 of her affidavit) . 6. Dr Makubalo also acknowledges the gender disparity that women, particularly women of reproductive age are more directly affected by the HIV epidemic than men (e.g. paragraphs 10.5, 10.9 and 11) 7. Inexplicably, Dr Makubalo denies the relevance of the epidemiological evidence that women are more directly affected by the epidemic than men. (paragraphs 10.5, 10.9 and 11) 8. Makubalo however disputes that the epidemic remains one that is 'explosive', contending that it has reached a 'plateau' (paragraphs 9.4 & 10.4). I disagree with her characterization of the epidemic at this juncture, but I have been advised that this is not the real issue in this application. The ressence of my previous affidavit is the seriousness of the HIV/AIDS epidemic, its disproportionate effect on women of reproductive age and the fact of new infections, including children infected at birth on a daily basis. PUBLIC HEALTH EMERGENCY 9. HIV/AIDS is a public health emergency. According to the Respondents' estimates, (compiled through the antenatal survey for which Dr Makubalo is responsible), projections of the estimated number of people infected with HIV in South Africa at the end of 2000 are as follows:- Women aged 15-49 years - 2.5 million; men aged 15-49 years - 2.2 million; and babies - 106109. This gives a total of 4.7 million South Africans infected with HIV at the end of 2000. These estimates suggest that approximately 1-in-9 South Africans are infected with HIV. This appears from annexure AN2 to the affidavit of Dr Ntsaluba (page 863) . 10. These facts are relevant because they provide the context for the public health intervention to reduce mother-to-child HIV transmission, they explain the scale of the epidemic and they suggest the seriousness and urgency of these proceedings. YOUNG WOMEN ARE DISPORPORTIONATELY AFFECTED 11. I am advised that this application is also about increasing the reproductive choices of pregnant women including women with HIV/AIDS. As stated in my original affidavit, women of reproductive age, especially younger women are infected at an earlier age with HIV, and more women than men are infected with the virus. I provided the epidemiological evidence for this, especially at paragraphs 21 and 22, that suggests women in the 20-24 year age group are most affected. 12. These facts suggest that targeted public health interventions such as the reduction of mother-to-child transmission, improved maternal and child care, improved health care services for women are essential to any response to the HIV/AIDS epidemic. 13. As part of an MTCT HIV prevention programme, the provision of counseling and testing alone at all antenatal clinics will provide women with greater options and reproductive choices, as well as education on HIV/AIDS. Regrettably, Dr Makubalo states that evidence on maternal mortality and HIV/AIDS is irrelevant to the application. (paragraphs 11.10—11.13) 14. I note that according to Annexure AN2 to the affidavit of Dr Ntsaluba: "Between 1999 and 2000, HIV point prevalence increased significantly among women in their twenties only. Pregnant women in their late twenties show the highest infection rate at 30.6% whereas survey participants aged 20—24 yielded a point prevalence of 29.1%. It is important to note that over the years women in their twenties have consistently shown the highest level of HIV infection, making up on average not less than half of the adult HIV positive population. It goes without say [sic] that the implications of such a distribution at social and economic levels are matters for concern. What is more this also significantly impacts on maternal care and child survival. " 15. Women are disproportionately affected by the HIV/AIDS epidemic,and the epidemiology of this gender imbalance requires that government take urgent policy and programmatic measures to provide women with increased reproductive choices and to reduce mother-to-child HIV transmission. EPIDEMIOLOGY 16. Epidemiology is centrally and fundamentally about the study of the distribution and determinants of disease phenomena in populations to guide public health action i.e. it is deeply rooted in societies and communities. As an epidemiologist I have studied and published extensively on the evolving epidemic in South Africa as well as the socio- epidemiological factors fuelling the spread of HIV in South Africa, including the phenomenon of gender and its role in increasing vulnerability of women to acquiring infection with HIV. Indeed, my doctoral dissertation is based on the study of women and AIDS, including the epidemiology and gender barriers to HIV prevention in KwaZuluNatal. 17. I cannot agree with Dr Makubalo and the Respondents that the epidemic has reached a 'plateau'. I note, for example, in the 3-monthly report of the KZN MTCT PROGRAMME (Annexed to the affidavit of Ronald Winston Green-Thompson), that 49,5% of the 3224 pregnant women who volunteered to be tested for HIV were HIV positive ("RWG3" at p 1617). I stand by the characterisation of the HIV/AIDS epidemic in most of South Africa as being an "explosive" epidemic. This is a well-established term in the epidemiological literature. However, this fact can be debated by statisticians and epidemiologists without detracting from the undisputed and undisputable fact that the HIV/AIDS epidemic is a public health crisis. 18. I can not agree with Dr Makubalo's assertion (paragraph 12.4.1) that mother-to-child HIV transmission has nothing to with sexual activity. Heterosexual intercourse is still the major mechanism for sexual reproduction in our society and it is an established scientific fact that HIV is transmitted primarily through unprotected sexual intercourse. OPERATIONAL DIFFICULTIES 19. Dr Makubalo states that I have no regard for the complexities and operational difficulties faced by the public sector. I have full appreciation for the difficulties faced by the state. As director of the national HIV/AIDS and STI programme from 1995 to mid 1996 I provided the first strategic vision and approach to HIV/AIDS and STI for the South African government. Some examples of successful policy implementation in these very early days of transformation and transition include: 19.1. increasing male condom distribution from 4 million per year prior to 1994 to 90 million by the end of 1995 and 120 million by the end of 1996; 19.2. the introduction of the syndromic management approach of sexually transmitted infections in the public sector; and 19.3. the introduction of the female condom in the public sector. 20. I have undertaken an evaluation of the KwaZulu Department of Health pilot home- based care programme. With respect to use of two dose nevirapine to reduce intrapartum transmission of HIV, I have successfully implemented a pilot programme on the use of 2 dose nevirapine at a peri-urban primary health care facility in KwaZulu- Natal. As Scientific Director of the Durban HIVNET site, I have worked extensively with hospitals in KwaZulu-Natal and have successfully implemented research projects that require rigorous Good Clinical Practice standards to be maintained at the self-same public sector facilities. My experience to date with working in the public sector in these various capacities has taught me that whilst there are resource limitations, these can be overcome. CONCLUSION 21. The scale of the epidemic, the disproportionate impact on women and the best interests of children require that the government urgently commit to a national programme to reduce mother-to-child HIV transmission. Such a programme cannot be implemented overnight and requires an interim solution as well. I support the relief sought by the Applicants in this matter. ______________________________ DEPONENT Quarraisha Abdool Karim, PhD I CERTIFY THAT THE DEPONENT HAS ACKNOWLEDGED THAT HE KNOWS AND UNDERSTANDS THE CONTENTS OF THIS AFFIDAVIT WHICH WAS SIGNED AND SWORN TO BEFORE ME AT DURBAN ON THIS DAY OF NOVEMBER 2001 AND THAT HE HAS NO OBJECTION TO TAKING THE PRESCRIBED OATH AND CONSIDERS SAME TO BE BINDING ON HIS CONSCIENCE. ______________________ COMMISSIONER OF OATHS 1