TAC Electronic Newsletter

31 January 2005

Contents

Calculation of Mortality in South Africa Confirms Massive Increase in AIDS Deaths

TAC Says Treat 200,000 People by 2006.

A report published in the journal AIDS on Friday by Medical Research Council and University of Cape Town researchers confirms that there has been a massive increase in AIDS deaths in South Africa (Groenewald et al., AIDS, 2005, 19:193-201). This yet again demonstrates the need to speed up the implementation of the Operational Plan for Comprehensive HIV and AIDS, Care, Management and Treatment (published by the Department of Health on 19 November 2003), particularly the rollout of antiretroviral medicine and the mother-to-child transmission prevention programmes.

The Actuarial Society of South Africa estimates that over 300,000 people died of AIDS in South Africa in 2004; the number will rise in 2005 unless many more people receive treatment. Only 20,000 people were receiving treatment in the public sector as of October 2004. This is why the TAC's campaign theme for this year is Treat 200,000 People by 2006.

The rise in AIDS deaths also signals how urgent it is to improve prevention efforts so as to stem unnecessary mortality in the future. Over 1,000 people are estimated to be infected daily in South Africa. A new bold approach to prevention is needed: one that encourages HIV testing and that is much more forthright about the need for condoms to be distributed in schools, places of worship and work. Public messaging must also include people with HIV, sex-workers and gay men and not seek to promote interventions or policies that stigmatise people.

End the Denial

AIDS denialists who argue that there is not a substantial AIDS epidemic have received publicity over the last year in the South African and British media. Yet not once have any of their views been published in peer-reviewed scientific journals. This is because their arguments have no scientific basis. The report by Groenewald et al. should signal to the media that continuing to give large space to AIDS denialists is irresponsible and contributing to public confusion. The questions that really do need to be debated more extensively in the media are much more important and complex such as:

Given the overwhelming evidence of a large increase in the number of deaths, it is an insult to the dignity of people with HIV as well as people who have lost family and friends to AIDS to continue denying that there is a massive HIV epidemic in South Africa.

What the Report by Groenewald et al. Shows

In 2001, Statistics South Africa (Stats SA) published a study that used a 12% sample of death certificates for the period 1996 to 2001 to calculate the proportion of deaths associated with different causes. Because death certificates frequently do not state HIV as the underlying cause of death, the proportion of deaths caused by HIV was substantially underestimated. Nevertheless, the study shows explicitly that HIV had become the largest cause of death (as indicated on death certificates) in women by 2001 and that a pattern of mortality had emerged in which young adults (aged 15-49) were dying in increasingly large numbers relative to the rest of the population.

Stats South Africa states "In cases where HIV or its synonyms (e.g., immunocompromised, immunosuppression, retroviral disease, wasting syndrome) are stated on the certificate, an appropriate code related to HIV is used. ... On the other hand, if HIV or its synonyms are not stated on the certificate, the reported diseases are coded as stated, with no relation to HIV. For example, if a physician certifies the death of a 25-year old urban, educated and employed person as being that of acute tuberculosis, with no mention of HIV, the code for acute tuberculosis is used. This is where official statistics stop and research begins." (p. 28)

The new report by Groenewald et al. takes up the research challenge, presented by the Stats SA report, to determine how many deaths classified under the disease categories other than HIV were actually due to HIV. It analyses the pattern of deaths for 22 different disease categories in particular ages. Nine causes of death categories showed substantial increases between 1996 and 2000-2001, with increases being particularly significant in young adults and in children below the age of 5. These categories are all death categories or opportunistic infections frequently associated with HIV (e.g. TB, pneumonia, diarrhoea). The only plausible explanation for the increase in deaths in most of these categories is an AIDS epidemic.

When combined with the deaths that were actually classified in the HIV category, the researchers found that they accounted for 93% of the deaths due to AIDS estimated by the Actuarial Society of South Africa's ASSA2000 model in 2000-2001. Furthermore, since people were presumably dying of AIDS before 1996, the actual number of AIDS deaths may be somewhat higher. AIDS denialists have frequently criticised ASSA2000 as merely a mathematical model not based on reality. The results of this report show, once again, the lie to this. Incidentally, the ASSA2002 model subsequently replaced the ASSA2000 model, and the estimated number of AIDS deaths in 2000-2001 was 7% lower in ASSA2002 than in ASSA2000.

It is untenable to argue that the increase in mortality is due to population growth. The Stats SA report shows a rise in the proportion of deaths due to HIV/AIDS and population growth affects the total number of deaths rather than the cause of death profile. Equally, it cannot be due to improved death registration, for the same reason. Nor can it be explained by poverty. Provision of housing, social grants and electricity have all improved since 1994 and employment and income-levels of th