Comment: Mbeki and AIDS

After 10 years of democracy we have many things to be grateful for, not least of all the fact that South Africa is preparing to launch the world's biggest public sector anti-retroviral treatment programme.

But our president does not want to celebrate that government, by deciding to provide the free drugs, may well have extended the lives of over 4.5 million people living with HIV by over 10 years.

Inconceivably - especially in an election year - President Thabo Mbeki refused to highlight this either when he opened Parliament a week ago or when he was interviewed by the national broadcaster last weekend.

Instead, he says that his deputy, Jacob Zuma, is in charge of HIV/AIDS policy and that government's campaign against "this thing" is well established and ongoing.

Instead of highlighting government's efforts, he said that diabetes and tuberculosis are serious health problems that are being overshadowed by HIV/AIDS.

It is true diabetes is a growing problem. But it is a non-contagious lifestyle disease linked to diet, lack of exercise and genetics. It is thus much more manageable than HIV/AIDS and accounted for around 1% of deaths in 2000, according to the Medical Research Council (MRC).

It is also true that we have a serious TB epidemic. TB is highly contagious, spread in the air, usually when an infected person sneezes or coughs.

But the rapid increase in TB is directly related to the HIV/AIDS epidemic.

Millions of South Africans carry latent TB bacteria, but if their immune systems become weak they are at great risk of getting TB disease.

The number of TB cases almost doubled between 1996 and 2002, according to the Department of Health, which correlates directly with maturing of the HIV epidemic.

Doctors at many KwaZulu-Natal hospitals say that around 70% of their TB patients are also HIV positive.

South Africa's cure rate for TB in 2001 was a mere 54%, a rate worse even than poverty-stricken Mozambique.

But again, HIV pays a role. Combined TB and HIV infections are causing complications, with hospitals in KwaZulu-Natal seeing increasingly unusual presentations of TB, including TB-meningitis, mental retardation from TB and fits, according to KwaZulu-Natal Health MEC, Dr Zweli Mkhize. These cases are far harder to cure.

In the context of AIDS, Mbeki also said that we lack proper mortality figures to tell us "what are the things that kill South Africans". This is being rectified, he said, by a study of all notices of death from 1996 to June 2003.

Statistics SA spoksperson Trevor Oosterwyk, confirmed that his organisation, in collaboration with the Medical Research Council (MRC), was in the process of compiling the study.

A few years back, the MRC's research into mortality estimated that, in 2000, about 40% of premature deaths of South Africans aged 15 to 49 were the result of AIDS.

However, the research caused a storm and the health minister ordered a forensic audit in the MRC to establish who had "leaked" the results.

Statistics SA, and the departments of health and home affairs also issued a statement in which they noted that "there are inherent problems in measuring AIDS related deaths, precisely because such deaths are often recorded under other causal categories. Accordingly, scientists are forced to use indirect measurements rather than simply count the numbers."

Such caution should be applied to the current study too. While the results will enable policy-makers to allocate resources better, it would be wrong to assume that the study will supply definitive figures about AIDS deaths.

According to Professor Carel van Aardt from Unisa's Bureau of Market Research, there is an under-registration of deaths in South Africa.

There is also a serious under-reporting of AIDS-related deaths, both because of the nature of the disease and the stigma associated with it. People die of the opportunistic infections that take advantage of the fact that the virus has weakened the person's immune system so such infections are recorded as the cause of death.

In the past, many doctors admitted that they did not record AIDS as the cause of death because they did not want to jeopardise people's death benefits. In response, the Department of Home Affairs introduced a confidential section to death registration report but this also has limitations.

"The doctor is supposed to give the family of the deceased the report in a sealed envelope. We only show them page one. The confidential part on page two is only for us and the doctor," said a home affairs official dealing with death registrations.

But the official, who asked not to be named, conceded that family members could read the confidential portion as they were responsible for taking the report to Home Affairs to get a death certificate. Thus a doctor not wishing to offend a family may well obscure AIDS as the cause of death.

Patterns of death are harder to obscure than causes, however. Before 1996, the mortality pattern was as expected for a country such as ours. But in 2000, three times the number of women aged 25 to 29 and two and a half times the number of men aged 35 to 39 died, than expected, according to Professor Van Aardt.

While South Africa has high levels of non-natural deaths, these accounted for about 12% to 15% of all deaths in 2002, according to the MRC. This does not fully explain the excessive deaths among men and women in their prime.

When a politician fails to claim credit for a policy that could reverse such perverse death patterns, alarm bells ring. We can only hope that such modesty is not caused by the AIDS denialism that has underpinned much of President Mbeki's view on AIDS since late 1999.

This article is courtesy of Health-e News Service.