The New York Times - September 8, 2006
Michael Wines

AIDS is not reported as a cause of death in South Africa. But the age patterns of the increased deaths and their reported causes -- in many cases parasitic infections, immune disorders and maternal conditions -- made it likely that AIDS and ailments related to H.I.V. were behind much of the trend, they stated.

The government report arrived as President Thabo Mbeki's cabinet simultaneously offered a fervent defense of its AIDS treatment program and appeared to shift some responsibility for the program from Mr. Mbeki's embattled health minister, Dr. Manto Tshabalala-Msimang.

Long under attack for her insistence that foods like garlic and beetroot can stave off AIDS complications, she has been besieged by criticism since the United Nations envoy on AIDS, Stephen Lewis, berated the government's polices at a global conference in Toronto last month.

Clearly referring to Dr. Tshabalala-Msimang, Mr. Lewis said the South African government "continues to propound theories more worthy of a lunatic fringe than of a concerned and compassionate state" and called its program to provide antiretroviral drugs "obtuse, dilatory and negligent."

After a cabinet meeting on Thursday with Mr. Mbeki, the government's ministers said they unreservedly rejected "all the unfounded claims that we don't have a comprehensive program to fight the pandemic."

At the same time, a spokesman said Mr. Mbeki had assigned his deputy president, Phumzile MlamboNgcuka, to oversee a new council of cabinet ministers to coordinate the government's anti-AIDS programs.

"The problem of addressing the challenge of dealing with H.I.V. and AIDS in this country is bigger than any individual, minister or department," the government spokesman, Themba Maseko, told reporters after the meeting. "We need to shift focus from saying the problem in the program is the minister of health."

Eighty-one scientists, including a Nobel Prize winner, were reported to have sent President Mbeki a petition on Sept. 4 calling for him to dismiss Dr. Tshabalala-Msimang, but his office was unable to say on Thursday whether he had seen the letter. He has steadfastly supported the health minister in the face of previous attacks.

The statistical report released Thursday covers deaths only through 2004. But it leaves little doubt that South Africa, with the largest number of H.I.V.-positive citizens of any nation, faces an AIDS problem on a huge scale.

The report indicates, for example, that the death rate among women aged 30 to 34 became 4.6 times as high as it was seven years earlier, leaping to nearly 23 per 1,000. The death rate among men aged 40 to 44 more than doubled, to nearly 28 per 1,000, during the same period.

The sharp increases in deaths in those and adjacent age groups is consistent with the pattern of deaths common in societies with high H.I.V. infection rates, the report stated. Although male death rates typically exceed female death rates at every age in most societies, the report noted, death rates among South African women were sharply higher than those for men until age 34, after which a bulge in male deaths occurred.

That pattern, with men's death rates spiking at a later age than those of women, also is typical of H.I.V. But the University of Michigan demographer who led the South Africa analysis, Barbara Anderson, said that not all of the increase in mortality could be laid to AIDS. Rising obesity and diabetes also contributed to increasing death rates, she said, and still-undetermined causes were also likely to have been at work.

"Those increases in female mortality in the middle adult age groups are extremely large," she said. "It's really big, very serious, and clearly a large portion of that is H.I.V. But that's not the only thing that's going on."

After a notably slow start, South Africa's government has lately increased its effort to provide life-saving antiretroviral drugs to people with AIDS, and the government now says that it has more people under drug treatment -- 134,000 as of last March, plus at least 80,000 more in private treatment -- than any other nation on earth.

The number of people being tested and counseled for H.I.V. infections nearly doubled from mid-2004 to mid-2005, to 1.3 million, and sites where free anti-AIDS drugs are distributed are now in each of South Africa's 53 districts.

But the number of H.I.V.-positive people in treatment falls far short of the number in need -- as many as 750,000 by some estimates -- and AIDS activists charge that the government condemned tens of thousands to death by the snail's-pace rollout of the drug program, which initially fell far short of its stated targets.

An ardent advocate of traditional and alternative medical treatments for AIDS and H.I.V. infections, Dr. Tshabalala-Msimang has lately emphasized in public statements that foods like beetroot are not AIDS cures, but part of a nutritional program that supplements antiretroviral drug regimens.

But she has been widely criticized for refusing to impose sanctions on promoters who offer vitamins and other nostrums as AIDS treatments. She has warned that antiretrovirals are toxic, especially those given to pregnant women to reduce the risk that AIDS will be passed on to their babies. And as recently as March, she told a parliamentary panel that garlic, beetroot and lemon "delay the development of H.I.V. to AIDS-defining conditions, and that's the truth."

She caused a stir at last month's international conference on AIDS in Toronto when South Africa's national exhibit highlighted baskets of those foods. Critics charged that vials of antiretroviral drugs were added to the baskets only after the contentious nature of the exhibit became clear. The government has said the vials were initially omitted because a shipment was late.
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