Sunday Times, South Africa - November 19, 2000
William Makgoba

SOUTH Africa appears to be in a state of profound national denial about the HIV/AIDS epidemic. Is it because the scale is too traumatic to contemplate, the mixed messages from the government or simply the lack of up-to-date and reliable statistics?

It is estimated that there were between 180 000 and 250 000 AIDS deaths in 1999. However, the lack of actual recorded statistics as opposed to estimates contributes to the denial of the problem.

Researchers at the Medical Research Council have recently developed techniques to obtain statistics which show that the rate at which young adults die in South Africa has increased unprecedentedly over the past few years.

Getting them has not been straightforward. The official death statistics are compiled by Statistics South Africa, based on information provided on the death certificate by a doctor. at the time of death. The most recent figures are for 1995, before deaths from the epidemic were significant. Furthermore, these statistics may well be unreliable because the true cause of death of someone dying from AIDS is often misreported.

Because of that, scientists often work with a mathematical approach, called a model, to predict AIDS deaths from other known factors such as the extent of HIV infection in the population. These models can also make predictions, for example on different interventions to reduce the epidemic.

Scientists at the Burden of Disease Research Unit of the Medical Research Council have been working with actuaries at the University of Cape Town, and with several government departments and agencies, to refine and update estimates of the epidemic in South Africa.

Preliminary results, showing changes in the deaths of young adults in the last decade, were presented in July to the panel of experts convened by President Thabo Mbeki and reported in the Sunday Times.

The results showed an increase in the total number of deaths and, more importantly, a pronounced shift in the pattern of deaths, with relatively more deaths among young adults than at the beginning of the decade.

Even allowing for the government's improvement of the death registration system and its extension to the rural areas and former homelands, the Medical Research Council concluded that the most likely explanation was AIDS.

Criticism was voiced by the AIDS dissident lobby, which thought most of the changing pattern could be explained by the fact that more deaths, particularly those of Africans, were being recorded.

The research group had in fact been working for many months to estimate the true death rates for South Africa from the '80s to the present.

In a briefing note released this month, the Medical Research Council showed how the overall mortality rates for South Africa have risen steadily since the early '90s. The results refer to the whole of South Africa. They show that mortality rates for adults were fairly stable during the '80s but there has been a marked increase in mortality of young adult women, starting about 1995.

The mortality of young men has also increased and the pattern suggests this may be a combination of a change in the injury-related deaths that occur among men in their 20s and a more recent increase in deaths in a slightly older age group related to AIDS.

This increasing trend of the young dying, especially young women, is the reverse of what would be expected. In countries not affected by HIV/AIDS, adult mortality rates have generally declined.

The rise in overall mortality is most noticeable for women aged 25 to 29, where rates are now more than three times what they were a decade ago. Among men, the rise is one-anda-half times, but starting from a higher rate.

The changes in mortality for men are more spread out than for women, reflecting the difference in age of infection between men and women - a consequence of older men tending to have sex with younger women.

The Medical Research Council's Burden of Disease Research Unit estimates that more than over half the deaths between 15 and 49 are now due to AIDS. Combined with the recent increases in child deaths, AIDS accounts for a quarter of total deaths and is likely to be the biggest single cause of death.

Epidemic.

Although the epidemic has been in South Africa for more than a decade, the long period between infection and death the impact on mortality is only now being reflected in the statistics.

This represents only the start of a rapidly rising number of deaths. Our predictions, and those of UNAIDS and the US Bureau of the Census indicate that left unchecked between five million and seven million South Africans will die from AIDS in the next 10 years, a figure comparable to the number of deaths in the Holocaust.

However, the predictions suggest that even at this late stage the impact can be reversed by interventions such as providing affordable anti-retroviral drugs.

Such will require more decisive action from the Government in challenging the pharmaceutical companies and strengthening the health services.

The models also suggest that it is not too late to reduce the spread of the disease by increasing the public's awareness and changing sexual behaviour. It is time for all South Africans to stop mucking about, to stop making AIDS a partypolitical or racial issue and to face the reality.

Makgoba is president of the Medical Research Council, David Bourne is a chief research officer in public health at the University of Cape Town, Rob Dorrington is the head of actuarial science at the University of Cape Town and chairman of the AIDS subcommittee of the Actuarial Society of South Africa and Debbie Bradshaw is the director of the Medical Research Council's Burden of Disease Unit.

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