Sunday Times (Johannesburg) - November 30, 2004
Rian Malan

THIS is a story about Aids statistics, but let's begin with a parable about soccer, one of South Africa's other great obsessions. When we emerged as frontrunner in the race to host the Soccer World Cup 2010, rivals initially claimed foreign fans would be scared off by South Africa's crime rate.

And when this had no effect, they started bombarding F d ration Internationale de Football Association delegates with information about our apparently insurmountable HIV/Aids problem.

South Africa has more HIV infections than any other country on the planet, they said. Life expectancy will plummet to 37 by 2010. Stadiums will be half-empty. You can't possibly stage the World Cup in such a setting.

Are these projections accurate? It depends who you believe. The US Census Bureau's International Division predicted that Aids would cause South Africa's population to start shrinking by 2003, but our most recent census showed population growing at 2% per annum - much faster than expected.

United Nations' demographers are at odds with South Africa's chief statistician, Pali Lehohla, who claims their most recent projections of Aids devastation are seriously exaggerated.

Similar problems have surfaced in eight other African countries, spurred by the discovery of flaws in UN sampling methods, which are heavily dependant on "sentinel surveys" at government antenatal clinics. In Kenya, for instance, antenatal screening showed that 15% of pregnant women were carrying the virus, but a broader survey in the general population found that only 6.7% of adults were infected.

In Cameroon, a similar survey revealed that HIV prevalence was less than half the level measured by UN methods. In Swaziland, antenatal testing found that "more than 20%" of girls aged 15-18 were HIV-positive. A survey in the general population found that the true prevalence level in this group was 6% - three times lower.

Discrepancies of this magnitude play havoc with the computer models used to estimate HIV prevalence, which in turn leaves Africans suspended in an agony of uncertainty. Predictions of HIV-related doom lead us to believe that we are surrounded by the walking dead, but an Afrobarometer Survey revealed that as of last year, "the average South African" still knew nobody who had actually died of Aids.

We are ceaselessly battered by stories of soaring Aids death rates in hospitals or remote rural areas, but most large corporations report no corresponding change in employee mortality. Some coffin factories - especially in Aids-stricken KwaZulu-Natal - report that demand for their product is rising rapidly, but the nation's two largest coffin manufacturers still see no clear sign of an apocalyptic surge in burials.

Hospitals in the Western Cape thought they'd be overwhelmed when Aids drugs were made freely available a year ago, but barely a quarter of the anticipated patients have thus far showed up for treatment.

Similar mysteries are emerging in the insurance sector. The Actuarial Society's latest model estimates that 40% of last year's adult (age 15 plus) mortality was caused by Aids, but insurance giant African Life stated this week that only 11% of claims in its mass-market burial insurance business involve HIV-related fatalities.

The number of medical aid members receiving HIV treatment has risen rapidly over the past year, but nearly half the Aids cases predicted by models are still missing.

We find similar confusion at Anglo American, where at least 8500 employees are thought to have reached the point in their illness where they will soon die of Aids unless they start taking antiretrovirals. But only about 2050 have signed up for Anglo's free treatment programme.

In a recent report in the Washington Post, Anglo executives attribute the shortfall to fear of stigmatisation and concerns about drug safety.

One struggles to believe that three out of four Anglo employees would rather die than listen to their doctors, but what would I know?

All that is clear is that something doesn't add up here. How accurate are the tests used to determine HIV status? And how many humans are really dying of HIV/Aids? The destiny of a continent turns on this question, and an answer is about to emerge in South Africa. Why South Africa? Because no other African government has the capacity to register enough real-life deaths to draw meaningful conclusions.

British demographer Ian Timaeus, a titan in his field, has calculated that around 90% of adult deaths are registered here. The Medical Research Council has published similar figures, as has Statistics SA, the official statistical service. By all accounts, then, we are unique insofar as we are the only corner of Africa where it's possible to judge computer-generated Aids estimates against empirical evidence.

A few years back, the US Census Bureau's computer models indicated that the HIV epidemic would drive overall annual deaths above one million by 2003. UN models are more restrained, showing around 800000 deaths last year. But real-life death registrations show a far less ominous trend, rising from 401615 in 1998 to 505871 in the year ending March 2004.

American researcher Dr Rodney Richards argues that this increase is influenced by government campaigns to improve registration but the Medical Research Council attributes it largely to Aids.

The debate is further complicated by the near-collapse of the Department of Home Affairs's data capture systems in the late 1990s, which caused long delays in the processing of death certificates.

A senior Home Affairs official says the problem was solved by the introduction of an electronic data management system. But this has created a new headache - while the overall total of registered deaths is roughly known, it is difficult to say in exactly which year any given death took place.

About a year ago, Statistician-General Pali Lehohla decided that the only way to solve these riddles was to return to the source documents - more than three million archived death certificates dating back to 1997 - and reprocess them.

A thousand-person task force has been working on this since March, with six teams cross-checking their results against each other. The US's Centre for Disease is providing expertise related to the coding of causes of death. "The process is transparent and defensible," says Lehohla, "and the outcome will be credible."

And so the moment of truth nears. Stats SA's findings remain confidential, but leaks suggest that things are not looking good for those who believe Aids is a hoax. According to sources at Stats SA, the final count will show a disturbing rise in mortality in precisely the age groups predicted by HIV theory.

But proponents of the apocalypse scenario (the World Bank, UNAids, the World Health Organisation and the US Census Bureau) are in equally big trouble, as their death estimates appear to have overshot the mark by several hundred thousand in recent years.

Aids activists might say this barely matters, but I wonder. Prophecies of Aids-related horror in the future are great fundraising tools, but in the present they can breed despair, obscure all other problems and distort government spending.

Losing the bid to host the Soccer World Cup would have injured our pride, but high Aids estimates threaten us in more serious ways.

Put yourself in the shoes of a foreign industrialist, considering a long-term investment in South Africa. Doomsayers tell you that Aids is already killing hundreds of thousands a year, and that your potential market will soon start shrivelling. They say our Gross Domestic Product will drop 17% by 2010, and that you might have to train three workers for every job because two are likely to die of Aids. Do you invest, or walk away?

Everything depends, in the end, on accurate statistics and accurate projections. It is against this backdrop that Statistics SA's forthcoming report assumes monumental importance. We are the only heavily Aids-afflicted country with viable death registration machinery. Statistics SA's attempt to determine the true number of deaths promises to deliver the closest thing to the truth we will ever get.

041130
ST041118

Always watch for outdated information. This article first appeared in 2004. This material is designed to support, not replace, the relationship that exists between you and your doctor.

AEGiS presents published material, reprinted with permission and neither endorses nor opposes any material. All information contained on this website, including information relating to health conditions, products, and treatments, is for informational purposes only. It is often presented in summary or aggregate form. It is not meant to be a substitute for the advice provided by your own physician or other medical professionals. Always discuss treatment options with a doctor who specializes in treating HIV.

Copyright ©1980, 2004. AEGiS. All materials appearing on AEGiS are protected by copyright as a collective work or compilation under U.S. copyright and other laws and are the property of AEGiS, or the party credited as the provider of the content. .