Feb 22, 2005 (050222)
(Reposted from sources cited below)
Between 1997 and 2002, according to a new report from Stats SA,
South Africa's official statistics agency, the number of recorded annual
deaths in the age group from 20 to 45 more than doubled, from a
little over 100,000 to more than 200,000. Although most deaths
likely to be linked to AIDS are officially recorded as due to
associated diseases such as TB and pneumonia, the age and disease
pattern provides strong evidence of the growing impact of AIDS.
Other previous studies, such as those from South Africa's Medical
Research Council, have provided similar indications. But the issue
is still contentious, as AIDS denialists have used the relatively
low numbers attributed directly to AIDS to claim that researchers
are exaggerating the problem. Activists, on the other hand, have
focused on the need to expand the government's treatment program to
save lives threatened by AIDS and other diseases clearly linked to
In a memorandum addressed to the government on February 16, the
Treatment Action Campaign (TAC) noted that the target of treating
53,000 through the public sector by March 2005 (originally set for
March 2004), is far behind schedule, with only 27,000 at the end of
December. Receiving the memorandum, Murphy Morobe, head of
communications in the South African president's office, praised the
activists as "our conscience," adding that "I bury my own cousins
every week and every month - six already in three years." In a
media briefing the next day, however, Minister of Health Manto
Tshabalala-Msimang outraged activists by claiming that she had no
data on the number dying of AIDS or the number receiving treatment.
This AfricaFocus Bulletin contains excerpts from the TAC newsletter
with comments on the most recent mortality report and their
memorandum to the South African government calling for more rapid
expansion of AIDS treatment programs.
Statistics South Africa mortality report confirms massive increase
in deaths due to AIDS
TAC Says: Treat 200,000 People by 2006
The TAC notes the publication of Statistics South Africa's report
"Mortality and Causes of Death in South Africa, 1997 - 2003." This
report, once more, confirms beyond reasonable doubt that South
Africa is in the midst of an HIV epidemic that is maturing into an
AIDS epidemic. It also provides useful information on the nature of
Between 1997 and 2002, the total number of deaths increased by 57%.
Deaths of people aged 15 years and above increased by 62%. While
some of this increase is due to population growth (10%) and
improved death registration, most of the increase can be explained
only by an HIV epidemic. A number of studies, mostly conducted by
Medical Research Council scientists, have demonstrated the
increase in mortality in South Africa due to HIV, but the
Statistics South Africa report is noteworthy for having been
approved by Cabinet.
The tragic implication of the report - that hundreds of thousands
of South Africans have died of AIDS in the last few years without
access to life-saving treatment - must be used as an impetus to
speed up the delivery of treatment and prevention programmes. The
report has been honestly conducted despite an overly-cautious tone
with regard to causes of death due to HIV.
The report is based on an analysis of 2.9 million valid death
certificates collected from 1997 to 2003. The causes of death as
written on these certificates were processed using a computer
programme. Statistics South Africa makes it clear that
approximately 90% of deaths are now certified but that the quality
of certification remains a serious problem. ...
HIV is frequently not stated as the underlying cause of death.
Instead, an opportunistic infection associated with HIV is usually
indicated as the cause. Therefore, the number of AIDS deaths cannot
be determined by simply reading the report. This is why the report
states "This release covers mortality and causes of death broadly,
and hence does not focus specifically on HIV and AIDS. It does,
however, provide indirect evidence that HIV may be contributing to
the increase in the level of mortality for prime-aged adults,
given the increasing number of deaths due to associated diseases."
Causes of death due to "tuberculosis" and "influenza and
pneumonia", which are frequently opportunistic infections
associated with HIV, more than doubled between 1997 and 2001. By
2001, these were the leading causes of death. Furthermore, the
report states "The proportion of deaths in the age group 20-49 is
increasing. While an increasing number of deaths are associated
with lifestyle diseases (such as heart disease and diabetes) as the
underlying cause, the dominant contributors to the growth in
mortality are deaths associated with tuberculosis, and influenza
and pneumonia." It therefore cannot be argued that the increase in
mortality is due primarily to better death registration data and
population growth, because neither of these would affect the
proportion of deaths recorded in the 20-49 category.
These facts, combined with all the other overwhelming evidence
that South Africa is experiencing an HIV epidemic (antenatal
surveys, HSRC study etc.), demonstrate beyond reasonable doubt
that HIV is causing a massive increase in mortality in South
Key Findings of the Statistics South Africa Report
The above table shows a 57% rise in recorded mortality from 1997
to 2002. The report estimates that 90% of adult deaths were
recorded in 2002 and that the population grew 10% during this
period. A report published by the MRC in the South African Medical
Journal last year analysed death registration data over a slightly
longer period, from 1996 to 2003, and found a 68% increase in
adult mortality. These consistent findings cannot be explained by
population growth or improved registration, but only by an
HIV/AIDS epidemic leading to unnecessary and premature death.
Adult deaths increased by 62% from 1997 to 2002, from 272,221 to
Recorded deaths in the age-group 20 to 45 more than doubled
between 1997 to 2002, from 106,033 to 221,260. That mortality in
this age-group increased so much faster than mortality overall
falsifies the argument offered by some AIDS denialists that the
increase in mortality could be due solely to population growth and
improved death registration, because the latter two causes of
increased mortality would affect all adult age-groups in equal
proportions. HIV mainly affects people in the 20 to 45 age-group
and therefore the pattern of mortality is consistent with HIV.
The number of recorded deaths of people aged 20 to 55 in 2002 was
250,873, more than 50% of all deaths.
In a population following normal mortality trends, a graph of the
number of deaths per age-group would gradually increase for adults
until the older age-groups. But in South Africa in 2002, this
graph increases swiftly among young adults peaking in the 30-34
age-group. This is an abnormal situation that can only be
explained by the HIV epidemic. This situation becomes steadily
more pronounced in the years 1997 to 2002. ... We recommend that
interested readers examine the graphs on pages 11 to 16 of the
Statistics South Africa report.
Recorded tuberculosis deaths increased by 131% from 22,021 to
50,872 between 1997 and 2001. Influenza and pneumonia increased by
197% from 11,503 to 31,495 during this time. These two causes are
frequently associated with AIDS-related opportunistic infections.
While some people die of these diseases in the absence of HIV, the
enormous increase in mortality in these categories can only be
explained by HIV. ...
Adding the largest causes of death most frequently associated
with AIDS (tuberculosis, influenza and pneumonia, intestinal
infections, HIV, immune disorders), the number of such deaths rose
by 244% from 45,978 in 1997 to 170,531 in 2002. Obviously not all
of these deaths are due to HIV. Likewise, these are not the only
HIV-related deaths. However, after correcting for population
growth and improved registration, most of the 244% increase can be
assigned to HIV.
Time to treat and prevent - Time for clear public messages - Time
to end pseudo-science
The implication of the report is clear. We must step up treatment
and prevention efforts in South Africa to curtail the effects of
the HIV epidemic. The premature adult death rate also speaks to an
increase in the number of vulnerable children and orphans.
According to the Department of Health, as of the end of December,
27,000 people were on treatment in the public sector. This is not
good enough, especially when one considers that Western Cape and
Gauteng provinces accounted for more than 50% of those treated. In
the Operational Plan released on 19 November 2003, government
committed to treating 53,000 by March 2004. We are far behind this
target. The TAC calls for government to treat at least 200,000
people with antiretrovirals by the beginning of 2006. Of these, at
least 10% should be children.
Furthermore prevention efforts must be stepped up. Public
messaging by institutions such as LoveLife and Khomanani must be
more explicit on the need for safer sex and condom use. Condoms
must be introduced into all high schools, as well as
sex-education. President Mbeki, Deputy-President Zuma and the
Minister of Health must regularly, on television and radio, call
for people to get counselled and, if necessary, treated.
It is time to end the pseudo-science emanating from some senior
government officials about the HIV epidemic. In a question and
answer session in Parliament on Friday attended by TAC members,
the Minister of Health again expressed doubts about
antiretrovirals and again suggested that traditional medicines and
her nutritional recommendations offered a viable alternative to
antiretrovirals. TAC members noted that she stated that she does
not know how many people have HIV, how many AIDS deaths there are
or how many people are receiving antiretroviral treatment.
[However] some of the best statistics come from the Minister of
Health's department. These estimates should be the basis of
The Department of Health estimates that 5.6 million people were
HIV-positive in 2003. The department also released on Friday the
number of people on antiretroviral treatment in the public sector.
The minister's incompetence, obstructionism and denialism are
hindering the response to the HIV /AIDS epidemic and the broader
health care crisis.
Thousands march to parliament demanding "Treat 200,000 by 2006"
At least 5,000 people marched through the streets of Cape Town to
Parliament on 16 February, demanding that government treat at least
200,000 people with antiretrovirals in the public sector by 2006.
People living with HIV/AIDS, the South African Council of
Churches, Cosatu, nurses, doctors, TAC and other organisations
marched to address the need for HIV treatment, the crisis in the
public health system and the inequality between private and public
health. The rural-urban inequalities were also addressed during
A memorandum was handed over to Head of Communications in the
Presidency, Comrade Murphy Morobe. He was accompanied by the
chairperson of the Portfolio Committee on Health, Comrade Jame
Ngculu. Morobe praised the marchers, saying they are "our
conscience". He urged TAC to continue marching and stated that he
had personally lost six cousins over three years to HIV/AIDS. A
special thanks to everyone in the Western Cape who worked
phenomenally hard to mobilise and to ensure that marchers had
water, emergency care and transport. Below is the memorandum
handed over to Comrade Murphy Morobe:
Memorandum to President Thabo Mbeki, Deputy-President Jacob Zuma,
Minister of Health, Dr Manto Tshabalala-Msimang and all MECs for
Parliament, Cape Town, 16 February 2005
Treat 200,000 People with Antiretrovirals by 2006!
Today, over 70,000 people in South Africa have had hope, life and
dignity restored. They have access to antiretroviral treatment. Not
long ago they faced almost certain death from HIV/AIDS. But now
people like Sindiswa Godwana, Gordon Mthembu and Vuyiseka Dubula,
who dedicate their lives to teaching people about the science,
treatment and prevention of HIV, can look forward to living longer,
Yet hundreds of thousands of their compatriots cannot yet exercise
this right. And this is why, again, we are marching to Parliament
to demand that government meet its constitutional duties to
respect, protect and promote life and dignity by ensuring access to
health-care services. The TAC welcomed the Operational Plan
published on 19 November 2003. We chose not to march to Parliament
at this time last year because we were hopeful that a turning point
had been reached in government's response to the HIV epidemic.
Indeed, the response of some provincial governments, especially
Western Cape and Gauteng, in implementing the Operational Plan has
Yet the National Department of Health continues to fail to show
leadership on HIV. According to the Actuarial Society of South
Africa, over 300,000 people died of AIDS last year. The Operational
Plan committed to treating 53,000 by the end of March 2004. But as
of end of December only 27,000 people were on treatment in the
public sector. Very few of these were children. Inexplicably, the
target for March 2004 was pushed to March 2005. This too will not
By the Department of Health's own admission, about half-a-million
people needed treatment in 2003. The pace of implementation is far
too slow and it is increasing inequity. 45,000 people are on
treatment in the private sector, substantially more than the
number in the public sector. The majority of people on treatment
in the public sector are from Gauteng and Western Cape meaning
that poorer provinces lag behind. People who have money can buy
their lives and people who live in wealthier provinces have access
This injustice exists because there is insufficient political
leadership to make the programme a success. President Mbeki said
in his State of the Nation address that we have one of the best
AIDS programmes in the world. We would like to agree: the
Operational Plan has the potential to be one of the best
programmes in the world, but currently its is far short of this
accolade. We need an honest assessment of the programme.
Lives depend on it. In 2005 TAC will campaign for the Operational
Plan to be implemented properly.
We urge you to treat 200,000 people with AIDS using antiretrovirals
in the public sector by the beginning of 2006, including at least
The treatment targets of the Operational Plan have been missed for
the following reasons:
Too few hospitals and clinics provide antiretroviral treatment,
especially in rural areas and at primary level in urban areas. For
example, hundreds of people with HIV/AIDS need to access treatment
in Acornhoek, Limpopo, the area served by Tintswalo Hospital. The
hospital staff are ready and willing to implement a treatment
programme, but have not received permission or medicines from the
Limpopo government. Residents of Orange Farm in Gauteng have to
travel dozens of kilometres to get treatment at Chris Hani
Baragwanath Hospital, a task that is unfeasible for many. Doctors
and nurses at Madwaleni in the Eastern Cape, who serve in the
public sector of this deep rural community with pride despite
difficult conditions, want to start providing treatment, but here
too they need the medicines, monitoring facilities and a state
pharmacist to dispense them.
The drug supply is irregular and uncertain, largely because the
procurement process has not been finalised, despite a commitment
from the Department of Health to have done this by June 2004.
There is still no generic competition on essential antiretrovirals
such as efavirenz and lopinavir/ritonavir, resulting in stock
shortages in some areas, as well as a lost opportunity to purchase
these medicines at lower prices. There are not enough paediatric
antiretroviral formulations and the supply is irregular by the few
manufacturers producing these.
Many health facilities remain short of health-care workers,
despite the promise of the Operational Plan to hire an additional
22,000 health-workers by 2008. The public sector is understaffed
because of uncompetitive salaries, poor working conditions, death
and illness due to HIV/AIDS, low morale caused by death and
illness among their patients due to HIV/AIDS and a lack of career
development opportunities. The Eastern Cape government has frozen
posts in the health sector because of its poor governance in other
areas of social delivery. As a result the national plan to treat
our people is undermined.
Too many people are not getting tested for HIV and dying
unnecessarily, often in hospital wards. The opportunity to save
lives by actively offering HIV tests and treatment to people who
present at health facilities is being lost. This is especially the
case with those who present with symptoms of AIDS. Public
messaging on HIV/AIDS remains weak. Not enough is being done to
encourage people to get tested and, if necessary, get treated.
To overcome these problems the following must be done:
The National Department of Health must direct provinces to make
treatment available wherever capacity exists at primary care
level. Where capacity does not yet exist, the resources, including
training and health-workers must be provided so that
antiretroviral treatment can commence. Treatment must be made
available in Tintswalo, Madwaleni and Orange Farm.
The procurement process must be finalised. Government must also
put pressure on pharmaceutical companies such as MSD and Abbot,
the patent-holders of efavirenz and lopinavir/ritonavir
respectively, to allow generic competition to ensure a sustainable
supply of affordable medicines. If necessary, government must use
its powers to license generic competitors where companies like MSD
and Abbott refuse to co-operate. Pressure must also be exerted on
manufacturers to supply paediatric formulations of antiretrovirals.
A human resource plan for the public health system must be
published. This plan must cater for improved conditions of
service, including higher salaries and real career growth
opportunities, as well as the recruitment of thousands more
workers to the public health-system immediately. Undoubtedly, this
will have budgetary implications, but the Freedom Charter and the
ANC's visions of health-care for all cannot be met unless we are
prepared to invest in the public sector.
President Mbeki and Health-Minister Tshabalala-Msimang must lead
the struggle against the HIV epidemic by making regular calls on
television and radio for people to access testing and, where
necessary, to get treated. Nurses and doctors should routinely
offer access to HIV-tests to patients presenting at public
hospitals and clinics, regardless of their state of health.
TAC, on our part, will assist government with meeting its targets
by continuing to increase the scale of our treatment-literacy
programme, providing treatment to our volunteers and community
members through our treatment project and promoting prevention of
HIV transmission. We will continue to campaign for cheaper
medicines and more competition among pharmaceutical companies. We
will also campaign for a more effective antiretroviral regimen
than single-dose nevirapine to be introduced for the
mother-to-child transmission prevention programme, as has already
been done by the Western Cape government.
Yet again we are marching in the streets and using the courts to
safeguard our constitutionally entrenched rights to life, dignity
and access to health-care services from our government of
liberation. But if the above demands are met, there will be every
opportunity for us to work together productively and harmoniously.
We call on you to lead the struggle against HIV/AIDS. Save lives
and ensure that we treat 200,000 by 2006.
AfricaFocus Bulletin is an independent electronic publication
providing reposted commentary and analysis on African issues, with
a particular focus on U.S. and international policies. AfricaFocus
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