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South Africa: Mortality Statistics, AIDS Action

AfricaFocus Bulletin
Feb 22, 2005 (050222)
(Reposted from sources cited below)

Editor's Note

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 AIDS.

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.

The full text of the Stats SA report is available on http://www.statssa.gov.za. Additional background on research and statistics on mortality and AIDS is available on the site of the Burden of Disease Unit of the Medical Research Council of South Africa (http://www.mrc.ac.za/bod). For more news on the Stats SA report, see http://allafrica.com/stories/200502200002.html and http://allafrica.com/stories/200502200001.html

Earlier AfricaFocus Bulletins with material on health and HIV/AIDS are available at http://www.africafocus.org/healthexp.php

++++++++++++++++++++++end editor's note+++++++++++++++++++++++

Treatment Action Campaign Electronic Newsletter

21 February 2005

[excerpts: for full text see TAC website - http://www.tac.org.za]

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 the epidemic.

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." (p. 2)

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 Africa. ...

Key Findings of the Statistics South Africa Report

Recorded Deaths in South Africa:

1997: 318,287
1998: 367,689
1999: 381,902
2000: 413,969
2001: 451,936
2002: 499,268

• 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 441,029.

• 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.

...

For a further discussion on mortality due to HIV, see the TAC newsletter of 31 January 2005:
http://www.tac.org.za/newsletter/2005/ns31_01_2005.htm

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 government policy.

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 the march.

...

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 Health

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, healthier lives.

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 been encouraging.

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 be met.

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 to treatment.

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 20,000 children.

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.

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