Monday, November 29

AIDS in South Africa II

What do we know about AIDS in South Africa? About 5.3 million people of an adult population of around 33 million in South Africa has HIV according to the UN. Adult Mortality in SA in 2003 was around 450 thousand a year, of which somewhere between half to two thirds has been attributed to AIDS. (source)

Lets make an assumption that the vast majority of infected people are going to die in the next 5 years. This is likely given that (a) anti-retrovirals are being rolled out very slowly, (b) there should be serious doubts as to the effectiveness of wide spread anti-retroviral treatment, especially if compared to the treatment of other difficult to treat diseases such as TB, (c) untreated and undernourished people living in unsanitary conditions such as squatter camps can expect to live less than 2 years with HIV/AIDS and (d) even with the correct anti-retroviral treatment life expectancy for most people living with the disease is going to be much lower than compared with first world countries.

Assuming deaths attributed to AIDS in 2003 was 250 thousand, some simple calculations should show that if mortality rates increase in a linear fashion, we can expect an increase of up to 50% to our mortality rate each year due t0 AIDS for the next 5 years, culminating in the death of 2 million people in 2008, two years before the 2010 Soccer world cup. For South Africa this is an almost existential crisis.

On the other hand, Adult mortality rates have been recorded since 1998. Taking them at face value, as the UN report does, the increases in mortality was only 16% in 1999 and has been increasing consistently at only 10% for the last 5 years despite the fact that half of all deaths have been attributed to AIDS since 2000.

If this trend were to continue, that would mean that only 400 thousand people are going to die of AIDS in 2008, and that only 1.7 million people are going to die of AIDS over the next 5 years.
If our assumption that most people with HIV is going to die in the next 5 years is correct however then the infection rate in SA is much lower than believed. (Only 5%,rather than the 16.5% that the UN believes).

I have assumed the increase in mortality is linear. That might be incorrect but is backed up by the behaviour or Adult mortality rates for the last 5 years. I have also assumed that the majority of people living with HIV today will be dead in 5 years. If this number is lower, that is people die sooner, then that means that the actual infection rate is even lower than 5%. If people live longer, how much longer?

Taking our current mortality rate increase of 10%, and the belief by the UN that there are 5.3 million people with AIDS in South Africa, how long will it take these people to die? Answer? 11 years.

These numbers are very suspicious. They are suspicious because that is about the minimum number of years that people can be expected to live with modern anti-retroviral drug therapies in western countries.

If a UN researcher went and did a quick back of the envelope calculation where people with HIV have a maximum life expectancy of 11 years (which is about the minimim in Zurich, plus a year) along with the mortality rate increase of South Africa (which is one of the few almost reliable statistics available to anyone), then the answer he would come up with is 5 million people in South Africa are infected with HIV. If people with HIV die sooner however, then the number of people infected decreases dramatically.

Are UN statistics on the number of people infected with HIV in South Africa being inflated? And for what purpose? If the current trend in the Adult mortality rate for South Africa continues, then one of two things could be possible. One, the UN statistics could be criminally wrong or two, most people with HIV in africa with no access to modern medicine living for the most part in squatter camps can live up to 11 years.

If you think the answer is the latter, then you have to meet one of my friends called Occum.

(Full disclaimer: I’m neither a statistician (I’ve a passing knowledge) , a doctor (I’ve done a first aid course), an AIDS activist (I’ve given to AIDS charities) or a prophet (I predict death and taxes). All predictions, assumptions or facts come with no warranty included.)

296 Comments:

Blogger Shaun Laurens said...

Hi Richard,

Another report from the South African Gov (Dept. Health) puts the estimated infection rate at 5.6million in 2003, however this has been extrapolated from a relatively small survey at public antenatal clinics (see http://www.southafrica.info/ess_info/sa_glance/health/hivinfections-report.htm).

One thing I was thinking about is surely the AIDs deaths are not necessarily linear - but rather increase steadily as the time since infection passes. Obviously, not everyone was infected on the same day, but since people are infected over time (as the virus performs its viral growth), so to me it makes sense that AIDs related mortalities increase at a faster and faster pace as time goes on.

I recommend watching Pieter Dirk Uys' new show - in which he has a pointed dialogue between Thabo and PW Botha, wherein PW congratulates Thabo for getting rid of the blacks, something he could never do. PW asks Thabo how he manages to do it, to which Thabo responds I do nothing - they die all by themselves.

30 November 2004 at 10:30  
Blogger Richard said...

I have to doubt the results of the AIDS studies at the antenatal clinics. The size of the sample and the kind of statistical pea games that result makes me very suspicious.

I expect AIDS deaths to have a gaussian distribution, much like any other disease. People are infected at different times however. If 5 million people in this country have HIV currently then that would mean we should see a 'dramatic' increase in the Adult mortality rate over the next few years.

If we don’t then we have to question the statistics.

South Africa has been in the grip of a full-blown epidemic for at least the last ten years though. The fact that we have not seen more dramatic growth in the adult mortality rate, but linear growth, makes me question the statistics.

Time will tell though. Accurate estimates are important for working out effective plans to combat the disease.

I’m wondering whether hyperbole and worst case scenarios are not being used by aid agencies to motivate western countries to donate, and whether that might be hurting our economy and health systems by not giving us accurate information to plan for the epidemic. (And hurting our economy by scaring people away from traveling or investing here, which is just as needed as AIDS drugs).

I’m going to try and see the show this week. Heard it was very good. How bad can a show be if it has Pieter Dirk Uys and hand puppets?

30 November 2004 at 18:07  
Blogger Kenya A. Hudson said...

Let me stipulate up front that like Richard I am not a statistician. Nor am I an epidemiologist or pathologist. It is my understanding that the length of time it takes for HIV to develop into "full-blown" AIDS with the attendant diseases that kill the patient is mediated by at least three other factors (beyond drug regimens): varying HIV hibernation periods, initial health particularly of the immune system and the stage at which a person is diagnosed. These factors singularly or in combination could affect your idea that prediction that half of those with HIV would die in five years. It is generally accepted that AIDS-related symptoms can take as long as 10 years to appear. It is likely that there are many people who are HIV+ but are also asymptomatic. I hate to be morbid, I don't think you should start the clock ticking from an infection point of which most are likely unaware. Like most people, they probably do not seek medical care (especially if it is not free and otherwise widely available) until they have symptoms of something. Instead, it is a more reasonable point to start from the date of diagnosis. I suspect that is what the study did that referenced longer lifespans with antiretroviral treatment. So it isn't 10 years of being HIV+, it is 10 years after being diagnosed which may in fact be 12, 15 or 20 years of being HIV+. Now, in the case of South Africa, the 5.3 million is an extrapolated number so it is not the number of people being treated right now. It includes all the other people below the iceberg whose diagnosis date clock has not started ticking. Thus, mortality rates would likely be less than 50% over a five year period.

Your larger point is that HIV+ statistics may be significantly inaccurate. I must say nearly all of my African friends believe this to be so. My experiences in Southern Africa didn't seem like experiences in a plague-filled land though there could be reasons for this beyond inaccurate statistics. I believe that the estimates of the proportions of HIV+ persons are overestimated though I don't know if it is marginal or gross error. Partly, this has to do with the sample. When one samples based on already pregnant young women, you begin with a skewed sample. According to their report, women are already more likely than men to be infected and the women are pregnant so that means they are sexually active. Furthermore, as far as I know, no country in Southern Africa has collected this data for all of its clinics so we are dealing with a skewed sample from a perhaps non-representative population. I have not read their methodological appendixes, but I would assume they could recognize this and would find ways of correcting it in their statistical analyses.

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