[procaare] Africa: Falling HIV Rates Tell a Complex Story

["The Nation" <procaare@healthnet.org>]

Africa: Falling HIV Rates Tell a Complex Story
The Nation (Nairobi)
5 August 2007
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When it comes to black Africa's devastating Aids crisis, there is an 
understandable tendency to latch onto any scrap of good news. Figures 
suggesting the epidemic is waning in some countries are being trumpeted by 
governments and international donor agencies as evidence that their 
prevention efforts are succeeding.
Kenya's National Aids Control Council recently reported a small drop in the 
country's HIV infection rate.

South Africa's Health minister Manto Tshabalala-Msimang said the first 
evidence of declining HIV prevalence in pregnant women - from 30.2 per cent 
in 2005 to 29.1 per cent in the latest survey - was mainly due to "our 
continued focus on prevention as the mainstay of our response to combat 
HIV".

But the real story behind increases and decreases in HIV prevalence is far 
less clear.

"There's an awful lot of vested interests, but it's sufficiently murky that 
no one really knows what's going on," said Prof John Hargrove, director of 
the Centre of Excellence in Epidemiological Modelling and Analysis (SACEMA) 
at the University of Stellenbosch, South Africa.

Twenty-five years is not long to get to grips with an epidemic that has 
evolved very differently in different parts of the world.

In Europe, North America and Asia it has largely been confined to high-risk 
groups like injecting drug users, sex workers and men who have sex with men; 
in southern Africa it has spread rapidly via heterosexual relationships.

"Nobody really knows why southern Africa is worst affected," said Dr Brian 
Williams, another epidemiologist at SACEMA. "And if we don't know that, it's 
very difficult to explain why prevalence is going up or down."

Reliable data

Part of the problem was having adequate, reliable surveillance figures. The 
first generation of HIV-prevalence figures were obtained by testing pregnant 
women at antenatal clinics, but the age groups of the women, and the fact 
they were clearly having unprotected sex, meant the numbers tended to 
overestimate infections in the general population.

Where possible, antenatal surveys are now combined with more representative 
data gathered in household surveys, but the Joint United Nations Programme 
on Aids (UNAIDS) noted in its 2005 epidemic update that the high numbers of 
people who refused to be tested in household surveys, or were absent from 
home, could lead to underestimations of HIV prevalence.

While prevalence only tells us how many people are living with HIV/Aids, 
incidence measures the number of new HIV infections occurring during a 
specific period. Incidence provides the most up-to-date and revealing 
snapshot of an epidemic. But the technology for determining recent 
infections is still quite new and prohibitively expensive for most African 
countries.

In the absence of such surveys, HIV prevalence in people aged 15 to 20 is 
often used as a proxy, because it is probable that most infections in this 
age group are recent. The variety and unreliability of most surveillance 
methods make epidemiologists like Hargrove and Williams take any news of 
apparent declines in HIV prevalence with a large pinch of salt.

For years, Uganda has been held up as the poster child of successful 
prevention policies: from a peak adult HIV-infection rate of about 15 per 
cent in the early 1990s, UNAIDS now estimates Uganda's prevalence at 6.7 per 
cent. President Yoweri Museveni swiftly responded to the emerging crisis as 
early as the late 1980s, and grassroots campaigns communicated basic 
prevention messages, such as abstinence from sex before marriage, being 
faithful to one's partner and the use of condoms. The ABC approach, as it 
has now been dubbed, combined with President Museveni's leadership, have 
been widely credited with reducing risky sexual behaviour and lowering the 
prevalence rate.

But Dr Williams pointed out that the evidence for Uganda's falling infection 
rate was "not really clear", and was based on a handful of antenatal surveys 
in the capital, Kampala.

"We're desperate for a success story, so Uganda will be a success story 
regardless of the lack of evidence," he said.

Justin Parkhurst of the London School of Hygiene and Tropical Medicine, also 
questioned the "so-called proof" of Uganda's success in reducing HIV 
infections in the British medical journal, The Lancet. He pointed out that 
the evidence supporting prevalence declines had been based on "selective 
pieces of information, which have been falsely presented as representative 
of the nation as a whole."

Parkhurst suggested that governments in low- and middle-income countries 
were under pressure to respond to donor fatigue by exaggerating the success 
of their AIDS programmes.

"The standard of proof for policy recommendations seems to have been 
lowered, to provide the international community with the African success 
story it wants, or even needs," he concluded.

If Uganda's prevalence had indeed declined, there was still no sure way of 
determining why. Parkhurst cautioned against attributing the decline to "a 
few specific interventions introduced by the Ugandan government": not only 
were there numerous players in the Aids fight besides the government, but 
"individuals can change their behaviour for reasons unrelated to 
intervention programmes".

Williams believed that while real behaviour changes, such as having fewer 
partners and higher condom use, might have taken place, they had less to do 
with the government's efforts and more with the widespread experience of 
watching friends and relatives die from Aids-related illnesses.

The dynamics of an epidemic can also bring about changes in HIV prevalence: 
in the early phases, HIV infections have tended to rise steeply and then 
level off as they reached a "saturation" point in the population; at a later 
stage, HIV prevalence might start declining, not necessarily because of 
widespread behaviour change, but because the number of people dying from 
AIDS-related illnesses has outpaced the number of new infections. When the 
mortality rate of those infected reaches a balance with the incidence of new 
infections, prevalence will plateau - the stage South Africa is currently 
experiencing.

Online: http://allafrica.com/stories/200708050021.html