Nokhwezi Hoboyi never imagined she would live to see her 25th birthday.
The petite woman’s playful smile masks memories of her life slipping away just two years ago, bed-ridden in a hospice, as she teetered on the brink of becoming yet another South African AIDS death statistic.
“I had given up ... I would say to my parents, ‘please, tell my friends to come to my funeral’,” the 26 year-old told Reuters, recalling her battle with the virus that infects an estimated one in 9 South Africans.
Hoboyi’s survival, made possible by antiretroviral (ARV) drugs, makes her a new South African HIV statistic - reflecting the growing numbers of people with the virus living normal lives in one of the countries worst hit by the AIDS disaster.
But it also represents a maturing stage in the epidemic, bringing new policy dilemmas for officials seeking to track Africa’s expanding AIDS crisis.
South Africa’s health department hailed new data released last month, saying surveys indicated only a marginal increase in new HIV/AIDS infections over the past year - an indication, it said, that the epidemic was stabilizing.
Some health experts, however, say the picture is not that clear-cut, or that optimistic.
A flattening of the HIV prevalence curve could mean that new infections are, in fact, keeping pace with rising numbers of AIDS deaths in the country.
“We need to start understanding the epidemic differently now,” said Olive Shisana, director of the state-funded Human Sciences Research Council (HSRC). “The leveling off does not necessarily mean that we don’t have a problem,” she said. “What it may mean is that infections are continuing to rise and at the same time more people are actually dying.”
DRUGS SKEW DATA
The distribution of ARVs in South Africa from 2004, after an about turn by President Thabo Mbeki’s government that refused for years to fund a state program, is prolonging tens of thousands of lives.
But the drugs also help to skew the data by ensuring prevalence figures remain high - making a positive development appear negative on paper.
“In the long run if we see more people start using antiretrovirals we will probably see an increase in the prevalence of HIV. I think this is something we need to clarify ... this is a very complex issue,” Shisana said.
The government’s annual study of pregnant women visiting antenatal clinics - a standard method of measuring HIV prevalence in Africa - showed an infection rate of 30.2 percent, compared with 29.5 percent previously.
From this, the department estimated about 5.4 million of South Africa’s 47 million people are HIV positive, down from earlier projections. This gives prevalence, as measured against the population, of around 11 percent.
But the data also shows that AIDS deaths are soaring, hinting that prevalence would be even higher if the epidemic was truly being brought under control.
A Statistics SA study of mortality between 1997 and 2002 found death increased by 62 percent among adults over the age of 15, underscoring the toll AIDS was taking on the population.
Countries with high HIV prevalence will eventually face sharply higher deaths as people live longer with the incurable disease - regardless of the success of their ARV programs.
Activists say deaths in South Africa are still rising with up to 900 people succumbing to the epidemic every day as the roll-out of drugs slowly picks up pace.
“NOT A GOOD THING”
The Treatment Action Campaign, the country’s most influential AIDS lobby group, said there was little evidence to support the government’s statement that its prevention efforts are cutting into AIDS prevalence.
“A decline in prevalence may not be a good thing,” national manager Nathan Geffen said in a statement.
“Infected people are living (so) if the number of people with HIV is declining, it could be because they are dying of AIDS instead of getting treated,” he added.
The use of antenatal testing to measure prevalence has also been challenged, notably in Kenya in 2004 when a study questioned United Nations estimates, suggesting the data was sharply inflated.
The debate over the figures may also have lessons for other countries at the center of the global AIDS epidemic.
South Africa’s neighbor Botswana is battling stubbornly high prevalence of around 24 percent, possibly a consequence of one the best ARV programs in the world that reaches up to 85 percent of those infected with the virus.
For HIV-positive South Africans like Hoboyi - who herself lost two infants to HIV/AIDS - the debate over South Africa’s AIDS data is of secondary importance, even though it may influence how government and ultimately global AIDS funds are allocated.
“Here I am today, I am able to wake up in the morning,” she said. “I never thought I would ever be able to wake up and go to work again.”
Revision date: July 6, 2011
Last revised: by Sebastian Scheller, MD, ScD