Some optimism despite gloomy new HIV figures

Reactions to news this week that Swaziland's HIV-prevalence rate - already the world's highest - continued to climb, have swung between deep pessimism and renewed determination by AIDS activists and government officials. Data taken from pregnant women visiting prenatal clinics last year as part of a Ministry of Health surveillance study showed that the prevalence rate had climbed by 6 percent since 2002, to 42.6 percent. The full results of the survey are to be released later this month. "The only way these numbers will go down is by death. The people found HIV-positive in 2004 will remain so in 2006, when the next survey is taken, if they are still alive. So, added to them will be those who are infected since then," said Derek von Wissell, director of the National Emergency Relief Committee on HIV/AIDS (NERCHA). His agency funds anti-AIDS initiatives with grants from the government, private donors and the Global Fund to Fight HIV/AIDS, Malaria and Tuberculosis. "These statistics sound a further death knell for the Swazi nation," said health worker Florence Gule. One writer in the independent Times of Swaziland called the survey's findings "a national extermination notice", but other health workers were less pessimistic. "We commend the government of Swaziland for releasing these figures - only through the truthful dissemination of sometimes-painful information can mitigation programmes be formulated: an alarm is sounded, and action follows," said Lois Lunga, executive director of the Southern African AIDS Information and Dissemination Service. Alan Brody, country representative for the UN's Children's Fund (UNICEF), compared the surveillance data with other studies, which helped provide a more complete picture of the AIDS situation in Swaziland. "We should note that the 42.6 percent HIV-prevalence rate figure is accurate for women from 20 to 35 or 40 years old. When women get above 40, it goes down a little, but the number of women in this age group is not that great. Men 25 to 40 are pushing 40 percent prevalence rate," Brody said. However, an estimate of older Swazis showed that about 15 percent were infected. "If you put the whole population together, you get approximately 20 percent HIV prevalence," Brody noted. NERCHA has estimated there are 220,000 HIV-positive Swazis, which would correspond to a 20 percent prevalence figure for a population of about one million people. UNICEF's figure is lower, at 200,000 infected Swazis. Most health officials agree that the percentage for HIV-positive people ranged from 18 percent to 20 percent. There has been debate over HIV figures because of the different methodologies that can be used to calculate prevalence, each of which are subject to potential biases. In much of Africa, UNAIDS and the World Health Organisation rely on statistics gleaned from antenatal clinics. However, data from population-based Demographic and Health Surveys (DHS) conducted in several countries last year "suggested that previous estimates based on sentinel surveillance were too high", UNAIDS acknowledged in its 2004 global report. Health minister Sipho Shongwe emphasised a decline in HIV prevalence among teenage girls, shown in the latest survey, as a sign that the AIDS protection message was getting through, and the apex of the health crisis might have passed. About 29.3 percent of pregnant girls were found to be HIV-positive in 2004, down from 33.5 percent in 2002. "We cannot say we have turned the corner on AIDS on the basis of that sampling, because it falls within the plus or minus 3 percent error rate of such statistical studies, but at least it didn't go up," said Brody. The apparent decline in HIV infections among teenage girls conforms to a 2003 UNICEF study that found a similar lessening of HIV prevalence in this group. Swazi health officials are looking forward to the completion of the country's first DHS by mid-year, which they expect will give a more complete picture of AIDS. The cost and technical expertise required for such a door-to-door survey prevented the use of a DHS in the past. All health experts agreed that a rise in Swaziland's overall HIV prevalence rate in the next survey might not be a disaster, and instead could point to the success of the country's nascent antiretroviral (ARV) treatment programme. "The ARV rollout is continuing, and more HIV-positive Swazis are on this programme and living longer. A higher HIV prevalence rate may actually mean that there are fewer deaths, thanks to ARVs," said health motivator Gule. Brody concurred: "If we are successful in keeping people alive with our ARV programme we will see an increase in the prevalence numbers. Over the past five years, 15,000 people have been dying annually, while 16,000 to 17,000 people are newly infected with HIV. If we see the [prevalence] numbers getting higher, it shouldn't frighten us." Health officials insisted AIDS prevention should still be a top priority. "We need to focus our interventions on children aged eight to 18 - the ones who are not yet sexually active. It's much easier to influence their behaviour and attitudes before they are sexually active," said Brody. Thandi Hlengetfwa, director of The AIDS Information and Support Organisation, noted: "We must also continue reinforcing the 18 to 24 group of young adults; you want to keep influencing them and creating an environment that reduces risk, including stronger law enforcement against sexual abusers, greater empowerment for women to say no to unwanted sex, and a change in the culture of casual sex."