Examination of Witness (Questions 102
- 119)
TUESDAY 20 JUNE 2000
PROFESSOR ALAN
WHITESIDE
Chairman
102. Can I welcome you, Professor Whiteside,
to our home, so to speak, because you last met us in South Africa
at a breakfast meeting in a hotel. You shocked us then and to
some extent the result has been that we have decided to investigate
the whole question of HIV/AIDS and see what can and should be
done. Your evidence, which you have submitted, is very useful
to us and we need to explore it further with you this morning.
Thank you very much for coming in. Would you like to introduce
yourself and perhaps make an opening statement.
(Professor Whiteside) Thank you. I am
very glad to have the opportunity to come and talk to you, because
I happen to believe that this is the most significant problem
that is facing Southern, Eastern and probably Central and Western
Africa at the moment—the HIV/AIDS epidemic. I believe this
means that effectively chances for successful development are
being lost. I believe we could face further political turmoil
and loss of standards and loss of development as a result. My
belief comes about because I happen to have lived and worked in
Southern Africa all my life, and I have seen the epidemic evolve.
I am the Director of the Health Economics and HIV/AIDS Research
Division at the University of Natal and, as such, we have been,
first of all, monitoring the development of the epidemic and currently
trying to find ways to mitigate it. I believe we need all the
help we can get and, because of that, I am very happy to come
and talk to a group of people who share our concerns about this
epidemic.
103. Can you tell us, first of all, what is
the main source of your statistics in South Africa for the contentions
you make that it is spreading rapidly?
(Professor Whiteside) I will talk about Southern Africa
more broadly, if I may, because I know the entire region, and
the statistics come from much the same area. The primary source
of data is the data collected on an annual basis through surveys
of women attending antenatal clinics in all the countries, and
that gives us a year-on-year picture of how the epidemic is spreading.
Of course, as everybody would realise, this is a group of people
who do not represent the entire population—but they do give
us a very good picture of what is going on. We can dis-aggregate
that by area from which the women come, by their age group which
is important, because obviously we would expect intervention to
start working among the younger age groups, and we should see
changes there. In South Africa we have obviously looked at it
by race, but that is rather more complicated. That is just one
source of data. There are increasingly other sources of data which
we regard as confirmatory for ANC data, and here there have been
a number of surveys done using saliva of broader population groups
which show prevalence in women and men, and particularly in the
number of companies in Southern Africa.
104. Are there significant differences in different
parts of South Africa? We have been told anecdotally that it is
much more severe in Kwazulu-Natal. If that is so, have you an
explanation for that?
(Professor Whiteside) I wish I did have the explanations,
but I do not think we do. Yes, it is absolutely right, it is worse
in Kwazulu-Natal. HIV prevalence in Kwazulu-Natal is currently
standing at 32.5 per cent, that is in the antenatal clinic attenders.
The next nearest data comes from the Free State where it is at
27.9 per cent. The lowest HIV prevalence recorded in the country
is in the Western Cape where it is 7.1 per cent, but that has
to be seen in the context where the largest increase was in the
Western Cape over the years 1998-99.
105. So it is spreading?
(Professor Whiteside) Yes. One fears the reality may
be that it is just a matter of time rather than any core differences
between the provinces in South Africa—although I hope I
am wrong.
Barbara Follett
106. At a recent conference at the South Africa
Embassy here we were told by a medical doctor he had evidence
that the spread of HIV/AIDS was less in populations where circumcision
was practised. Have you any evidence about this?
(Professor Whiteside) Yes, there is a growing body
of evidence that suggests that this could well be the case—that
circumcision is the protector for both the male and the female
in terms of HIV transmission. This is something which needs further
examination. The correlation between HIV and circumcision is being
assessed. I certainly would not propose it as a preventative measure.
One of the problems in South Africa was, although we do find circumcision
goes on among certain of the groups in South Africa, particularly
among the Xhosa people—
107. Which is why I came in, because the Xhosa
are in the Western Cape whereas the Zulus are in Kwazulu-Natal?
(Professor Whiteside) Yes, but the thing about their
circumcision is that it tends to take place very late in life—late
teens, early 20s—by which time it may well be too late for
that to have a protection against HIV transmission. It is really
going to be pre-puberty circumcision which would provide the protection.
108. I do not know if you can say how it provides
protection? Do societies where circumcision is practised emphasise
sexual hygiene, or what?
(Professor Whiteside) I am not an expert on this,
but I will certainly try to explain what I understand. Basically
it is a question of sexual hygiene. In an uncircumcised male after
sexual intercourse the foreskin extends over the head of the penis
and that means that under the foreskin there is a little area
where germs, bacteria, viruses can all be protected and will continue
to survive. Obviously when the man has intercourse again then
the foreskin retracts and basically you have a situation where
those bugs are now entering a woman. Basically it is question
of hygiene as much as anything else. Obviously with uncircumcised
men who have access to good hygienic facilities, running water,
probably there would not be very much difference; but in rural
Africa there is a problem.
Mr Robathan
109. Can I take you back to the data. One hears
very conflicting views on this, and you point out the basic data
comes from the antenatal clinics. First, do you think that the
data in South Africa is better than other countries of sub-Saharan
Africa? Sierra Leone's data is probably not a good example but
is practically non-existence. Zimbabwe has troubles there as well.
Would you say it is true that South Africa has a better record
of data?
(Professor Whiteside) Absolutely. I think the countries
where you will find excellent data are South Africa, Botswana
and Swaziland, and Namibia has been doing regular surveys; and
there is good but patchy data from countries like Uganda, Kenya
and Tanzania. Certainly there are real problems with data collection
and really getting a grip as to the scale of the epidemic.
110. In your opinion (and this must be an opinion)
and I will only ask you about South Africa, is the data approximately
right, under-estimated or over-estimated? The antenatal clinic
evidence is obviously of a particular age group so do you think
it is about right?
(Professor Whiteside) I think it is about right. I
think that in parts of South Africa it is under-estimated. The
problem is, as an epidemic matures so the antenatal clinic data
tends to under-estimate the scale of the problem, because women
who are infected are less likely to fall pregnant; and even if
they do, they are less likely to carry a child beyond the first
trimester of their pregnancy, so they are not going to show up
in the antenatal clinics. Obviously in earlier epidemics the women
who turn up in the antenatal clinic are obviously sexually active,
so they are likely to over-estimate. I think, on the whole, what
you would do is take a figure like the South African figure of
22.5 per cent for the antenatal clinic attenders and then you
turn that into a figure for all adults, which would be about 13
or 14 per cent.
Mr Khabra
111. The variation you mentioned with regard
to the present age between different areas, is it anything to
do with the economic and social conditions of those areas?
(Professor Whiteside) Yes, I think it has got quite
a lot to do with it. I think Kwazulu-Natal has a particularly
bad problem, because although South Africa (and you have visited
and seen the country) is not what we would call "over-populated",
Kwazulu-Natal has something like 20 per cent of the population
and 8 per cent of the land—so we have a very much more concentrated
population. In terms of the movement of people, and very many
more migrants particularly men from Kwazulu Natal, we obviously
have the major transport nodes of the ports of Durban and Richards
Bay. That has an awful lot to do with it. It has a lot to do with
the relative wealth and poverty in a province, yes.
Mr Worthington
112. Your expression about "as the epidemic
matures", can you take us through that, because this is the
issue which concerns me? At what stage in its maturity is the
epidemic? Where will it get to at present rates? The preventive
mechanisms, such as condoms, abstinence and so on, how much impact
will they have? You must have been extrapolating and saying, "This
is where we are, if we do nothing this is where we will be in
five or ten years". Can you take us through that?
(Professor Whiteside) Basically when you look at the
epidemic you make an assumption that it will reach a certain prevalence
in a population. I think it would be fair to say that five or
six years ago we would have said that in no antenatal clinic attenders
would it exceed 25 per cent, and that clearly is not the case.
In Kwazulu it is 32.5 per cent. In Francistown in Botswana it
has consistently been over 40 per cent for the last five years;
in Bietbridge, on the South Africa/Zimbabwe border, it has been
in this population over 60 per cent for the last couple of years;
and in a town in Zimbabwe called Chiredzi I am told it has reached
70 per cent. I have to say I think this is a very peculiar set
of circumstances which are operating in these very high prevalence
areas. It is my belief that HIV prevalence will not exceed 35
per cent of antenatal clinic attenders in South Africa, so we
must be nearing the peak of the prevalence curve.
113. Why is that?
(Professor Whiteside) Because I think there is a natural
peak to a curve. Any sigmoid curve that we have has a peak. I
just have to believe that it will not exceed 35 per cent and it
is a gut feeling. We have not seen it exceeded anywhere else.
Barbara Follett
114. Are you talking about a resistance?
(Professor Whiteside) No. What I am talking about
is, with any given population with a disease you are going to
get so many people who will be infected and so many people who
will not be infected. Once people have been infected they either
recover or die so they leave the pool of infected people. With
HIV and AIDS it fortunately is a very hard virus to transmit in
the absence of certain factors, like sexually transmitted infections.
The chances, if I was an uninfected man having sex with an infected
woman, of my being infected (provided I am sexually healthy) would
be about 1:1000. It is not an easily transmittable virus. That
is a fact which is perhaps not fully understood. The other thing
which is very important to realise is that, in order to become
infected, you either have to do something or you have to have
something done to you. That is, either have or be forced to have
sexual intercourse. In any given population how many people are
likely to be exposed. Obviously there are going to be those people
who do not have sex, who will not have sex, who cannot have sex.
There are going to be those people who will stick to one partner.
There are going to be those people who may have more partners
but are very lucky, or with partners who are not going to be infected.
The pool of people that will not be infected will probably be
in the order of 65-70 per cent in any susceptible population.
Chairman
115. Having explored those important preliminaries,
we must now try to cover the ground we planned to do. The first
question is relating to the international development targets,
three of which I think must be affected. I wanted to ask you whether
you think these will be effective, and they include: on education—universal
primary education in all countries by 2015; on poverty—a
reduction by one half of the proportion of people living in extreme
poverty by 2015; and maternal and child mortality. Are the plus
5 conferences, such as the Cairo plus 5 and the forthcoming Copenhagen
plus 5, taking account of HIV/AIDS in terms of both funding commitments
and strategies to meet these targets?
(Professor Whiteside) The answer to the first part
of the question is very simple: the chances of reaching those
targets in the countries where there is an HIV and AIDS epidemic
are non-existent and receding. Indeed, I think in some situations
we may battle to maintain the current level of development in
the years ahead. We are certainly going to see a decline in life
expectancy which will affect the poverty indexes. With regard
to the conferences, I am not in a position to answer that because
I have not been involved with them. Certainly my perspective as
a lay person and a reader of the world wide web is most people
have not woken up to the severity of the epidemic.
116. Do you think donors are yet doing enough
to respond to HIV/AIDS, both in terms of AIDS-specific funding
and programmes and by taking account of HIV/AIDS in all development
planning? How do the Department for International Development
and the European Union compare with other donors?
(Professor Whiteside) On the first part, I do not
think donors are doing enough. I think the evidence of the rising
epidemic in many countries is indication enough of that. I also
think the other problem is that donors have not understood that
an HIV epidemic is inevitably and inexorably going to be followed
by an AIDS epidemic, and an AIDS epidemic is going to be followed
by orphaning, social problems and potentially political problems.
I do not think people understand that. I have to say, donors are
not doing enough to respond. They are certainly not doing enough
to respond to the impact that we will feel as a result of this
epidemic, and that is the thing which worries me most. AIDS-specific,
I would put a note of caution here. I think there is a real problem
with going into a country and saying AIDS is a problem. The World
Bank, I believe, is currently falling into this trap, but if you
go in and say, "AIDS is a problem", the country is going
to turn round to you say, "If you see it's a problem, you
solve it", and when you do not solve it then they will blame
you. Also I think there are problems of absorbative capacity.
You cannot go into some of these countries and expect to spend
more money with the whole concept of local partnerships, with
the concept of building local capacity, when there is not the
local capacity or the local people to do it. The AIDS epidemic
is making it worse, of course. Putting HIV/AIDS into development
planning—not even in this ball park, never mind got to first
base. Absolutely appalling is the inability of donors to understand
that AIDS goes far beyond health. That is true for most of the
donor agencies. The one which is probably at the forefront of
this is USAID at the moment. I was involved in some work with
the European Union where we developed a tool kit for putting AIDS
into development projects and, frankly, it appears to have sunk
without a trace except in the transport sector. Unless there is
an overview of people watching the agencies and saying, "Okay,
why isn't AIDS in the agricultural project; why isn't it in the
transport project", or indeed a legal framework to make them
do it, then you are not going to get the agriculturalists putting
it into agriculture and you are not going to get the transport
people putting it into transport. There really has to be a firm,
committed framework for that.
Chairman: Something has got to be put
into a single developmental project, absolutely.
Mr Robathan
117. This is obviously your field, Professor
Whiteside, so you might be an interested observer in this, but
both in development terms and in a wider sense would you agree
that the HIV/AIDS epidemic is much the biggest problem facing
sub-Saharan Africa at the moment?
(Professor Whiteside) Absolutely.
Mr Colman
118. I understand there is going to be a very
large conference in South Africa in a couple of weeks time. Could
you perhaps briefly outline what the conference will be covering?
Do you think that will deal with the issues which you have raised,
or have been raised by our Chairman?
(Professor Whiteside) I think the answer is that it
will not be covering the issues raised by your Chairman. Unfortunately,
AIDS and development, AIDS the economic impact, the social impact,
the political impact (and maybe we will touch on this later in
the day) are really not on the agenda. This is going to be a bun
fight, a gathering of scientists, community activists, everybody
working in the field coming together to talk about the science,
the recent developments around HIV and AIDS. I am not that involved
in the conference. I think a lot of the business which is important
will be done around it in other meetings, and I am obviously involved
in some of those. I think the best thing that can come out of
it is some sort of statement from our President on the cat that
he let out of the bag—the thing that has been going on with
the dissident groups and the other groups around HIV and AIDS,
and whether HIV causes AIDS. A statement out from our President
in South Africa on that would be a big help. The other thing would
be if the developing world and the scientists (who are working
on AIDS in laboratories around the world in the comfortable settings
of Imperial College or University College in London, or Berkeley
or any of the many developed world countries) would actually understand
what HIV and AIDS means on the ground, and the misery it is causing
to many millions of African people. If they were to see that and
understand exactly what this was doing then we would have achieved
a great deal.
Chairman
119. You did not comment on the Department for
International Development HIV/AIDS programme. Do you think that
is a good programme? Do you have any knowledge of that?
(Professor Whiteside) They are about to support some
of the work we are doing for the first time. We have had some
contact with them through Pretoria. I think it is a good programme
but if I were to give them a report card it would be "C+—can
do better."
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