Mbeki's opposition to ARVs cost 330,000 lives, shows study

The refusal of the Mbeki government to roll-out antiretroviral therapy and treatment to prevent mother-to child transmission in South Africa resulted in 330,000 needlessly premature HIV-related deaths and 35,000 avoidable case of mother-to-child HIV transmission according to estimates published in the December 1^st edition of the Journal of Acquired Immune Deficiency Syndromes.

South Africa is one of the countries hardest hit by HIV. UNAIDS estimates that 19% of the adult population is HIV-positive, some 5.5 million individuals. In 2005, an estimated 320,000 individuals died because of HIV.

President Thabo Mbeki’s government consistently resisted the provision of antiretroviral therapy. The first important evidence of this was in 1999 when, under pressure to provide AZT monotherapy to prevent mother-to-child transmission of HIV, President Mbeki announced that the drug was dangerous and that it would therefore not be provided by his government. This was followed by Mbeki publicly questioning that HIV caused AIDS and the efficacy of antiretroviral therapy. The Mbeki administration then resisted the use of nevirapine to prevent mother-to-child transmission and obstructed the acquisition of grants from the Global Fund.

US investigators estimated the lost benefits resulting from the Mbeki government’s opposition to provision of antiretroviral therapy and treatment to prevent mother-to-child transmission. To do this, they compared the actual number of people who received HIV treatment or therapy to prevent mother-to-child transmission between 2000 and 2005 and compared this to the number that could feasibly have been treated during this period. This difference was multiplied by the average efficacy of antiretroviral treatment and treatment to prevent mother-to-child transmission to give the lost benefits consequent upon the South African government’s decision to prevent access to anti-HIV drugs.

“Our overriding values in choosing methods were transparency and minimization of assumptions and we were purposely conservative”, write the investigators.

When estimating the number of people who could reasonably have been provided with antiretroviral therapy or treatment to prevent mother-to-child transmission, the investigators noted that HIV treatment became significantly more accessible between 2000-2005. This was because:

• The price of anti-HIV drugs fell significantly in this period.
• More money was available for donor organisations, such as the Global Fund and PEPFAR, to purchase antiretroviral drugs.

Nevertheless, the South African government still maintained opposition to the provision of HIV drugs.

To estimate the number of people who should have been eligible to receive antiretroviral therapy, the investigators obtained from UNAIDS the number of HIV-related deaths in South Africa between 2000-2005. Patients who died of HIV without receiving anti-HIV drugs lost the entire potential benefits of antiretroviral therapy.

Next, the investigators obtained figures showing how many individuals received antiretroviral therapy in the same period. Their sources were UNAIDS and the World Health Organization’s (WHO’s) “3 x 5” antiretroviral treatment access programme. These figures showed that fewer than 3% of patients received antiretroviral treatment in 2000, increasing to approximately 10% in 2003 and 23% in 2005.

The researchers considered it reasonable that South Africa could have treated no more than 5% of eligible patients with HIV in 2000. However, because drugs became less expensive and more international funding became available, “ramping up” access to treatment was feasible, meaning that by 2005, 50% of HIV-positive patients in South Africa should have been receiving antiretroviral therapy. They note that the maximum of 50% treatment coverage is significantly lower than the 71% achieved by Namibia and the 85% achieved by Botswana.

Finally they estimated the number of life years that would be gained per patient due to antiretroviral therapy. They used the most conservative estimate of 6.7 years.

Their calculations showed that 330,000 lives and 2.2 million person years were lost because the Mbeki government resisted the implementation of a reasonable antiretroviral treatment programme.

They tested their model using a number of other assumptions. For example, if they reduced the number of patients who could reasonably be expected to receive antiretroviral therapy in 2005 to 40%, then the number of lives lost fell to 226,800 or 1.5 million person years.

Consequences of opposition to treatment to prevent mother-to-child transmission

The researchers' model to test the impact of the Mbeki administration’s opposition to treatment to prevent mother-to-child transmission also included a number of conservative assumptions.

First, they calculated the number of children infected with HIV vertically. They looked at a number of sources and selected the lowest estimate of 68,000 per year and revised this down to 60,000 to take into account the high adult HIV population and marginal increase in population growth in South Africa during this period.

A number of sources suggested that in 2005, coverage of treatment to prevent mother-to-child transmission was 30%, having increased from below 3% before 2000.

To estimate the proportion of women who could have received treatment to prevent mother-to-child transmission, they considered that treatment would have been free during this period, that it is easy to administer and that 84% of pregnant women in South Africa receive antenatal care.

Based on these assumptions, the investigators calculated that no more than 5% of women would have received treatment to prevent mother-to-child transmission in 2000, but that this could have increased to 55% by 2005.

Next the investigators estimated the efficacy of such therapy, taking as their benchmark the HIVNET 012 study which showed that single-dose nevirapine reduced the risk of transmission by 47% compared to short-course AZT amongst women who breastfeed.

Finally, they assumed an average life-expectancy at birth of 48 years, and subtracted from this the average three year life-expectancy of infants infected with HIV at birth.

The investigators therefore estimated that 35,000 cases of mother-to-child transmission (or 1.6 million life years) were the result of the Mbeki administration’s policies.

One again, the investigators tested their results using other assumptions. If they accepted 40% coverage of treatment as acceptable, then the excess number of babies infected because of government policies was 18,000, a loss of 800,00 life years. However, had there been 70% coverage (still below what was achieved in Namibia and Botswana), then HIV infections in 44,000 babies (or 2 million life years), would have been avoided.

When the investigators combined their two estimates – years of life lost because of opposition to antiretroviral treatment, and life years lost because of the failure to provide treatment to prevent vertical transmission – they found that some 3.8 million life years were lost because of the Mbeki administration’s policies.

They conclude, “in the case of South Africa, many lives were lost because of failure to accept the use of available antiretrovirals to prevent and treat HIV/AIDS in a timely manner.”