Select Committee on International Development Minutes of Evidence

Examination of Witness (Questions 102 - 119)




  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.


  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.


  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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