From: MPetrelis@aol.com Date: Sat, 29 Jul 2000 19:33:33 EDT Subject: Vital Stats: AIDS reporting needs to be skeptical Web link: Click here: Death in the Shadowlands. VitalSTATS July 2000 http://www.stats.org/newsletters/0007/africa.htm Vital Stats, The Numbers Behind The News July 2000 Statistical Assessment Service 2100 L Street, NW, Suite 300 Washington, DC 20037 P: 202-223-3193 E: vital@stats.org Death in the Shadowlands Another crisis whose urgency may depend as much upon definitions as disease is AIDS in Africa. The topic has generated intense media exposure, with over 350 Nexis citations on that topic during June and early July alone. The coverage has been extensive, focused on State Department and White House announcements, national security considerations, and the sheer human tragedy. There have been news weekly cover stories, in-depth portrayals on network TV, numerous sober editorials, and more feature articles in major dailies than one could possibly read (over 165 citations in the nine days between July 1 and July 10) which all have hammered home the stunning news -` Africa is going up in sexual flames. Fewer than half of one percent of North Americans and Europeans are HIV positive. However, in parts of southern Africa, such as Botswana, as many as 35 percent of the population is said by London-s Daily Telegraph (Jul. 10) to be HIV positive. (Reuters, however, places the figure at 29%, while the July 7 Science, using official figures from the South African government, offers 23%). But what has not received media attention is a troubling realization. Based on standard medical practice, we actually have no idea how widespread the disease is in Africa. There are two related problems -- the reliability of HIV prevalence estimates, often nationwide extrapolations from selected sites, and the accuracy of a full-blown AIDS diagnosis. Not only are public health figures in several African regions dubious in general (as are nearly all government data in these areas), practically every commentator speaking out on the African holocaust neglects to mention what may well be the heart of the matter: The criteria for declaring an AIDS case in Africa do not include an actual blood test to determine whether or not the patient is HIV positive. According to what is known as the -Bangui definition,- named for the city in the Central African Republic where it was adopted in 1985, a diagnosis of AIDS could be given in the presence of features such as -prolonged fevers (for a month or more), weight loss of 10 percent or greater, and prolonged diarrhea.- But no blood test is required. That is, deaths that heretofore were attributed to malaria, dysentery, or tuberculosis, for instance, may now be classified and accounted as AIDS deaths. (In fact, the June 23 Science reports that one study found TB in 40% of HIV-infected people upon autopsy). As a November, 1986 article in Science (-AIDS in Africa: An Epidemiologic Paradigm-) observed, -while pediatric HIV disease in Africa resembles HIV infections in children in the United States, it is difficult to distinguish HIV-associated disease in Africa on clinical grounds, where failure to thrive, malnutrition, and pulmonary disease are common pediatric problems.- Hence, while estimates of the extent of HIV infection have been forthcoming (ideally based on blood analysis), the true scope of the crisis is simply unknown. There could be vastly more cases lurking than have been dreamed of in the current nightmare -` or there could be substantially less. A medically precise definition of an African AIDS case, though difficult to obtain, is an essential tool in fighting the disease, particularly when it comes to directing resources (According to the April 27 Nature, World Bank President James Wolfensohn -promised that there would be -no limit- to the funds available for combating AIDS in the developing world.-). It would compound one assured (but still shadowy in scale) public health tragedy if the world were to mobilize to -save-Africa -- only to find that it had sent condoms and the AIDS drug AZT, when what was most needed on the docks in Maputo and Luanda were clean water and antibiotics. Proper reportorial skepticism and careful medical accounting have never been more in need. ======================== Michael Petrelis Welcome to AIDS-STATISTICS www.AIDS-statistics.com 2215-R Market Street, #413 San Francisco, CA 94114