Overstating AIDS

A few years back, I was visiting the offices of a government aid agency in Accra with a colleague from the company – IESC – that had bought my organization, Geekcorps. We’d talked with this funder about their priorities in Ghana, and my colleague was very surprised that HIV/AIDS was not at the top of this funder’s list of priorities. She mentioned this, and I pointed out that HIV hadn’t affected Ghana to the extent that it had affected southern Africa, quoting 6% as the adult infection rate. Convinced that I must have my numbers wrong, she went back into the funder’s office to ask what the rate was – they confirmed the figure I’d offered.

My colleague lived in Zambia, where the adult HIV rate was reported at 21.5%. At that point in Zambia, it was very difficult to talk about anything other than HIV in the context of development, and she was shocked that the incidence of the disease in West Africa was comparatively so low.

As it turns out, the figure I quoted my colleague was high by almost a factor of three. The adult AIDS rate (15-49) in Ghana is 2.2%… higher than in many developing nations, but nowhere near the rates of incidence seen in nations like Botswana, where that rate is above 30%. I’m not the only one who got it wrong – almost everyone working in Africa for the past decade has paid close attention to statistics compiled by UNAIDS. And, according to recent research by ORC Macro, a research company hired by USAID to conduct HIV infection studies across the continent, UNAIDS got their numbers badly wrong.

UNAIDS based their numbers on tests performed on women they saw at prenatal clinics. The infection figure for these women was used as a proxy for the infection rate for the adult (15-49) population. As it turns out, this is a really bad proxy. Health clinics were in urban areas, and the women living in these areas turn out to have a much higher rate of infection than women in rural areas. And women, in general, have a higher HIV infection rate, than men in Africa. ORC Macro tested randomly selected men and women, in rural and urban areas, and performed two blood tests on each individual, to reduce the number of false positive tests. They were able to lower the estimate of HIV incidence in Zambia from 21.5% to 15.6% and in Rwanda from 8.3% to 5.4%. UNAIDS had estimated HIV incidence in Sierra Leone at 7% – it turned out to be less than 1%.

UNAIDS is aware that their numbers are high, and is now gradually revising their estimates downward. Craig Timberg’s story in the Washington Post includes a couple of quotes that imply that the inaccuracy was perpetuated to make it easier for UNAIDS and other groups to raise money to combat the disease. The article quotes a British economist who argues “They were not predisposed, let’s put it that way, to weigh the counterevidence. They were looking to generate big bucks.”

Whether or not UNAIDS consciously misled donors, or whether they simply had a hard time letting go of overestimates, their statistics did help raise consciousness of the disease and raise money towards combatting it. Perhaps this is a good thing – AIDS is a major health crisis in Southern Africa and resources are desperately needed to combat it. Maybe it’s okay that the crisis was overstated since the result was increased aid, and increased awareness, which led towards prevention efforts. Given the high cost of anti-retroviral drugs, perhaps any money towards combatting AIDS is a blessing.

Or perhaps it’s not okay. If AIDS had been recognized as the primary health crisis in Southern Africa and one of several major health crises – including endemic malaria – on the rest of the continent, it’s possible that some of the money raised to focus on HIV could have focused on the other diseases that shorten Africans’ lives. Or perhaps some of the money could have gone towards other pressing development needs, like education, water and sewage systems, food security. When deciding between school funding and health funding, it makes a big difference whether you’re dealing with a 7% HIV rate or a 1% rate.

There’s a more subtle effect of the UN’s misstated numbers: the extent to which the story of contemporary Africa and AIDS have been intertwined. At the Pop!Tech 2005 panel on African issues, moderator David Kirkpatrick expressed surprise that a two-hour conversation hadn’t touched on AIDS, and asked the panelists to address the crisis. Panelists responded angrily, with Emeka Okafor of Timbuktu Chronicles declaring:

My problem with the question is that when mainstream media frames Africa, two or three topics come up again and again: AIDS, AIDS and AIDS. The relentless focus on AIDS plays into the framework of helplessness associated with the continent.

In framing Africa as “ravaged” by AIDS, it’s hard to see it – simultaneously – as a hotbed of business innovation or an exporter of culture. The repetition of the truths – and half truths – about Africa and AIDS build the story that Africa is a problem, a crisis, a land in need of ever-increasing amounts of outside aid to address these problems. My friends got angry at Pop!Tech because Kirkpatrick forced a discussion about Africa’s potential into a discussion about intractable African problems. Discovering that this problem was exaggerated on much of the continent – and perhaps intentionally so – is profoundly frustrating for everyone invested in the business of imagining, promoting and rebranding Africa as a land of opportunity, not of crisis.

I do not mean to dismiss the magnitude of the AIDS crisis on the continent, especially in Southern Africa where AIDS is a tremendous health problem and one of the major issues governments and donors need to address. Even in West Africa, AIDS is a huge health problem and one that needs to be addressed. Organizations that are working to make antiretroviral drugs available and affordable, and to help prevent the spread of the disease – including UNAIDS – should be commended and supported.

But Africa needs help beyond AIDS. And Africa is hurt in some complicated ways by the reinforcement of the equation “Africa = AIDS”. UNAIDS and others have worked very hard to help people understand that AIDS is a crisis for Africa. How hard will we have to work to get people to understand what the crisis really is… and really isn’t?