From The Washington Post.

A FEW HIGHLIGHTS

How AIDS in Africa Was Overstated
Reliance on Data From Urban Prenatal Clinics Skewed Early Projections
By Craig Timberg
Washington Post Foreign Service
Thursday, April 6, 2006; Page A01


http://www.washingtonpost.com/wp-dyn/content/article/2006/04/05/AR2006040502517.html?sub=new


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But AIDS deaths on the predicted scale never arrived here, government health officials say. A new
national study illustrates why: The rate of HIV infection among Rwandans ages 15 to 49 is 3 percent,
according to the study, enough to qualify as a major health problem but not nearly the national
catastrophe once predicted. The new data suggest the rate never reached the 30 percent estimated by
some early researchers, nor the nearly 13 percent given by the United Nations in 1998.
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Most of the studies were conducted by ORC Macro, a research corporation based in Calverton, Md., and
were funded by the U.S. Agency for International Development, other international donors and various
national governments in the countries where the studies took place. Taken together, they raise
questions about monitoring by the U.N. AIDS agency, which for years overestimated the extent of
HIV/AIDS in East and West Africa and, by a smaller margin, in southern Africa, according to
independent researchers and U.N. officials. "What we had before, we cannot trust it," said Agnes
Binagwaho, a senior Rwandan health official.
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Years of HIV overestimates, researchers say, flowed from the long-held assumption that the extent of
infection among pregnant women who attended prenatal clinics provided a rough proxy for the rate
among all working-age adults in a country. Working age was usually defined as 15 to 49. These rates
also were among the only nationwide data available for many years, especially in Africa, where
health tracking was generally rudimentary. The new studies show, however, that these earlier
estimates were skewed in favor of young, sexually active women in the urban areas that had prenatal
clinics. Researchers now know that the HIV rate among these women tends to be higher than among the
general population.
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The new studies rely on random testing conducted across entire countries, rather than just among
pregnant women, and they generally require two forms of blood testing to guard against the numerous
false positive results that inflated early estimates of the disease. These studies also are far more
effective at measuring the often dramatic variations in infection rates between rural and urban
people and between men and women.

UNAIDS, the agency headed since its creation in 1995 by Peter Piot, a Belgian physician, produced
its first global snapshot of the disease in 1998. Each year since, the United Nations has issued
increasingly dire assessments: UNAIDS estimated that 36 million people around the world were
infected in 2000, including 25 million in Africa. In 2002, the numbers were 42 million globally,
with 29 million in Africa.

But by 2002, disparities were already emerging. A national study in the southern African country of
Zambia, for example, found a rate of 15.6 percent, significantly lower than the U.N. rate of 21.5
percent. In Burundi, which borders Rwanda in central East Africa, a national study found a rate of
5.4 percent, not the 8.3 percent estimated by UNAIDS.
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In West Africa, Sierra Leone, just then emerging from a devastating civil war, was found to have a
national prevalence rate of less than 1 percent -- compared with an estimated U.N. rate of 7
percent.
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Such disparities, independent researchers say, skewed years of policy judgments and decisions on
where to spend precious health-care dollars. "From a research point of view, they've done a pathetic
job," said Paul Bennell, a British economist whose studies of the impact of AIDS on African school
systems have shown mortality far below what UNAIDS had predicted. "They were not predisposed, let's
put it that way, to weigh the counterevidence. They were looking to generate big bucks."
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Peter Ghys, an epidemiologist who has worked for UNAIDS since 1999, acknowledged in an interview
from his office in Geneva that HIV projections several years ago were too high because they relied
on data from prenatal clinics.
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"What has happened is we have come to realize that indeed we have overestimated the epidemic a bit,"
he said.
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On its Web site, UNAIDS describes itself as "the chief advocate for worldwide action against AIDS."
And many researchers say the United Nations' reliance on rigorous science waned after it created the
separate AIDS agency in 1995 -- the first time the world body had taken this approach to tackle a
single disease.
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In the place of previous estimates provided by the World Health Organization, outside researchers
say, the AIDS agency produced reports that increasingly were subject to political calculations, with
the emphasis on raising awareness and money.
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Chin, speaking from Stockton, Calif., added, "They keep cranking out numbers that, when I look at
them, you can't defend them."
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Rwandan health officials say their national HIV infection rate might once have topped 3 percent and
then declined. But it's just as likely, they say, that these apparent trends reflected nothing more
than flawed studies.
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