Lost benefit of ARVs in South Africa

Nathan Geffen, Treatment Action Campaign

Two studies have calculated the number of excess AIDS deaths due to the South African overnment’s delayed rollout of highly active ARV treatment (HAART) and prevention of mother-to-child transmission (PMTCT).

Nicoli Nattrass analysed what would have happened if PMTCT had been rolled out from 1998 instead of 2001 and HAART was rolled out at the same rate as the Western Cape Province (from 10% in 2000 to 65% in 2007), the province credited with the most expeditious implementation. [1]

She compared these scenarios using the Actuarial Society of South Africa’s ASSA2003 model [2] and estimated that 343,000 deaths could have been averted.

Pride Chigwedere and colleagues at Harvard School of Public Health used a slightly different method. [3]

They argued that reduced drug prices and the availability of resources from programmes like the Global Fund and PEPFAR enabled the South African government to implement PMTCT and HAART earlier. South Africa’s public sector HAART programme only moved beyond pilot sites in 2004. According to the WHO and UNAIDS 3×5 records, South Africa scaled up HAART from less than 3% in 2000 to 23% in 2005. The authors considered the number of life-years that could have been saved had the state initiated its ARV programme at 5% coverage in 2000, scaling up to 50% by end of 2005, which is
lower than the 85% achieved by Botswana or 71% by Namibia. They used UNAIDS estimate of AIDS deaths to determine the number of people who were eligible for HAART but did not receive it.

For PMTCT, they used data from the Department of Health’s PMTCT Task Team showing that coverage rose from less than 3% in 2000 to 30% in 2005 and compared this to a programme that started with 5% coverage in 2000 and scaled up to 55% in 2005.

Their model calculated that the delayed HAART rollout resulted in 2.2 million lost person-years and over 330,000 deaths.

Delayed PMTCT resulted in over 35,000 excess infections and 1.6 million lost person-years. This is a total of 3.8 million lost person-years.

Both studies were intentionally conservative. For example, Chigwedere et al. assumed low estimates for additional life expectancy on HAART (6.7 years) and paediatric infections. Both studies assumed low peak coverage rates in the alternative scenarios and that only the sub-optimal single-dose nevirapine PMTCT regimen was feasible. Neither took into account less tangible parameters such as deaths due to the promotion of quackery and infections due to poor state condom messaging
and equivocation on the cause of AIDS.

Chigwedere et al. also performed several sensitivity tests. They found, for example, that by varying HAART peak coverage from 40% to the Namibian rate of 71%, excess deaths varied from about 226,000 to 503,000. They concluded: “Access to appropriate public health practice is often determined by a small number of political leaders. In the case of South Africa, many lives were lost because of a failure to accept the use of available ARVs to prevent and treat HIV/AIDS in a timely


These studies both calculated very similar estimates for the number of lives lost due to the delayed rollout of HAART and PMTCT, even though they use different methodologies. Communication between Nattrass and Chigwedere after the latter’s paper was published shows that they were unaware of each other’s work. This increases confidence in their findings.

Their calculations confirm that the policies of President Thabo Mbeki and Minister of Health Manto Tshabalala-Msimang resulted in hundreds of thousands of avoidable deaths. Mbeki and Tshabalala-Msimang also created long-term problems, such as the proliferation of quackery and loss of public confidence in scientific medicine.

The Rome Statute of the International Criminal Court, to which South Africa is a signatory, defines the “intentional infliction of conditions of life, inter alia the deprivation of access to food and medicine, calculated to bring about the destruction of part of a population” as a crime against humanity.


  1. Nattrass N. AIDS and the Scientific Governance of Medicine in Post-Apartheid South Africa [Internet]. African Affairs. 2008 Feb 7;107(427):157-176.[cited 2008 Sep 11 ].
  2. Actuarial Society of South Africa. ASSA2003 [Internet]. [cited 2008 Jan 8 ].
  3. Chigwedere P, Seage G, Gruskin S, Lee T, Essex M. Estimating the Lost Benefits of Antiretroviral Drug Use in South Africa [Internet]. J Acquir Immune Defic Syndr. 2008 Oct 16; [cited 2009 Jan 5 ].

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