Plague in their midst

In a focus on research in South Africa, Karen MacGregor reports on the fight against Aids and, below, on science funding. Next week we return to Australia

The first one was my son. He was about 20 years old. He died in December. The second one was my eldest son. They all died one after another. Then it was the child - two years old. The mother of the two-year-old died. The same problem, she also lost lots of weight. She was 23."

These are the words of a black woman describing the deaths from Aids of members of her family and relatives. Her nightmare is echoed by others throughout a report, which has just been published, describing through the voices of the poor, the impact the epidemic is beginning to have on communities in KwaZulu-Natal, on South Africa's east coast.

Tessa Marcus, a sociologist at the University of Natal in Pietermaritzburg, and researchers conducted a qualitative investigation of 120 people affected by Aids in seven communities in and around the city.

They also interviewed in depth ten people who have been diagnosed as terminally ill. What is striking, Professor Marcus writes in It is Destroying the Children - Living and Dying with Aids, is that five of the ten interviewees and one or more participants in most of 15 focus groups have experienced multiple deaths - "two, three or even four close family members dying in the recent past".

"HIV-Aids is sending shock waves into

a social web that has as its epicentre their immediate family but which extends to more distant relatives, friends, neighbours, colleagues and casual acquaintances," writes Professor Marcus.

"The very scale of these micro-social shocks has meso and macro impacts, which require a level of social mobilisation that extends well beyond the particular circumstances and experiences of the individual who is diagnosed as HIV-positive."

One in three adults in KwaZulu-Natal is now believed to be infected with HIV. The province, home of the Zulus, has suffered a 20 per cent rise in infection in one year and is the country's worst hit region. Nationally, one in five adults may be infected.

Alan Smith, of the department of virology at the University of Natal Medical School, conducted a study of pregnant women in KwaZulu-Natal as part of an annual government survey. At an HIV-Aids Update Symposium in Durban in February, Professor Smith broke the news that the incidence of HIV had reached 32.4 per cent in the province.

If current trends continue, the United Nations Development Programme predicted in a recently published report on HIV-Aids in South Africa, there will be 2.9 million HIV-positive adults in the country by next year and 4.5 million by the year 2005 - although this figure could decline substantially if people begin to modify their behaviour.

The UNDP report also forecast a "steep rise" in deaths soon among people infected between 1994 and 1996, and a population of 200,000 orphans by next year and 900,000 by the 2005.

By 2010, the report goes on gloomily, life expectancy will fall from 68.2 years to 48 years, and child mortality rates will rise to 99.5 per 1,000, a rate of nearly 10 per cent.

Professor Smith's conclusion, and that of other experts, is that the many campaigns aimed at preventing the spread of HIV-Aids have "failed miserably". For that reason, research efforts are increasingly being focused on how to manage the immense personal, social, economic and other impacts of the epidemic.

There is still a lot of work being done on prevention, says Karen Michael, a researcher for the Health Economics and HIV-Aids Research Division (Heard) in the department of economics at the University of Natal.

"But it is clear that preventive efforts have failed. That window has passed us by. In an era where we have to manage as well as prevent Aids, research into the impact of the disease has taken off."

Major research programmes into HIV-Aids are under way at several of the country's universities, ranging from medical studies into drugs such as AZT, which might lower the chances of mothers infecting their babies, to drug trials and studies of the implications of the disease for families, society and the economy.

Local companies, the government and foreign donors are pouring hundreds of millions of rand into Aids research, which has been one of the fastest growing study areas in South Africa for several years. About 11 per cent of total British aid committed to South Africa over the next three years, for instance, is to be spent on research and interventions aimed at containing HIV.

Much of the research is concentrated in KwaZulu-Natal because of its high rate of infection. South Africa's largest current non-pharmaceutical health research effort is a

multidisciplinary collaborative project involving the universities of Natal and Durban-Westville and the Medical Research Council. It is being funded by Britain's Wellcome Trust, to the tune of nearly R40 million (Pounds 5 million) over five years.

In 1997 the project set up the Africa Centre for Research in Population Studies and Reproductive Health. One key reproductive issue, of course, is sexually transmitted diseases and HIV infection, which the centre's research is aimed at reducing.

Part of the programme is based at Hlabisa, in northern KwaZulu-Natal, where half of all patients admitted to the local hospital have been found to be HIV-positive. Clinical trials will begin there within the next two years on an Aids vaccine.

The University of Natal, long the country's focal point for HIV-Aids research, has a range of other projects under way at the medical school and several departments in Durban and Pietermaritzburg.

Heard is one of the largest and oldest. One of its major activities is producing toolkits that will help staff and consultants working for aid agencies to consider the implications of the HIV epidemic in the provision of development assistance.

Ms Michael says the division has been developing documents suggesting how to integrate Aids into development plans in, for example, transport and education, and setting out how each sector is vulnerable to the epidemic.

"The United States Agency for International Development liked the idea, and we got a contract to update the toolkits, but for government ministries rather than non-governmental organisations and companies," Ms Michael says.

Ms Michael is also charged with keeping the provincial government informed, through cabinet briefings and reports, of the spread and likely impact of the disease on its activities in different sectors. The same applies to local governments.

"We try to set out the internal and external impacts of the Aids epidemic, for instance how teachers and pupils are likely to be affected and the effects that increased illness and death in schools will have on resource allocations."

It is important, Ms Michael also points out, for the Durban metropolitan council to know that some mortuaries in the city are now stretched beyond capacity.

Rodney Harber, an architect, estimates from the number of people being infected that the city will require 44 hectares of graveyard space per month to bury Aids victims within the next three or four years.

In her study, Professor Marcus finds that with Aids killing young adults, the social and economic consequences are "profound and negative, especially for women and children".

"South Africa needs now to begin gearing up service provision across a range of areas. There is an urgent need for professions that deal with dying and death to be better organised to cope with the complex consequences of Aids."

HIV-Aids is decimating South Africa's poorest people, particularly in KwaZulu-Natal. Among those communities, after years of denial, there is now awareness of the unfolding tragedy. This is not yet realised by many other South Africans elsewhere.

"Millions of people will die in the next four to five years," Professor Smith says. "The epidemic is horrific but nobody seems to care."