AIDS in Africa

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AIDS education at a school in Uganda.

The HIV/AIDS epidemics spreading through the countries of Sub-Saharan Africa are highly varied. Although it is not correct to speak of a single African epidemic, Africa is without doubt the region most affected by the virus. Inhabited by just 10% of the world's population, Africa is estimated to have more than 60% of the AIDS-infected population.

World region	Adult HIV prevalence (ages 15–49)	Total HIV cases (0–49)	AIDS deaths in 2004
Sub-Saharan Africa	7.4%	25.4m	2.3m
North America	0.6%	1.0m	16,000
Western Europe	0.3%	570,000	16,000

Regional comparisons of HIV (Source: UNAIDS)

1 General overview
2 Measuring the epidemic
3 Access to treatment
4 Regional analysis
5 References
6 External links

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General overview

HIV prevalence is stable throughout most of Sub-Saharan Africa, is still rising in a few countries such as Madagascar and Swaziland and is falling in smaller areas in several other countries. Uganda has had the world's most successful national response to date, and has witnessed consistent national declines since the mid-1990s. However, several agencies have cautioned against viewing the stablised infection levels as the beginning of the end of the pandemic in Africa. Such trends often result from rising death rates from AIDS, which conceal a continuing high rate of new infections. When HIV prevalence falls, as in Uganda, the number of new infections can remain high. National prevalence statistics can also conceal much higher levels of infections in certain areas or among high-risk groups.

The number of African people infected with HIV has exploded since the mid-1980s.

In the 35 African nations with the highest prevalence, average life expectancy is 48.3 years—6.5 years less than it would be without the disease. For the eleven countries in Africa with prevalence rates above 13 percent, life expectancy is 47.7 years—11.0 years less than would be expected without HIV/AIDS.

The Joint United Nations Programme on HIV/AIDS (UNAIDS) has predicted outcomes for the region to the year 2025. These range from a plateau and eventual decline in deaths beginning around 2012 to a catastrophic continual growth in the death rate.

Health spending in Africa has historically been inadequate, leaving a legacy of poor health care capacity in many regions. This situation was often compounded after independence by the distorted spending priorities of the many military regimes across the continent. The health care systems inherited from colonial powers were oriented toward curative treatment rather than preventative programs. Strong prevention programs are the cornerstone of effective national responses to AIDS, and the required changes in the health sector have presented a huge challenge.

Without the kind of nutrition, health care and medicines (such as anti-retrovirals) that are available in developed countries, large numbers of people in these countries will begin to develop full-blown AIDS. They will not only be unable to work, but will also require significant medical care. It is forecast that this will likely cause a collapse of economies and societies in the region. In some heavily infected areas, the epidemic has left behind many orphans being cared for by elderly grandparents. UNAIDS, WHO and UNDP have already documented decreasing life expectancies and lowering of GNP in many African countries with prevalence rates of 10% or more.

Many governments in sub-Saharan Africa denied that there was a problem for years, and are only now starting to work towards solutions. Lack of money is the core reason why most AIDS deaths occur in Third World countries. All areas of HIV prevention are underfunded when compared to even conservative estimates of the problems.

Changes in life expectancy in several African countries. Botswana has been particularly badly hit [1], whilst public education projects campaigns have had a positive effect in Uganda [2]. (Source: World Bank World Development Indicators, 2004).

An expanding body of evidence challenges the conventional hypothesis that sexual transmission is responsible for more than 90% of adult HIV infections in Africa. Differences in epidemic trajectories across Africa do not correspond to differences in sexual behavior. Studies among African couples find low rates of heterosexual transmission, as in developed countries. Many studies report HIV infections in African adults with no sexual exposure to HIV and in children with HIV-negative mothers. Unexplained high rates of HIV incidence have been observed in African women during antenatal and postpartum periods. Many studies show 20%–40% of HIV infections in African adults associated with injections (though direction of causation is unknown). These and other findings that challenge the conventional hypothesis point to the possibility that HIV transmission through unsafe medical care may be an important factor in Africa's HIV epidemic. [3]Pyro

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Measuring the epidemic

It should be borne in mind that national prevalence levels present a delayed representation of the epidemic as they account for the HIV infections of many years previously. That is, prevalence includes everyone in the country living with HIV and AIDS. Incidence, in contrast, measures the number of new infections, usually over the previous year. Unfortunately, there is no reliable way to assess incidence in sub-Saharan Africa. The closest approximation has been found to be prevalence in 15–24 year old pregnant women attending antenatal clinics, these measurements are known as serosurveys.

However, some doubt has been cast on the such reporting of HIV cases by health units, which rarely operate in remote rural communities and do not account for people who may decide, for example, to die at home or seek traditional healthcare. New national population or household-based surveys are increasingly being used to address the shortfalls in serosurveys. These collect data from both sexes, non-pregnant women and from the more remote areas, resulting in a more refined overall picture when combined with antenatal data. These measurements have adjusted the recorded national prevalence levels for several countries in Africa and elsewhere.

Both serosurveys and national surveys have their disadvantages. People may not participate in household surveys because they fear they may be HIV positive or because they are absent from home, excluding the high risk group of travelling labourers. Extrapolating national data from antenatal surveys relies on a set of key assumptions which may not hold across all regions and at different stages in an epidemic.

Occasionally, observers have gone so far as to suggest there may be significant disparities between official figures and actual HIV prevalence in some countries, such as Uganda. The Ugandan government vigorously maintains, however, that the figures are accurate.

As a word of caution, it should be born in mind, that the numbers that are generated by these surveys largely determine how the epidemic is viewed. Serosurveys routinely give much higher national infection rates (40% higher or more) than the far more representative national surveys (called DHS or Demographic and Health Surveys) which in Africa are often carried out in coordination with the CDC, instead of by the WHO/UNAIDS. The hysterical atmosphere that is created by serosurvey results (see the bloodred charts on this page) give rise to wrongheaded national health policies, which together with healthcare and food access cutting "Structural Adjustment Programs" in fact kill far more people due to malaria, tuberculosis and malnutrition, than HIV ever can.

Another anomaly is the fact that countries in Africa (including Swaziland, see map) have the highest population growth in the world. The population of South Africa went from 40.6 million in 1996, to 44.8 million in 2001 and 46.9 million in mid-year 2005 (see population censuses of Statistics South Africa). This can mean only one of two things. HIV/AIDS in Africa is only one among a large number of killer diseases and as a result has a limited impact on population growth. Or, the numbers are wrong. As the serosurvey numbers are much higher than the national survey numbers, it should be seriously considered that HIV infection numbers in Africa are at best shaky, at worst dramatically overstated.

See: http://www.boston.com/news/world/articles/2004/06/20/estimates_on_hiv_called_too_high/

South Africa, population census 2001 (compared with 1996 data) http://www.statssa.gov.za/census01/html/default.asp

See especially the quotes of Paul Bunnell and Rian Malan: Is the African AIDS pandemic a bluff? http://www.afrol.com/printable_feature/11116

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Access to treatment

"Treatment is technically feasible in every part of the world. Even the lack of infrastructure is not an excuse—I don't know a single place in the world where the real reason AIDS treatment is unavailable is that the health infrastructure has exhausted its capacity to deliver it. It's not knowledge that's the barrier. It's political will." Peter Piot, Executive Director of UNAIDS

New anti-retroviral drugs (ARVs) can slow down and even reverse the progression of the HIV virus, delaying the onset of AIDS by twenty years or more. Because of their high cost, however, only 7 percent of the 6 million people in developing countries who are urgently in need of ARV treatment are able to access them.

Access to drugs is increasingly recognised as a key component to comprehensive AIDS strategies. ARVs play a central role in prevention as well as treatment. People are more likely to come forward for testing if there is some hope of receiving treatment and are more likely to adopt lower risk behaviours to avoid infecting others. ARVs also reduce the amount of HIV in the blood, thus reducing the risk of further transmission. Slowing the onset of AIDS allows people to continue leading a relatively normal life, fully contributing to the social and economic life of their country.

The use of ARVs must be continuous, in order to prevent the number of drug-resistant strains of HIV from spreading. In areas where drug therapy is expensive, such resistant strains have been observed as people have interrupted their treatment at times when they cannot afford to continue purchasing the drugs. There is no available cure for HIV and no prospect of one being developed for a significant time to come. Once ARV treatment has started, it must be continued for the rest of the patient's life.

In Europe, ARV treatment is very expensive: it can cost between $10,000 and $15,000 per person per year (pppy). The key factor in the expense of ARVs is their patent status, allowing drug companies to profit from their costly research and further incentivise future development. However, some international aid organisations such as VSO, Oxfam and Médecins Sans Frontières have questioned whether the revenues generated by ARVs really tally with research costs.

By contrast, in some African countries, ARVs are available for under $140 pppy. They are supplied by drug manufacturers in South Africa and also in India, Brazil, Thailand and China,who have manufactured generic copies of patented ARV drugs. Fees are not paid to the patent holders and the drugs can consequently be distributed at prices agreeable to the governments and people of developing countries. The reduction in cost has come about from a combination of generic production and 'price offers', voluntary donations by companies. Patent holders began to reduce their prices when faced with competition from politically savvy generic firms.

Another component of the cost of HIV therapy is the need for regular testing of viral load and CD4 cell count in order to prevent cases of drug-resistance. This, however, requires expensive laboratory equipment and good logistics, whose cost per patient in African countries are greater than those for the ARVs. So the total cost of the therapy still amounts to $800, if it is done according to Western standards of excellence.^[4]

Consequently, ARV treatment is still relatively expensive for most Africans; for those living below the poverty threshold of a $2 / day income, it is still inaccessible. So the only option for treating especially the poor patients is providing free treatment.

The World Health Organisation's 3 by 5 initiative aims to provide three million people with ARV treatment by the end of 2005. International aid organisations have lobbied for an expansion of generic production in developing countries, for immediate short term and stable, predictable long term financing of the 3 by 5 initiative.

The DREAM (short for "Drug Resources Enhancement against Aids and Malnutrition", formerly "Drug Resource Enhancement against AIDS in Mozambique") promoted by the Community of Sant'Egidio has proven to be an efficient means of giving access to free ARV treatment with generic HAART drugs to the poor on a large scale: So far, 5.000 people are receiving ARV treatment, especially in Mozambique, but the program is being built up also in other countries: Malawi, Guinea, Tanzania and others. Despite being free, the program aims at excellence in treatment, providing the best existent range of drugs (HAART) and regular blood testing according to European standards. It is linked with a nutrition program as well as guidance and sanitary education by volunteers (other HIV patients taking part in the program), which encourages new patients to comply and come to the appointments. The compliance rate is very high (94 percent).

National infection rates for HIV. No data is available for white coloured areas.

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Regional analysis

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East-central Africa

In this article, East and central Africa consists of Uganda, Kenya, Tanzania, Democratic Republic of Congo, the Congo Republic, Gabon, Equatorial Guinea, the Central African Republic, Rwanda, Burundi and Ethiopia and Eritrea on the Horn of Africa. In 1982, Uganda was the first state in the region to declare HIV cases. This was followed by Kenya in 1984 and Tanzania in 1985.

Country	Adult prevalence	Total HIV	Deaths 2003
Uganda	4.1%	450,000	78,000
Kenya	6.7%	1,100,000	150,000
Tanzania	8.8%	1,500,000	160,000
Congo	4.9%	80,000	9,700
Congo DR	4.2%	1,000,000	100,000
Ethiopia	4.4%	1,400,000	120,000
Eritrea	2.7%	55,000	6,300

HIV in East-central Africa (Source: UNAIDS)

Some areas of East Africa are beginning to show substantial declines in the prevelance of HIV infection. In the early 1990s, 13 percent of Ugandan residents were HIV positive; This has now fallen to 4.1 percent by the end of 2003. Evidence may suggest that the tide may also be turning in Kenya: prevalence fell from 13.6 percent in 1997–1998 to 9.4 percent in 2002. Data from Ethiopia and Burundi are also hopeful. HIV prevalence levels still remain high, however, and it is too early to claim that these are permanent reversals in these countries' epidemics.

Most governments in the region established AIDS education programmes in the mid-1980s in partnership with the World Health Organization and international NGOs. These programmes commonly taught the 'ABC' of HIV prevention: a combination of abstinence (A), fidelity to your partner (Be faithful) and condom use (C). The efforts of these educational campaigns appear now to be bearing fruit. In Uganda, awareness of AIDS is demonstrated to be over 99 percent and more than three in five Ugandans can cite two or more preventative practices. Youths are also delaying the age at which sexual intercourse first occurs.

Circumcision of the penis is believed to reduce the risk of HIV infection in males. This may have contributed to the relatively lower rates of infection in Congo, Ethiopia and Eritrea, where circumcision is widely practised, as compared to other countries in the region.

There are no non-human vectors of HIV infection. The spread of the epidemic across this region is closely linked to the migration of labour from rural areas to urban centres, which generally have a higher prevalence of HIV. Labourers commonly picked up HIV in the towns and cities, spreading it to the countryside when they visited their home. Empirical evidence brings into sharp relief the connection between road and rail networks and the spread of HIV. Long distance truck drivers have been identified as a group with the high-risk behaviour of sleeping with prostitutes and a tendency to spread the infection along trade routes in the region. Infection rates of up to 33 percent were observed in this group in the late 1980s in Uganda, Kenya and Tanzania.

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West Africa

For the purposes of this discussion, Western Africa shall include the coastal countries of Mauritania, Senegal, The Gambia, Cape Verde, Guinea-Bissau, Guinea, Sierra Leone, Liberia, Côte d'Ivoire, Ghana, Togo, Benin, Nigeria and the landlocked states of Mali, Burkina Faso and Niger.

The region has high levels of infection of both HIV-1 and HIV-2. The onset of the HIV epidemic in West Africa began in 1985 with reported cases in Cote d'Ivoire, Benin and Mali. Nigeria, Burkina Faso, Ghana, Cameroon, Senegal and Liberia followed in 1986. Sierra Leone, Togo and Niger in 1987; Mauritiana in 1988; The Gambia, Guinea-Bissau, and Guinea in 1989; and finally Cape Verde in 1990.

HIV prevalence in West Africa is lowest in Chad, Niger, Burkina Faso, Mali, Mauritania and highest in Burkina Faso, Côte d'Ivoire, and Nigeria. Nigeria has the second largest HIV prevalence in Africa after South Africa.

The main driver of infection in the region is commercial sex. In the Ghanaian capital Accra, for example, 80 percent of HIV infections in young men had been acquired from women who sell sex. In Niger, the adult national HIV prevalence was 1 percent in 2003, yet surveys of sex workers in different regions found a HIV infection rate of between 9 and 38 percent.

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Southern Africa

In the mid-1980s, HIV and AIDS were virtually unheard of in Southern Africa - it is now the worst-affected region in the world. There has been no sign of overall national decline in any of the eleven countries: Angola, Namibia, Zambia, Zimbabwe, Botswana, Malawi, Mozambique, South Africa, the two small states of Lesotho and Swaziland and the island of Madagascar. Almost 30 percent of the global number of people living with HIV live in an area where only 2 percent of the world's population reside.

Nearly every country in the region has a national HIV prevalence level of at least 10 percent. The only exception to this rule is Angola, with a rate of less than 5 percent. Tragically, this is not the result of a successful national response to the threat of AIDS but of a long running civil war.

Most HIV infections found in Southern Africa are HIV-1, the world's most common HIV infection, which predominates everywhere except West Africa, home to HIV-2. The first cases of HIV in the region were reported in Zimbabwe in 1985.

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