HIV/AIDS in Africa

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 over 12% of the world's population, Africa is estimated to have more than 60% of the AIDS-infected population.

General overview
Some say that HIV prevalence is stable throughout most of Sub-Saharan Africa, but reports illustrate that it is still rising in most southern African countries (although some country regions remain stable). Uganda has had the world's most successful national response to date reducing from 11% prevalence to around 6% (although there are conflicting reports as to whether this number is rising again); initially it had witnessed consistent national declines since the early 1990s (see UNAIDS website for more on these statistics). However, several agencies have cautioned against viewing the sporadic stablized 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. Additionally, certain countries have high numbers of migrants due to unrest (ie in Zimbabwe) thus leading to skewed numbers (for example, in certain regions of Botswana, when individuals are tested, they are not asked where their permanent country of residence is; thus foreigners are often included in-country statistics).

There are controversial reports in current literature concerning the high prevalence levels in the richest southern countries of Africa (such as South Africa and Botswana) that state that reasonably efficient medical care available to HIV infected people from these countries has led to the increased ability to maintain a healthy appearance. Because of the stigma in admitting to HIV infection and in the use of condoms, some individuals choose to continue to engage in unsafe sexual practices which thus spreads HIV to new sexual partners.

Furthermore, in certain parts of Southern Africa there is widespread denial that HIV does in fact cause AIDS. Thabo Mbeki and Robert Mugabe have both propounded the theory that AIDS in fact stems from poverty rather than HIV infection. (While this is not necessarily untrue, the arguments used have been quite controversial because they overlook the medical link between HIV and AIDS.) In addition, there are many myths attached to the use of condoms, such as the idea that they are used to limit the growth of the African population, that eating a chicken is dangerous because it may have ingested a condom (with the virus) and that condoms stifle the traditional power of the man in his community.

In the 35 African nations with the highest prevalence, average life expectancy is 48.3 years&mdash;6.5 years less than it would be without the disease. For the eleven countries in Africa with prevalence rates above 13%, life expectancy is 47.7 years&mdash;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 with potentially 90 million cases of infection.

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 all of the severely affected countries, the epidemic has left behind many orphans, who are either cared for by extended family members, or left with no choice but to live in orphanages or on the streets. 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 although they have now begun to work toward solutions, there are several problems that block a decrease in the spread of the disease. Although some say that lack of money is at the root of the problem, in fact, there is a great deal of aid distributed throughout developing countries with high HIV/AIDS rates. Core problems occur because of: newly decentralized systems, lack of infrastructure (particularly with health clinics), corruption at all levels (within donor agencies as well as government agencies), accountability to foreign donors rather than the communities at hand, and misguided resources. While each country has specific problems concerning the distribution of resources, these themes tend to prevail throughout those most affected.



A minority of scientists claim that as many as 40% of HIV infections in African adults may be associated with injections. However this theory is rejected by most experts, including those at the World Health Organisation, who assert that the vast majority of infections result from heterosexual transmission..

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 practicable and 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 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.

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.

Access to treatment

 * "Treatment is technically feasible in every part of the world. Even the lack of infrastructure is not an excuse&mdash;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 HIV infection, delaying the onset of AIDS by twenty years or more. Because of their high cost, however, only 7% of the 6 million people in developing countries who are in need of ARV treatment have access to medication. Access to the ARV therapy has increased more than eightfold since the end of 2003, with about 810,000 people on the treatment.

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 were unable to afford medication. Patients who start HIV treatment generally have to continue taking medications for the rest of their lives, although many HIV positive individuals undergo periods (commonly referred to as drug holidays) where they do not take ARV drugs. The UNAIDS has reported an oubreak of extensively drug resistant tuberculosis in KwaZulu-Natal which was detected in early September and has a combination of HIV and TB in South Africa, where it is estimated 60% of TB patients overall are also infected with HIV.

In Western societies, ARV treatment is very expensive, costing between $10,000 and $15,000 per person per year (pppy). The key factor in the expense of ARVs is their patent status, which allow drug companies to recoup research costs and turn a profit, enabling the development of new drugs. 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.

In contrast, in some African countries, ARVs are available for under $140 per person per year (pppy). They are supplied by drug manufacturers in India, South Africa, 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 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, making the total cost of the therapy approximately $800 when done according to Western standards.

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, leaving free treatment as the only option for many.

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 United States AIDS initiative, PEPFAR, is focusing two thirds of its resources on AIDS in Africa. Starting in 2004, expenditures rose from $2.3B world-wide to $3.3B in 2006. A funding level of $4B is requested for 2007.

The DREAM (short for "Drug Resources Enhancement against Aids and Malnutrition", which used to be "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%).



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.

Some areas of East Africa are beginning to show substantial declines in the prevalence of HIV infection. In the early 1990s, 13% of Ugandan residents were HIV positive; This has now fallen to 4.1% by the end of 2003. Evidence may suggest that the tide may also be turning in Kenya: prevalence fell from 13.6% in 1997–1998 to 9.4% 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% 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.

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% were observed in this group in the late 1980s in Uganda, Kenya and Tanzania.

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 generally 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, Mali, Mauritania and highest in Burkina Faso, Côte d'Ivoire, and Nigeria. Nigeria has the second largest HIV prevalence in Africa after South Africa, although the infection rate (number of patients relative to the entire population) based upon Nigeria's estimated population is much lower, generally believed to be well under 7%, as opposed to South Africa's which is well into the double-digits (nearer 30%).

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

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 HIV/AIDS 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. In its December 2005 report, UNAIDS reports that Zimbabwe has experienced a drop in infections; however, most independent observers find the confidence of UNAIDS in the Mugabe government's HIV figures to be misplaced, especially since infections have continued to increase in all other southern African countries (with the exception of a possible small drop in Botswana). Almost 30% of the global number of people living with HIV live in an area where only 2% of the world's population reside.

Nearly every country in the region has a national HIV prevalence level of at least 10%. The only exception to this rule is Angola, with a rate of less than 5%. 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.

Impacts of the AIDS Epidemic
Africa's HIV/AIDS epidemic has had important effects on society, economics and politics in the continent. Tony Barnett and Alan Whiteside, "AIDS in the 21st Century: Disease and Globalization," (MacMillan Palgrave 2003). The economic impact of AIDS is noticed in slower economic growth, a distortion in spending, increased inflows of international assistance, and changing demographic structure of the population. There are also fears that a major long-term drop in adult life-expectancy will change the rationale for economic decision-making, contributing to lower savings and investment rates. However, most of these impacts remain theoretically possible rather than empirically observed. Economists in South Africa have developed the most sophisticated models for the impacts of the epidemic, and Nicoli Nattrass in "The Moral Economy of AIDS in South Africa" estimates that it is possible for the South African government to provide universal access to anti-retroviral therapy without overstretching the national budget. AIDS has intersected with drought, unemployment and other sources of stress to create what Alan Whiteside and Alex de Waal have called "new variant famine," characterized by the inability of poor, AIDS-affected households to cope with the demands of securing sufficient food during a time of food crisis.

The social impact of HIV/AIDS is most evident in the continent's orphans crisis. Approximately 12 million children in sub-Saharan Africa are estimated to be orphaned by AIDS. These children are overwhelmingly cared for by relatives including especially grandmothers, but the capacity of the extended family to cope with this burden is stretched very thin and is, in places, collapsing. UNICEF and other international agencies consider a scaled-up response to Africa's orphan crisis a humanitarian priority. Practitioners and welfare specialists are sensitive to the need not to identify and isolate children orphaned by AIDS from other needy and vulnerable children, in part because of fear of stigmatizing them. Therefore, there is a search for effective social policies and programs that will provide necessary assistance and protection for all orphans and vulnerable children.

The political impact of the epidemic has been little studied. There has been much concern that high levels of HIV among soldiers and political leaders could lead to a "hollowing out" or even collapse of essential state structures, and an escalation of conflict. Laurie Garrett of the Council on Foreign Affairs is most publicly associated with this position. However, it is also clear that the epidemic has coincided with the entrenchment of democracy in much of Africa, and that governments and armies have learned to cope with the effects of the epidemic.

Video

 * Video interview with Emily OsterPreventing HIV in Africa: Understanding Sexual Behavior Change

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