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HIV & AIDS in Africa Continent
How many people in Africa are infected with HIV?
How are different countries in Africa affected?
Trends in the epidemic
What is the effect of these levels of infections?
What is the impact of HIV & AIDS on Africa?
HIV prevention in Africa
HIV/AIDS-related care in Africa
What need to be done to make a difference in Africa?
The way forward
Approximately 95 percent of all AIDS orphans in the
world live in sub-Saharan Africa
Sub-Saharan Africa is the region of the world that is most affected
by HIV & AIDS. An estimated 25.4 million people are living with HIV
and approximately 3.1 million new infections occurred in 2004. In
just the past year the epidemic has claimed the lives of an
estimated 2.3 million people in this region. Around 2 million
children under 15 are living with HIV and more than twelve million
children have been orphaned by AIDS.
The extent of the epidemic is only now becoming
clear in many African countries, as increasing numbers of people
with HIV are now becoming ill. In the absence of massively expanded
prevention, treatment and care efforts, the AIDS death toll on the
continent is expected to continue rising before peaking around the
end of the decade. This means that the worst of the epidemic's
impact on these societies will be felt in the course of the next ten
years and beyond. Its social and economic consequences are already
being felt widely not only in health but in education, industry,
agriculture, transport, human resources and the economy in general.
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Large variations exist between individual countries.
In some African countries, the epidemic is still growing despite its
severity. Others face a growing danger of explosive growth. The
sharp rise in HIV prevalence among pregnant women in Cameroon (more
than doubling to over 11% among those aged 20-24 between 1998 and
2000) shows how suddenly the epidemic can surge.
National HIV prevalence rates vary greatly between
countries. In Somalia and Gambia the prevalence is under 2% of the
adult population, whereas in South Africa and Zambia around 20% of
the adult population is infected.
In four southern African countries, the national
adult HIV prevalence rate has risen higher than was thought possible
and now exceeds 24%. These countries are Botswana (37.3%), Lesotho
(28.9%), Swaziland (38.8%) and Zimbabwe (24.6%).
West Africa is relatively less affected by HIV
infection, but the prevalence rates in some countries are creeping
up. In west and central Africa HIV prevalence is estimated to exceed
5% in several countries including Cameroon (6.9%), Central African
Republic (13.5%), Cτte d'Ivoire (7.0%) and Nigeria (5.4%).
Until recently the national prevalence rate has
remained relatively low in Nigeria, the most populous country in
sub-Saharan Africa. The rate has grown slowly from 1.9% in 1993 to
5.4% in 2003. But some states in Nigeria are already experiencing
HIV prevalence rates as high as those now found in Cameroon. Already
around 3.6 million Nigerians are estimated to be living with HIV.
HIV infection in Eastern Africa varies between adult
prevalence rates of 2.7% in Eritrea to 8.8% in Tanzania. In Uganda
the countrywide prevalence among the adult population is 4.1%.
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The prevalence of HIV infections among a country's
adult population - that is, the percentage of the adult population
living with HIV - is a measure of the overall state of the epidemic
in a country. But the prevalence gives a less clear picture of
recent trends in the epidemic, because it does not distinguish
between people who acquired the virus very recently and those who
were infected a decade or more ago.
Regular measurement of HIV prevalence amongst groups
of young people can give an indication of the HIV incidence amongst
them, that is, the number of new infections occurring. The steadily
dropping HIV prevalence over the last few years, among 15-19 year
olds in Uganda, provide a more accurate picture of the trend in the
epidemic in Uganda, and in this instance the effectiveness of
prevention efforts among young people.
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Over and above the personal suffering that
accompanies HIV infection wherever it strikes, HIV in sub-Saharan
Africa threatens to devastate whole communities, rolling back
decades of progress towards a healthier and more prosperous future.
Sub-Saharan Africa faces a triple challenge of
colossal proportions:
bringing health care, support and solidarity to a
growing population of people with HIV-related illness,
reducing the annual toll of new infections by
enabling individuals to protect themselves and others,
coping with the cumulative impact of over 17
million AIDS deaths on orphans and other survivors, on communities,
and on national development.
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In many countries of Sub-Saharan Africa, AIDS is
erasing decades of progress made in extending life expectancy.
Millions of adults are dying young or in early middle age. Average
life expectancy in Sub-Saharan Africa is now 47 years, when it could
have been 62 without AIDS.
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Children orphaned by AIDS in Ethiopia
The toll of HIV/AIDS on households can be very
severe. Many families are losing their income earners and the
families of those that die have to find money to pay for their
funerals. Many of those dying have surviving partners who are
themselves infected and in need of care. They leave behind children
grieving and struggling to survive without a parent's care. HIV/AIDS
strips the family assets further impoverishing the poor. In many
cases, the presence of AIDS means that the household eventually
dissolves, as the parents die and children are sent to relatives for
care and upbringing.
In all affected countries, the HIV/AIDS epidemic
is bringing additional pressure to bear on the health sector. As the
epidemic matures, the demand for care for those living with HIV
rises, as does the toll amongst health workers. Health-care services
face different levels of strain, depending on the number of people
who seek services, the nature of their need, and the capacity to
deliver that care.
How schools and other educational institutions are
able to cope is a major factor in how well societies will eventually
recover from the HIV/AIDS epidemic. A decline in school enrolment is
one of the most visible effects of the HIV/AIDS epidemic on
education in Africa.
HIV/AIDS dramatically affects labour, setting back
economic activity and social progress. The vast majority of people
living with HIV/AIDS in Africa are between the ages of 15 and 49 -
in the prime of their working lives. Employers, schools, factories
and hospitals have to train other staff to replace those at the
workplace who become too ill to work.
Through its impacts on the labour force,
households and enterprises, HIV/AIDS can act as a significant brake
on economic growth and development. HIV/AIDS is already having a
major affect on Africa's economic development, and in turn, this
affects Africa's ability to cope with the epidemic.
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A continuing rise in the number of HIV infected
people is not inevitable. There is growing evidence that prevention
efforts can be effective, and this includes initiatives in some of
the most heavily affected countries.
In some countries there has been early and sustained
prevention efforts. For example in Senegal there was effective
prevention, which is still reflected in the relatively low adult
prevalence rate of 0.8%. Also, Uganda shows that a widespread
epidemic can be brought under control.
However, much of the progress is still occurring in
localised settings. One new study in Zambia has shown success in
prevention efforts. The study reported that urban men and women are
less sexually active, that fewer had multiple partners and that
condoms were used more consistently. This is in line with findings
that HIV prevalence has declined significantly among 15-29 year-old
urban women (down to 24.1% in 1999 from 28.3% in 1996), as well as
amongst rural women aged 15-24 (down from 16.1% to 12.2% in the same
period). Although these rates are still unacceptably high, this drop
has prompted a hope that, if Zambia continues this response, it
could become the second African country (after Uganda) to reverse a
devastating epidemic. However, many hurdles still separate the
country from such a milestone. For example, condom use amongst rural
men remains very low (reported as 15% in 2001 compared to 68% for
urban men when they last had sex with a casual or paid partner).
A mural in Durban, South Africa designed to
increase awareness about HIV/AIDS in Africa
In South Africa, for pregnant women under 20, HIV
prevalence rates fell to 15.4% in 2001 (down from 21% in 1998). This
suggests that awareness campaigns and prevention programmes are now
starting to work. But a major challenge now is to sustain and build
on such uncertain success, not least because HIV infection levels
continue to rise among older pregnant women.
In Cτte d'Ivoire the prevalence amongst female sex
workers fell from 89% to 32% in the period 1991 to 1998. Partly
explaining this positive development is the fact that the number of
workers who said they had used condoms in their most recent working
day, increased from 20% in 1992 to 78% in 1998. Sustained prevention
efforts, built around local initiatives, have been central to this
shift.
Overall a massive expansion in prevention efforts is
needed, and although there is not one proven way to prevent new
infections, the major components of a successful prevention
programme are now known.
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It was reported in 2001, that the overall provision
of condoms to sub-Saharan Africa is only 4.6 per man per year. So
another 1.9 billion condoms need to be provided if all countries are
to have the same amount as the highest six countries in Africa.
Botswana, South Africa, Zimbabwe, Togo, Congo and Kenya are supplied
with about 17 condoms per man aged 15 to 59 years. It would cost an
estimated $47.5 million (£34m) a year to fill the 1.9 billion condom
gap excluding service delivery costs and production. Relative to the
enormity of the HIV/AIDS pandemic in Africa, providing condoms is
cheap and cost effective.
However, condoms are not without their drawbacks,
especially in the context of a stable partnership where pregnancy is
desired, or where it may be difficult for one partner to suddenly
suggest using condoms. For many individuals and couples in Africa,
where HIV prevalence rates are high, finding out their infection
status could expand their range of HIV prevention options.
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The provision of voluntary HIV counselling and
testing (VCT) is an important part of any national prevention
program. It is widely recognised that knowledge of their HIV
infection can help a person to stay healthy for longer as well as
preventing new infections. VCT also provides benefit for those who
test negative. For those people who learn that they are negative, it
may result in a change of behaviour. The provision of VCT has become
easier, cheaper and more effective as a result of the availability
of rapid HIV testing and therefore could and indeed needs to be made
much more widely available in many sub-Saharan African countries.
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A tiny fraction of the millions of Africans in need
of antiretroviral treatment are receiving it. Many millions are not
even receiving treatment for opportunistic infections. These figures
reflect the world's continuing failure, despite the progress of
recent years, to mount a response that matches the scale and
severity of the global HIV/AIDS epidemic.
Treatment and care for HIV/AIDS consists of a number of different
elements apart from antiretroviral drugs. These include voluntary
counselling and testing (VCT), food and management of nutritional
effects, follow-up counselling, protection from stigma and
discrimination, treatment of STIs, and the prevention and treatment
of opportunistic infections (OIs). All the things that need to be
provided apart from antiretrovirals (ARVs) can, and indeed should be
provided before ARVs are available. This does not exclude the
provision of ARVs when they are available. Indeed, when
antiretrovirals do become available the provision of antiretroviral
therapy should be easier and quicker to implement because many of
the things apart from drugs that are needed for successful ART are
already in place.
The World Health Organisation (WHO) in its guidance
for the use of ARVs in resource limited countries, has stated that
for the successful use of antiretroviral drugs, there needs to be
access to specific services and facilities, which include:
HIV counselling and testing and follow-up
counselling services
Capacity to appropriately manage HIV related
illness and opportunistic infections
A continuous supply of medicines for the treatment
of opportunistic infections and other HIV related illnesses.
Little emphasis is being placed by many countries on
the provision of these services, despite the fact that many
countries are discussing the provision of ARVS for those living with
HIV/AIDS.
Botswana has become the first African country to aim
to provide antiretroviral therapy to its citizens on a national
scale. It is believed by many that if any country in Africa is going
to succeed in implementing such a comprehensive HIV/AIDS care and
treatment programme, then it is Botswana. But its ambitious
antiretroviral drug programme, MASA, has not yet been as successful
as first hoped. Of the 300,000 HIV-infected people, 110,000 were
estimated to meet the criteria to qualify for treatment. The
government aimed to enrol 19,000 people in the first year, but only
3,500 were actually enrolled. By June 2004, this had risen to around
18,000.
This disappointing outcome has highlighted a number
of issues related to providing antiretroviral therapy. These include
the education and training of health care workers and the strength
of the infrastructure. If other countries with fewer resources by
head of population are to follow the example of Botswana, there are
still many lessons to be learned. A considerable emphasis needs to
be placed not only on the availability of antiretroviral drugs, but
the availability of health care professionals and an adequate
infrastructure.
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A mural in Durban, designed to increase awareness
about HIV/AIDS in Africa
Additional money is needed to combat the epidemic in
Africa. It was estimated in 2000, that US$ 1.5 billion a year would
make it possible to achieve higher levels of implementation of
successful prevention programmes for the whole of Sub Saharan
Africa. These prevention programmes would cover sexual,
mother-to-child and blood transfusion related HIV transmission. In
the area of care for orphans and for people living with HIV or AIDS,
costs depend very much on what kind of care is being provided. It is
estimated that, with at least US$ 1.5 billion a year, countries in
sub-Saharan Africa could provide some people with symptom and pain
relief (palliative care), could treat and prevent opportunistic
infections and provide care for orphans. Making a start on providing
antiretroviral therapy would add several billion dollars annually to
the bill.
In April 2001, the U.N. Secretary General, Kofi
Annan, called for action what is now known as the Global Fund to
fight AIDS, Tuberculosis and Malaria. When the Global Fund was
started, it was hoped that it would be an effective mechanism to
attract and manage resources to deal with international health
issues. In 2001, the UN Secretary General quoted an estimate of
$7-10 billion being required annually to tackle the HIV/AIDS
epidemic in low and middle income countries worldwide.
In its first year, in two rounds of programme
proposals and approvals, the Global Fund has awarded $1.5 billion,
of which Africa is being given 62%. Of the overall total 56% is
being given for HIV/AIDS related purposes. The Global Fund has
unfortunately not raised as much money as it was first hoped. Also,
the administrative processing of the funds has been slow and has
delaying the actual distribution of the money. By the beginning of
June 2003 only 9 African countries had actually received money from
the fund for HIV/AIDS, and the total distributed for projects in
Africa was only $5,8 million.
But more than money is needed to provide HIV/AIDS
related prevention, care and treatment. In order to implement
prevention, care and treatment programmes, a country's health,
education, communications and other infrastructures have to be well
enough developed in order to deliver these interventions. In some
countries, these systems are already under strain and they are
likely to crumble even further under the weight of AIDS. Money can
also only be used wisely if there are sufficient people available.
And the shortage of trained adults is already acute in some
countries of sub-Saharan Africa. If antiretroviral drug programmes
are to be implemented, the health infrastructure to do this must be
in place and must be strong enough to support the programme.
African countries also, in many instances, need more
commitment from their governments. There are promising signs that
some governments are starting to respond and becoming more and more
involved.
HIV-related stigma and discrimination remains an
enormous barrier to effectively fighting the HIV and AIDS epidemic
in Africa. Fear of discrimination often prevents people from getting
tested, seeking treatment for AIDS or from admitting their HIV
status publicly. More HIV/AIDS related education is needed in Africa
since no policy or law alone can combat HIV/AIDS related
discrimination. The fear and prejudice that lies at the core of the
HIV/AIDS discrimination needs to be tackled at both community and
national levels.
Also, in many parts of Sub-Saharan Africa, as
elsewhere in the world, the inequality between men and women, and
economic deprivation helps to drive the epidemic. Women and girls
are commonly discriminated against in terms of access to education,
employment, credit, health care, land and inheritance. In countries
with generalised epidemics in Africa, up to 80% of women aged 15-24
have been shown to lack sufficient knowledge about HIV/AIDS. Women
and girls may need to receive specific attention in any HIV
prevention program.
These are some of the serious challenges that
African countries and their partners in the global community will
have to face if they are to make a real difference to the epidemic.
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To tackle HIV/AIDS in Africa is not an easy task.
Many efforts are and will be needed. The long-term planning to slow
the epidemic and reduce its impact needs be highlighted. One of the
best ways to tackle HIV/AIDS is prevention. Those prevention efforts
that work in Africa and individual countries need to be identified
and sustained. This also means enabling the more-than 90% of
Africans to protect themselves against infection. The other massive
challenge is that of ensuring that the estimated 9% of African
adults who are HIV-positive get the treatment and care they need.
More resources are needed in Africa for HIV/AIDS
including money. However, if there are no resources to be used,
innovative solutions need to be developed at lower cost. These
efforts may be small but they will still play a role before
sufficient resources are in place. Innovative and culturally
specific approaches are needed to deal with any aspect of HIV/AIDS.
They may not only be cheaper but more suitable for the people that
they engage.
It is also likely to be many years until ARVs are
widely available in Africa. Therefore, it is important everything
that can be done and should be done to provide care and support for
people living with HIV/AIDS before the arrival of antiretroviral
drugs. For example, many of the common HIV-related opportunistic
infections are fairly easy to prevent and treat. The prevention and
treatment of opportunistic infections can result in significant
gains in life expectancy and quality of life among people living
with HIV. It is vitally important that all aspects and means of
prevention, treatment and care are considered and used in Africa.
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