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HIV/AIDS is a major public health concern and cause of death in Africa. Although Africa is inhabited by just over 14.7% of the world's population, it is estimated to have more than 67% of people living with HIV and 75% of all AIDS deaths in 2007. [1]

Contents

Overview

World region Adult HIV prevalence
(ages 15–49)
Total HIV
cases
AIDS deaths
in 2005
Sub-Saharan Africa 6.1% 24.5m 2.0m
Worldwide 1.0% 38.6m 2.8m
North America 0.55% 1.3m 27,000
Western Europe 0.3% 5.8m 12,000
Regional comparisons of HIV in 2005 (Source: UNAIDS, 2006 Report on the global AIDS epidemic)
Changes in life expectancy in several African countries. Botswana has been particularly badly hit [1], while public education projects campaigns have had a positive effect in Uganda [2]. (Source: World Bank World Development Indicators, 2004).

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.

Without the kind of nutrition, health care and medicines (such as antiretrovirals) that are available in developed countries, large numbers of people in Africa will develop full-blown AIDS. They will not only be unable to work, but will also require significant medical care. This will likely cause a collapse of economies and societies.

In an article titled "Death Stalks A Continent," Johanna McGeary attempts to describe the severity of the issue. “Society's fittest, not its frailest, are the ones who die--adults spirited away, leaving the old and the children behind. You cannot define risk groups: everyone who is sexually active is at risk. Babies too, [are] unwittingly infected by mothers. Barely a single family remains untouched. Most do not know how or when they caught the virus, many never know they have it, many who do know don't tell anyone as they lie dying.” [2]

History

Although many governments in sub-Saharan Africa denied that there was a problem for years, they have now begun to work toward solutions.

Health spending in Africa has never been adequate, either before or after independence. 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 huge challenges. what

Causes

Several factors contribute to the spread of HIV. For one, a stigma is attached to admitting to HIV infection and to using condoms. As well, many deny that HIV causes AIDS. Thabo Mbeki, former President of South Africa, and Robert Mugabe, current President of Zimbabwe, have both suggested AIDS stems from poverty rather than HIV infection. And finally, many myths are attached to the use of condoms, such as the ideas that a conspiracy wants to limit the growth of the African population and that condoms stifle the traditional power of the man in his community.

Lack of money is an obvious challenge, although a great deal of aid is distributed throughout developing countries with high HIV/AIDS rates. Response to the epidemic is also hampered by lack of infrastructure, corruption within both donor agencies and government agencies, foreign donors not coordinating with local government and misguided resources.

There may be elements in general African culture that discourage discussion and the practice of prophylaxis: “Even when a woman wants to protect herself, she usually can't: it is not uncommon for men to beat partners who refuse intercourse or request a condom." [2]

Measuring the epidemic

Prevalence measures include everyone living with HIV and AIDS, and present a delayed representation of the epidemic by aggregating the HIV infections of many years. Incidence, in contrast, measures the number of new infections, usually over the previous year. There is no practical, reliable way to assess incidence in sub-Saharan Africa. Prevalence in 15–24 year old pregnant women attending antenatal clinics is sometimes used as an approximation. The test done to measure prevalence is a serosurvey in which blood is tested for the presence of HIV.

Health units that conduct serosurveys rarely operate in remote rural communities and the data collected also does not measure people who seek alternate healthcare. And extrapolating national data from antenatal surveys relies on assumptions which may not hold across all regions and at different stages in an epidemic.

Recent national population or household-based surveys, collecting data from both sexes, pregnant and non-pregnant women and rural and urban areas, have adjusted the recorded national prevalence levels for several countries in Africa and elsewhere. These too, are not perfect: People may not participate in household surveys because they fear they may be HIV positive and do not want to know their test results. Household surveys also exclude migrant labourers, who are a high risk group.

Thus, there may be significant disparities between official figures and actual HIV prevalence in some countries.

A minority of scientists claim that as many as 40% of HIV infections in African adults may be caused by unsafe medical practices rather than by sexual activity.[3] The World Health Organization states that about 2.5% of AIDS infections in sub-Saharan Africa are caused by unsafe medical injection practices and the "overwhelming majority" by unprotected sex.[4]

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 antiretroviral 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 ($10,000 to $15,000 USD per person per year (pppy) in the West for patent drugs and approximately $800 USD pppy in some African countries for generic drugs), only a few of the 6 million people in developing countries who need ARV treatment have access to medication. Nevertheless, access to ARV therapy has increased more than eightfold since the end of 2003, with about 810,000 people (13.5 per cent of the 6 million in need) on the treatment.

ARVs play a central role in prevention as well. When treatments are known to be available, people are more likely to come forward for testing and well as more likely to adopt lower risk behaviours.[citation needed] ARVs also reduce the amount of HIV in the blood, thus reducing the risk of further transmission.

Patients who start HIV treatment generally have to continue taking medications for the rest of their lives. In areas where drug therapy is expensive, some people must interrupt their treatment. The key factor in the expense of ARVs is their patent status, which allows drug companies to recoup research costs and turn a profit, enabling the development of new drugs. International aid organisations such as VSO, Oxfam and Médecins Sans Frontières have questioned whether the revenues generated by ARVs really tally with research costs.

Generic copies of patented ARV drugs are supplied by drug manufacturers in India, South Africa, Brazil, Thailand, and the People's Republic of China. Because fees are not paid to the patent holders, the drugs can be distributed at low prices in developing countries. Generic production competition and 'price offers' (voluntary donations by companies) have forced patent holders to reduce their prices.

ARV patients need regular testing of viral load and CD4 cell count. This requires expensive laboratory equipment and good healthcare logistics. These costs drive the price of generic ARV therapy in African countries up from under $140 USD per person per year (pppy) for the drugs alone to approximately $800 USD pppy when done according to Western standards.[5]

For many Africans, living below the poverty threshold of a $2 USD / day, free (government or NGO-funded) treatment remains the only option.

The World Health Organisation's 3 by 5 initiative aimed 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[6], is focusing two thirds of its resources on AIDS in Africa. Starting in 2004, expenditures rose from $2.3B worldwide to $3.3B in 2006. A funding level of $4B was requested for 2007.[7]

The Drug Resources Enhancement against AIDS and Malnutrition (DREAM) initiative promoted by the Community of Sant'Egidio has given access to free ARV treatment with generic drugs to the poor on a large scale. So far, 5,000 people are receiving ARV treatment, especially in Mozambique, but the program is also being built up in Malawi, Guinea, Tanzania and other countries. The program includes regular blood testing according to European standards. It is linked with nutrition and sanitation programs run by volunteers. The compliance rate is 94%.

Impacts of the AIDS epidemic

In the twenty-six African nations with the highest prevalence, average life expectancy is 48.3 years—6.5 years less than it would be without the disease.[citation needed] For the eleven countries in Africa with prevalence rates above 13%, life expectancy is 47.7 years—11.0 years less than would be expected without HIV/AIDS.

Africa's HIV/AIDS epidemic has had important effects on society, economics and politics in the continent.[8] 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. Nicoli Nattrass, in his work "The Moral Economy of AIDS in South Africa," estimates that it is possible for the South African government to provide universal access to antiretroviral therapy without overstretching the national budget. [9] 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.[10][8]

In all of the severely affected countries, the epidemic has left behind many orphans, who are either cared for by extended family members, or must live in orphanages or on the street. Of the ones who are left unattended, these orphans must find ways to fend for themselves. While struggling to fend for themselves, they must also try and find ways to take care of sick relatives and grandparents who are also suffering from AIDS. In turn, this not only deprives children of their very livelihood but also deprives them of many educational opportunities, which have a profound effect on their self confidence. UNAIDS, WHO and UNDP have already documented decreasing life expectancies and lowering of gross national product in many African countries with prevalence rates of 10% or more.[citation needed]

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 effect of the HIV/AIDS crisis on the education system in Sub-Saharan Africa also demonstrates the epidemic's negative social impact. The Basic Education Coalition underlines the importance of investing in education to “...turn back the AIDS epidemic... [W]ithout education, AIDS will continue its rampant speed. With AIDS out of control, education will be out of reach”[11]. Currently preventing Education for All, is the alienation students stigmatized by HIV/AIDS feel within their schooling systems. This is especially true in orphans, where after losing both parents to HIV/AIDS, 22% of children find themselves excluded from the schooling system, and indirectly forced to live on the streets[12]. In Tanzania, more than 3000 children have been lured away from their rural homes to Dodma in hopes of finding work[12]. Due to low teacher-to-student ratios, anywhere from 1:50 to 1:120[13], schools are often forced to illegally turn students away. In Uganda, it's estimated that 1/3 of students have at some point been sent home, regarding unpaid tuition fees, or simply the fact that they lack the required school supplies or can not afford to buy the school uniform[14]. The additional stresses effectuated by HIV/AIDS in a child's life (strenuous household labor, nursing one's parents, or being the family's financial provider) significantly contribute to the resulting behaviors (lack of concentration in class, frequent incompletion of homework, emotional outbursts of aggression and crying, or withdrawal from fellow students) causing 32% of urban and 68% of rural HIV/AIDS orphaned children to be not currently enrolled in their local Kagera, Tanzania schooling program[12]. However, it is becoming increasingly common for an orphaned student's absenteeism rate to be lower than that of a student not directly impacted by the epidemic[14]. The “normalcy” that school instills by being a constant in the child's life, along with a free daily nutritious meal, a program mandatory only in Botswana, draws the child to school, even if the learning environment is not always friendly and welcoming.[14]

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.

Regional analysis

National infection rates for HIV. No data is available for the areas shown in white.

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
Tanzania 8.8% 1,500,000 160,000
Kenya 6.7% 1,100,000 150,000
Congo 4.9% 80,000 9,700
Ethiopia 4.4%* 1,400,000 120,000
Congo DR 4.2% 1,000,000 100,000
Uganda 4.1% 450,000 78,000
Eritrea 2.7% 55,000 6,300
HIV in East-central Africa (Source: UNAIDS)

* A 2005 survey by the Central Statistical Agency of Ethiopia showed that Adult (ages 15–49) prevalence was only 1.4%, with prevalence among women at 1.9% and among men at 0.9%.[15]

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 dropped 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 strategy' of HIV prevention, which is a combination of abstinence, sexual fidelity to one's partner, and condom use. 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, Niger and Cameroon.

Country Adult prevalence Total HIV Deaths 2005
Cameroon 15.9% 100,000 82,000
Côte d'Ivoire 7.1% 750,000 65,000
Liberia 5.9% 100,000 72,000
Guinea-Bissau 3.8% 32,000 2,700
Togo 3.2% 110,000 9,100
Nigeria 2.5% 3,600,000 310,000
Gambia 2.4% 20,000 1,300
Ghana 2.3% 320,000 29,000
Burkina Faso 2.0% 150,000 12,000
Benin 1.8% 87,000 9,600
Mali 1.7% 130,000 11,000
Sierra Leone 1.6% 48,000 4,600
Guinea 1.5% 85,000 7,100
Niger 1.1% 79,000 7,600
Senegal 0.8% 44,000 3,500
Mauritania 0.7% 12,000 <1,000

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 Côte 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 number of people living with HIV 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. Of the eleven southern African countries - Angola, Namibia, Zambia, Zimbabwe, Botswana, Malawi, Mozambique, South Africa, Lesotho, Swaziland, Madagascar- at least six estimate an infection rate of over 20%. Angola presents the lowest infection rate of less than 5%. This is not the result of a successful national response to the threat of AIDS but of the long-running Angolan Civil War (1975-2002). In most African communities, as in other communities around the world, people do not limit their sexual activities to one lifetime partner. Aside from polygynous relationships, which can be quite prevalent in parts of Africa, there are also widespread practices of sexual networking that involve multiple overlapping or concurrent sexual partners.[16] Men’s sexual networks, in particular, tend to be quite extensive, a fact that is tacitly accepted by many communities. Cultural or social norms often indicate that while women must remain faithful men are able and even expected to philander irrespective of their marital status. Along with the occurrence of multiple sexual partners, unemployment and population displacements that result from drought and conflict contribute to the spread of HIV/AIDS.

There are few indicators of country wide declines in infection. 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.

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.

As existential threat in Swaziland

The HIV infection rate in Swaziland is unprecedented and the highest in the world at 26.1% of all adults,[17] and at over 50% of adults in their 20s.[18] This has stopped possible economic and social progress, and is at a point where it endangers the existence of its society as a whole. The United Nations Development Program has written that if the expansion continues unabated, the "longer term existence of Swaziland as a country will be seriously threatened". [18]

Swaziland's HIV epidemic has reduced life expectancy to only 32 years as of 2009, which is the lowest in the world by six years. The next highest is 38 years in Angola, also from HIV. From another perspective, HIV/AIDS currently causes 61% of all deaths in the country. With an unmatched crude death rate of 30 per 1,000 people per year, about 2% of Swaziland's total population dies of HIV/AIDS every year.[19]

AIDS and tuberculosis

Much of the deadliness of the epidemic in Sub-Saharan Africa has to do with a deadly synergy between HIV and tuberculosis,[20] though this synergy is by no means limited to Africa. In fact, tuberculosis is the world's greatest infectious killer of women of reproductive age and the leading cause of death among people with HIV/AIDS.[21]

Because HIV has destroyed the immune systems of at least a quarter of the population in some areas, far more people are not only developing tuberculosis but spreading it to otherwise healthy neighbours.[20]

See also

References

  1. ^ UNAIDS. "2008 report on the global AIDS epidemic". http://www.unaids.org/en/KnowledgeCentre/HIVData/GlobalReport/2008/2008_Global_report.asp. Retrieved March 1, 2010. 
  2. ^ a b McGeary, Johanna (12 Feb 2001). "Death stalks a continent". Time Magazine. http://www.time.com/time/magazine/article/0,9171,999190-12,00.html. 
  3. ^ http://www.africaaction.org/docs02/hiv0210t.htm
  4. ^ http://www.who.int/mediacentre/news/statements/2003/statement5/en/
  5. ^ This is the cost pppy of the DREAM program. Source: IPS News. "A Church Group Makes Strides in Supplying ARVs"
  6. ^ US State Dept: About PEPFAR
  7. ^ PEPFAR: Making a Difference: Funding (June 2006)
  8. ^ a b Whiteside, Alan; Barnett, Tony (2003). AIDS in the 21st Century: Disease and Globalization. MacMillan Palgrave. ISBN 1-4039-0006-X. 
  9. ^ Nattrass, Nicoli (2003). The Moral Economy of AIDS in South Africa. Cambridge University Press. ISBN 0-521-54864-0. 
  10. ^ de Waal, Alex (2006). AIDS and Power: Why there is no political crisis--yet. Zed Books. ISBN 1-84277-707-6. 
  11. ^ EFA Global Monitoring Report 2008
  12. ^ a b c Tungaraza, Frida. Sutherland, Maragaret. (2005). Capturing the minds of a lost and lonely generation. International Journal of Technology and Design Education, 187-198.
  13. ^ Robson, Sue., Sylvester, Kanyanta B. (2007). Orphaned and vulnerable children in Zambia: The impact of the HIV/AIDS epidemic on basic education for children at risk. Educational Research, 259-272.
  14. ^ a b c Bennell, Paul. (2005). The impact of the AIDS epidemic on the schooling of orphans and other directly affected children in Sub-Saharan Africa. Journal of Developmental Studies, 467-488.
  15. ^ "HIV/AIDS Data from the 2005 Ethiopia Demographic and Health Survey". United nations Children's fund (UNICEF). http://www.childinfo.org/mics/mics3/docs/dissemination/DHS_Ethiopia_%20HIV_factsheet.pdf. Retrieved 2006-06-21. 
  16. ^ Poku, N. K. and Whiteside, A. (2004) 'The Poltical Economy of AIDS in Africa', 235.
  17. ^ October 2008 Kaiser Family Foundation HIV/AIDS Policy Fact Sheet
  18. ^ a b Country programme outline for Swaziland, 2006-2010. United Nations Development Program. http://www.undp.org.sz/index.php?option=com_docman&task=doc_download&gid=19&Itemid=67. Accessed November 22, 2009
  19. ^ Swaziland, Mortality Country Fact Sheet 2006. WHO. http://www.who.int/whosis/mort/profiles/mort_afro_swz_swaziland.pdf. Accessed November 22, 2009
  20. ^ a b 'Dual epidemic' threatens Africa, BBC News
  21. ^ Stop TB Partnership. London tuberculosis rates now at Third World proportions. PR Newswire Europe Ltd. 4 December 2002. Retrieved on 3 October 2006.
  • Encyclopedia of AIDS: A Social, Political, Cultural, and Scientific Record of the HIV Epidemic, Raymond A. Smith (ed), Penguin Books. ISBN 0-14-051486-4.
  • John Iliffe, "The African AIDS Epidemic: A History," James Currey, 2006, ISBN 0-85255-890-2
  • Pieter Fourie, "The Political Management of HIV and AIDS in South Africa: One burden too many?" Palgrave Macmillan, 2006, ISBN 0-230-00667-1

Further reading








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