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. Much of the deadliness of the epidemic in Sub-Saharan Africa has to do with a deadly synergy between HIV and Tuberculosis. 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.
|World region|| Adult HIV prevalence|
| Total HIV|
| AIDS deaths|
|Regional comparisons of HIV in 2005 (Source: UNAIDS, 2006 Report on the global AIDS epidemic)|
In Southern Africa, several factors contribute to the spread of the HIV virus. For one, a stigma is attached to admitting to HIV infection and to using condoms. For another, many deny that the HIV virus causes AIDS: Thabo Mbeki and Robert Mugabe 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.
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%, life expectancy is 47.7 years—11.0 years less than would be expected without HIV/AIDS.
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.
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.
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 anti-retrovirals) 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 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 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.
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. The World Health Organization states that 2.5% of infections are caused by unsafe medical injection practices and all the others by unprotected sex.
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.
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 ($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. ARVs also reduce the amount of the HIV virus 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 when they were unable to afford medication. Drug-resistant strains of HIV have been observed in such areas.
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 pppy for the drugs alone to approximately $800 USD pppy when done according to Western standards.
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, 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 was requested for 2007.
The DREAM ("Drug Resources Enhancement against AIDS and Malnutrition", formerly "Drug Resource Enhancement against AIDS in Mozambique") initiative promoted by the Community of Sant'Egidio has given 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 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 per cent.
| 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%.
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.
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%.
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 the long-running Angolan Civil War (1975-2002).
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.
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.