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Africa
In the early 1990s, no-one really saw quite how massive a problem HIV could become in sub-Saharan Africa. While some countries, notably Uganda and Senegal, and more recently Zambia, have been credited with impressive achievements in limiting and reversing the spread of HIV, other countries have seen rises to levels that were previously thought extremely unlikely.
Current estimates from UNAIDS are that 29.4 million people are living with HIV or AIDS in sub-Saharan Africa. 3.5 million people were newly infected with HIV during 2002 in this region, and 2.4 million adults and children died during the same period, many of them with diseases such as tuberculosis in addition to HIV.
An estimated ten million young people (aged 15-24) and almost 3 million children under 15 are living with HIV .
The adult HIV prevalence rate in this region is 8.8%.
It is the interaction between HIV, tuberculosis, parasitic diseases and sexually transmitted infections, in the context of widespread poverty and inadequate healthcare, that has led to the problems now confronting many African countries.
As the numbers of people living with HIV in any population rises, and sexual risk taking remains constant, the likelihood of acquiring HIV becomes greater, simply because the pool of people with HIV is larger and the chance of meeting an HIV-positive partner is greater.
There are sixteen countries in which more than one-tenth of the adult population aged 15-49 is HIV-positive. In seven, more than one adult in five now has HIV.
HIV prevalence is estimated to exceed 5% in eight countries in west and central Africa, including Cameroon (11.8%), Central African Republic (12.9%), Côte d’Ivoire (9.7%) and Nigeria (5.8%). 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.
Rampant epidemics are under way in southern Africa where, in four countries, national adult HIV prevalence has risen higher than thought possible, exceeding 30%: Botswana (38.8%), Lesotho (31%), Swaziland (33.4%) and Zimbabwe (33.7%). The food crises faced in the latter three countries are linked to the toll (on the lives of young, productive adults, particularly) of their longstanding HIV/AIDS epidemic.
Across the whole region, there are frighteningly high prevalence rates among teenage girls and women under 25, especially in rural areas. In seven of eleven studies conducted across sub-Saharan Africa, more than one in five women under 25 were found to be HIV-positive. Rates of infection in young African women are far higher than those found in young men. The same eleven studies found the rate of HIV infection among teenage girls to be 5 times higher than in teenage boys. Among women under 25 the rate was 3 times higher than in men under 25.
Young women are much more likely to have sex with or be coerced into sex by older men with more sexual experience. It is these men who place young women at a higher risk of HIV infection. Women are less likely to be able to negotiate safer sex because of the power imbalance between the genders. Additionally, women are more likely than men to become infected during vaginal intercourse.
More positively, there is evidence from a number of countries that if children - and especially girls - can delay the age at which they first have sex, they are much less likely to become HIV-positive.
The worst of the epidemic's impact in sub-Saharan Africa remains to be felt, and will probably be felt in the course of the next decade and beyond.
Nineteen African countries have set up national HIV/AIDS councils or commissions at senior levels of government, and local responses are growing in number. Across the region, 40 countries have completed national strategic AIDS plans—evidence of their determination to reach the targets outlined in the UN Declaration of Commitment on HIV/AIDS. Also encouraging is the active involvement of regional bodies, such as the Economic Commission for Africa, the Africa Union, and the Southern African Development Community, in tackling HIV/AIDS as a development issue.
The vast majority of Africans—more than 90%—have not acquired HIV. Enabling them to remain HIV-free is a massive challenge, with the protection of young people a priority.
According to December 2002 estimates from UNAIDS, HIV has hit the following nations in sub-Saharan Africa hardest:
South Africa
With 4.2 million people living with HIV/AIDS, South Africa has the largest number of HIV-positive people in the world. Current estimates suggest that 19.9% of the adult population are HIV-positive.
In South Africa, for pregnant women under 20, HIV prevalence rates fell to 15.4% in 2001 (down from 21% in 1998). This, along with the drop in syphilis rates among pregnant women attending antenatal clinics (down to 2.8% in 2001, from 11.2% four years earlier) suggests that awareness campaigns and prevention programmes are bearing fruit. A major challenge now is to sustain and build on such tentative success, not least because HIV infection levels continue to rise among older pregnant women.
Ethiopia
There are an estimated 3 million people living with HIV/AIDS in Ethiopia. It is estimated that just over 10% of the adult population are infected.
A decline in HIV prevalence has been detected among young inner-city women in Addis Ababa in Ethiopia.; infection levels among women aged 15–24 attending antenatal clinics dropped from 24.2% in 1995 to 15.1% in 2001 (however, similar trends were not evident in outlying areas of the city, nor is there yet evidence of them occurring elsewhere in the country).
Nigeria
There are an estimated 2.7 million people living with HIV/AIDS. This equals around 5% of the adult population.
Kenya
There are an estimated 2.1 million people living with HIV/AIDS. This is around 14% of the adult population.
Zimbabwe
1.5 million people living with HIV/AIDS. This is 25% of the adult population.
Tanzania
1.3 million people estimated to be living with HIV/AIDS or 8% of the adult population.
Botswana
290,000 people living with HIV/AIDS, or almost 36% of the adult population.
Botswana is the first African country to adopt a policy to ultimately make antiretrovirals available to all citizens who need them. However, comparatively few people (approximately 2000) are currently benefiting from this commitment.
Swaziland
130,000 people living with HIV/AIDS or just over 25% of the adult population.
Lesotho
240,000 people living with HIV/AIDS, or almost 24% of the adult population.
Namibia
160,000 people living with HIV/AIDS, or almost 20% of the adult population.
Zambia
870,000 people living with HIV/AIDS, or almost 20% of the adult population.
South Africa - Breaking the Silence
In July 2000 the 13th International AIDS conference was held in Durban, South Africa. This was the first time that the conference was ever held in a developing nation. The theme of the conference was to 'break the silence' around HIV and AIDS.
During the period 1994 to 2000 there was a tremendous growth in the number of HIV infections in South Africa. The HIV epidemic in South Africa developed later than the epidemics afflicting other sub-Saharan African nations. South Africa's responses to HIV were tempered by the tremendous political, legislative and delivery challenges faced by the country's first democratically elected government in 1994. Advances in strategic policy development have been slow, whilst the rise in new infections has been rapid.
An insurmountable problem?
With prevalence rates higher than 20% of the population, it is hard to imagine a way forward for many of these resource poor countries. However, the most inspirational example of a country that, through its own determination, has managed to turn the HIV epidemic round is also to be found in this region.
In the early 1990s the estimated adult prevalence rate in Uganda was almost 14%, after nearly a decade of prevention work, the rate has now declined to around 5%. The government, under the leadership of President Yoweri Museveni was quick to act upon the realisation that HIV represented a grave threat to national development and adopted a strong response to the epidemic. They enrolled support from religious and other community organisations in order to reach as large a proportion of the population as possible and to communicate in the most effective and meaningful ways.
There is early evidence that the epidemic in Zambia may be following a similar course, as HIV rates among pregnant 15-19 year olds in the capital Lusaka have almost halved from around 28% to near 14% over the past six years.
Surveillance systems in Senegal appear to show that HIV infection rates in Senegal have stabilised at a relatively low rate, with only 1.77% of the adult population (79,000 adults and children) estimated to be HIV-positive. Traditionally, rates of male circumcision are high and alcohol use is low.
AIDS Orphans
When one considers that half of all people who become HIV-positive do so before they reach their 25th birthday and progress to AIDS and death by the time that they reach 35, it is hardly surprising that a generation of children are left parentless, to be brought up by their grandparents or often among child headed households.
Current estimates suggest that the cumulative number of children who have lost their mother or both parents to AIDS before the age of 15 since the epidemic began stands at 12,100 000 for sub-Saharan Africa alone. By 1997, in many African countries, the propotion of children who had lost one or both parents to AIDS had reached between 7 and 11%. Pre-AIDS estimates of orphans in developing nations pitched the rate at 2%.
Across Africa, many governments have rallied support in order to set up mechanisms to care for the children left behind. As early as 1986, Janet Museveni, wife of the Ugandan President Yoweri Museveni set up UWESO, the Uganda Women's Effort to Save Orphans. It was intended to assist orphans in the resettlement camps used after the civil war and eventually return the children to their extended families. The organisation now has 35 branches nationwide and funds education and training for the children as well as helping the guardians of the children- usually female relatives of the children -to set up small businesses.
The impact on education
It has been suggested that children finish school when their parents die, regardless of their age. Large household surveys are beginning to validate these claims. Certainly, it would appear that when both parents die the likelihood of a child continuing in education diminishes even further.
It is not uncommon for dying parents to marry their daughters off, partly to ensure that she is cared for after their death. In one study of orphans in Kenya, 41% of girls left school to get married and 28% because they became pregnant.
HIV has been shown to take up precious resources, and even when a child has two parents who are alive, the cost of care for them should they become sick, can have a direct effect upon the amount of money that is available for education.
In the Central African Republic, a recent study has shown that as many as 107 schools have closed due to staff shortage, and only 66 remain open. Over 85% of deaths among teachers between 1996 and 1998 were due to AIDS. As many teachers died between 1996 and 1998 as retired.
In Zambia, around 2000 new teachers are trained each year. During the first ten months of 1998, the country lost 1300 teachers to AIDS. It has been suggested that HIV has further exacerbated the gap between educational achievement in rural areas and the cities. Many teachers are disinclined to work in rural areas, largely because of a desire to be close to some kind of health care.
The impact on the economy
HIV has the potential to restrict economic growth through;
- reducing the number of workers available and increasing production costs which in turn, could reduce international competitiveness
- decreasing personal, corporate and public sector savings as a result of HIV-related expenses
- reducing the amount any government can invest in infrastructure, as spending on HIV increases.
A security issue
Development in countries badly affected by HIV has clearly been undermined. HIV in sub-Saharan Africa is now deadlier than war itself. To put this in context, during 1998 200,000 people died as a result of war in sub-Saharan Africa. The number lost to AIDS in the same year was already ten times higher, at 2 million.
AIDS is rapidly becoming the major issue for human security in sub-Saharan Africa. On the 10 January 2000 the United Nations Security Council held a meeting on AIDS in Africa. This was the very first time that the Security Council had discussed any health issue.
The prevalence of HIV among military personnel is often higher than in the population as a whole, following the long-established pattern of other sexually transmitted infections. This has serious implications for the role of the military within societies as well as internationally, in peacekeeping operations.
An even deeper concern raised by HIV and AIDS is that large numbers of orphans, lacking in education and adult guidance, may be recruited into militias and armies that then destabilise the continent. The breakdown of government and society in Sierra Leone and Liberia is seen as an awful warning of what could happen elsewhere.
This concern can be overdone: some have suggested that the current regimes in Uganda and Rwanda, which are credited with having restored order and improved government to deeply traumatised countries, were both installed by "armies of orphans".
Uganda
In Uganda there has been a steady drop in HIV prevalence among 15–19-year-old pregnant women. Trends in behavioural indicators are in line with this apparent decline in HIV incidence. Condom use by single women aged 15–24 almost doubled between 1995 and 2000/2001, and more women in that age group delayed sexual intercourse or abstained entirely.