AIDS in Africa

HIV/AIDS in Africa is one of the most important global public health issues of our time, and perhaps, in the history of mankind. In Africa, AIDS is one of the top causes of death. While only comprising slightly under 15% of the total population of the world, Africans account for nearly 70% of those who live with HIV and are dying of AIDS.

Southern Africa exhibits pandemic-level HIV infection rates, with extreme levels in the countries of Botswana, Lesotho, South Africa, Namibia, Zimbabwe, Swaziland, and Zambia. By contrast, some countries in North Africa have HIV prevalence rates lower than most cities in the USA.

Overview

Outcomes  for Africa have been predicted to the year 2025, by the Joint United Nations Programme on HIV/AIDS  (UNAIDS). The predictions yielded a full range of results, to include stability in infection rate and even a descent in cases in some regions. Nonetheless, a strongly defined situation shows potential societal disaster in other regions, particularly Sub-Saharan Africa. The outcomes showed an alarming, systematic growth in the infection and mortality rate, with the possibility of millions of cases to ensue. It has also been found that in many cases, the adults in these communities (the individuals with the means to educate themselves and economically and emotionally support a family) are the ones dying of the disease.

Origins of AIDS in Africa

West Africa has been identified as the location of the first known incidents of AIDS, but the occurrences of the disease were shrouded in secrecy.  There are a number of hypotheses present in regard the origins of HIV, including a linking the disease to the preparation of bushmeat (wild animals, including primates, hunted for food) in Cameroon and early to mid-20th-century medical practices.  It is also inferred that since the virus transferred itself from chimpanzees (or other apes) to humans, this might have been the catalyst for origination of HIV in human populations in this region around 1930.

HIV-2 compounds the problem in Africa. There is part of the population, mainly in West Africa, infected with HIV-2. HIV-2 is much like HIV-1 (usually simply “HIV”), in that it leads to AIDS. HIV-2 is genetically different and characterized clinically as having a consistent low viral load for much longer periods of time, and is intrinsically resistant to many common antiretrovirals.

History

For years, many governments in Sub-Saharan Africa denied that HIV infection was an issue, which stunted their ability to stem the progress of AIDS. Now, many have begun to work toward solutions. The introduction of the ABC method of AIDS prevention has been proven to garner the strongest and most effective results.

The ABC method stands for “Abstinence, Be faithful, and Condom use”. It seeks to promote a different cultural view regarding safer sexual behavior, with an emphasis on fidelity, fewer sexual partners, and a later age of sexual debut. One successful example statistically demonstrates that the ABC method assisted in a 10% drop in the percentage of HIV cases in Uganda between the years 1990-2001. Thus, it seems that the foundation for an effective national response is a strong prevention program. For this to occur, there are necessary changes in the health sector, both cultural and monetary, which currently  present huge challenges. Still, the global response to HIV/AIDS has recently seen a substantial improvement, as funding has come from many sources, largely the Global Fund to Fight AIDS, Tuberculosis and Malaria, and the US initiative known as PEPFAR.

Causes and spread

 Cultural factors

A large factor preventing people from getting tested and treated for HIV/AIDS is the cultural stigma associated with it. In addition to stigma, there are several other factors medical professionals site as being detrimental to HIV treatment such as male promiscuity and polygamy in some places. One unproven cultural factor consistently mentioned is that the practice of female genital mutilation has led to an increased occurrence of AIDS in Africa. The hypothesis is that  intercourse with a circumcised female is conducive to an exchange of blood.

Political factors

As stated before, many major African political leaders have denied the link between HIV and AIDS, favoring alternate theories. The general global scientific community considers the evidence that HIV causes AIDS to be conclusive, thus completely rejecting any denial of such as pseudoscience. Still, despite its lack of scientific acceptance, the methodical denial of  AIDS has had a significant political impact – especially under the former South African presidency of Thabo Mbeki.

Religious factors

In Kenya, safe-sex commercials are banned. In addition, in 2009, the Pope Benedict, on a trip through Africa, banned the use of condoms in general. In 2013 the catholic church renewed banning of condoms in catholic schools. Muslim leaders have taken a similar stance in 2008. These are just a few examples demonstrating the significant pressure – and in some cases, condemnation – from both Christian and Muslim religious leaders in regard to AIDS and preventative-care education. Unfortunately, these stances  have significantly impeded progress of a variety of safe-sex campaigns.

Medical Suspicion

Suspicions about modern medicine are common throughout the world, and especially in sub-Saharan Africa. Such distrust appears to have an essential impact on utilizing medical services. This distrust is occasionally associated with theories of a “Western Plot” of mass sterilization or reduction in population; thought to be an aftermath of multiple high profile occurrences including Western medical practitioners.

Economic factors

The most obvious challenge to the AIDS pandemic is the lack of funding for medical facilities and treatment distribution in developing countries, even with plenty of aid distributed throughout. Facilities and pharmaceuticals are expensive; patents on many drugs add to the problem of discovering cost effective alternatives. The general poverty and political instability throughout the region also increase risky behaviors such as increasing people’s entry into the sex trade. Natural disasters and conflict decrease the client base for these sex workers so they are less likely to insist on client’s condom usage and other safer-sex practices.

Pharmaceutical industry

There was much experimentation performed on numerous medications in Africa. Unfortunately, the AIDS/HIV pandemic has also led to the rise in unethical medical Experimentation in Africa. Since the disease is so widespread, many African governments have relaxed their laws in order entice research – which they could otherwise not afford – to be conducted in their countries.  To compound this issue, once approval is obtained for a drug, accessibility of the drug in Africa can become difficult (see Economic Factors section). Therefore African countries often lobby against biased practices in the international pharmaceutical industry.  However, the fact remains: drug companies are still companies, and are obliged to their stock holders. These companies utilize some money used for work and research investments to secure patents on their intellectual capital investments.  Patents restrict the opportunities to produce generic alternatives, as these pharmaceutical companies recommend drugs to be purchased from them.

Fortunately, despite barriers, research and development of affordable treatment continues. For example, the University of KwaZulu-Natal performed a study in which scientists of South Africa mutually cooperated with scientists of America to invent an AIDS gel which has 40% of success in women. This drug is groundbreaking. The government revealed enthusiasm to expand the drug’s availability. Eventually it will become available to other people in Africa and abroad. Currently, the FDA within the United States is examining the drug to assess its approval for use in the US.

Health industry

Medical facilities in many African countries are lacking.  There are also not enough health care workers available. This is partly due to lack of training available. It is also because of the promise of far better living conditions for workers by foreign medical organizations. In many African countries, there is no formal health care infrastructure at all.  Many individuals in their respective communities either rely on “folk” remedies to try to heal, or they simply live with no care at all. In an attempt to get care in locations there is an option to do so, when family members get sick with HIV (or other sicknesses), the family often ends up selling most of their belongings in order to provide health care for the individual. This starts a negative cycle, as the family often ends up  in a long-term situation without necessary provisions for life…in addition to a gravely ill family member.

Brain drain

In addition, the African health care industry has been hard hit by a “brain drain”. This is the phenomena where large numbers of qualified doctors, nurses, and other health care professionals emigrate from developing countries to other, more developed countries and do not return.  The drain occurs largely through immigration laws that encourage recruitment in professional fields (special skill categories) like doctors and nurses in countries like Australia, Canada, and the U.S. One striking example of the brain drain was when at a certain point (according to the University of Malawi), there were more Malawian doctors in Manchester than in the entire country of Malawi.  According to Dr. Ken Sagoe, of the Ghana Health Service, “604 out of 871 medical officers who trained in the country between the years of 1993-2002 now practice overseas”. The country of Zimbabwe has documented having trained roughly 1,200 doctors in the 1990s with only 360 currently remaining in the country. Another example is the country of Zambia is also an example, where records show having only 50 out of the 600 doctors trained in the country still remaining there over the last 40 years.

Other reasons

As is the case with any effort with money, response to the epidemic is also hampered by corruption within both donor agencies and government agencies, foreign donors not coordinating with local government, and misguided resources.

Measurement

There are two dominant types of measurement: prevalence and incidence. Prevalence is the number of  people living with AIDS and HIV. The problem with using prevalence alone to measure an epidemic is that it presents a faulty perspective because one person can live with HIV for many years and therefore is counted multiple times. Incidence is the number of new cases of infection, usually within the previous year. Incidence is theoretically the best way to evaluate the HIV epidemic’s proliferation, and a combination of these figures would provide the most accurate representation of the HIV/AIDS burden. Unfortunately, both if these tools are difficult to measure, and there isn’t any reliable and practical way to evaluate them in sub-Saharan Africa. Healthcare providers and NGOs still need statistics to evaluate care and aid, so a few numbers are used to estimate a country’s prevalence and incidence. These include the prevalence of pregnant women ranging from 15 to 24 years going to antenatal clinics, and extrapolate from that. However, using antenatal surveys to extrapolate national data depends on assumptions that might not be applicable to all stages and regions. Another way to measure prevalence is the HIV serosurvey performed at a doctor’s office. However, health units conducting serosurveys rarely function within rural communities in remote areas.  This collected data also excludes people seeking alternate healthcare. As a result, there may be significant disparities between official figures and actual HIV prevalence in some countries.

Lately, many African countries have implemented household-based surveys and national population are done to collect data from both man and woman, rural and urban areas, non-pregnant and pregnant women, and they have altered the recorded national prevalence levels of HIV. Still, these are imperfect, as people might fear testing positive for HIV, or their HIV status being revealed, and thus hesitate to fill out the household survey accurately. Additionally, migrant laborers, a high risk group, are excluded from household surveys.

 

An example of this sampling bias lies in some of the reports on HIV transmission/infection. A minor group of scientists announces that about 40% of HIV infections among adults might result from risky medical practices rather than from sexual activity. The World Health Organization presents a contrasting stance, stating that an overwhelming majority is caused by unprotected sex while only approximately 2.5% of all sub-Sahara African HIV infections result from risky medical injection practices.

Regional analysis

North Africa

North Africa has one of the lowest HIV prevalence rates worldwide. This low rate is usually attributed to the essential role that Islam plays in the region’s societies. This strong influence on local values, morals, and government policies has sustained infection rates at a negligible level. As documented, there is a strong social taboo discouraging extra-marital sexual relations in Muslim communities. Thus, the HIV prevalence rates in 2009 were lower than 0.1% in Egypt and Tunisia, 0.1% in Morocco and Algeria, 0.7% in Mauritania, and 0.5% in Sudan.

Horn of Africa

Horn of Africa has a fairly low infection rates like North Africa. This low rate may also be a result of the loyal adherence to Islamic values and morals and the Muslim beliefs of many local communities. The HIV prevalence rates in 2009 were estimated at 0.3% in Somalia, 0.8% in Eritrea, and 2.5% in Djibouti. Ethiopia’s rate in 2003 was estimated to be slightly higher, at 4.4%.

 

East and Central Africa

In contrast with the predominantly Muslim areas in North Africa and the Horn region, traditional cultures and religions in much of Sub-Saharan Africa have generally exhibited a more liberal attitude in regard to sexual activity. The latter includes practices which lead to a higher risk of HIV including multiple partners and promiscuity especially for males. These values and cultural practices have been implicated in the region’s higher rates of HIV/AIDS.

HIV infection rates in East and Central Africa are generally moderate to high. Uganda has experienced a slow decline in HIV rates, decreasing the rate in school girls in Central African Republic from 10.6% to a stable 6.5 – 7.0% from 1997 to 2001 respectively. This trend is often described as a direct result of changes in behavioral patterns. More participants report wider use of contraceptives and fewer participants report casual sexual encounters with multiple partners. Similarly, the HIV infection rate in Kenya dropped from around 14% in the mid-1990s to 5% in 2006. Between 2004-2008, Tanzania had a prevalence rate of 3.4%, and Rwanda maintains a regional low of about 3.0% since 2005.

West Africa

 

Countries in Western Africa include Senegal, The Gambia, Cape Verde, Guinea-Bissau, Guinea, Sierra Leone, Liberia, Côte d’Ivoire, Ghana, Togo, Benin, Cameroon, Nigeria, and the landlocked states of Mali, Burkina Faso and Niger.

 

The region has relatively moderate levels of HIV-1 and HIV-2 infections. The HIV epidemic in west Africa commenced 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; The Guinea-Bissau, Gambia, and Guinea in 1989; and Cape Verde in 1990.

 

Chad, Niger, and Mali have the lowest HIV prevalence in West Africa while Burkina Faso, Côte d’Ivoire and Nigeria have the highest. Nigeria ranks second in having the largest number of people living with HIV in Africa, with South Africa ranks first.  The infection rate (ratio of number of patients to the total population) based upon Nigeria’s estimated population is much smaller, as Nigeria is the most populace in Africa, and is generally believed to be well under 7%, as opposed to South Africa’s which is well into the double-digits (nearer 30%).

 

In this region, commercial sex is an increasingly large trade, and the main cause of infection. For example, in Accra, the capital of Ghana, HIV infections from women who sell sex make up 80% of all infections. 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

HIV and AIDS were unfamiliar to the area of southern Africa as recently as the mid 1980s; now, it is the most affected area worldwide. Of the eleven countries in South Africa (Angola, Namibia, Zambia, Zimbabwe, Botswana, Malawi, Mozambique, South Africa, Lesotho, Swaziland, Madagascar) at least 7 are deemed to exceed 15% for infection rate. Angola presents one of the lowest infection rates at 2.1%. However, this may simply be a reporting error and is not the result of a successful national response to the threat of AIDS but of the long-running (1975–2002) Angolan Civil War (see Economic Factors section).

 

Besides polygamous relationships, a prevalent occurrence in some areas of Africa, sexual networking is a widespread practice involving numerous concurrent and overlapping sexual partners. Particularly, men’s sexual “networks” are more likely to be extensive. 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. Aside from the occurrence of having several sexual partners, population displacements and unemployment due to conflicts and droughts promote the HIV/AIDS spread.

 

A study done in Swaziland, Botswana, and Namibia found that four factors – extreme poverty, intimate partner violence, income disparity, and low levels of education in one or both partners – provided at least a partial explanation for the HIV prevalence in adults from 15 to 29 years old. The HIV rate was 17.1% within the group of women possessing at least one of these factors, compared to a 7.7% rate in the general female population. Approximately 26% of young women with 2 factors, 36% of women with 3 factors, and 39.3% of women with 4 factors were HIV positive

 

Reassuringly, there are a few indicators of some decline in rates of infection. For example, in its December 2005 report, UNAIDS reports that Zimbabwe experienced a drop in infections. (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 population alive with HIV live in Southern Africa; an area where only 2% of the world’s population reside.  HIV-1 makes up the bulk of all HIV infections in southern Africa and dominates everywhere except west Africa, home to HIV-2. The first cases of HIV in the region were reported in Zimbabwe in 1985.

 

Special Note: Swaziland

The HIV infection statistic in Swaziland is unprecedented and the highest globally at 26.1% of all adults, and at over 50% of adults in their 20s. This dire situation has stopped possible economic and social progress, and the 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 long term livelihood of Swaziland can face a serious threat.

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 epidemic is also producing a generation of orphans, with 42.6% of women seeking antenatal care having HIV. From another perspective, 61% of the country’s total deaths result from HIV/AIDS. With an unmatched crude death rate of 30 per thousand people each year, about 2% of Swaziland’s total population dies of HIV/AIDS every year.

 

Tuberculosis and HIV

The deadly synergistic combination of tuberculosis and HIV intensifies the epidemic of HIV/AIDS within sub-Saharan Africa. Tuberculosis is the world’s greatest infectious killer of women of reproductive age, and it is the leading cause of death among people with HIV/AIDS. Since 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 their otherwise healthy neighbors.

Prevention efforts

 

As stated previously, there are numerous initiatives and campaigns which have been trying to curb the spread of HIV in Africa. The ABC campaign is one of them, and it has garnered positive results. Still, there are issues within these efforts, and among the biggest problems is “HIV fatigue” where populations grow tired of learning more about a disease they hear about constantly.

Addressing this problem, innovative approaches become necessary. The Bill and Melinda Gates Foundation as well as the Henry J.Kaiser family funded LoveLife website in 1999.  LoveLife website was an online resource about sexual health and relationship for teenagers. The Botswana Ministry of Education started to introduce new technology for HIV/AIDS education in schools in an effort to guide in regard to preventative measures in 2011.  The technology, called “TeachAIDS”, coming from Stanford University, was to be used in all educational institutions, targeting learners of 6-24 years old nationwide.