HIV/AIDS in Africa

Numerous public education initiatives have been launched to curb the spread of HIV in Africa.

Many activists have drawn attention to stigmatization of those testing as HIV positive. This is due to many factors such as a lack of understanding of the disease, lack of access to treatment, the media, knowing that AIDS is incurable, and prejudices brought on by a cultures beliefs.[24] "When HIV/AIDS became a global disease, Some African leaders played ostrich and said that it was a gay disease found only in the West and Africans did not have to worry because there were no gays and lesbians in Africa".[25] Africans were blind to the already huge epidemic that was infesting their communities. The belief that only homosexuals could contract the diseases was later debunked as the number of heterosexual couples living with HIV increased. Unfortunately there were other rumors being spread by elders in Cameroon. These "elders speculated that HIV/AIDS was a sexually transmitted disease passed on from Fulani women only to non-Fulani men who had sexual contact with them. They also claimed if a man was infected as a result of having sexual contact with a Fulani woman, only a Fulani healer could treat him".[26] This communal belief is shared by many other African cultures who believe that HIV and AIDS originated from women. Because of this belief that men can only get HIV from women many "women are not free to speak of their HIV status to their partners for fear of violence".[24] In general HIV carries a negative stigma in Sub-Saharan Africa. Unfortunately This stigma makes it very challenging for Sub-Saharan Africans to share that they have HIV because they are afraid of being an outcast from their friends and family. In every Sub-Saharan community HIV is seen as the bringer of death. The common belief is that once you have HIV you are destined to die. People seclude themselves based on these beliefs. They do not tell their family and live with guilt and fear because of HIV. However, there is a way to treat HIV and AIDS the problem is that many are just not aware of how HIV is spread or what effects it has on the body. "80.8% of participants would not sleep in the same room as someone who was HIV positive, while 94.5% would not talk to someone who was HIV positive".[24]

Social stigma plays a significant role in the state of HIV and AIDS infection in Africa. "In a normatively HIV/AIDS-stigmatizing Sub Saharan African communities, this suspicion of one's status by others is also applicable to individuals who are not HIV positive, but who may wish to utilize healthcare services for preventive purposes. This group of individuals under fear of suspicion may avoid being mistakenly identified as stigmatized by simply avoiding HARHS utilization." (151)[18]

"At the individual level, persons living with HIV/AIDS in Sub-Saharan Africa likely want to conceal their stigmatized identities whenever possible in order to gain these rewards associated with having a 'normal' identity. The rewards of being considered normal' in the context of high-HIV-prevalence Sub-Saharan Africa are varied and great... such rewards for which there is empirical support in this context include perceived sexual freedom, avoidance of discrimination, avoidance of community or family rejection, avoidance of losing one's job or residence, and avoidance of losing one's sexual partners. Other potential rewards of being considered normal include avoidance of being associated with promiscuity or prostitution, avoidance of emotional, social and physical isolation and avoidance of being blamed for others' illness" (150).[18]

The Joint United Nations Program on HIV/AIDS defines combination prevention programs as:

rights-based, evidence-informed, and community-owned programs that use a mix of biomedical, behavioral, and structural interventions, prioritized to meet the current HIV prevention needs of particular individuals and communities, so as to have the greatest sustained impact on reducing new infections. Well-designed programs are carefully tailored to national and local needs and conditions; focus resources on the mix of programmatic and policy actions required to address both immediate risks and underlying vulnerability; and are thoughtfully planned and managed to operate synergistically and consistently on multiple levels (e.g. individual, relationship, community, society) and over an adequate period of time. Using different prevention strategies in combination is not a new idea combination approaches have been used effectively to generate sharp, sustained reductions in new HIV infections in diverse settings. Combination prevention reflects common sense, yet it is striking how seldom the approach has been put into practice. Prevention efforts to date have overwhelmingly focused on reducing individual risk, with fewer efforts made to address societal factors that increase vulnerability to HIV. UNAIDS' combination prevention framework puts structural interventions—including programs to promote human rights, to remove punitive laws that block the AIDS response, and to combat gender inequality and HIV related stigma and discrimination—at the center of the HIV prevention agenda.[27]

"It is the consensus in the HIV scientific community that abstinence, be faithful, use a condom [(ABC)] principles are vital guides for public health intervention, but are better bundled with biomedical prevention approaches; lone behavioral change approaches are not likely to stop the global pandemic."[28] Uganda has replaced its ABC strategy with a combination prevention program because of an increase in the annual HIV infection rate. Most new infections were coming from people in long-term relationships who had multiple sexual partners.[29]

The abstinence, be faithful, use a condom (ABC) strategy to prevent HIV infection promotes safer sexual behavior and emphasizes the need for fidelity, fewer sexual partners, and a later age of sexual debut. The implementation of ABC differs among those who use it. For example, the President's Emergency Plan for AIDS Relief has focused more on abstinence and fidelity than condoms[30] while Uganda has had a more balanced approach to the three elements.[31]

The effectiveness of ABC is controversial. At the 16th International AIDS Conference in 2006, African countries gave the strategy mixed reviews. In Botswana,

Much of the ABC message was getting through, but it was not making much of a difference. A program called Total Community Mobilization sent 450 AIDS counselors door-to-door, giving prevention advice, urging HIV testing and referring infected people to treatment. People who had talked to the counselors were twice as likely to mention abstinence and three times as likely to mention condom use when asked to describe ways to avoid infection. However, they were no more likely than the uncounseled to mention being faithful as a good strategy. The people who had been counseled were also twice as likely to have been tested for HIV in the previous year, and to have discussed that possibility with a sex partner. However, they were just as likely to have a partner outside marriage as the people who had not gotten a visit from a counselor, and they were no more likely to be using a condom in those liaisons.[32]

In Nigeria,

There was a somewhat different result in a study of young Nigerians, ages 15 to 24, most unmarried, living in the city and working in semiskilled jobs. People in specific neighborhoods were counseled with an ABC message as part of a seven-year project funded by the U.S. Agency for International Development and its British counterpart. The uncounseled group showed no increase in condom use—it stayed about 55 percent. In the counseled group, however, condom use by women in their last nonmarital sexual encounter rose from 54 percent to 69 percent. For men, it rose from 64 percent to 75 percent. Stigmatizing attitudes appeared to be less common among the counseled group. But "We did not see a reduction in the number of partners," said God power Omoregie, the researcher from Abuja who presented the findings.[32]

In Kenya,

A survey of 1,400 Kenyan teenagers found a fair amount of confusion about ABC's messages. Half of the teenagers could correctly define abstinence and explain why it was important. Only 23 percent could explain what being faithful meant and why it was important. Some thought it meant being honest, and some thought it meant having faith in the fidelity of one's partner. Only 13 percent could correctly explain the importance of a condom in preventing HIV infection. About half spontaneously offered negative opinions about condoms, saying they were unreliable, immoral and, in some cases, were designed to let HIV be transmitted.[32]

Eswatini in 2010 announced that it was abandoning the ABC strategy because it was a dismal failure in preventing the spread of HIV. "If you look at the increase of HIV in the country while we've been applying the ABC concept all these years, then it is evident that ABC is not the answer," said Dr. Derek von Wissell, Director of the National Emergency Response Council on HIV/AIDS.[33]

In 1999, the Henry J. Kaiser Family Foundation and the Bill and Melinda Gates Foundation provided major funding for the Love Life website, an online sexual health and relationship resource for teenagers.[34]

In 2011, the Botswana Ministry of Education introduced new HIV/AIDS educational technology in local schools. The TeachAids prevention software, developed at Stanford University, was distributed to every primary, secondary, and tertiary educational institution in the country, reaching all learners from 6 to 24 years of age nationwide.[35]

During the Abuja African Union Summit on HIV/AIDS in April 2001, the heads of state and heads of government of Botswana, Ethiopia, Kenya, Mali, Nigeria, Rwanda, South Africa, and Uganda established the AIDS Watch Africa (AWA) advocacy platform. The initiative was formed to "accelerate efforts by Heads of State and Government to implement their commitments for the fight against HIV/AIDS, and to mobilize the required national and international resources."[36] In January 2012, AWA was revitalized to include all of Africa and its objectives were broadened to include malaria and tuberculosis.[37]

In 2012, the African Union adopted a Roadmap on Shared Responsibility and Global Solidarity for AIDS, TB and Malaria Response in Africa.[8] This Roadmap presents a set of practical African-sourced solutions for enhancing shared responsibility and global solidarity for AIDS ... responses in Africa on a sustainable basis by 2015. The solutions are organized around three strategic pillars: diversified financing; access to medicines; and enhanced health governance. The Roadmap defines goals, results and roles and responsibilities to hold stakeholders accountable for the realization of these solutions between 2012 and 2015.[38]

The Joint United Nations Program on HIV/AIDS reported that the following sixteen African nations in 2012 "ensure[d] that more than three-quarters of pregnant women living with HIV receive antiretroviral medicine to prevent transmission to their child": Botswana, Gabon, Gambia, Ghana, Mauritius, Mozambique, Namibia, Rwanda, São Tomé and Principe, Seychelles, Sierra Leone, South Africa, Eswatini, Tanzania, Zambia and Zimbabwe.[8][13]

High-risk behavioral patterns are largely responsible for the significantly greater spread of HIV/AIDS in Sub-Saharan Africa than in other parts of the world. Chief among these are the traditionally liberal attitudes espoused by many communities inhabiting the subcontinent toward multiple sexual partners and pre-marital and outside marriage sexual activity.[39][40] HIV transmission is most likely in the first few weeks after infection, and is therefore increased when people have more than one sexual partner in the same time period. In most of the developed world outside Africa, this means HIV transmission is high among prostitutes and other people who may have more than one sexual partner concurrently. Within the cultures of sub-Saharan Africa, it is relatively common for both men and women to be carrying on sexual relations with more than one person, which promotes HIV transmission.[22] This practice is known as concurrency, which Helen Epstein describes in her book, The Invisible Cure: Africa, the West, and the Fight against AIDS, in which her research into the sexual mores of Uganda revealed the high frequency with which men and women engage in concurrent sexual relationships.[41] In addition, in sub-Saharan Africa AIDS is the leading killer and a large reason for the high transmission rates is because of the lack of education provided to youth. When infected, most children die within one year because of the lack of treatment.[42] All demographic populations in Sub-Saharan Africa have been infected with HIV, from men to women, and from pregnant woman to children. Rather than having more of a specific group infected, male or female, the ratio of men and women infected with HIV are quite similar. With the HIV infection, 77% of men, women, and children, develop AIDS, and die in Sub-Saharan Africa. In addition, "more than 90% of AIDS orphans and children [were] infected with HIV".[43]

Lack of money is an obvious challenge, although a great deal of aid is distributed throughout developing countries with high HIV/AIDS rates. For African countries with advanced medical facilities, patents on many drugs have hindered the ability to make low cost alternatives.[44]

Natural disasters and conflict are also major challenges, as the resulting economic problems people face can drive many young women and girls into patterns of sex work in order to ensure their livelihood or that of their family, or else to obtain safe passage, food, shelter or other resources.[45] Emergencies can also lead to greater exposure to HIV infection through new patterns of sex work. In Mozambique, an influx of humanitarian workers and transporters, such as truck drivers, attracted sex workers from outside the area.[45] Similarly, in the Turkana District of northern Kenya, drought led to a decrease in clients for local sex workers, prompting the sex workers to relax their condom use demands and search for new truck driver clients on main highways and in peri-urban settlements.[45]

Sub-Saharan "Africans have always appreciated the importance of health care because good health is seen as necessary for the continuation and growth of their lineage".[46] Without proper health the culture will not be able to thrive and grow. Unfortunately, "health services in many countries are swamped by the need to care for increasing numbers of infected and sick people. Ameliorative drugs are too expensive for most victims, except for a very small number who are affluent".[46] The greatest number of sick people with the fewest doctors, Sub-Saharan Africa "has 11 percent of the world's population but carries 24 percent of the global disease burden. With less than 1 percent of global health expenditure and only 3 percent of the world's health workers".[47]

Measuring an HIV patient's CD4 count at the Kyabugimbi Health Center in Uganda

When family members get sick with HIV or other sicknesses, family members often end up selling most of their belongings in order to provide health care for the individual. Medical facilities in many African countries are lacking. Many health care workers are also not available, in part due to lack of training by governments and in part due to the wooing of these workers by foreign medical organizations where there is a need for medical professionals.[48] Unfortunately, many individuals who get a medical degree end up leaving Sub-Saharan Africa to work abroad "either to escape instability or to practice where they have better working conditions and a higher salary".[49] Many low income communities are very far away from a hospital and they cannot afford to bus there or pay for medical attention once they arrive. "Healthcare in Africa differs widely, depending on the country and also the region – those living in urban areas are more likely to receive better healthcare services than those in rural or remote regions".[49] It is very common to just wait out a sickness or seek help from a neighbor or relative. Currently antiretroviral therapy is the closest to a cure. However, many hospitals lack enough antiretroviral drugs to treat everyone. This may be because most Sub-Saharan African countries invest "as little as 1-4 dollars per capita, [so] overseas aid is a major source of funding for healthcare".[49] Many overseas organizations are very hesitant to give antiretroviral drugs to Sub-Saharan Africa because they are expensive, which means that there is only so much they can give. Relying on other countries for help in general requires more paperwork and faith in another country very far away. Also, delivery of drugs and other aid takes many month and years to arrive in the hands of those that need help.

According to a 2007 report, male and female circumcision were statistically associated with an increased incidence of HIV infection among the females in Kenya and the males in Kenya, Lesotho, and Tanzania who self-reported that they both underwent the procedure and were virgins.[Note 1] "Among adolescents, regardless of sexual experience, circumcision was just as strongly associated with prevalent HIV infection." Circumcised adults, however, were statistically less likely to be HIV positive than their uncircumcised counterparts, especially among older age groups.[Note 2][50]

Similarly, a randomized, controlled intervention trial in South Africa from 2005 found that male circumcision "provides a degree of protection against acquiring HIV infection [by males], equivalent to what a vaccine of high efficacy would have achieved".[51]

An HIV/AIDS educational outreach session in Angola

There are high levels of medical suspicion throughout Africa, and there is evidence that such distrust may have a significant impact on the use of medical services.[52][53] The distrust of modern medicine is sometimes linked to theories of a "Western Plot"[54] of mass sterilization or population reduction, perhaps a consequence of several high-profile incidents involving western medical practitioners.[55]

African countries are also still fighting against what they perceive as unfair practices in the international pharmaceutical industry.[56] Medical experimentation occurs in Africa on many medications, but once approved, access to the drug is difficult.[56]

South African scientists in a combined effort with American scientists from Gilead Sciences recently tested and found effective a tenofovir-based anti-retroviral vaginal gel that could be used as pre-exposure prophylaxis. Testing of this gel was conducted at the University of KwaZulu-Natal in Durban, South Africa.[57] The FDA in the US is in the process of reviewing the drug for approval for US use.[58][59] The AIDS/HIV epidemic has led to the rise in unethical medical experimentation in Africa.[56]

Since the epidemic is widespread, African governments sometimes relax their laws in order to get research conducted in their countries which they would otherwise not afford.[56] However, global organizations such as the Clinton Foundation, are working to reduce the cost of HIV/AIDS medications in Africa and elsewhere. For example, the philanthropist Inder Singh oversaw a program which reduced the cost of pediatric HIV/AIDS drugs by between 80 and 92 percent by working with manufacturers to reduce production and distribution costs.[60] Manufacturers often cite distribution and production difficulties in developing markets, which create a substantial barrier to entry.

Major African political leaders have denied the link between HIV and AIDS, favoring alternate theories.[61] The scientific community considers the evidence that HIV causes AIDS to be conclusive and rejects AIDS-denialist claims as pseudoscience based on conspiracy theories, faulty reasoning, cherry picking, and misrepresentation of mainly outdated scientific data.

In Africa, subtype C of HIV-1 is very common, whereas it is rare in America or Europe. People with subtype C progress to AIDS faster than those with subtype A, the predominant subtype in America and Europe (see HIV disease progression rates#HIV subtype variation and effect on progression rates).

Pressure from both Christian and Muslim religious leaders has resulted in the banning of a number of safe-sex campaigns, including condom promoting advertisements being banned in Kenya.[62]

As with North Africa, the HIV infection rates in the Horn of Africa are quite low. This has been attributed to the Muslim nature of many of the local communities and adherence to Islamic morals.[40]

Ethiopia's HIV prevalence rate has decreased from 3.6 percent in 2001 to 1.4 percent in 2011.[13] The number of new infections per year also has decreased from 130,000 in 2001 to 24,000 in 2011.[13]

HIV infection rates in central Africa are moderate to high.[39]

World AIDS Day 2006 event in Kenya

HIV infection rates in eastern Africa are moderate to high.

Kenya, according to a 2008 report from the Joint United Nations Program on HIV/AIDS, had the third largest number of individuals in Sub-Saharan Africa living with HIV.[69] It also had the highest prevalence rate of any country outside of Southern Africa.[69] Kenya's HIV infection rate dropped from around 14 percent in the mid-1990s to 5 percent in 2006,[39] but rose again to 6.2 percent by 2011.[69] The number of newly infected people per year, however, decreased by almost 30 percent, from 140,000 in 2001 to 100,000 in 2011.[13]

As of 2012, Nyanza Province had the highest HIV prevalence rate at 13.9 percent, with the North Eastern Province having the lowest rate at 0.9 percent.[69]

Christian men and women also had a higher infection rate than their Muslim counterparts.[69] This discrepancy was especially visible among women, with Muslim women showing a rate of 2.8 percent versus 8.4 percent among Protestant women and 8 percent among Catholic women.[69] HIV was also more common among the wealthiest than among the poorest (7.2 percent versus 4.6 percent).[69]

Historically, HIV had been more prevalent in urban than rural areas, although the gap is closing rapidly.[69] Men in rural areas are now more likely to be HIV-infected (at 4.5 percent) than those in urban areas (at 3.7 percent).[69]

Between 2004 and 2008, the HIV incidence rate in Tanzania for ages 15–44 slowed to 3.37 per 1,000 person-years (4.42 for women and 2.36 for men).[70] The number of newly infected people per year increased slightly, from 140,000 in 2001 to 150,000 in 2011.[13] There were also significantly fewer HIV infections in Zanzibar, which in 2011 had a prevalence rate of 1.0 percent compared to 5.3 percent in mainland Tanzania.[71]

Uganda has registered a gradual decrease in its HIV rates from 10.6 percent in 1997, to a stabilized 6.5–7.2 percent since 2001.[39][40] This has been attributed to changing local behavioral patterns, with more respondents reporting greater use of contraceptives and a two-year delay in first sexual activity as well as fewer people reporting casual sexual encounters and multiple partners.[40]

The number of newly infected people per year, however, has increased by over 50 percent, from 99,000 in 2001 to 150,000 in 2011.[13] More than 40 percent of new infections are among married couples, indicating widespread and increasing infidelity.[72] This increase has caused alarm. The director of the Centre for Disease Control – Uganda, Wuhib Tadesse, said in 2011 that,

for every person started on antiretroviral therapy, there are three new HIV infections[,] and this is unsustainable. We are very concerned. Complacence could be part of the problem. Young people nowadays no longer see people dying; they see people on ARVs but getting children. We need to re-examine our strategies.... Leaders at all levels are spending [more] time in workshops than in the communities to sensitive the people[,] and this must stop."[73]

Western Africa has moderate levels of infection of both HIV-1 and HIV-2. The onset of the HIV epidemic in the region began in 1985 with reported cases in Senegal,[74] Benin,[75] and Nigeria.[76] These were followed in 1986 by Côte d'Ivoire.[77] The first identification of HIV-2 occurred in Senegal by microbiologist Souleymane Mboup and his collaborators.[74]

HIV prevalence in western Africa is lowest in Senegal and highest in Nigeria, which has the second largest number of people living with HIV in Africa after South Africa. Nigeria's infection rate (number of patients relative to the entire population), however, is much lower (3.7 percent) compared to South Africa's (17.3 percent).

In Niger in 2011, the national HIV prevalence rate for ages 15–49 was 0.8 percent while for sex workers it was 36 percent.[13]

Graphs of life expectancy at birth for some Sub-Saharan countries showing the fall in the 1990s primarily due to the AIDS pandemic[78]

In the mid-1980s, HIV and AIDS were virtually unheard of in southern Africa. However, it is now the worst-affected region in the world. Currently, Eswatini and Lesotho have the highest and second highest HIV prevalence rates in the world, respectively.[68] Of the nine southern African countries (Botswana, Lesotho, Malawi, Mozambique, Namibia, South Africa, Eswatini, Zambia, and Zimbabwe), four are estimated to have an infection rate of over 15 percent.

In Botswana, the number of newly infected people per year has declined by 67 percent, from 27,000 in 2001 to 9,000 in 2011. In Malawi, the decrease has been 54 percent, from 100,000 in 2001 to 46,000 in 2011. All but two of the other countries in this region have also recorded major decreases (Namibia, 62 percent; Zambia, 54 percent; Zimbabwe, 47 percent; South Africa, 38 percent; Eswatini, 32 percent). The number has remained virtually the same in Lesotho and Mozambique.[13]

Zimbabwe's first reported case of HIV was in 1985.[79]

There are widespread practices of sexual networking that involve multiple overlapping or concurrent sexual partners.[80] Men's sexual networks, in particular, tend to be quite extensive,[81][82] a fact that is tacitly accepted or even encouraged by many communities.[83] Along with having multiple sexual partners, unemployment and population displacements resulting from drought and conflict have contributed to the spread of HIV/AIDS.[83] According to Susser and Stein (2000), men refuse to use condoms during intercourse with girls or women performing sex work (p. 1043–1044). The girls and women are in desperate need of money and do not have a choice. This leads to multiple sex partners, which increases the likelihood of their infection with HIV/AIDS.[84]

A 2008 study in Botswana, Namibia, and Eswatini found that intimate partner violence, extreme poverty, education, and partner income disparity explained almost all of the differences in HIV status among adults aged 15–29 years. Among young women with any one of these factors, the HIV rate increased from 7.7 percent with no factors to 17.1 percent. Approximately 26 percent of young women with any two factors were HIV positive, with 36 percent of those with any three factors and 39.3 percent of those with all four factors being HIV-positive.[85]

As of 2011, the HIV prevalence rate in Eswatini was the highest in the world at 26.0 percent of persons aged 15–49.[68] The United Nations Development Program wrote in 2005,

The immense scale of AIDS-related illness and deaths is weakening governance capacities for service delivery, with serious consequences on food security, economic growth[,] and human development. AIDS undermines the capacities of individuals, families, communities[,] and the state to fulfill their roles and responsibilities in society. If current trends are not reversed, the longer-term survival of Swaziland as a country will be seriously threatened.[86]

The HIV epidemic in Eswatini has reduced its life expectancy at birth to 49 for men and 51 for women (based on 2009 data).[87] Life expectancy at birth in 1990 was 59 for men and 62 for women.[88]

Based on 2011 data, Eswatini's crude death rate of 19.51 per 1,000 people per year was the third highest in the world, behind only Lesotho and Sierra Leone.[89] HIV/AIDS in 2002 caused 64 percent of all deaths in the country.[90]