1.0 Introduction
UNAIDS (2006) states; Africa is the world’s second largest continent, encompassing about 22% of the total land area in the world, nearly 12 million square miles. The Sub-Saharan region covers the entire continent with the exception of the northernmost countries of Algeria, Egypt, Libya, Morocco, Tunisia, Western Sahara and, arguably, Mauritania (The Canadian International Development Agency). Sub-Saharan Africa is faced with numerous challenges and is characterized by high population growth, an increasing HIV/AIDS health crisis, limited financial resources, negative growth in agricultural and economic output, drought and political instability.
Sub-Saharan Africa has significantly greater prevalence of People Living with HIV/AIDS (PLWHA) than anywhere else in the world (UNAIDS, 2006). Although it accounts for only 10% of the world’s population, it has 63% of the PLWHA. Seventy-two percent of the estimated 2.1 million AIDS-related deaths in 2006 were in Sub-Saharan Africa (UNAIDS/WHO, 2006). Of the 380,000 children who died in 2006 of AIDS, 87% (330,000) were in Sub-Saharan Africa. Although the epidemic has stabilized in the region, this means that the numbers of people who are newly affected with HIV are still roughly equivalent to the number of people who are dying from AIDS.
There are regional variations of AIDS patterns within Sub-Saharan Africa. AIDS can be considered as multiple, regional epidemics (UNAIDS, 2004b). In East Africa, Uganda has had the greatest gradual decline in prevalence rates, combating the problem through information and communication campaigns aimed at prevention. Infection rates for HIV/AIDS in Uganda have dropped from estimates of 18.5% in 1995 (Uganda AIDS Commission Secretariat, 2001) to 6.7% in 2005 (UNAIDS, 2006). These declines, however, may be deceiving; they may be the result of mortality statistics rather than a real drop in incidence. UNAIDS (2004b) suggest, “Adult HIV prevalence has been roughly stable in recent years. But stabilization does not necessarily mean the epidemic is slowing. On the contrary, it can disguise the worst phases of an epidemic when roughly equally large numbers of people are being newly infected with HIV and are dying of AIDS.”
Statistics about HIV/AIDS prevalence often come from prevalence statistics among pregnant women in urban antenatal clinics as representative of the entire population. The same pattern of gradual decline is seen in other East African countries as well as Uganda. Despite the decline, however, HIV/AIDS remains a serious epidemic with the numbers of deaths from AIDS rising dramatically each year.
In West and Central Africa, prevalence rates appear to have changed very little, stabilizing around 5% or below with the exception of Cameroon and Cote d’Ivoire whose rates are upwards of 10% among pregnant women at the antenatal sites. This is similar to the rates found in most countries of Southern Africa, with the exception of Angola, where the rate remains steady at around 5% (UNAIDS, 2004a).
Women are excessively affected by HIV, accounting for more than half of the people living with HIV/AIDS in Sub-Saharan Africa (UNAIDS, 2004c). In most Sub-Saharan countries, the age of sexual debut for women is earlier than for men (Green, 2003). This suggests that women are likely to be infected at earlier ages and more frequently than men, particularly among those aged 15-24 years (UNAIDS, 2004c).
2.0 Current Situation
The HIV/AIDS epidemic has had its most profound impact to date in sub-Saharan Africa. The majority of people living with HIV/AIDS (67%), new HIV infections (70%), and AIDS-related deaths (75%) are in this region, which only accounts for about 11–12% of the world’s population. HIV is the leading cause of death in the region and studies have found declines in life expectancy due to HIV in many of the hardest hit countries in sub-Saharan Africa, especially those in southern Africa. There are more than 5 million people living with HIV in South Africa alone, the greatest number of any country in the world, and Swaziland has the world’s highest HIV/AIDS prevalence rate (the percent of the population living with HIV/AIDS). Almost all countries in sub-Saharan Africa have generalized epidemics; that is, their prevalence rates are greater than 1%, and, in 9 countries, rates exceed 10%. Women comprise the majority of those living with HIV/AIDS in the region, and young people are at particular risk.
The epidemic has already posed serious development challenges for the region, where most countries are already considered to be low-income and heavily or moderately indebted, according to the World Bank, affecting communities, families, livelihoods, and numerous sectors of society. Some of these countries also face other challenges that may exacerbate or be exacerbated by HIV, including food insecurity, internal migration, and conflict. Yet the epidemic is quite diverse throughout sub-Saharan Africa and, despite these challenges, there have been success stories and even new, encouraging signs.
The latest estimates from UNAIDS and WHO indicate that in most sub-Saharan African countries, HIV/AIDS prevalence has stabilized, although often at high levels. In addition, some countries have even begun to experience declines.
Sub-Saharan Africa is more heavily affected by HIV and AIDS than any other region of the world. An estimated 22 million people were living with HIV at the end of 2007 and approximately 1.9 million additional people were infected with HIV during that year. In just the past year, the AIDS epidemic in Africa has claimed the lives of an estimated 1.5 million people in this region. More than eleven million children have been orphaned by AIDS. “Care of orphans is an enormous social problem, which will only get worse as more parents die of AIDS. In 2005, an estimated 15.2 million children had lost one or both parents to AIDS, 80% of them in sub-Saharan Africa. By 2010, the figure is likely to rise to more than 20 million” (HIV & AIDS, 2007).
3.0 Facts and figures
HIV & AIDS (2008) summarized the following facts and figures in most infected regions of sub-Saharan Africa. Over the last 2 years, the number of people living with HIV has increased in every region of the world. 39.5 million people were living with HIV in 2006. Two thirds of these people live in sub-Saharan Africa. 4.3 million people were newly infected with HIV and 2.9 million people died from AIDS in 2006. The top three countries with the highest numbers of people living with HIV in 2005 are South Africa, 5.5 million; Nigeria 2.9 million; India 2.5 million. India halved its count from 5.2 million to 2.5 million, based on better data in 2007. The feminization of the epidemic is becoming increasingly apparent. Worldwide, 17.7 million women are HIV-positive, more than ever before. In sub-Saharan Africa, they make up 59% of all people living with HIV. And, for every 10 adult men living with HIV, there are 14 adult women infected. Young women are particularly affected. In South Africa, young women (aged 15 to 24) are four times as likely to be HIV infected than young men. In Malawi, where 14% of adults are living with HIV, only one quarter (23%) of young women (aged 15 to 24) and one third (36%) of young men can correctly identify ways to prevent HIV. By the end of 2005, 15 million children had been orphaned by AIDS. Each day, 1,800 children worldwide become infected with HIV – the vast majority of them newborns. The UK government will spend at least £1.5 billion over three years (2005-08) on AIDS related work in developing countries. Since 2001, the UK has provided over 1 billion condoms for use in developing countries.
3.0 HIV Transmission
Fact sheet: HIV/AIDS (2008) HIV does not survive well outside the body. Therefore, it cannot be transmitted through casual, everyday contact. Mosquitoes and other insects do not transmit HIV. It is primarily spread through unprotected vaginal or anal intercourse with someone who is HIV-positive, by sharing contaminated needles, syringes and/or other injecting equipment and, less commonly, through transfusions of infected blood or blood clotting agents (in countries where blood is not screened for HIV antibodies). Babies born to HIV-positive women may become infected before or during birth or through breast-feeding after birth. Mother to child transmission (MTCT) the vast majority of these children will have become infected with HIV during pregnancy or through breastfeeding when they are babies, as a result of their mother being HIV-positive. Sub-Saharan Africa continues to be severely affected by the problem, due to a lack of drugs, services and information. The shortage of testing facilities in many areas is also contributing. In 2006, preventive drugs reached only 31% of HIV-infected pregnant women in Eastern and Southern Africa, and only 7% in West and Central Africa (Kanabus & Bass, 2009).
4.0 HIV Prevention
Microbicides are substances that can substantially reduce transmission of one or more
sexually transmitted diseases (STDs). They work by either destroying the microbes or preventing them from establishing an infection. Condom use is one of the least expensive, most cost-effective methods for preventing HIV transmission. Consistent, correct use of condoms significantly reduces the risk of transmission of HIV and other STDs. Post-exposure prophylaxis (PEP) involves the short-term use of antiretrovirals to prevent infection in people who have recently been exposed (such as health care workers through needles tick injuries or women who have been raped). PEP significantly reduces the risk of infection, but is not 100% effective. Socio-behavioral interventions are educational programs designed to encourage individuals to change their behaviour to reduce their exposure to HIV and risk for infection. Such efforts include encouraging proper and consistent condom use, a reduction in the number of sexual partners, abstinence and the delaying of sexual initiation among youth. Pre-Exposure Prophylaxis (PREP): involves taking antiretrovirals before engaging in behaviour(s) that place one at risk for HIV infection (such as unprotected sex or sharing needles) in order to reduce or prevent the possibility of HIV infection. Provision of Voluntary HIV Counseling & Testing (VCT): The provision of voluntary HIV counseling and testing (VCT) is an important part of any national prevention program. It is widely recognised that individuals living with HIV who are aware of their status are less likely to transmit HIV infection to others, and that through testing they can be directed to care and support that can help them to stay healthy. VCT also provides benefit for those who test negative, in that their behaviour may change as a result of the test (Kanabus & Bass, 2009).
5.0 HIV/AIDS related treatment and care in Africa
1) ARV stands for antiretroviral and refers to a type of drug that works by interfering
with the replication of HIV. The five classes of antiretroviral drugs currently available are: 1) Nucleoside Reverse Transcriptase Inhibitors (NRTIs; 2) Non-nucleoside Reverse Transcriptase Inhibitors (NNRTIs; 3) Protease Inhibitors (PIs); 4) Entry Inhibitors; 5) Integrase Inhibitors. For most Africans living with HIV, ARVs are still not available – fewer than one in five of the millions of Africans in need of the treatment are receiving it
2) HAART (Highly Active Antiretroviral Treatment) is a modality of antiretroviral treatment that involves the use of three or more ARVs in a treatment regimen. HAART interferes with the virus’ ability to replicate, which allows the body’s immune system to maintain or recover its ability to produce the white blood cells necessary to respond to opportunistic infections. Despite significant medical advances in the treatment and prevention of HIV, there is still no cure for this devastating disease.
6.0 Inadequacies of Existing Approaches
Information and communication campaigns that are designed to promote healthcare have not been adequately researched and evaluated for their effectiveness (Noar and Zimmerman, 2005).
7.0 Is HIV/AIDS Epidemic Outcome of Poverty in Sub-Saharan Africa?
According to Mbirimtengerenji (2007), many of the poorest are women who often head the poorest households in Africa. Inevitably, such women are often engaged in commercial sexual transactions, sometimes as commercial sexual workers (CSW) but more often, as part of survival strategies for themselves and their dependents. However, the consequences of poverty have mostly been associated with migration, sexual trade, polygamy, and teenage marriages.
Commercial sex and poverty: Poverty does seem to be the crucial factor in the spread of HIV/AIDS through sexual trade. The extreme poverty compels most of the young women to indulge into risky behavior that can easily bring money and resources for survival. Commercial sex workers are perceived to be highly instrumental in the HIV/AIDS pandemic as a high-risk group, reservoir of infection, and bridge into the general population. Commercial sexual exploitation of children is another serious problem, which has the underlying causes in poverty, gender discrimination, war, organized crime, globalization, greed, tradition, and beliefs. In the absence of alternative opportunities to earn a livelihood for themselves and their households, millions of women in Africa indeed sell sex. However, the minority of children who do manage to escape sex trade face social stigma, family rejection, shame, fear of retribution, and loss of future economic prospects.
Therefore, it is a natural fact that commercial sex is an indisputable indicator of poverty and the fatal predictor of deadly HIV/AIDS.
Teenage marriage and poverty: Indeed, girls who marry young in Africa are mostly from poor families and have low levels of education. Traditionally, if they marry men outside their village, they must move away, which may cause loneliness and isolation. As these girls assume their new roles as wives and mothers, they also inherit the primary job of a domestic worker. Because the husband has paid a hefty dowry, the girl is also under an immediate pressure to prove her fertility. This vicious cycle of poverty is compounded by the pandemic HIV/AIDS that is in many cases an outcome in the process for the forced teenage marriages.
Migration and poverty: Migration is often seen simply as a “flight from poverty;” there are no opportunities available locally, so people migrate in order to survive in another region or country. It was emphasized that as a solution to poverty most young people in Africa resort to migrate to neighboring countries or across the Atlantic and Indian ocean. When these people are displaced they have no shelter, food, or clothes. As a result, most of the refugees indulge into commercial sex work as a means of survival.
The distribution of poverty and HIV/AIDS in top 20 Sub-Saharan African countries*
Poverty level 2006
National HIV prevalence (15-49 y, %)
No of people with HIV
Country
GDP per capita ($US)
Percent of population below UN poverty line (US $1 a day)
2003
2005
In millions
Swaziland
5200
69
32.4
33.4
0.22
Botswana
11 400
30
24.0
24.1
0.27
Lesotho
2600
49
23.7
23.2
0.27
Zimbabwe
2000
80
22.1
20.1
1.10
Namibia
7400
56
19.6
19.5
0.23
South Africa
13 000
50
18.6
18.8
5.5
Zambia
1000
86
16.9
17.0
1.8
Mozambique
1500
70
16.0
16.1
1.8
Malawi
600
55
14.2
14.1
0.94
Central African Republic
1100
57
10.0
10.1
0.25
Gabon
7200
NA
7.8
7.9
0.06
Cote de Ivoire
1600
NA
7.0
7.1
0.75
Uganda
1800
35
6.8
6.7
1.0
Kenya
1200
50
6.8
6.1
1.3
Tanzania
800
51
6.6
6.5
1.4
Cameroon
2400
48
5.7
5.4
0.51
Congo
1300
NA
5.4
5.3
0.21
Nigeria
1400
45
4.0
3.9
2.9
Ethiopia
1000
50
3.8
3.5
1.3
Guinea Bisau
2000
40
3.2
3.5
0.03
7.0 Recommendations
Without major improvements to existing health care systems, it will be impossible to scale up good quality HIV prevention and AIDS treatment and care, including access to anti-retroviral. While prices have tumbled in recent years, the cost of antiretroviral drugs is still far beyond the means of many governments and individuals. More effective health services will depend on: employing more doctors and nurses; removing bottlenecks in drug production and supply; establishing reliable and accountable supply chain management and reporting systems; promoting better awareness and availability of services; NGO mobilization to make treatment effective; and a massive scaling up of HIV testing services so people can find out if they need treatment. Additionally, one of the most important ways in which the situation in Africa can be improved is through increased funding for HIV/AIDS. More money would help to improve both prevention campaigns and the provision of treatment and care for those living with HIV
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