Sub-Saharan Africa is more heavily affected by HIV and AIDS than any other region of the world. An estimated 22.4 million people are living with HIV in the region – around two thirds of the global total. In 2008 around 1.4 million people died from AIDS in sub-Saharan Africa and 1.9 million people became infected with HIV. Since the beginning of the epidemic, more than 14 million children have lost one or both parents to HIV/AIDS.
In the absence of massively expanded prevention, treatment and care efforts, it is expected that the AIDS death toll in sub-Saharan Africa will continue to rise. This means the impact of the AIDS epidemic on these societies will be felt most strongly in the course of the next ten years and beyond. Its social and economic consequences are already widely felt, not only in the health sector but also in education, industry, agriculture, transport, human resources and the economy in general. The AIDS epidemic in sub-Saharan Africa threatens to devastate whole communities, rolling back decades of development progress.
Sub-Saharan Africa faces a triple challenge:
- Providing health care, antiretroviral treatment, and support to a growing population of people with HIV-related illnesses.
- Reducing the annual toll of new HIV infections by enabling individuals to protect themselves and others.
- Coping with the impact of over 20 million AIDS deaths, on orphans and other survivors, communities, and national development.
In Somalia and Senegal the HIV prevalence is under 1% of the adult population, whereas in Namibia, South Africa, Zambia and Zimbabwe around 15-20% of adults are infected with HIV. In three southern African countries, the national adult HIV prevalence rate now exceeds 20%. These countries are Botswana (23.9%),Lesotho (23.2%) and Swaziland (26.1%).
West Africa has been less affected by HIV and AIDS, but some countries are experiencing rising HIV prevalence rates. In Cameroon HIV prevalence is now estimated at 5.1% and in Gabon it stands at 5.9%. In Nigeria, HIV prevalence is low (3.1%) compared to the rest of Africa. However, because of its large population (it is the most populous country in sub-Saharan Africa), this equates to around 2.6 million people living with HIV.
Adult HIV prevalence in East Africa exceeds 5% in Uganda, Kenya and Tanzania.
Overall, rates of new HIV infections in sub-Saharan Africa appear to have peaked in the late 1990s, and HIV prevalence seems to have declined slightly, although it remains at an extremely high level. History of AIDS in Africa has more information about how HIV prevalence has changed over time.
HIV and AIDS are having a widespread impact on many parts of African society. The points below describe some of the major effects of the HIV/AIDS epidemic. For a more detailed examination, visit our African impact page.
- The effect on life expectancy. In many countries of sub-Saharan Africa, AIDS is erasing decades of progress made in extending life expectancy. Millions of adults are dying from AIDS while they are still young, or in early middle age. Average life expectancy in sub-Saharan Africa is now 47 years, when it could have been 62 without AIDS.
- The effect on households. The effect of the AIDS epidemic on households can be very severe. Many families are losing their income earners. In other cases, people have to provide home based care for sick relatives, reducing their capacity to earn money for their family. Many of those dying from AIDS have surviving partners who are themselves infected and in need of care. They leave behind orphans, grieving and struggling to survive without a parent’s care.
- The effect on healthcare. In all affected countries, the epidemic is putting strain on the health sector. As the epidemic develops, the demand for care for those living with HIV rises, as does the number of health care workers affected.
- The effect on schools. Schools are heavily affected by AIDS. This a major concern, because schools can play a vital role in reducing the impact of the epidemic, through HIV education and support.
- The effect on productivity. The HIV and AIDS epidemic has dramatically affected labor, which in turn slows down economic activity and social progress. The vast majority of people living with HIV and AIDS in Africa are between the ages of 15 and 49 – in the prime of their working lives. Employers, schools, factories and hospitals have to train other staff to replace those at the workplace who become too ill to work.
- The effect on economic growth and development. The HIV and AIDS epidemic has already significantly affected Africa’s economic development, and in turn, has affected Africa’s ability to cope with the epidemic.
A number of African countries have conducted large-scale HIV prevention initiatives in an effort to reduce the scale of their epidemics. Senegal, for example, responded early to the emergence of HIV with strong political and community leadership.5 It is impossible to predict how Senegal’s epidemic would have progressed without intervention, but Senegal now has one of the lowest HIV prevalence rates in sub-Saharan Africa.
The situation in Uganda is similarly successful. HIV prevalence among pregnant women in Uganda fell from a high of around 30% in the early 1990s to around 10% in 2001;6 a change which is thought to be largely a result of intensive HIV prevention campaigns. Declines in HIV prevalence have also been seen in Kenya, Zimbabwe and urban areas of Zambia and Burkina Faso.
However, not all African countries have had such successful HIV prevention campaigns. In South Africa, the government’s failure to respond to the AIDS crisis has lead to an unprecedented number of people living with HIV. An estimated 70,000 babies are born with HIV every year, reflecting significant failures in prevention of mother-to-child transmission initiatives.
Condom use and HIV
Condoms play a key role in preventing HIV infection around the world. In sub-Saharan Africa, most countries have seen an increase in condom use in recent years. In studies carried out between 2001 and 2005, eight out of eleven countries in sub-Saharan Africa reported an increase in condom use.
The distribution of condoms to countries in sub-Saharan Africa has also increased: in 2004 the number of condoms provided to this region by donors was the equivalent of 10 for every man, compared to 4.6 for every man in 2001.9 In most countries, though, many more condoms are still needed. For instance, in Uganda between 120 and 150 million condoms are required annually, but less than 40 million were provided in 2005.
Relative to the enormity of the HIV/AIDS epidemic in Africa, providing condoms is cheap and cost effective. Even when condoms are available, though, there are still a number of social, cultural and practical factors that may prevent people from using them. In the context of stable partnerships where pregnancy is desired, or where it may be difficult for one partner to suddenly suggest condom use, this option may not be practical.
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 recognized that individuals living with HIV who are aware of their status are less likely to transmit HIV infection to others, and are more likely to access treatment, care and support that can help them to stay healthy for longer. VCT also provides benefit for those who test negative, in that their behavior may change as a result of the test.
The provision of VCT has become easier, cheaper and more effective as a result of the introduction of rapid HIV testing, which allows individuals to receive a test and the results in the same day. VCT could – and needs to be – made more widely available in most sub-Saharan African countries.
Around 390,000 children in sub-Saharan Africa became infected with HIV in 2008.11 The vast majority of these children have been infected with HIV during pregnancy, childbirth or breastfeeding, as a result of their mother being infected with the virus.
Without interventions, there is a 20-45% chance that an HIV-positive mother will pass infection on to her child. If a woman is supplied with antiretroviral drugs, however, this risk can be significantly reduced. Before these measures can be taken the mother must be aware of her HIV infection, so testing also plays a vital role in the prevention of MTCT.
In many developed countries, these steps have helped to virtually eliminate MTCT. Yet sub-Saharan Africa continues to be severely affected by the problem, due to a lack of drugs, services and information, and the shortage of testing facilities. 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.
Given the scale of the MTCT crisis in Africa, it is remarkable that more is not being done (by both the international community and domestic governments) to prevent the rising numbers of children becoming infected with HIV, and dying from AIDS. This crisis is discussed in more detail in our PMTCT worldwide page.
Antiretroviral drugs (ARVs) – which significantly delay the progression of HIV to AIDS and allow people living with HIV to live relatively normal, healthy lives – have been available in richer parts of the world since around 1996. Distributing these drugs requires money, a well-structured health system and a sufficient supply of healthcare workers. The majorities of developing countries are lacking in these areas and have struggled to cope with the increasing numbers of people requiring treatment.
For most Africans living with HIV, ARVs are still not available – just under half of those in need of treatment are receiving it. Millions are not even receiving treatment for opportunistic infections, which affect individuals whose immune systems have been weakened by HIV infection. These facts reflect the world’s continuing failure, despite the progress of recent years, to mount a response that matches the scale and severity of the global AIDS epidemic.
Botswana pioneered the provision of ARVs in Africa, starting its national treatment program in January 2002. By 2005 this program was providing treatment to the vast majority of those in need. According to World Health Organization figures, 93,000 people were receiving treatment in Botswana at the end of 2007 – a coverage rate of around 80%.14 Among the other countries that have made advances are Rwanda and Namibia, where more than 70% of people in need of ARVs are receiving them.
While most African countries have now started to distribute ARVs, progress in providing sufficient quantities of the drugs has been uneven and Botswana’s success has not been emulated elsewhere. In Cameroon, Côte d’Ivoire, Kenya, Malawi and Nigeria, between 25% and 45% of people requiring antiretroviral drugs were receiving them in December 2007. While South Africa is the richest nation in sub-Saharan Africa and should have led the way in ARV distribution, its government was slow to act, and so far, only 28% of those in need of treatment in South Africa are receiving it. In other countries, such as Chad, Congo, Ghana, Sudan and Zimbabwe, the figure is less than 20%.
Nonetheless, the overall situation is slowly improving; the number of people receiving ARVs in Africa doubled in 2005 alone.16 International support has helped this increase, with numerous governments and international organizations encouraging progress. In 2003 the World Health Organization (WHO) initiated the ‘3 by 5’ program, which aimed to have three million people in developing countries on ARVs by the end of 2005. While this target was not reached, a number of African nations made substantial progress under the scheme. The latest international target, ‘All by 2010’, is aiming at universal access to treatment by 2010. In pursuit of this goal it is hoped that considerable progress will be made in Africa’s fight against AIDS.
There are still, however, a number of impediments to ARV provision. One major challenge is the fact that the majority of African countries have a poor healthcare infrastructure and a shortage of medical professionals. A considerable emphasis needs to be placed not only on the availability of ARVs, but also the availability of professionals who are able to administer the drugs.
Another major challenge is ensuring that drugs are not only supplied to a lot of areas, but that sufficient quantities of drugs are supplied to those areas. This is critically important; because once an individual starts to take ARVs they have to take them for the rest of their life. If, for instance, their local hospital runs out of ARVs, the interruption that this causes in their treatment could result in drug resistance. To improving treatment programs, African countries face the double challenge of getting new people to start treatment and maintaining the supply of treatment to those who are already receiving ARVs.
Treatment and care for HIV/AIDS consists of a number of different elements apart from ARVs. These include voluntary counseling and testing, food and management of nutrition, follow-up counseling, protection from stigma and discrimination, treatment of other sexually transmitted infections, and the prevention and treatment of opportunistic infections. Alongside antiretroviral treatment, all of these elements should be made available for all people living with HIV.
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. Developed countries have increased funding for the fight against AIDS in Africa in recent years, perhaps most significantly through the Global Fund. The Global Fund was started in 2001 to co-ordinate international funding and has since approved grants totaling US $7.2 billion to help fight AIDS, TB and Malaria in 137 countries. This funding is making a significant difference, but given the massive scale of the AIDS epidemic more money is still needed.
The US Government has shown a commitment to fighting AIDS in Africa through the President’s Emergency Plan for AIDS Relief (PEPFAR). Started in 2003, PEPFAR provides money to fight AIDS in numerous countries, including 15 focus countries, most of which are African. In Fiscal Year 2009, PEPFAR allocated almost US $6.5 billion for combating AIDS, TB and Malaria.18 The US Government is also the largest contributor to the Global Fund.
Among other things, organizations like PEPFAR and the Global Fund provide vital support to local and community groups that are working ‘on the ground’ to provide relief in Africa. These groups are directly helping people in need, and many rely on international funding in order to operate. Getting money from large, international donors to small, ‘grassroots organizations’ can present a number of difficulties though, as money is lost or delayed as it is passed down large funding chains.
More than money is needed if HIV prevention and treatment programs are to be scaled up in Africa. In order to implement such programs, a country’s health, education and communication systems and infrastructures must be sufficiently developed. In some African countries these systems are already under strain and are at risk of collapsing as a result of AIDS. Money can also only be used efficiently if there are sufficient human resources available, but there is an acute shortage of trained personnel in many parts of Africa.
Increased international funding should not result in reduced domestic expenditure on health, as domestic financing is necessary for the sustainability of health programs. Some research shows that, particularly in sub-Saharan Africa, government spending on health is reduced in response to receiving large amounts of development assistance for health.19 Although this might be partly a result of government spending being redirected to other sectors such as education and industry, it is vital that sustainability and self-sufficiency in the health sector is encouraged so that the governments of sub-Saharan African countries are well equipped to deal with their HIV/AIDS epidemics even if donor funding dries out.
Reducing stigma and discrimination
HIV-related stigma and discrimination remains an enormous barrier to the fight against AIDS. Fear of discrimination often prevents people from getting tested, seeking treatment and admitting their HIV status publicly. Since laws and policies alone cannot reverse the stigma that surrounds HIV infection, AIDS education in Africa needs to be scaled-up to combat the ignorance that causes people to discriminate. The fear and prejudice that lies at the core of HIV and AIDS discrimination needs to be tackled at both community and national levels.
In many parts of Africa, as elsewhere in the world, the AIDS epidemic is aggravated by social and economic inequalities between men and women. Women and girls commonly face discrimination in terms of access to education, employment, credit, health care, land and inheritance. These factors can all put women in a position where they are particularly vulnerable to HIV infection. In sub-Saharan Africa, around 59% of those living with HIV are female.
In many African countries, sexual relationships are dominated by men, meaning that women cannot always practice safer sex even when they know the risks involved. Attempts are currently being made to develop a microbicide – a cream or gel that can be applied to the vagina, preventing HIV infection – which could be a significant breakthrough in protecting women against HIV. It is likely to be some time before a microbicide is ready for use, though, and even when it is, women will only use it if they have an awareness and understanding of HIV and AIDS. To promote this, a greater emphasis needs to be placed on educating women and girls about AIDS, and adapting education systems to their needs. In some Southern African countries the rate of HIV among 23-24 year old females is far higher than that of 15-17 year old girls. This suggests prevention activities should target women at a young age and ensure they have the knowledge and skills to avoid HIV infection from when they become sexually active.
Tackling the AIDS crisis in Africa is a long-term task that requires sustained effort and planning – both within African countries themselves and amongst the international community. One of the most important elements of the fight against AIDS is the prevention of new HIV infections. HIV prevention campaigns that have been successful within African countries need to be highlighted and repeated.
The other main challenge is providing treatment and care to those living with HIV in Africa, in particular ARVs, which can allow people living with HIV to live longer and healthier lives. Many African countries have made significant progress in their treatment programs in recent years and it is likely that the next few years will see many more people receiving the drugs.