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Africa: AIDS Report
AfricaFocus Bulletin
Dec 3, 2004 (041203)
(Reposted from sources cited below)
Editor's Note
Despite over 3 million deaths from AIDS worldwide this year, the
number estimated to be living with HIV continued to climb to an
all-time high of 39.4 million people around the world. Almost two thirds
of those infected (25.4 million), and almost 75 percent of
the deaths (2.3 million) were in Sub-Saharan Africa.
The AIDS Epidemic Update 2004, from UNAIDS (
http://www.unaids.org/wad2004/report.html)
notes that the AIDS epidemics in different African regions differ
substantially, with declines in prevalence being registered in some
East African countries, still relatively low levels in most West
African countries, and devastatingly high levels throughout
Southern Africa, except Angola. Common to the pandemic in Africa
and worldwide, however, is the fact that gender inequality fuels
the pandemic. It does this both by making prevention messages
irrelevant when women are unable to make their own decisions to
protect themselves and by imposing disproportionate burdens of care
on women.
Inadequate financial resources, lack of political will, and
shortages of health care personnel are also fundamental factors in
the failure of the world's response to keep pace with the pandemic.
But, as this report stresses, the shortfall in prevention and
treatment programs is not only quantitative. No program can be
successful in confronting AIDS unless it also confronts the power
inequalities between men and women.
This AfricaFocus Bulletin contains excerpts from the introduction
and from chapter on Africa of the full UNAIDS report. Another
Bulletin sent out today has excerpts from the report of the UN
Secretary-General's Task Force on Women, Girls and HIV/AIDS in
Southern Africa
For previous AfricaFocus Bulletins on AIDS and other health issues,
visit http://www.africafocus.org/healthexp.php
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AIDS epidemic update: December 2004
Excerpts from Introduction
The total number of people living with the human immunodeficiency
virus (HIV) rose in 2004 to reach its highest level ever: an
estimated 39.4 million [35.9 million-44.3 million] people are
living with the virus. This figure includes the 4.9 million [4.3
million-6.4 million] people who acquired HIV in 2004. The global
AIDS epidemic killed 3.1 million [2.8 million-3.5 million] people
in the past year. ...
Sub-Saharan Africa remains by far the worst-affected region, with
25.4 million [23.4 million-28.4 million] people living with HIV at
the end of 2004, compared to 24.4 million [22.5 million-27.3
million] in 2002. Just under two thirds (64%) of all people living
with HIV are in sub-Saharan Africa, as are more than three
quarters (76%) of all women living with HIV.
The epidemics in sub-Saharan Africa appear to be stabilizing
generally, with HIV prevalence at around 7.4% for the entire
region. But such a summary perspective hides important aspects.
First, roughly stable HIV prevalence means more or less equal
numbers of people are being newly infected with HIV and are dying
of AIDS. Beneath the apparent constancy of steady prevalence
levels lie devastating realities especially in southern Africa,
which accounts for one third of all AIDS deaths globally. Second,
the epidemics in Africa are diverse, both in terms of their scale
and the pace at which they are evolving. There is no single
"African" epidemic. Some urban parts of East Africa display modest
declines in HIV prevalence among pregnant women, while in West and
Central Africa prevalence levels have stayed roughly steady at
lower levels than in the rest of sub-Saharan Africa. ...
...
Women Are Increasingly Affected
The AIDS epidemic is affecting women and girls in increasing
numbers. Globally, just under half of all people living with HIV
are female. Women and girls make up almost 57% of all people
infected with HIV in sub-Saharan Africa, where a striking 76% of
young people (aged 15-24 years) living with HIV are female. In most
other regions, women and girls represent an increasing proportion
of people living with HIV, compared with five years ago.
These trends point to serious gaps in the AIDS response. ... the
vulnerability of women and girls to HIV infection stems ...their
pervasive disempowerment. Most women around the world become
HIV-infected through their partner's high-risk behaviour, over
which they wield little if any control. ...
AIDS Response Needs to Keep Growing
There has been a sea-change in the global AIDS response since 2001.
Global funding has increased from roughly US$ 2.1 billion to an
estimated US$ 6.1 billion in 2004 , and access to key prevention
and care services has improved markedly (UNAIDS, 2004). The number
of secondary-school students receiving AIDS education has nearly
tripled, the annual number of voluntary counselling and testing
clients has doubled, the number of women offered services to
prevent mother-to-child transmission has increased by 70%, and the
number of people receiving antiretroviral therapy has increased by
56%, according to a recent survey in 73 low- and middle-income
countries which represent almost 90% of the global burden of HIV
(Policy Project et al., 2004). ...
Despite the improvements, however, coverage remains uneven and, in
several respects, highly unsatisfactory. Approximately 440,000
people in low- and middle-income countries were receiving
antiretroviral treatment as of June 2004 (WHO, 2004). This means
that nine out of every ten people who need antiretroviral
treatment - the majority of them in sub-Saharan Africa - are not
receiving it. ...
Business as usual spells disaster. A massive effort is needed to
achieve a response on a scale that matches that of the global AIDS
epidemic. Without invigorated HIV prevention strategies that deal
boldly with the epidemic, and that also address the wider
imperatives of social justice and equality, the world is unlikely
to gain the upper-hand over AIDS in the long run.
AIDS epidemic update: December 2004
Excerpts from chapter on Sub-Saharan Africa
Table: Sub-Saharan Africa
HIV and AIDS statistics and features, end of 2002 and 2004
Adults and children living with HIV
2004: 25.4 million [23.4-28.4 million]
2002: 24.4 million [22.5-27.3 million]
Number of women living with HIV
2004: 13.3 million [12.4-14.9 million]
2002: 12.8 million [11.9-14.3 million]
Adults and children newly infected with HIV
2004 3.1 million [2.7-3.8 million]
2002 2.9 million [2.6-3.6 million]
Adult prevalence (%)
2004: 7.4% [6.9-8.3%]
2002: 7.5% [7.0-8.4%]
Adult and child deaths due to AIDS
2004: 2.3 million [2.1-2.6 million]
2002: 2.1 million [1.9-2.3 million]
The AIDS epidemics coursing through this region are highly varied.
There is no single, "African" epidemic. Sub-Saharan Africa has just
over 10% of the world's population, but is home to more than 60% of
all people living with HIV some 25.4 million [23.4 million-28.4
million]. ...
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.
Not one epidemic, but many
While a bird's-eye view might discern overall stabilizing trends in
HIV prevalence, the AIDS epidemics coursing through this region are
highly varied both between and within sub-regions. It is therefore
inaccurate to speak of a single, "African" epidemic and misleading
to apply insights about the epidemic gleaned from specific parts or
subregions, to the entire sub-Saharan Africa region. ...
East Africa now boasts several examples of gradual, modest declines
in median HIV prevalence among pregnant women in urban areas. These
are still early days, though. Even Uganda, which has shown
consistent declines in HIV prevalence levels since the mid-1990s,
remains burdened with a serious epidemic. In West and Central
Africa there is little evidence of changes in prevalence levels,
which have stayed steady at 5% or lower (with the significant
exceptions of Cameroon and Cote d'Ivoire, where median
HIV-prevalence levels have reached and then remained at roughly the
10% mark among pregnant women at some sites in recent years)
(Asamoah-Odei, Garcia-Calleja and Boerma, 2004). National
prevalence statistics, though, can hide much higher levels of
infection in particular provinces, states or districts.
Unfortunately, southern Africa offers only faint hints of impending
declines in HIV prevalence. With the exception of Angola (where the
epidemic's progression may have been retarded during the country's
long civil war with the result that national HIV prevalence has not
exceeded 5%), each country in this subregion is experiencing
national HIV prevalence of at least 10%. This means that an
estimated 11.4 million (10.5 million-12.6 million) people are
living with HIV in these nine countries almost 30% of the global
number of people living with HIV in an area where only 2% of the
world's total population resides.
While HIV prevalence measured at antenatal clinics has edged lower
in parts of some countries and in specific age groups (for example,
Lilongwe, Malawi), there is no sign yet of an overall, national
decline in any southern African country. ...
But underlying this diversity are some striking consistencies.
Across the region, women are disproportionately affected by HIV. On
average, there are 13 women living with HIV for every 10 infected
men and the gap continues to grow. In most countries, women are
being infected with HIV at earlier ages than men. The differences
in infection levels between women and men are most pronounced among
young people (aged 15-24 years). Recent population-based studies
suggest that there are on average 36 young women living with HIV
for every 10 young men in sub-Saharan Africa. In Ghana the ratio
widens to more than nine to one.
In a study among women in Harare (Zimbabwe), Durban and Soweto
(South Africa), 66% reported having one lifetime partner, 79% had
abstained from sex until at least their 17th birthday (roughly the
average age of first sex in most countries in the world), and 79%
said they used a condom. Yet, 40% of the young women were
HIV-positive (Meehan et al., 2004). Many are being infected despite
staying loyal to one partner.
Sexual abuse and violence much, but not all of it directed against
females are serious problems that transcend economic, social,
ethnic and geographical lines. Adolescents, children and young
women and girls in particular experience increased abuse in the
form of domestic violence, rape and sexual assault, and sexual
exploitation or undergo female genital mutilation. In some Ugandan
surveys, 46% of women said they have endured regular physical
abuse, while in Kenyan and Zambian studies more than 40% of women
have reported abuse. For some young women, their first sexual
encounter occurs under coercion or force, which can be associated
with an increase in HIV transmission.
Southern Africa
Southern Africa remains the worst affected subregion in the world,
with data from selected antenatal clinics in urban areas showing
HIV prevalence surpassing 25%, having risen sharply from around 5%
in 1990.
South Africa continues to have the highest number of people living
with HIV in the world. An estimated 5.3 million [4.5 million 6.2
million] people were living with HIV end-2003 in South Africa 2.9
million [2.5 million 3.3 million] of them women. Unfortunately,
there is no sign yet of a decline in the epidemic. Overall HIV
prevalence among pregnant women was 27.9% in 2003, compared with
26.5% in 2002 and 25% the year before that. ... One recent
population-based survey has indicated possible shifts towards safer
sex among young South Africans (Reproductive Health Research Unit,
Medical Research Council, 2004). However, prevalence levels among
pregnant women aged 15 24 years have continued to rise from 23.1%
in 2001 to 24.3% in 2003. ...
Very high HIV prevalence often exceeding 30% among pregnant women
is still being recorded in four other countries in the region, all
with small populations: Botswana, Lesotho, Namibia and Swaziland.
There, comparisons of prevalence levels at selected antenatal
clinics have shown no evidence of a decline. ... Elsewhere in the
subregion, HIV infections in pregnant women appear to be
stabilizing at lower levels around 18% in Malawi (2003), 16% in
Zambia (2003), and 25% in Zimbabwe (2003) but there is little
evidence of an impending decline. In Zimbabwe's case, it is
estimated that new HIV infections have stayed roughly steady since
1996-1997. As in the other countries in the region, women are
disproportionately bearing the brunt. ... Overall, almost 57% of
people with HIV in 2003 were women and an equal proportion of AIDS
deaths were among women (Ministry for Health and Child Welfare
Zimbabwe, 2004). ...
Angola is an exception in the region. During nearly two generations
of war, civilians' movements were restricted, transport links
severed, and parts of the country were intermittently cut off from
the outside world. Available data suggest that those conditions
probably slowed the spread of HIV. ...After two years of relative
peace and with normal life resuming for millions of Angolans, there
is every reason to fear much more widespread and rapid HIV
transmission in this country.
Newly published study findings show southern Africa to be firmly in
the grip of the AIDS epidemic, as more people succumb to
HIV-related illnesses and die. Life expectancy at birth has dropped
below 40 years in nine African countries Botswana, Central African
Republic, Lesotho, Malawi, Mozambique, Rwanda, Swaziland, Zambia
and Zimbabwe. ...
Detailed demographic surveillance is providing further evidence of
steep rises in mortality. One such survey, conducted in a rural
area of KwaZulu-Natal province, which has high HIV prevalence among
pregnant women, has confirmed a sudden and massive rise in adult
mortality starting in the late 1990s, with AIDS (with or without
TB) constituting the leading cause of adult death (48%) by 2000.
The risk of dying from AIDS for women peaks among women aged 25-39
years and among men aged 30-44 years. These AIDS mortality rates
will almost certainly worsen in the coming years, since
HIV-prevalence levels in this particular district rose steeply in
the late 1990s. AIDS mortality reflects HIV incidence roughly a
decade or so earlier (Hosegood, Vanneste and Timaeus, 2004).
Youth, sex and HIV in South Africa
Effective prevention among young people is essential. Throughout
southern Africa, HIV prevalence sharply increases once people reach
their twenties. The trend is vividly captured in a new,
comprehensive study on HIV and sexual behaviour among young South
Africans (conducted by the Reproductive Health Research Unit and
Medical Research Council).
The study shows HIV prevalence to be comparatively low among 15-19
year-olds, at 4.8%. This is not that surprising, given that the
mean age of first sex reported by respondents was 16.4 years for
young men and 17 years for young women. It's in the next age group
among 20-24 year-olds that HIV prevalence soars, reaching 16.5%. In
this age group, HIV infections are massively concentrated among
women. About one-in-four (24.5%) women surveyed was HIV-positive,
compared to one-in-thirteen (7.6%) men. Indeed, more than three
quarters (77%) of young South Africans living with HIV are female,
a discrepancy that only begins to fade among South Africans 30
years and older. Similar to young people around the world, many
young South Africans (62%) who learn they are HIV-positive believed
they had faced little or no risk of contracting the virus.
Young women were found to be disproportionately at risk of HIV
infection. Sexual aggression is common, with more than one quarter
(28%) of the women saying their first sexual experience was
unwanted, and one in ten (10%) saying they had been forced to have
sex. Almost half (49%) the young women who'd had sex said they had
been pregnant at some point suggesting that condom use was not the
norm. Indeed, fully one third of those youth who had had sex in the
previous 12 months never used a condom, and two thirds had not used
one with their most recent sexual partner (Reproductive Health
Research Unit, Medical Research Council, 2004).
East Africa
Some countries in East Africa do display signs of real declines in
HIV infection levels. Uganda, where national prevalence fell from
13% in the early 1990s to 4.1% (2.8 6.6%) by end-2003, is the most
notable, but by no means the only example. Comparisons of HIV
prevalence among antenatal clinic attendees across the subregion
show an overall significant decline from a median of 12.9% (7.0-
16.9%) in 1997-1998 to 8.5% (5.3-14.0%) in 2002 (Asamoah-Odei,
Garcia-Calleja and Boerma, 2004). ...
The downward trend is most firmly established in Uganda, which saw
HIV prevalence decline steeply during the mid- and late-1990s,
remaining subsequently at 5% to 6%. Recent data suggest Kenya could
be on a similar path. There, data from antenatal clinics show
median HIV prevalence falling from 13.6% (12.2-27.1%) in 1997-1998
to 9.4% (6.6-14.3%) in 2002 and then staying largely unchanged in
2003. Figures for Burundi also suggest a decline in HIV prevalence,
but this is based on limited data from only six clinics
(Asamoah-Odei, Garcia-Calleja and Boerma, 2004).
Ethiopia's epidemic is most severe in urban areas, including in the
capital Addis Ababa. However, there are encouraging signs that the
declining HIV trend among pregnant women in the capital (first
detected in 1997) is continuing. By 2003, HIV prevalence in the
city had fallen to 11%, less than half the level (24%) it had
reached in the mid-1990s. Overall, in 10 antenatal clinics in
Ethiopia, median prevalence dropped from 13.7% in 1997-1998 to
11.8% in 1999-2000, and has remained at about 12% since then
(Asamoah-Odei, Garcia-Calleja and Boerma, 2004).
These are heartening developments but still-high HIV-prevalence
levels underscore the need to redouble and extend prevention
efforts throughout these countries. It is much too early to claim
that these recent declines herald a definitive reversal in these
countries' epidemics and, furthermore, the need for treatment, care
and support will continue to increase for years to come.
Meanwhile, a clearer picture is emerging of the epidemic in
Eritrea, where the most detailed round of HIV sentinel surveillance
to date has fixed prevalence at 2.4% in 2003. Overall HIV
prevalence in the country appears to be stabilizing. However,
infection levels vary considerably highlighting a need to intensify
and to refine the focus of prevention efforts. Prevalence reached
7.2% along the country's southern coastal strip, and was more than
three times as high in urban than in rural areas. ... (Ministry of
Health Eritrea, 2004).
Overall, there is no evidence of nationwide HIV prevalence decline
in Tanzania. However, in Mbeya region, which has been the focus of
intense prevention efforts over the past 13 years, HIV prevalence
among 15-24 year-old women fell from 20.5% in 1994-1995 to 14.6% in
2000, while condom use rose and treatment for other sexually
transmitted infections increased, and a significant delay in age at
first sex was noted over the same period. ...
AfricaFocus Bulletin is an independent electronic publication
providing reposted commentary and analysis on African issues, with
a particular focus on U.S. and international policies. AfricaFocus
Bulletin is edited by William Minter.
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