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Africa: AIDS Epidemic Update

AfricaFocus Bulletin
Jun 3, 2006 (060603)
(Reposted from sources cited below)

Editor's Note

"Sub-Saharan Africa remains the worst-affected region in the world. ... Overall, HIV prevalence in this region appears to be levelling off, albeit at exceptionally high levels in southern Africa. Such apparent 'stabilization' of the epidemic reflects situations where the numbers of people being newly infected with HIV roughly match the numbers of people dying of AIDS-related illnesses." - 2006 Report on the Global AIDS Epidemic

Despite some signs of progress, such as declining rates in AIDS prevalence in Kenya and Zimbabwe, the report noted that only one of five Africans needing antiretroviral treatment has access to treatment. "Seven times more people have access to treatment" than five years ago, UN Secretary General Kofi Annan told the General Assembly on June 2. "But the epidemic continues to outpace us. Last year, globally, there were more new infections than ever before, and more people died than ever before."

UNAIDS estimates that some 2 million people died of AIDS in subSaharan Africa in 2005, compared to approximately 1.9 million in 2003. The number of AIDS orphans increased from an estimated 10.2 million to an estimated 12 million and the number of people living with HIV from an estimated 23.5 million to an estimated 24.5 million.

This AfricaFocus Bulletin contains excerpts from the section on Africa in UNAIDS 2006 Report of the Global AIDS Epidemic. For the full report visit the UNAIDS website (http://www.unaids.org). Another Bulletin also sent out today contains reports on the civil society critique of the official statement agreed by government representatives yesterday.

For earlier AfricaFocus Bulletins on health issues, visit http://www.africafocus.org/healthexp.php

++++++++++++++++++++++end editor's note+++++++++++++++++++++++

2006 Report on the Global AIDS Epidemic

Excerpts from Chapter 02 Overview of the Global AIDS Epidemic

An estimated 38.6 million [33.4 million--46.0 million] people worldwide were living with HIV in 2005. An estimated 4.1 million [3.4 million--6.2 million] became newly infected with HIV and an estimated 2.8 million [2.4 million--3.3 million] lost their lives to AIDS. Introduction

Overall globally, the HIV incidence rate (the annual number of new HIV infections as a proportion of previously uninfected persons) is believed to have peaked in the late 1990s and to have stabilized subsequently, notwithstanding increasing incidence in a number countries. In several countries, favourable trends in incidence are related to changes in behaviour and prevention programmes. Changes in incidence along with rising AIDS mortality have caused global HIV prevalence (the proportion of people living with HIV) to level off (see Figure 2.1). However, the numbers of people living with HIV have continued to rise, due to population growth and, more recently, the lifeprolonging effects of antiretroviral therapy.

In sub-Saharan Africa, the region with the largest burden of the AIDS epidemic, data also indicate that the HIV incidence rate has peaked in most countries. However, the epidemics in this region are highly diverse and especially severe in southern Africa, where some of the epidemics are still expanding.

New survey data underscore the disproportionate impact of the AIDS epidemic on women, especially in sub- Saharan Africa where, on average, three women are HIV-infected for every two men. Among young people (15 24 years), that ratio widens considerably, to three young women for every young man.

Among the notable new trends are the recent declines in national HIV prevalence1 in two sub-Saharan African countries (Kenya and Zimbabwe), urban areas of Burkina Faso and similarly in Haiti, alongside indications of significant behavioural change including increased condom use, fewer partners and delayed sexual debut. In the rest of sub-Saharan Africa, the majority of epidemics appear to be levelling off but at exceptionally high levels in most of southern Africa.

...

Sub-Saharan Africa

Sub-Saharan Africa remains the worst-affected region in the world. Across the region, rates of new HIV infections peaked in the late 1990s, and a few of its epidemics show recent declines, notably in Kenya, Zimbabwe and in urban areas of Burkina Faso. Overall, HIV prevalence in this region appears to be levelling off, albeit at exceptionally high levels in southern Africa. Such apparent 'stabilization' of the epidemic reflects situations where the numbers of people being newly infected with HIV roughly match the numbers of people dying of AIDS-related illnesses.

A little more than one-tenth of the world's population live in sub-Saharan Africa which is home to almost 64% of all people living with HIV--24.5 million [21.6 million--27.4 million]. Two million [1.5 million--3.0 million] of them are children younger than 15 years of age. Indeed, almost nine in ten children (younger than 15 years) living with HIV are in sub-Saharan Africa. An estimated 2.7 million [2.3 million--3.1 million] people in the region became newly infected, while 2.0 million [1.7 million--2.3 million] adults and children died of AIDS. There were some 12.0 million [10.6 million--13.6 million] orphans living in sub-Saharan Africa in 2005.

Three-quarters of all women (15 years and older) living with HIV are in sub-Saharan Africa. In most of the region, women are disproportionately affected by AIDS, compared with men expressions of the often highly unequal social and socioeconomic status of women and men. Women comprise an estimated 13.2 million [11.4 million-15.1 million] or 59% of adults living with HIV in Africa south of the Sahara.

An estimated 930,000 [790,000-1.1 million] adults and children died of AIDS in southern Africa in 2005-one-third of all AIDS deaths globally. Access to antiretroviral therapy has increased more than eight-fold since the end of 2003, with about 810,000 people on treatment in December 2005. About one in six (17%) of the 4.7 million people in need of antiretroviral therapy in this region now receive it. Progress is uneven, however, with coverage reaching or exceeding 50% in only three countries (Botswana, Namibia and Uganda) but remaining below 20% in most others. South Africa accounts for one-quarter of all people receiving antiretroviral therapy in sub-Saharan Africa (WHO/UNAIDS, 2006).

It bears reminding that there is no single, 'African' epidemic, and that HIV prevalence varies significantly between and within subregions and countries. Such general trends in HIV prevalence therefore should not obscure the highly varied nature of the AIDS epidemics underway throughout this region.

Southern Africa remains the global epicentre of the epidemic. Almost one in three people infected with HIV globally live in this subregion. About 43% (860,000 [560,000-1.4 million]) of all children (under 15 years) living with HIV are in southern Africa, as are approximately 52% (6.8 million [5.9 million-7.7 million]) of all women (15 years and older) living with HIV.

Except in Angola, national HIV infection levels are exceptionally high and show no signs of abating. (In Angola's case, isolation and inaccessibility of the population during the country's prolonged conflict may have served to restrict the spread of HIV.) However, in Zimbabwe, data from national sentinel surveillance, and national and local community-based surveys show a declining trend in HIV prevalence. National adult HIV prevalence is estimated at 20.1% [13.3%-27.6%], down from 22.1% [14.6%-30.4%] in 2003. HIV prevalence among pregnant women attending antenatal clinics fell from 32% in 2000 to (a still-very-high) 24% in 2004, while in Harare it declined from 35% in 1999 to 21% in 2004 (Mahomva et al., 2006; Hargrove et al., 2005; Mugurungi et al., 2005). ...

Nationally, there appears to have been a substantial increase in condom use since the early 1990s. Such behavioural change is likely associated with a combination of AIDS awareness, relatively extensive health infrastructure and a growing fear of AIDS mortality. However, a significant part of the decline in HIV prevalence is attributable to high mortality rates. With 1.7 million [1.1 million-2.2 million] people living with HIV, Zimbabwe needs to sustain the declining trend in HIV prevalence and dramatically improve the provision of antiretroviral treatment if it is to gradually bring its epidemic under control. An estimated 320,000 people needed antiretroviral treatment in 2005, yet about 23,000 were receiving antiretroviral drugs (WHO/UNAIDS, 2006).

South Africa's AIDS epidemic -- one of the worst in the world -- shows no evidence of a decline. Based on its extensive antenatal clinic surveillance system, as well as national surveys with HIV testing and mortality data from its civil registration system, an estimated 5.5 million [4.9 million-6.1 million] people were living with HIV in 2005. An estimated 18.8% [16.8%-20.7%] of adults (15-49 years) were living with HIV in 2005. Almost one in three pregnant women attending public antenatal clinics were living with HIV in 2004 and trends over time show a gradual increase in HIV prevalence (Department of Health South Africa, 2005). While household surveys with HIV testing in 2003 and 2005 show lower HIV prevalence, they are plagued by high nonresponse rates (over 40%). The 2005 national household HIV survey found high levels of HIV infection levels among young people (aged 15-24 years), which were about the same as those found in a national young people survey in 2003, a sign that the epidemic has not lost momentum (Shisana et al., 2005; Reproductive Health Research Unit and Medical Research Council, 2004). ...

While South Africa's HIV prevention efforts have not made notable inroads against the epidemic, there has been significant progress on the treatment front. With approximately 190,000 people receiving antiretroviral treatment by the end of 2005, South Africa accounts for a large share of the treatment scale-up in sub-Saharan Africa overall this decade (WHO/UNAIDS, 2006). However, this still means that less than 20% of the almost one million South Africans in need of antiretroviral treatment were receiving it in 2005 (WHO/UNAIDS, 2005).

There are no clear signs of declining HIV prevalence elsewhere in southern Africa including in Botswana, Namibia and Swaziland, where exceptionally high infection levels continue. In Swaziland, national adult HIV prevalence is estimated at 33.4% [21.2%-45.3%]. HIV prevalence among pregnant women attending antenatal clinics rose from 4% in 1992 to 43% in 2004 (Ministry of Health and Social Welfare Swaziland, 2005). Although many young women report delaying their sexual debut, once women do have unprotected sex, the odds of acquiring HIV are dauntingly high. Sexual aggression appears to be widespread: in a study among high school students, almost one in five (18%) of the sexually active female students said their first sexual experience had been coerced (Buseh, 2004).

Botswana's epidemic is equally serious, with national adult HIV prevalence estimated at 24.1% [23.0%-32.0%] in 2005. Among pregnant women attending antenatal clinics, prevalence in 2004 was 34% overall, and close to 50% among women 30-34 years of age. ...

Lesotho's epidemic seems to be relatively stable at very high levels, with an estimated national adult HIV prevalence of 23.2% [21.9%-24.7%]. High infection levels of 27% were observed among antenatal clinic attendees in 2004, when over one-third (36%-38%) of pregnant women 25 34 years of age tested HIV-positive. ...

In parts of sparsely populated Namibia, the epidemic is as intense as in some of its neighbours, with HIV prevalence estimated at 19.6% [8.6%-31.7%] among adults nationally. In antenatal clinic attendees, HIV prevalence is surpassing 42% in Katima Mulilo (in the Caprivi Strip flanked by Angola, Botswana and Zambia) and ranging between 22% and 28% in the port cities of Luderitz, Swakopmund and Walvis Bay (Ministry of Health and Social Services Namibia, 2004). To the north, Angola remains an anomaly, with HIV prevalence much lower than in any other country in this subregion. An estimated 3.7% [2.3%-5.3%] of adults were HIV-positive in 2005. Although the country's HIV surveillance system has improved dramatically in recent years, it remains difficult to discern clear trends in the epidemic (Ministerio da Saude do Angola, 2004). Where comparable data do exist in the capital, Luanda, for example prevalence rose from 0.3% in 1986 to 4.4% in 2004.

On the eastern coastline, a dynamic epidemic is underway in Mozambique, where the estimated national adult HIV prevalence is 16.1% [12.5%-20.0%]. HIV is spreading fastest in provinces linked by major transport routes to Malawi, South Africa and Zimbabwe. High infection levels are being found in Gaza (from where large numbers of migrants working in South Africa originate) and Sofala provinces (which is traversed by Zimbabwe's main export route) (Ministry of Health Mozambique, 2005). In neighbouring Malawi, national adult HIV prevalence is estimated at 14.1% [6.9%-21.4%]. ... Zambia's epidemic appears not to be relenting either, with adult HIV prevalence estimated at 17.0% [15.9%-18.1%]. There is wide geographic variation, though, with HIV infection levels among pregnant women ranging from under 10% in some places (e.g. Kasaba, Macha and Mukinge) to as high as 30% in others (e.g. Matero and Livingstone). Cities and towns with the highest HIV prevalence tend to be clustered along major transport routes including Kabwe, Livingstone and Ndola (National HIV/ AIDS Council Zambia, 2005).

The picture is starkly different in the island nations of southern Africa. National adult HIV prevalence in Madagascar stood at an estimated 0.5% [0.2%-1.2%] in 2005, but low levels of HIV knowledge and significant risk behaviour mean this could change. ...Meanwhile, high levels of transmission of HIV among injecting drug users (with estimated HIV prevalence of 10%-20%) and significant infection levels (3%-7%) among female sex workers in Mauritius indicate that larger HIV outbreaks are possible there.

In the countries of East Africa, HIV prevalence has either decreased or remained stable in the past several years. Here, too, women face considerably higher risk of HIV infection than men, especially at younger ages. The epidemics are varied, with HIV prevalence among pregnant women ranging from approximately 2% in Eritrea to 7% and higher in Kenya, Uganda and United Republic of Tanzania (Ministry of Health Eritrea, 2006; Ministry of Health Uganda, 2005; National AIDS Commission Tanzania, 2005; Ministry of Health Kenya et al., 2003).

While Burundi and Uganda's epidemics appear to have stabilized, HIV prevalence among pregnant women in Kenya has been declining, especially in urban areas (Cheluget et al., 2006;WHO,2005a; Baltazar, 2005). As a result, national adult HIV prevalence is estimated to have fallen from 10% in the late 1990s to about 7% in 2003 (Ministry of Health Kenya, 2005). Various behavioural surveys show the proportion of adults with more than one sexual partner is shrinking, more women are delaying their sexual debut, and condom use is rising. Increased mortality and the saturation of infection among people most at risk also appear to be the factors associated with the decline in HIV prevalence (Cheluget et al., 2006). ...

In Uganda, which saw a steep decline in HIV prevalence during the mid- and late-1990s, adult HIV prevalence was an estimated 6.7% [5.7%-7.6%] in 2005. New HIV surveillance data indicate that HIV prevalence continues to decline among pregnant women in the capital, Kampala, and has remained stable elsewhere, including in most rural areas since 2001. However, a 2004-2005 national household survey found condom use was erratic (only about half the men and women surveyed reported using a condom the last time they had sex with a casual partner), and almost one in three men said they had had more than one sexual partner in the previous year (Ministry of Health Uganda, 2005).

Overall, Rwanda's epidemic has been stable in recent years, with 190,000 people [180,000-210,000] (3.1% of adults [2.9%-3.2%]) estimated to live with HIV in 2005. Observed national HIV prevalence has declined since the late 1990s, but improved HIV surveillance methodology probably accounts for an important part of that trend. ... HIV trends in neighbouring Burundi, where adult HIV prevalence is estimated at 3.3% [2.7%-3.8%], are also ambiguous. ...

On the mainland of the United Republic of Tanzania, an estimated 1.4 million people [1.3 million-1.6 million] (6.5% of adults [5.8%- 7.2%]) were living with HIV in 2005, highlighting the challenges of improving prevention efforts and substantially expanding access to treatment and care. HIV infection trends suggest a relatively stable epidemic, but prevalence has increased markedly in older age groups, reaching 13% among women aged 30-34 years (Tanzania Commission for AIDS, 2005). Injecting drug use is increasing here, too not only in Dar es Salaam, but also on the island of Pemba (Beckerleg et al., 2005).

In Ethiopia's urban areas, HIV prevalence among women seeking antenatal care has remained stable at high levels since the late 1990s (almost 15% in Addis Ababa and 12% in other urban areas in 2003), the exception being among 15-24-year-old pregnant women where prevalence fell from 15.0% in 2000 to 11.5% in 2003. (Hladik et al., 2006; Federal Ministry of Health Ethiopia, 2004). Meanwhile, the epidemic appears to have intensified in some rural areas in recent years, with rising HIV infection levels in women attending antenatal clinics (2.6% in 2003, up from 1.9% in 2000) (Hladik et al., 2006; Federal Ministry of Health Ethiopia, 2004). ... Meanwhile, neighbouring Eritrea's epidemic appears to be stable, with adult HIV prevalence having remained at 2.4% [1.3%- 3.9%]. However, infection levels are considerably higher in the south of the country and in 2005 exceeded 7% in Assab town (Ministry of Health Eritrea, 2006).

Less is known about HIV trends in Djibouti and Somalia. The former has a serious epidemic, with national adult HIV prevalence estimated at 3.1% [0.8%-6.9%] in 2005. ... In Somalia, a 2004 survey indicated that the virus was present in most of the country, but HIV prevalence among pregnant women nationally was still low, at 0.6% (WHO, 2005b). ...

West Africa is less severely affected than other parts of sub-Saharan Africa, with national adult HIV prevalence estimates lower than 2% in several countries. The highest adult prevalence in the region is in Cote d'Ivoire at 7.1% [4.3%-9.7%]. Significant declines in HIV prevalence among pregnant women have been observed in urban areas of Burkina Faso, and in Abidjan, Cote d'Ivoire, and Lome , Togo, (WHO, 2005). However, in Dakar, Senegal, and Accra, Ghana, infection levels have been rising among antenatal clinic attendees (WHO, 2005). Nigeria has the third-largest number of people living with HIV -- 2.9 million [1.7 million-4.2 million] -- in the world. The median HIV prevalence among antenatal clinics has levelled off at around 4%, but infection levels vary radically across this large country (from 2.6% in the South West to 6.1% in the North Central zones) (Federal Ministry of Health Nigeria, 2006). ...

Senegal's epidemic, meanwhile, still pivots mainly on the sex trade, and there is an ongoing danger of HIV spreading more widely from sex workers and their clients to lower-risk sections of the population. HIV prevalence among female sex workers has remained high (at around 20% in Dakar and 30% in Ziguinchor) for almost a decade (Gomes et al., 2005; WHO, 2005a). National HIV prevalence was estimated at 0.9% [0.4%-1.5%] in 2005, ... Sex work is also a driving factor in Ghana's epidemic, where adult HIV prevalence is estimated at 2.3% [1.9%-2.6%]. ...


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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