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This is one of two pages of questions and answers about HIV and AIDS in Africa. To learn more about issues such as poverty, and what is being done to confront HIV and AIDS, see our other Q&A page.

• Are there any differences between AIDS in Africa and AIDS elsewhere in the world?
• How serious a problem is AIDS in Africa?
• Is the problem getting better or worse?
• What is the impact of AIDS in Africa?
• Why is HIV more widespread in Africa than elsewhere in the world, and why are some parts of Africa affected more than others?
• Which part of Africa is worst affected?
• How many of the Africans living with HIV are women?
• How many African children have been orphaned by AIDS?
• Did AIDS originate in Africa?
• What is the difference between HIV incidence and HIV prevalence?
• How do we know how many people are living with HIV if not everyone has been tested?
• What does it mean if HIV prevalence remains stable?
• Is a fall in HIV prevalence a good thing or a bad thing?
• If a country is effectively tackling HIV and AIDS, what is the effect on incidence and prevalence?
• Do unsafe injections cause many HIV infections in Africa?
• Do many people become infected with HIV as a result of cultural and traditional practices such as polygamy, widow inheritance, sexual cleansing, dry sex, blood oaths, scarification or tattooing?
• Does male circumcision have any effect on rates of HIV transmission?
• Is AIDS just a new name for old diseases?
• Why do some websites say that HIV doesn’t cause AIDS in Africa, and that it’s caused by malnutrition or dirty water?

Are there any differences between AIDS in Africa and AIDS elsewhere in the world?

AIDS in Africa is basically exactly the same thing as AIDS in the USA, China or anywhere else. The cause of AIDS is always the same – a virus called HIV (Human Immunodeficiency Virus). There are just a couple of small differences worth noting:

1. The most common HIV subtypes in Africa are slightly different to the most common subtypes in the developed world, and this might affect responses to treatment and future vaccines (should any be developed). However, the routes of transmission are exactly the same, and all HIV subtypes cause AIDS.
2. Some opportunistic infections are more common in Africa than elsewhere. For example, someone living with HIV in Botswana is more likely to fall ill with tuberculosis than someone living with HIV in the USA, who is more likely to develop other illnesses.

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How serious a problem is AIDS in Africa?

The numbers are staggering. At the end of 2007 there were an estimated 22.5 million people living with HIV in sub-Saharan Africa (the part below the Sahara desert), and 380,000 in North Africa and the Middle East. AIDS is now the leading cause of death in sub-Saharan Africa – killing an estimated 1.6 million people in 2007 alone. In the same year another 1.7 million became infected with HIV.¹

Read more HIV and AIDS statistics.

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Is the problem getting better or worse?

Africa's overall HIV prevalence (the proportion of people living with HIV) appears to have declined slightly since 2000. However, because of general population growth the number of people living with HIV continues to rise.²

Read the History of AIDS in Africa to see how the epidemic has changed over time.

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What is the impact of AIDS in Africa?

The impact of AIDS is extremely severe and wide-ranging. Life expectancies have fallen below 40 years in some African countries, whereas they would have been above 60 years without AIDS. Most AIDS deaths occur among young adults, and these deaths have a devastating effect on families, communities and economies. The epidemic is wiping out development gains, orphaning millions of children, fuelling the spread of other diseases (including tuberculosis), and even threatening to undermine national security in highly-affected societies.³

Read more about the impact of AIDS on Africa.

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Why is HIV more widespread in Africa than elsewhere in the world, and why are some parts of Africa affected more than others?

No-one really knows the full answer to this question. However we do know there are many factors that influence the rate at which HIV is transmitted. Such factors include poverty; economic disparity; social instability; gender inequality; sexual violence; other sexually transmitted infections (which facilitate HIV transmission); lack of male circumcision; high mobility; rapid urbanisation and modernisation; and ineffective leadership during critical periods in the epidemic’s spread. Some scientists believe that differences between HIV subtypes also have an effect on transmission rates.^{4 5}

People in sub-Saharan Africa don't have many more lifetime partners than people in other parts of the world. However, researchers have found that in some areas it is not uncommon for people to have two or more regular sex partners at the same time. Someone is most likely to transmit HIV during the period shortly after they are infected, when they have very high levels of virus in their body. Therefore someone who has two or more concurrent partners is more likely to transfer HIV between their partners than someone who has a series of monogamous relationships. This too may help to explain why HIV is more widespread in Africa.^{6 7}

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Which part of Africa is worst affected?

Although HIV has now spread throughout Africa, the proportion of people living with the virus varies widely between countries. In Botswana, Lesotho, Zimbabwe and Swaziland, more than one in five adults are infected, whereas in some parts of North Africa the rate is below one in a thousand, which is much lower than in the USA.

Today the highest HIV rates are found in Southern Africa. Several East and Central African countries also have very severe and mature epidemics, which are causing a very high number of AIDS deaths. West Africa has been less severely affected but, because it has such a large population, Nigeria has more people living with HIV than any other African country except South Africa. The lowest HIV rates are found in North Africa, where only Sudan has so far been badly affected.⁸

For the latest data, see our sub-Saharan Africa statistics.

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How many of the Africans living with HIV are women?

At the end of 2007, around 61% of adults living with HIV in sub-Saharan Africa were women.⁹

Read more about women and AIDS.

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How many African children have been orphaned by AIDS?

At the end of 2007, Africa was home to an estimated 11.4 million children under 18 who had lost at least one parent to AIDS.¹⁰

Read more about AIDS orphans.

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Did AIDS originate in Africa?

On current evidence, it seems likely that Africa was where the transfer of HIV to humans first occurred. However, how exactly the virus spread from Africa to America and beyond remains a mystery. It is quite possible that separate 'pockets' of the virus could have been developing in a number of different countries years before the first cases were ever officially identified, making it virtually impossible to trace one single source.

Read more about the origin of HIV.

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What is the difference between HIV incidence and HIV prevalence?

HIV incidence means the number of new HIV infections per year. HIV prevalence means the proportion of people (usually adults) living with HIV at a moment in time. For example, if a survey finds there are 5,000 adults living with HIV in a town of 100,000 adults, then the adult HIV prevalence in that town is 5% (five per hundred). If 500 of these people became infected within the last twelve months, then the HIV incidence among adults is 500 per year. In the real world it is much easier to measure HIV prevalence than HIV incidence.

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How do we know how many people are living with HIV if not everyone has been tested?

It is not possible to work out the number of Africans living with HIV by testing every single person on a regular basis. Estimates of HIV prevalence are therefore based on the results of large surveys.

In a country with a generalised epidemic (a high level of infection in the whole population), estimates are mainly based on surveys of pregnant women attending antenatal clinics. Because antenatal clinics are well-attended in most parts of Africa, these data provide a good basis for comparisons; they are also very reliable at revealing trends. Many studies have shown that HIV prevalence among pregnant women attending antenatal clinics is generally very similar to prevalence in the adult population as a whole.

Read more about understanding HIV & AIDS statistics.

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What does it mean if HIV prevalence remains stable?

In some African countries, HIV prevalence appears to have stabilized at a very high level. This means that two things are happening at the same time: many people are becoming infected with HIV and many people are dying. Thousands of new infections each year are being offset by thousands of deaths, so the proportion of people living with HIV stays the same. And if a country's total population continues to grow then the number of people living with HIV will increase even while the prevalence rate remains stable.

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Is a fall in HIV prevalence a good thing or a bad thing?

Two main factors can cause a fall in HIV prevalence:

1. Fewer people are becoming infected with HIV
2. More people are dying of AIDS

The first of these is obviously a good thing, and could well be a sign that HIV prevention campaigns are working. However, the second factor is clearly a very bad thing. An increase in the AIDS death rate could be a sign of worsening health care, meaning that people with HIV are dying sooner than before. Alternatively, it could be the result of an earlier increase in HIV incidence. This is because people usually survive for a number of years after becoming infected with HIV, so incidence trends have a delayed effect on death trends.

Read more about understanding HIV & AIDS statistics.

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If a country is effectively tackling HIV and AIDS, what is the effect on incidence and prevalence?

An effective HIV prevention programme will lower the number of new infections (HIV incidence). If other factors remain the same then this will eventually cause a decline in HIV prevalence. However, increasing access to antiretroviral therapy will lower the death rate. If the fall in the death rate is greater than the fall in incidence then HIV prevalence will rise.

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Do unsafe injections cause many HIV infections in Africa?

Most experts agree that the vast majority of HIV infections in Africa are the result of unsafe sex, not unsafe injections. The World Health Organisation (WHO) says that it has "previously estimated that unsafe injection practices account for about 2.5% of HIV infections in sub-Saharan Africa. Although there is a margin of uncertainty around this estimate, the conclusion remains that unsafe sex is by far the predominant mode of transmission in sub-Saharan Africa." There is strong evidence to support this position. Nevertheless, the number of infections due to unsafe injections is not insignificant, and efforts to improve the safety of medical procedures form an essential part of HIV prevention programmes across Africa.^{11 12}

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Do many people become infected with HIV as a result of cultural and traditional practices such as polygamy, widow inheritance, sexual cleansing, dry sex, blood oaths, scarification or tattooing?

Some cultural and traditional practices do have an effect on HIV transmission in some parts of Africa. For example, drying the vagina before sex can increase the likelihood of abrasions, which in turn may increase the chances of the virus being transmitted (though the evidence for this is as yet inconclusive).¹³ Also any practice that involves transferring fresh blood carries a significant risk of infection. But it should be remembered that Africa is a very large and highly diverse continent, home to hundreds of distinct cultures. A practice that is traditionally widespread in one region may be completely unheard of elsewhere.

In the West there is a temptation for people to focus on the “exotic” aspects of HIV in Africa and to forget that the major problems of HIV prevention are much the same as those in Europe, the USA or anywhere else. The vast majority of HIV transmissions in Africa occur during unprotected heterosexual sex. HIV prevention efforts should aim to make behaviour and practices safer while respecting local cultures. In many cases this may be achieved through relatively small changes in cultural practices, such as sterilising blades or switching to alternative rituals that are culturally acceptable but carry a lower risk of HIV transmission.¹⁴

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Does male circumcision have any effect on rates of HIV transmission?

This is an example of a cultural practice that lowers the rate of HIV transmission. There is now very strong evidence that circumcised men are about half as likely as uncircumcised men to acquire HIV through heterosexual sex.¹⁵ However, studies also suggest that male circumcision does not reduce the rate of transmission from man to woman, and having sex before the wound is fully healed may increase the risk.¹⁶

Circumcision in no way removes the need for other prevention strategies including abstinence, partner reduction and condom use. There are a number of difficulties associated with promoting circumcision as an HIV prevention strategy, including issues of acceptability, safety and demands on resources. Read more about HIV and circumcision.

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Is AIDS just a new name for old diseases?

AIDS is a name created in 1982 to describe an entirely new epidemic caused by a virus called HIV, which until the early 1980s was very rare in Africa and elsewhere. HIV gradually destroys the human immune system, making people much more vulnerable to other infections and cancers, such as pneumonia, Kaposi’s sarcoma and tuberculosis (TB). AIDS describes the syndrome (a group of symptoms) associated with the most advanced stages of HIV disease.

Although the germs that cause AIDS-defining diseases have been around for a long time, most of them don’t usually cause severe illness or death in people without HIV. For example, someone infected with both TB and HIV is 30-50 times more likely to develop the active form of TB than someone infected with TB alone.¹⁷ Tuberculosis disease in Africa was once confined to the poor, the weak and the elderly, but today it kills many thousands of young adults who are HIV-positive, including well-educated members of the middle class. Unless treated, most people develop a severe AIDS-defining illness within ten years of becoming infected with HIV.¹⁸

Read more about tuberculosis and HIV.

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Why do some websites say that HIV doesn’t cause AIDS in Africa, and that it’s caused by malnutrition or dirty water?

A tiny minority of scientists dispute the theory that HIV causes AIDS, and some have suggested various non-infectious causes. These theories have gained a certain amount of popularity on the Internet. However, the vast majority of scientists agree that the evidence that HIV causes AIDS is abundant and conclusive. Numerous studies in Africa and elsewhere have shown that HIV infection is the only factor that predicts who will develop AIDS, and that AIDS does not occur without HIV.

AVERT.org has a review of the evidence that HIV causes AIDS.

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AVERT.org has more about:

• HIV & AIDS in Africa
• AIDS in Africa Q & A (part two)
• African AIDS statistics
• HIV & AIDS in America