AIDS & HIV in Africa questions and answers: the issues

This is one of two pages of questions and answers about AIDS and HIV in Africa. To learn more about statistics and transmission routes, see our other Q&A page.

Does poverty cause AIDS?
How does poverty affect the response to HIV and AIDS?
Is AIDS a “solution” to overpopulation in Africa?
Are Africans unaware of HIV? If not then why is it still spreading?
Are there any African “success stories”?
How is the world responding to HIV and AIDS in Africa?
Are anti-AIDS drugs effective in Africa?
Can Africans adhere to daily treatment?
How many people are receiving treatment in Africa?
What are the benefits of increasing access to treatment in Africa?
What are the challenges to scaling up treatment access in Africa, and can they be overcome?
Are there already any successful national treatment programmes?
What targets have been set for scaling-up treatment access?
Many Africans suffer from malnutrition, poor sanitation and other diseases like TB and malaria, so why spend so much money tackling AIDS?
Is the response to HIV and AIDS cost effective?
Is the world providing enough assistance to Africa?

Does poverty cause AIDS?

AIDS is caused by HIV, the Human Immunodeficiency Virus. AIDS is not caused by poverty.

Poverty is one of a number of factors that can, in some situations, make people more likely to become infected with this virus. For example, some poor people may be more vulnerable because they have not been taught about HIV prevention; because they are compelled to exchange sexual favours for gifts or money; because they cannot afford to buy condoms or to treat other sexually transmitted infections (which facilitate HIV transmission); or because they are struggling just to keep themselves fed, and have little time to worry about less immediate threats like AIDS. In addition, poorer people usually have less access to HIV counselling and testing facilities, and those who are unaware of their infection are more likely to pass it on.

On the other hand, in some cases the most vulnerable people may be those who can afford to travel around a lot, or to pursue a busy social life, or whose jobs keep them away from home for long periods. In the mid-1980s, when the epidemic was in its early stages, a number of studies found HIV to be associated with relatively rich city-dwellers. More recently, similar patterns have been observed in Tanzania and elsewhere.¹

In summary, the relationship between AIDS and poverty is both complex and varied.² ³ A comprehensive review of the issue published in 2007 concluded that:

"AIDS cannot accurately be termed a 'disease of poverty'. Although it is true that poor individuals and households are likely to be hit harder by the downstream impacts of AIDS, their chances of being exposed to HIV in the first place are not necessarily greater than wealthier individuals or households."⁴

How does poverty affect the response to HIV and AIDS?

Poor African countries are less able to provide adequate HIV education, prevention and testing services, and to care for those who are already infected, than are richer parts of the world. It is quite possible that if Africa had been much richer in the 1980s then the response to HIV and AIDS would have been more effective, and fewer people would have become infected. It is certain that poverty has worsened and is continuing to worsen the suffering from AIDS, by restricting access to treatment and care.

Is AIDS a “solution” to overpopulation in Africa?

AIDS is not a solution to anything. Most people killed by AIDS are young adults – among the most productive members of society. Their deaths not only cause immense human suffering, but also worsen poverty, food shortages and social instability - the very same problems that overpopulation can cause. The solution to excessive population growth is a reduction in birth rates. This has already been achieved elsewhere in the world, largely through poverty reduction, promotion of gender equality and family planning services. Such measures also play an important role in HIV prevention.

Are Africans unaware of HIV? If not then why is it still spreading?

These days the vast majority of Africans are aware that HIV causes AIDS and that the virus can be transmitted through unprotected sex. However, this knowledge by itself does not always lead to lower rates of transmission. Many people find it very difficult to permanently change their sexual behaviour.

In many countries women have a lower status than men and are unable to negotiate condom use or to demand fidelity from their husbands. Moreover condoms are often inaccessible or unaffordable, especially in rural areas, and unprotected sex is necessary for couples who wish to have children. Another problem is that most Africans have never been tested for HIV and so don't know whether or not they are infected. Usually when people know that they are infected with HIV they take more precautions so as not to infect others.

To read about effective responses to such problems, see our overview of HIV prevention.

Are there any African “success stories”?

Some African countries have seen declines in the proportion of adults living with HIV (known as HIV prevalence). The most celebrated example is Uganda, where prevalence fell from around 15% in the early 1990s to 5% in 2001. This decline is thought to be at least partly due to effective HIV prevention campaigns, though an increase in the AIDS death rate was probably also significant. Smaller declines in HIV prevalence have been seen among adults in Kenya and Zimbabwe, and among young women in Zambia. Senegal has also won praise, for keeping HIV prevalence low.

Most African countries have yet to see any decline in HIV prevalence, and even Uganda still has a very serious epidemic. But examples such as these demonstrate that HIV in Africa does yield to determined, sustained interventions.

AVERT.org has more about HIV and AIDS in Uganda, and more about understanding HIV and AIDS statistics.

How is the world responding to HIV and AIDS in Africa?

The global response to HIV and AIDS has improved considerably in recent years. Funding comes from many sources, the largest of which are the Global Fund to Fight AIDS, Tuberculosis and Malaria, and the US initiative known as PEPFAR. In Africa the response includes:

Education and prevention, including efforts to change sexual behaviour, to prevent mother-to-child transmission of HIV and to improve the safety of blood supplies.
HIV testing and counselling.
Care for people living with HIV, AIDS orphans and other affected groups.
Measures to prevent and treat HIV-related opportunistic infections.
Antiretroviral treatment programmes.

Read more about funding the response to HIV/AIDS, and about HIV & AIDS treatment and care.

Are anti-AIDS drugs effective in Africa?

Numerous studies have demonstrated that antiretroviral treatment is just as effective in Africa as it is in the USA and Europe. The drugs delay the onset of AIDS and enable people to live longer, healthier lives. However, there are some difficulties in providing the treatment, and currently few needy Africans have access.⁵

Can Africans adhere to daily treatment?

A comprehensive analysis of 58 studies involving nearly thirty thousand patients found that Africans are even better at following antiretroviral treatment regimens than North Americans are. In sub-Saharan Africa, 77% of patients took their drugs correctly, compared to 55% in North America. This result debunks the myth that Africans are incapable of taking daily medication properly.⁶

Nevertheless some African treatment programmes have reported relatively high rates of patients lost to follow-up. One review found that on average 22% of people discontinued treatment within 10 months, either because of death (40% of cases) or loss to follow-up (56%). After 2 years, around 38% discontinued treatment. Reasons for people dropping out include the cost of treatment, poor drug supply, and problems with transport. These issues can be overcome and are generally not the fault of the patients.⁷

How many people are receiving treatment in Africa?

In 2002, only around 50,000 people in sub-Saharan Africa were receiving antiretroviral treatment. By the end of 2004 this number had risen to an estimated 310,000, and by the end of 2006 it was around 1.34 million. Current guidelines recommend that people should not usually begin antiretroviral therapy until they have reached an advanced stage of HIV disease. This means that around 4.8 million Africans were in immediate need of the treatment at the end of 2006, including those already receiving it, giving a coverage rate of 28%.⁸

Read more about who is receiving AIDS drugs.

What are the benefits of increasing access to treatment in Africa?

Antiretroviral treatment relieves suffering and saves lives. Providing access to treatment is therefore a moral obligation. It is also an effective way to lessen the social and economic impact of AIDS, by allowing people to remain at work and look after their families. One of the best ways to help children and address the rise in orphanhood is to prevent deaths among parents.

Providing treatment can reduce overall health costs by preventing serious illness. It can also give a substantial boost to HIV prevention efforts, by offering an incentive for people to get tested.

What are the challenges to scaling up treatment access in Africa, and can they be overcome?

African countries face some very substantial challenges in scaling up treatment. Perhaps the greatest of these is a shortage of trained staff to provide the medicines, counselling and regular check-ups. Another major obstacle is widespread reluctance to be tested for HIV, which is fuelled by stigma and fear. The cost of the drugs themselves is less of a problem than some people might imagine. Prices have fallen sharply in recent years, and the total cost of providing treatment is now a few hundred dollars per patient per year, making it a very cost effective way to save lives.

Programmes across Africa are demonstrating that the challenges to providing treatment can be overcome through the dedicated efforts of African governments and external donors, with help from local organisations, churches and the private sector. Training and recruitment programmes can ease staff shortages, while treatment-awareness and education campaigns can counter stigma and increase the demand for testing.

Read more about the challenges involved in providing treatment to millions.

Are there already any successful national treatment programmes?

Some pioneering countries have already shown that national treatment programmes can succeed even in the worst affected parts of Africa. Botswana began the first such programme in January 2002. By December 2006, almost all of those who needed treatment in Botswana (around 84,000 people) were receiving it, most of whom were getting it free through the public sector.

Namibia and Rwanda have also succeeded in providing treatment to more than 70% of those in need.⁹

Read more about Botswana’s treatment programme.

What targets have been set for scaling-up treatment access?

The world’s leaders have pledged to provide as close as possible to universal access to treatment by 2010. If this is to be anything more than an empty promise then those leaders must take action now, as current progress is much too slow. After the failure of the "3 by 5" initiative to put 3 million people on treatment by the end of 2005, it is vital that this next target is taken seriously. Millions of lives are at stake.

Find out more about treatment targets and results.

Many Africans suffer from malnutrition, poor sanitation and other diseases like TB and malaria, so why spend so much money tackling AIDS?

The AIDS epidemic in Africa causes immense suffering and millions of deaths. It is also inextricably linked to many of the other major problems Africa faces. AIDS distorts social structures by killing young adults and orphaning children; it fuels the spread of other infectious diseases, including tuberculosis; and it seriously threatens economic development and national security in the worst affected countries.

Africa has many problems that require action. The answer is not to pick and choose between them, but to address all of them together as effectively as possible. In many cases, efforts aimed at one problem will help to solve others. For example, measures to reduce poverty, improve education and promote gender equality are important components of the response to HIV and AIDS. Likewise, development organisations see combating the epidemic as central to their campaign to end poverty; World Vision has called AIDS “the biggest single challenge facing development”.¹⁰

Is the response to HIV and AIDS cost effective?

There is wide agreement among economists and public health experts that combating AIDS should be one of the very highest priorities for donor funding; the ratio of benefits to costs is exceptionally high. In fact, some economists reckon the response to HIV and AIDS should be the world’s number one priority.¹¹ ¹²

Is the world providing enough assistance to Africa?

Despite growing substantially in recent years, spending on HIV and AIDS still falls well short of what is required. UNAIDS estimates that $18.1 billion will be needed to effectively respond to the epidemic in low- and middle-income countries in 2007, rising to $22.1 billion in 2008, most of which must come from the international community. Yet spending in 2006 was just $8.9 billion, and UNAIDS expects that only $10 billion will be made available in 2007 – barely half of what is needed.¹³

Read more about funding the response to HIV/AIDS.