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HIV and AIDS in sub-Saharan Africa
Sub-Saharan Africa has the most serious HIV and AIDS epidemic in the world. In 2012, roughly 25 million people were living with HIV, accounting for nearly 70 percent of the global total. In the same year, there were an estimated 1.6 million new HIV infections and 1.2 million AIDS-related deaths. 1
As a result, the epidemic has had widespread social and economic consequences, not only in the health sector but also in education, industry and the wider economy.
HIV prevalence in sub-Saharan Africa
HIV prevalence varies greatly between regions in sub-Saharan Africa as well as individual countries. 2
HIV prevalence in selected countries across sub-Saharan Africa in 2012
|Country||HIV Prevalence (%)|
Our History of HIV and AIDS in Africa page details how HIV prevalence has changed over time.
In the mid-1980s, HIV and AIDS were virtually unheard of in southern Africa. Now, it is the worst affected region and widely regarded as the 'epicentre' of the global HIV epidemic. In 2012, Swaziland had the highest HIV prevalence rate of any country in the world (26.5 percent). HIV prevalence is also particularly high in Botswana (23 percent) and Lesotho (23.1 percent). With 6.1 million people living with HIV - a prevalence of 17.9 percent - South Africa has the largest HIV epidemic of any country. The remaining countries in southern Africa have a HIV prevalence between 10 and 15 percent. 3
Polygynous relationships, as well as multiple partners have been highlighted as key drivers of HIV transmission in these countries. 4 Indeed, the sexual networks of men in particular are quite extensive and are accepted, even encouraged in many communities. 5 Unemployment, labour migration, and displacement as a result of conflict have also contributed to the HIV epidemic in this region. 6 7
In comparison, West Africa has only been moderately affected by HIV and AIDS. For example, in Senegal, HIV prevalence is as low as 0.5 percent, whereas in Cameroon and Gabon it is an estimated 4.5 and 4 percent respectively. In Nigeria, HIV prevalence is also relatively low (3.1 percent). However, because of its large population (it is the most populous country in sub-Saharan Africa), this equates to around 3.4 million people living with HIV putting it only second behind South Africa in terms of absolute numbers. 8
In West Africa, the main driver of HIV transmission is sex work, accounting for between 10-32 percent of new infections, 9 In Niger, in 2011, HIV prevalence among sex workers was 36 percent compared to just 0.8 percent for 15-49 year olds in the general population. 10 Natural disasters have also played a role in the spread of HIV in West Africa as well as other illnesses.
HIV prevalence in East Africa is generally moderate to high, and second behind southern Africa. However, general prevalence has been in decline for the past two decades. For example, Kenya has seen its HIV prevalence drop from a high of 14 percent to nearly 6 percent. Uganda and Tanzania also have prevalence over 5 percent, with the lowest seen in Madagascar (0.5 percent) and Mauritius (1.2 percent). 11
Despite this progress, there are new areas of concern with HIV prevalence on the rise among vulnerable groups including people who inject drugs (PWIDs), prisoners and uniformed services (such as the armed forces and the police). 12
The impact of HIV and AIDS on sub-Saharan Africa
HIV and AIDS have, and are still having, a widespread impact in many parts of sub-Saharan Africa.
For a more detailed examination, visit our Impact of HIV and AIDS in sub-Saharan Africa page.
- Life expectancy
At the height of the HIV epidemic in sub-Saharan Africa, life expectancy was stagnating, even falling in some countries. Despite the rapid scaling up of antiretroviral treatment in recent years, the worst affected countries still have particularly low life expectancies.
In the most affected parts of sub-Saharan Africa, the HIV epidemic has had a devastating impact on households. When the income earners fall too ill to work, they have to be cared for by other household members or extended family. Children can also be removed from school to provide care or to put to work to generate income. In the worst cases, households simply dissolve.
HIV and AIDS have also put serious pressure on the health sector, particularly on hospital resources. Moreover, there is a chronic shortage of healthcare workers, who themselves, are often living with HIV. However, in many parts of sub-Saharan Africa, antiretroviral treatment is relieving this burden.
- Schools and education
The epidemic has also impacted heavily on education. School attendance drops as children become sick or return home to look after affected family members. Many lose their parents to HIV and AIDS meaning they can no longer afford to go to school, or are required to work and generate income instead. The epidemic also impacts upon the already limited supply of teachers. However, education is regarded as key to tackling the spread of HIV. Moreover, it is cost-effective.
- Labour and productivity
HIV and AIDS have had an enormous impact on labour and productivity. The vast majority of people living with HIV in this region are of working age (15-49 years old).
- Economic development
The combined impact of the epidemic on households, healthcare, education and productivity has stalled, even reversed economic development in parts of sub-Saharan Africa.
HIV prevention programmes in sub-Saharan Africa
A number of countries in sub-Saharan Africa have conducted large-scale prevention initiatives in an effort to contain and reduce their HIV and AIDS epidemics.
Senegal has been particularly successful in managing its HIV epidemic and maintaining a low overall HIV prevalence among the general population. Strong political leadership and early involvement in the epidemic, as well as leadership among religious leaders and conservative cultural norms around sexual practices have all been attributed to Senegal's success. The country has been able to keep HIV prevalence rates low through intensive screening of the national blood supply, the provision of HIV testing equipment and healthcare professionals, HIV education programmes as well as the promotion of condom use. Despite this, HIV prevalence among vulnerable groups, particularly sex workers remains high (18.5 percent). 13
By comparson, it is widely felt that the failure of the South Africa's government to respond quickly to their HIV epidemic at the outset has led to an unprecedented number of people living with HIV. Despite now having the biggest antiretroviral treatment roll-out programme in the world, there were still an estimated 370,000 new infections in 2012. 14
Condom distribution and use in sub-Saharan Africa
Condom use and distribution play a key role in preventing HIV transmission around the world.
Over the last decade, condom use in sub-Saharan Africa has generally been on the rise. However, in some countries, condom use has actually declined (including the Ivory Coast, Niger, Senegal and Uganda). 15
While the supply of condoms increases year on year, this does not guarantee an increase in their use. Poverty, relationship with parents, peers and partners, limited HIV information and education, gender dynamics, and beliefs and attitudes about HIV have all been found to work against condom use across sub-Saharan Africa. 16
For example, research in Kenya and Zambia has shown how marriage increases the frequency of sexual intercourse and hinders a woman's ability to negotiate safe sex or abstain. This is a particular problem for younger women whose husbands tend to be older and have a higher HIV prevalence. 17
HIV Testing and Counselling (HTC) in sub-Saharan Africa
The provision of HIV testing and counselling (HTC) services is an important component of any HIV prevention programme. HTC services have helped millions of people learn their HIV status and for those who test positive, learn about the options for treatment, care and support. It is widely noted that individuals living with HIV who are aware of their status are also less likely to transmit HIV to others. 18
A number of countries in sub-Saharan Africa have implemented national campaigns to encourage uptake of HIV testing. In 2010, Botswana, Kenya, Uganda, Malawi and Rwanda were just some of the countries that conducted testing campaigns to increase the number of people testing for HIV. Overall, nearly 6 million people, aged over 15 received HIV testing and counselling in Kenya in 2010, an increase of over a million compared with 2009 figures. 19
In South Africa, the number of people receiving HIV testing and counselling has significantly increased in recent years. However, while more than 6.5 million people received HIV testing and counselling in 2010, this was less than in 2009 (7 million). 20 In the same year, an estimated 82 tests per 1000 people were carried out in sub-Saharan Africa. 21
- Voluntary Counselling and Testing (VCT)
VCT for HIV normally involves two sessions. 'Pre-test counselling' (happens before the HIV test), and the second session, 'post-test counselling' (occurs after the test) gives the results. VCT has become very popular in sub-Saharan Africa as a way of someone learning their HIV status. VCT centres and healthcare professionals are increasingly using rapid HIV tests which are cheap, need minimal training, and provide accurate results within 30 minutes. 22
A number of different strategies have been used to increase delivery and access to VCT services:
Home-based Voluntary Testing (HBT): HBT is proving successful in sub-Saharan Africa, with a meta-analysis reporting a 70 percent acceptance rate among people offered a HIV test in their home. 23 A study from South Africa showed how HBT increased HIV testing in rural settings with high levels of stigma, as well as encouraging couples counselling and testing and reducing high-risk sexual behaviour. 24
Mobile Testing: Tests are performed in vehicles that travel between different locations, increasing accessibility for many communities. One study demonstrated how the addition of mobile HIV screening to existing testing programs in Cape Town, South Africa can be cost-effective in resource-limited settings. 25
Other incentives: Additionally, a study has found that inviting people personally and offering them incentives such as food vouchers can encourage people to get tested. 26
However, testing coverage in sub-Saharan Africa remains low, particularly among young people. As treatment becomes more widely available, it is important that as many different strategies towards increasing VCT coverage are explored. For example, research from Tanzania showed how offering an 'opt-out strategy' encouraged more young people to get an HIV test. 27
Preventing mother-to-child transmission of HIV in sub-Saharan Africa
In the last decade, significant progress has been made in the prevention of mother-to-child transmission (PMTCT) of HIV in sub-Saharan Africa.
PMTCT programmes for HIV include; antenatal HIV testing and counselling, provision of appropriate antiretroviral treatment for both mothers and newborns, support for safer feeding options and avoiding unintended pregnancy. 28
In 2012, PMTCT coverage for HIV in sub-Saharan Africa reached 65 percent, with a number of countries reporting coverage of more than 80 percent: Botswana, Ghana, Mozambique, Namibia, Rwanda, Sierra Leone, South Africa, Swaziland, Togo, Zambia and Zimbabwe. However, several countries reported PMTCT coverage of less than 50 percent: Angola, Chad, Congo, Democratic Republic of Congo, Eritrea, Ethiopia, Guinea, Guinea Bissau, Nigeria and South Sudan. 29
An estimated 260,000 children became infected with HIV in sub-Saharan Africa in 2012. 30 The vast majority of these children (over 90 percent), contracted HIV during pregnancy, childbirth or breast-feeding as a result of their mother being HIV-positive. 31
Given the scale of the MTCT in sub-Saharan Africa, it is surprising that both the international community and domestic governments have not committed more resources towards tackle the rising number of children becoming infected with HIV. However, there have been some successful interventions. For example, a UNICEF supported programme in Ethiopia has trained over 2000 nurses and midwives in PMTCT services. 32
However, research has highlighted a number barriers to achieving comprehensive coverage of PMTCT in sub-Saharan Africa within the health system (a shortage of staffing and accessability) as well as a range of social (e.g. lack of partner support), economic (e.g. funding) and cultural (e.g. stigma) barriers at the client, health clinic and country levels. 33 34
Reducing injecting drug use in sub-Saharan Africa
Compared to other HIV epidemics globally, HIV transmission via injecting drug use is a comparatively low in sub-Saharan Africa.
In 2012, 5-10 percent of global HIV infections were due to injecting drug use (IDU). When sub-Saharan Africa was excluded, this increased to almost 30 percent. 35 At a region-specific level, only 0.2 percent of the general population in sub-Saharan Africa inject drugs, compared to 1.3 percent in Eastern Europe and Central Asia. 36 Although this is a small percentage, it still equates to a large number of people potentially at risk of HIV transmission.
Moreover, there are fears that HIV prevalence among people who inject drugs (PWIDs) will increase. Although surveillance of PWIDs in sub-Saharan Africa is limited, the evidence available suggests developing intertwined epidemics of injecting drug use and HIV infection, like those seen in Asia. 37 As well as generally high HIV prevalence rates, in sub-Saharan Africa, economic and social hardship is common and drug trafficking routes as well as injecting drug use among vulnerable groups is on the rise. 38 39
In response to this developing issue, in 2012, the African Union Plan of Action on Drug Control for 2013-2017 was adopted. The plan focuses on reducing the supply and demand of drugs as well as scaling up harm reduction measures for the first time. Kenya and Tanzania are leaders in the region on harm reduction, and evidence from their practices has informed the Plan of Action. All countries are required to carry out research on drug use as part of the agreement, which aims to build the evidence base for HIV prevention initiatives. 40
Antiretroviral treatment in sub-Saharan Africa
In 2012, 68 percent of people living with HIV in sub-Saharan Africa had access to antiretroviral treatment (ART). 10 countries reported reaching universal access (at least 80 percent of adults eligible for ART) under the World Health Organisations (WHO) 2010 guidelines (those with a CD4 count of 350 cells/mm3 or less). 41 The WHO's 2013 guidelines have subsequently made many more people eligible for treatment by expanding the CD4 treatment initiation to 500 cells/mm3 or less for adults, adolescents and older children. 42
Despite a dramatic increase in the roll-out of antiretroviral treatment in sub-Saharan Africa, there are big disparities between regions as well as individual countries. For example, ART coverage in Botswana is over 95 percent but only 38 percent in the Democratic Republic of Congo. 43 Of the 21.2 million people living with HIV on the entire African continent (the vast majority in sub-Saharan Africa), only 7.6 million were reached by antiretroviral treatment in 2012. 44
Moreover, even where the number of people receiving ART is on the increase, roughly 75 percent of adults living with HIV in sub-Saharan Africa have not achieved viral suppression. This has been attributed mainly to treatment gaps in the provision of ART. ART reduces viral loads in people living with HIV, due to the treatment as prevention approach. 45
Access to antiretroviral drugs is particularly low for certain groups. For example, children living with HIV in sub-Saharan Africa are only half as likely to receive treatment than HIV-positive adults. One study found that in 9 of the 21 countries researched in sub-Saharan Africa, fewer than 25 percent of children living with HIV received antiretroviral treatment in 2012. 46
Moreover, adolescents (10-19 year olds) were the only group that saw increases in AIDS-related deaths between 2001 and 2012, with the annual number of AIDS-related deaths doubling from 2005-2012. 47
Barriers to HIV prevention in sub-Saharan Africa
A number of HIV prevention programmes have been implemented in sub-Saharan Africa in order to tackle the regions HIV epidemic and have had varying degrees of success.
However, while substantial progress has been made, particularly in the last decade, there are still a number of barriers to HIV service provision in this region.
Sustainable financing is essential in order to expand the global HIV response.
The costs of future antiretroviral treatment remains unaddressed with the majority of the existing funding only available on a short term basis. Many countries in sub-Saharan Africa are dependent upon external funds and resources in order to tackle their HIV epidemics. In countries such as Uganda and Swaziland, the commitment to providing life-long HIV treatment is predicted to put huge pressure on domestic finances. In fact, in the next two decades, the cost of treatment in some countries in sub-Saharan Africa may rise to nearly three times gross domestic product (GDP). 48
While external funds account for two-thirds of spending on HIV services in sub-Saharan Africa, two-thirds of general healthcare expenditure is sourced from domestic governments, which in turn, fund the healthcare systems that HIV services often rely upon. 49 Raising taxes has the potential to increase health expenditure in some countries but not all.
For example, Zambia's economy is expected to grow by nearly 5 percent a year between 2011 and 2017, creating an additional $21.8 per capita in health spending. In contrast, Swaziland has a projected growth of minus 0.1 percent for the same period, and therefore has very limited scope to increase domestic spending on healthcare. 50 External borrowing is also an option but many countries in sub-Saharan Africa already have high levels of debt compared to their economic output. 51
Social and cultural barriers
- Stigma and discrimination
HIV-related stigma and discrimination remains a major barrier to tackling the HIV and AIDS epidemic in sub-Saharan Africa. It stops people from getting tested, seeking treatment and disclosing their HIV status publicly.
In sub-Saharan Africa, cultural constructions of HIV and AIDS based on beliefs around contamination, sexuality and religion have played a crucial role in the development of HIV-related discrimination in society. In many places, it is thought to have actually increased the number of HIV infections. 52
Moreover, studies have shown how healthcare workers negative and discriminatory views towards HIV-positive people are influenced by, and often similar, to those in the general population. 53
- The status of women
In sub-Saharan Africa, like many parts of the world, the HIV epidemic disproportionately affects women, often as a result of social and economic inequality. In 2012, 59 percent of all people living with HIV in the region were female. 54 The highest HIV prevalence rates among women occur in southern Africa, particularly in South Africa, Botswana, Lesotho and Swaziland. 55
Women and girls often face discrimination in terms of access to education, employment and healthcare. In this region, men often dominate sexual relationships. As a result, women cannot always practice safer sex even when they know the risks that are involved. Indeed, gender-based violence has been identified as a key driver of HIV transmission in the region. 56
Efforts are being made to improve the situation regarding women and HIV. For example, a High-Level Taskforce on Women, Girls, Gender Equality and HIV for Eastern and Southern Africa was launched at the 16th International Conference on AIDS and STIs in Africa. It aims to improve country actions and monitor the implementation of the draft 'Windhoek Declaration for Women, Girls, Gender Equality and HIV'. The Windhoek Declaration draft (April 2011), recommends action in a number of areas including sexual and reproductive health, violence against women and HIV, as well as the law, gender and HIV. 57 58
In many countries, there are laws criminalising people who expose others to HIV or transmit the virus via sexual intercourse.
Supporters of criminalisation often claim they are promoting public health or justify these laws on moral grounds. However, such laws do not acknowledge the role of ART in reducing transmission risk and improving quality of life for those living with HIV. 59
The past decade has seen new wave of HIV-specific criminal legislation in parts of Asia and Latin America but most notably in sub-Saharan Africa. In West Africa, a number of countries have passed such laws following a regional workshop in Chad in 2004 which aimed to develop a 'model' law on HIV and AIDS for the region. 60
The law guarantees pre and post-testing counselling and anti-discrimination protections in employment and insurance for people living with HIV. However, it holds HIV-positive people responsible for disclosing their status to anyone they have sexual intercourse with as well as measures to prevent HIV transmission. If they do not, they face criminal sanctions. Under these types of laws, there is the possibility that HIV-positive women could be prosecuted for transmitting the virus to their baby during pregnancy. 61
Combating HIV and AIDS in sub-Saharan Africa
Increased funding is at the centre of efforts to improve HIV and AIDS service provision in sub-Saharan Africa. Developed countries have increased funding for the fight against HIV and AIDS in sub-Saharan Africa in recent years, perhaps most significantly through the Global Fund.
- Global Fund
The Global Fund works with governments, civil society, the private sector and local communities to combat HIV and AIDS, Tuberculosis and Malaria around the world.
To date, the organisation has provided 3.6 million people with HIV treatment, and in 2012, accounted for roughly 21 percent of international public funding for HIV and AIDS worldwide. 62
In sub-Saharan Africa, 2.3 million people received ART through Global Fund-supported programmes in 2010. In the same year, ART in Ethiopia, Ghana, Guinea, Malawi, Namibia and Tanzania was financed exclusively by the Global Fund. Between 2002 and 2010, it distributed 1.7 billion condoms, provided 62 million people with HIV testing and counselling sessions, and supported 860,000 HIV-related PMTCT courses throughout the region. 63
The U.S. President's Emergency Plan for AIDS Relief (PEPFAR) is the United States Government's initiative to tackle the global HIV and AIDS epidemic.
In 2013, PEPFAR supported HTC for nearly 13 million pregnant women in sub-Saharan Africa. For 780,000 women who tested positive for HIV, PEPFAR provided treatment to prevent mother-to-child transmission. From 2011 to 2013, 1.5 million pregnant women with HIV accessed interventions to prevent MTCT and improve maternal health. 64
17 million people were provided with HIV-related care and support in sub-Saharan Africa, including 5 million children and orphans. The organisation also provided HIV testing and counselling for more than 57.7 million people in 2013. 65
As we have seen, international funding and support plays a key role in HIV prevention in sub-Saharan Africa. The Global Fund alone is financing 100 percent of antiretroviral treatment programmes in a number of countries in sub-Saharan Africa.
However, increases in international funding should not reduce or replace domestic expenditure on healthcare, with domestic financing necessary for the long-term sustainability of such programmes. Research has shown how, particularly in sub-Saharan Africa, government spending on healthcare often falls in response to the arrival of development assistance. 66 In 2010, 80 percent of funding for HIV and AIDS programmes in sub-Saharan Africa was from donor governments. 67
There are exceptions to this. For example, South Africa has the most people living with HIV anywhere in the world. However, it now has the largest antiretroviral treatment programme in the world, and what's more, it is mostly self-funded. 68 Kenya, Togo and Rwanda have all doubled their HIV spending in the past few years. 69
Nonetheless, the implementation of many HIV treatment and prevention programmes requires a country's health, education and infrastructure to be development sufficiently. Indeed, in many countries in sub-Saharan Africa, these limited resources were stretched previous to the HIV epidemic, and have come under increasing pressure as the epidemic has evolved. This is worsened by the acute shortage of trained healthcare professionals in the region. 70
The way forward
Tackling the HIV epidemic in sub-Saharan Africa is a long-term task that requires sustained effort and planning from both domestic governments and the international community. One of the most important elements of the fight against HIV and AIDS is the prevention of new HIV infections. HIV prevention campaigns that have been successful in sub-Saharan Africa need to be repeated, but also scaled up, especially in response to the 2013 World Health Organisation guidelines on treatment initiation.
As the HIV epidemic develops, countries in sub-Saharan Africa will need to assess how to allocate what are currently limited treatment resources. Ultimately, the region requires more money and resources especially in order to deal with future lower productivity in the workforce. There are also more fundamental barriers to overcome, particularly HIV-related stigma and discrimination, the issue of gender inequality and HIV-specific criminal legislation. Removing such barriers would encourage more people to get tested and seek out treatment, reducing the burden of HIV across the region.
- Impact of HIV and AIDS in sub-Saharan Africa
- History of HIV and AIDS in Africa
- Timeline of HIV and AIDS in Africa
- Africa HIV and AIDS Statistics
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