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HIV and AIDS in Africa
Sub-Saharan Africa is more heavily affected by HIV and AIDS than any other region of the world. An estimated 22.9 million people are living with HIV in the region - around two thirds of the global total.1 In 2010 around 1.2 million people died from AIDS in sub-Saharan Africa and 1.9 million people became infected with HIV. Since the beginning of the epidemic 14.8 million children have lost one or both parents to HIV/AIDS.2
The social and economic consequences of the AIDS epidemic are widely felt, not only in the health sector but also in education, industry, agriculture, transport, human resources and the economy in general. The AIDS epidemic in sub-Saharan Africa continues to devastate communities, rolling back decades of development progress.
Sub-Saharan Africa faces a triple challenge:
- Providing health care, antiretroviral treatment, and support to a growing population of people with HIV-related illnesses.
- Reducing the annual toll of new HIV infections by enabling individuals to protect themselves and others.
- Coping with the impact of millions of AIDS deaths3 on orphans and other survivors, communities, and national development.
How are different countries in Africa affected by HIV and AIDS?
Both HIV prevalence rates and the numbers of people dying from AIDS vary greatly between African countries.
In Somalia and Senegal the HIV prevalence is under 1% of the adult population, whereas in Namibia, Zambia and Zimbabwe around 10-15% of adults are infected with HIV. Southern Africa is the worst impacted by AIDS; in South Africa the HIV prevalence is 17.8% and in three other southern African countries, the national adult HIV prevalence rate now exceeds 20%. These countries are Botswana (24.8%), Lesotho (23.6%) and Swaziland (25.9%).4
West Africa has been less affected by HIV and AIDS, but some countries are experiencing rising HIV prevalence rates. In Cameroon HIV prevalence is now estimated at 5.3% and in Gabon it stands at 5.2%. In Nigeria, HIV prevalence is low (3.6%) compared to the rest of Africa. However, because of its large population (it is the most populous country in sub-Saharan Africa), this equates to around 3.3 million people living with HIV.5
Overall, rates of new HIV infections in sub-Saharan Africa appear to have peaked in the late 1990s, and HIV prevalence seems to have declined slightly, although it remains at an extremely high level of 5 percent among adults.7 History of AIDS in Africa has more information about how HIV prevalence has changed over time.
What is the impact of AIDS on Africa?
HIV and AIDS are having a widespread impact on many parts of African society. The points below describe some of the major effects of the HIV/AIDS epidemic. For a more detailed examination, visit our impact of HIV and AIDS in Africa page.
- The effect on life expectancy. In many countries of sub-Saharan Africa, AIDS has erased decades of progress made in extending life expectancy. Average life expectancy in sub-Saharan Africa is now 54.4 years and in some of the most heavily affected countries in the region life expectancy is below 49 years.8
- The effect on households. The effect of the AIDS epidemic on households can be very severe, especially when families lose their income earners. In other cases, people have to provide home based care for sick relatives, reducing their capacity to earn money for their family. Many of those dying from AIDS have surviving partners who are themselves infected and in need of care. They leave behind orphans, who are often cared for by members of the extended family.
- The effect on healthcare. In all affected countries, the epidemic is putting strain on the health sector. As the epidemic develops, the demand for care for those living with HIV rises, as does the number of health care workers affected.
- The effect on schools. Schools are heavily affected by AIDS. This a major concern, because schools can play a vital role in reducing the impact of the epidemic, through HIV education and support.
- The effect on productivity. The HIV and AIDS epidemic has dramatically affected labour, which in turn slows down economic activity and social progress. The vast majority of people living with HIV and AIDS in Africa are between the ages of 15 and 49 - in the prime of their working lives. Employers, schools, factories and hospitals have to train other staff to replace those at the workplace who become too ill to work.
- The effect on economic growth and development. The HIV and AIDS epidemic has already significantly affected Africa's economic development, and in turn, has affected Africa's ability to cope with the epidemic.
HIV prevention in Africa
A number of African countries have conducted large-scale HIV prevention initiatives in an effort to reduce the scale of their epidemics. Senegal, for example, responded early to the emergence of HIV with strong political and community leadership.9 It is impossible to predict how Senegal's epidemic would have progressed without intervention, but Senegal now has one of the lowest HIV prevalence rates in sub-Saharan Africa.
The situation in Uganda was similarly successful. HIV prevalence among pregnant women in Uganda fell from a high of around 30% in the early 1990s to around 10% in 2001 and is now estimated to be 6.5%;10 a change which is thought to have been largely a result of intensive HIV prevention campaigns. However, a high rate of new HIV infections in the country has led to fears that HIV prevalence may increase again. Declines in HIV prevalence have also been seen in Kenya, Zimbabwe and urban areas of Zambia and Burkina Faso.11
However, not all African countries have had such successful HIV prevention campaigns. In South Africa, the previous government's failure to respond to the AIDS crisis has lead to an unprecedented number of people living with HIV. Despite recent improvements, an estimated 48,000 babies are still born with HIV every year, reflecting continued failures in prevention of mother-to-child transmission initiatives.12
Condom use and HIV
Condoms play a key role in preventing HIV infection around the world. In sub-Saharan Africa, most countries have seen an increase in condom use in recent years. In studies carried out between 2001 and 2005, eight out of eleven countries in sub-Saharan Africa reported an increase in condom use.13
The distribution of condoms to countries in sub-Saharan Africa has also increased: in 2004 the number of condoms provided to this region by donors was the equivalent of 10 for every man,14 compared to 4.6 for every man in 2001.15 However, this was still estimated to represent an annual gap of anywhere between 1.9 to 13.1 billion condoms.16
Relative to the enormity of the HIV/AIDS epidemic in Africa, providing condoms is cheap and cost effective. Even when condoms are available, though, there are still a number of social, cultural and practical factors that may prevent people from using them. In the context of stable partnerships where pregnancy is desired, or where it may be difficult for one partner to suddenly suggest condom use, this option may not be practical.
Provision of Voluntary HIV Counselling & Testing (VCT)
The provision of voluntary HIV counselling and testing (VCT) is an important part of any national prevention programme. It is widely recognised that individuals living with HIV who are aware of their status are less likely to transmit HIV infection to others, and are more likely to access treatment, care and support that can help them to stay healthy for longer.
A number of countries in the region have implemented national campaigns to encourage uptake of HIV testing. Botswana, Kenya, Uganda, Malawi and Rwanda are some of the countries that have conducted testing campaigns that increased the numbers of people tested in 2010. Overall, nearly 6 million people, aged over 15 years, received HIV testing and counselling in Kenya in 2010, an increase of over a million compared to 2009 figures.17 Rwanda has also succeeded in improving the number of people receiving HIV testing and counselling, with 469 per 100,000 individuals over 15 years receiving this service in 2010, a total of 2.4 million individuals.18
In South Africa, the number of people receiving HIV testing and counselling has significantly increased in recent years as a result of the governments national HIV testing campaign. However, whilst the estimated number of people receiving HIV testing and counselling in 2010 was more than 6.5 million, this is notably less than in 2009 when nearly 7 million people received testing and counselling.19 Across sub-Saharan Africa it is estimated that 82 tests per 1000 people were carried out in 2010.20
The provision of VCT has become easier, cheaper and more effective as a result of the introduction of rapid HIV testing, which allows individuals to receive a test and the results in the same day. Various different strategies to increase access to VCT have been tried out. Mobile testing, where tests are performed in a vehicle that travels to different places, is more accessible for some communities. Additionally, a study has found that inviting people personally and offering them incentives such as food vouchers, can reach people who are less likely to otherwise decide to be tested.21 However, VCT could – and needs to be – made more widely available in most sub-Saharan African countries.
Mother-to-child transmission of HIV
Around 360,000 children in sub-Saharan Africa became infected with HIV in 2010.22 The vast majority of these children have been infected with HIV during pregnancy, childbirth or breastfeeding, as a result of their mother being infected with the virus.
Without interventions, there is a 20-45% chance that an HIV-positive mother will pass the virus on to her child. If a woman is supplied with antiretroviral drugs, however, this risk can be significantly reduced. Before these measures can be taken the mother must be aware of her HIV infection, so testing also plays a vital role in the prevention of MTCT.
In many developed countries, these steps have helped to virtually eliminate MTCT. Yet sub-Saharan Africa continues to be severely affected by the problem, due to a lack of drugs, services and information, and the shortage of testing facilities. In 2010, preventive drugs reached 64 percent of HIV-infected pregnant women in Eastern and Southern Africa, and 18 percent in West and Central Africa, a decline on 2009 figures.23
Given the scale of the MTCT crisis in Africa, it is remarkable that more is not being done (by both the international community and domestic governments) to prevent the rising number of children becoming infected with HIV. This crisis is discussed in more detail on our PMTCT worldwide page. Despite this, there are reports of some improvements: in Ethiopia, a UNICEF supported programme has been increasingly successful in preventing MTCT, thanks to new support for the training of 2,000 nurses and midwives in PMTCT services.24
Injecting drug use safety
Sub-Saharan Africa is rarely highlighted as a region with high levels of HIV transmission via injecting drug use; only 0.2 percent of the adult population inject drugs, compared to over 1.3 percent in Eastern Europe and Central Asia.25 Although this is a small percentage of the region's population, it still equates to a large number of people potentially at risk of HIV exposure.
In 2012, the African Union Plan of Action on Drug Control for 2013-2017 was adopted, which is a progressive agreement compared to previous ones. This plan focuses on reducing the demand and supply of drugs, alongside scaling up harm reduction measures for the first time. Kenya and Tanzania are leaders in the region on harm reduction, and evidence from their practises have informed the Plan of Action. States are required to carry out studies on drug use as part of the agreement; this will provide greater evidence for HIV prevention initiatives.26
HIV/AIDS related treatment and care in Africa
Antiretroviral drugs (ARVs) - which significantly delay the progression of HIV to AIDS and allow people living with HIV to live relatively normal, healthy lives – have been available in richer parts of the world since around 1996. Distributing these drugs requires money, a well-structured health system and a sufficient supply of healthcare workers. The majority of developing countries are lacking in these areas and have struggled to cope with the increasing numbers of people requiring treatment.
Despite a notable increase in access to antiretroviral treatment across the African region between 2009 and 2010, for many Africans living with HIV, ARVs are still not available. Of an estimated 10 million people in need of treatment in 2010, only 5 million received it.27 Children are even less likely to access treatment than adults in the African region, with only 21 percent of those in need of treatment receiving it in 2010.28 Millions are not even receiving treatment for opportunistic infections, which affect individuals whose immune systems have been weakened by HIV infection. These facts reflect the world’s continuing failure, despite the progress of recent years, to mount a response that matches the scale and severity of the global AIDS epidemic.
Botswana pioneered the provision of ARVs in Africa, starting its national treatment programme in January 2002. By 2005 this programme had been significantly scaled up. More than 161,219 people were receiving treatment in Botswana at the end of 2010 - a coverage rate of around 93 percent.29 Other countries that have achieved more than 80 percent treatment coverage are Rwanda and Namibia.
While most African countries have now started to distribute ARVs, progress in providing sufficient quantities of the drugs has been uneven.30 31 Cameroon, Côte d’Ivoire, Nigeria, Chad and Ghana are some of the countries in sub-Saharan Africa where between 20-39 percent of people requiring antiretroviral drugs are receiving them. Countries where treatment coverage is less than 19 percent include the Dominican Republic of Congo, Djibouti, Somalia and Madagascar. Access to treatment is extremely low in Somalia where it is estimated that only 878 people out of an estimated 25,000 individuals needing antiretroviral therapy are receiving it; a coverage of only 3 percent. While South Africa is the richest nation in sub-Saharan Africa and should have led the way in ARV distribution, its government was slow to act, and so far, only 55 percent of those in need of treatment in South Africa are receiving it.
Nonetheless, the overall situation is slowly improving; the number of people receiving ARVs in Africa doubled in 2005 alone.32 By the end of 2010, the number of individuals in need of antiretroviral treatment in Africa that were receiving it had increased, from 37 percent in 2009, to 49 percent.33 34 Between 2009 and 2010 certain countries succeeded in achieving impressive increases in the number of people accessing treatment. For example, Zimbabwe, Tanzania and South Africa increased treatment coverage by 49 percent, 29 percent and 43 percent, respectively, in the 12 months since 2009. Whilst the number of countries achieving universal access is still low, many are nearing 80 percent coverage. International support has helped this increase, with numerous governments and international organisations encouraging progress. In 2003 the World Health Organisation (WHO) initiated the ‘3 by 5’ programme, which aimed to have three million people in developing countries on ARVs by the end of 2005. While this target was not reached, a number of African nations made substantial progress under the scheme. The latest international target agreed at the UN General Assembly High Level Meeting on AIDS in mid-2011, aims for universal access to treatment by 2015.35
There are still, however, a number of impediments to ARV provision. One major challenge is the fact that the majority of African countries have a poor healthcare infrastructure and a shortage of medical professionals. A considerable emphasis needs to placed not only on the availability of ARVs, but also the availability of professionals who are able to administer the drugs.
Another major challenge is ensuring that drugs are not only supplied to a lot of areas, but that sufficient quantities of drugs are supplied to those areas. This is critically important, because once an individual starts to take ARVs they have to take them for the rest of their life. If, for instance, their local hospital runs out of ARVs, the interruption that this causes in their treatment could result in drug resistance. To improve treatment programs, African countries face the double challenge of getting new people to start treatment and maintaining the supply of treatment to those who are already receiving ARVs.
Treatment and care for HIV/AIDS consists of a number of different elements apart from ARVs. These include voluntary counselling and testing, food and management of nutrition, follow-up counselling, protection from stigma and discrimination, treatment of other sexually transmitted infections, and the prevention and treatment of opportunistic infections. Alongside antiretroviral treatment, all of these elements should be made available for all people living with HIV.
What needs to be done to make a difference in Africa?
One of the most important ways in which the situation in Africa can be improved is through increased funding for HIV/AIDS. More money would help to improve both prevention campaigns and the provision of treatment and care for those living with HIV. Developed countries have increased funding for the fight against AIDS in Africa in recent years, perhaps most significantly through the Global Fund. The Global Fund was started in 2001 to co-ordinate international funding and by the end of 2008 had approved grants totalling US $7.2 billion to help fight AIDS, TB and Malaria in 137 countries.36 This funding is making a significant difference, but given the massive scale of the AIDS epidemic more money is still needed. Since the 2007 financial crisis, funding for HIV/AIDS has decreased and the Global Fund replenishment meeting in October 2010 saw a commitment of only $11 billion over a 3 year period, short of the 'minimum' $13 billion it calculated it needed to fully fund existing programmes. In November 2011, as a result of limited financial resources the Global Fund effectively cancelled Round 11, replacing it instead with a Transitional Funding Mechanism.37
The US Government has shown a commitment to fighting AIDS in Africa through the President’s Emergency Plan For AIDS Relief (PEPFAR). Started in 2003, PEPFAR provides money to fight AIDS in numerous countries, including 15 focus countries, most of which are African. In Fiscal Year 2009, PEPFAR allocated almost US $6.5 billion for combating AIDS, TB and Malaria.38 From 2009-2010, PEPFAR funding flatlined for the first time since its creation.
Among other things, organisations like PEPFAR and the Global Fund provide vital support to local and community groups that are working 'on the ground' to provide relief in Africa. These groups are directly helping people in need, and many rely on international funding in order to operate. Getting money from large, international donors to small, 'grassroots organisations' can present a number of difficulties though, as money is lost or delayed as it is passed down large funding chains.
More than money is needed if HIV prevention and treatment programmes are to be scaled up in Africa. In order to implement such programmes, a country’s health, education and communication systems and infrastructures must be sufficiently developed. However, in many sub-Saharan Africa countries these systems were already under strain before the AIDS epidemic and they have experienced increased pressure on their resources as a result of AIDS. Money can also only be used efficiently if there are sufficient human resources available, yet there is an acute shortage of trained personnel in many parts of Africa.
Increased international funding should not result in reduced domestic expenditure on health, as domestic financing is necessary for the sustainability of health programmes. Some research shows that, particularly in sub-Saharan Africa, government spending on health is reduced in response to receiving large amounts of development assistance for health.39 Although this might be partly a result of government spending being redirected to other sectors such as education and industry, it is vital that sustainability and self-sufficiency in the health sector is encouraged so that the governments of sub-Saharan African countries are well equipped to deal with their HIV/AIDS epidemics even if donor funding dries out. Currently, around 80% of funding for HIV/AIDS programmes in sub-Saharan Africa is from donor governments.40
Reducing stigma and discrimination
HIV-related stigma and discrimination remains an enormous barrier to the fight against AIDS. Fear of discrimination often prevents people from getting tested, seeking treatment and admitting their HIV status publicly. Since laws and policies alone cannot reverse the stigma that surrounds HIV infection, AIDS education in Africa needs to be scaled-up to combat the ignorance that causes people to discriminate. The fear and prejudice that lies at the core of HIV and AIDS discrimination needs to be tackled at both community and national levels.
Helping women and girls
In many parts of Africa, as elsewhere in the world, the AIDS epidemic is aggravated by social and economic inequalities between men and women. Women and girls commonly face discrimination in terms of access to education, employment, credit, health care, land and inheritance. These factors can all put women in a position where they are particularly vulnerable to HIV infection. In sub-Saharan Africa, around 59% of those living with HIV are female.41 The proportion is even more inequitable for young people, with women making up 70% of young people in the region living with HIV.42
In many African countries, sexual relationships are dominated by men, meaning that women cannot always practice safer sex even when they know the risks involved. Attempts are currently being made to develop a microbicide – a cream or gel that can be applied to the vagina, preventing HIV infection – which could be a significant breakthrough in protecting women against HIV. It is likely to be some time before a microbicide is ready for use, though, and even when it is, women will only use it if they have an awareness and understanding of HIV and AIDS. To promote this, a greater emphasis needs to be placed on educating women and girls about AIDS, and adapting education systems to their needs. In some Southern African countries the rate of HIV among 23-24 year old females is far higher than that of 15-17 year old girls. This suggests prevention activities should target women at a young age and ensure they have the knowledge and skills to avoid HIV infection from when they become sexually active.43 Efforts are being made to improve the situation. In April 2011 a draft was written of ‘The Windhoek Declaration for Women, Girls, Gender Equality and HIV’, and following this a taskforce of people, such as the UNAIDS director and government representatives from across Southern and Eastern African countries, was set up to monitor its implementation in the region.44 45
Read more about women and HIV.
The way forward
Tackling the AIDS crisis in Africa is a long-term task that requires sustained effort and planning - both within African countries themselves and amongst the international community. One of the most important elements of the fight against AIDS is the prevention of new HIV infections. HIV prevention campaigns that have been successful within African countries need to be highlighted and repeated.
The other main challenge is providing treatment and care to those living with HIV in Africa, in particular ARVs, which can allow people living with HIV to live longer and healthier lives. Many African countries have made significant progress in their treatment programmes in recent years. However, sustained domestic and international commitment to scaling up existing programmes is needed, especially as the latest WHO treatment guidelines (2010) recommend starting treatment earlier and have therefore increased the number of people estimated to be in need of treatment. In 2011, UNAIDS released a report that commended successes in sub-Saharan Africa including 25% reductions in new HIV infections in 22 countries in the region, between 2001 and 2009, as well as reduced AIDS mortality.46 However, without sustained domestic and international commitment to the AIDS epidemic in the region, years of hard won success in treatment and prevention risk being reversed.
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