Sub-Saharan Africa has the most serious HIV and AIDS epidemic in the world. In 2013, an estimated 24.7 million people were living with HIV, accounting for 71% of the global total. In the same year, there were an estimated 1.5 million new HIV infections and 1.1 million AIDS-related deaths.1
HIV prevalence for the region is 4.7% but varies greatly between regions within sub-Saharan Africa as well as individual countries. For example, Southern Africa is the worst affected region and is widely regarded as the 'epicentre' of the global HIV epidemic. Swaziland has the highest HIV prevalence of any country worldwide (27.4%) while South Africa has the largest epidemic of any country - 5.9 million people are living with HIV. By comparison, HIV prevalence in West and East Africa is low to moderate ranging from 0.5% in Senegal to 6% in Kenya.2
While many countries have large, generalised epidemics, research has shown how groups such as young women and men who have sex with men are particularly at risk of HIV.
Key affected populations in sub-Saharan Africa
While the vast majority of new HIV infections in sub-Saharan Africa occur in adults over the age of 25, HIV disproportionately affects young women. More than 4 in 10 new infections among women are in young women aged 15-24. 15-19 year olds are particularly at risk equating to higher HIV prevalence rates when they are older.3
For example, in Mozambique, HIV prevalence is 7% among 15-19 year olds but rises to 15% for 25 years olds. Likewise, in Lesotho, HIV prevalence rises from 4% among 15-19 year olds to 24% among 20-24 year olds.4
A review of 45 studies across sub-Saharan Africa found that relationships between young women and older men are common and associated with unsafe sexual behaviour and low condom use, which heightens their risk of HIV infection.5
Since 2009, there has been a 43% decline in new HIV infections among children in the Global Plan priority countries, from 350,000 to 200,000 in 2013. However, declines vary greatly between countries.7
For example, in this period, new HIV infections among children in Malawi declined by 67% and by over 50% in Botswana, Ethiopia, Ghana, Mozambique, Namibia, South Africa and Zimbabwe. By contrast, Nigeria only achieved a 19% fall and accounted for a quarter of new HIV infections among children in Global Plan priority countries in 2013 (51,000 cases).8
Sex workers are also at particularly high risk of HIV in sub-Saharan Africa. Average HIV prevalence among this group is an estimated 20% compared to just 3.9% globally. In fact, 17 of the top 18 countries where HIV prevalence exceeds 20% among sex workers, are in sub-Saharan Africa.9
In 2013, five of the six sub-Saharan African countries that reported prevalence rates among both female and male sex workers found female sex workers were more affected. However, HIV prevalence among male sex workers was still high (13%).10
This is despite high levels of reported condom use where 86% of sex workers used one the last time they had sex, while 78% of female sex workers reported receiving a free condom. However, condom distribution often varies greatly within countries.11
Men who have sex with men
While data on men who have sex with men (MSM) is very limited for sub-Saharan Africa, HIV prevalence is believed to be very high. According to national AIDS response progress reports, HIV prevalence among this group is 15% across West and Central Africa and 14% across East and Southern Africa.12
However, there are great disparities between countries. For example, HIV prevalence among MSM in nine countries was reported at under 1%. By contrast, up to 54% of MSM in Mauritania and 57% of MSM in Guinea are thought to be living with HIV.13
People who inject drugs
Compared to other regional HIV epidemics, HIV transmission via injecting drug use is comparatively low in sub-Saharan Africa (0.2%). Although this is a small percentage, it still equates to a large number of people potentially at risk of HIV transmission.14
Moreover, there are fears that HIV prevalence among people who inject drugs (PWID) will increase. Although surveillance of PWID in sub-Saharan Africa is limited, the evidence available suggests a close relationship between injecting drug use and HIV infection.15
HIV testing and counselling (HTC) in sub-Saharan Africa
In recent years, a number of countries in sub-Saharan Africa (such as Botswana, Kenya, Uganda, Malawi and Rwanda) have implemented national campaigns to encourage uptake of HIV testing. In 2013, 6.4 million people were tested for HIV in Kenya compared to just 860,000 in 2008.18
However, in many countries, more than half the people estimated to be living with HIV are still not aware of their HIV status.19
A number of different strategies have been used to increase delivery and access to HTC services in this region. For example, home-based testing (HBT) is proving successful, with a meta-analysis reporting a 70% acceptance rate among people offered a HIV test in their home.20 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.21
Another 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.22
Additionally, a study has found that inviting people personally and offering them incentives such as food vouchers can encourage people to get tested.23 Community-based programmes have also been found to significantly increase HIV testing uptake.24
However, even where people have accessed testing, many who test positive do not enrol on treatment. One study reported that roughly 50% of people who test positive for HIV in sub-Saharan Africa are lost between testing and being assessed for eligibility for treatment. A further 32% who find out they are eligible for treatment do not initiate ART.25
HIV prevention programmes in sub-Saharan Africa
A number of countries in sub-Saharan Africa have conducted large-scale prevention programmes in an effort to contain and reduce their HIV epidemics.
Condom use and distribution
Over the past decade, condom use in sub-Saharan Africa has generally been on the rise. However, in some countries, condom use has actually declined (e.g. Ivory Coast, Niger, Senegal and Uganda).26
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.27
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 particularly a problem for younger women whose husbands tend to be older and have a higher HIV prevalence.28
Prevention of mother-to-child transmission (PMTCT)
Significant progress has been made in the prevention of mother-to-child transmission (PMTCT) of HIV in sub-Saharan Africa. In 2013, over 900,000 pregnant women living with HIV accessed antiretroviral treatment, equating to a coverage of 68%. In four countries (Botswana, Namibia, South Africa, Swaziland) more than 90% of pregnant women were accessing ART.29
However, there is evidence that progress in the scaling up of ART for pregnant women is slowing. 37,000 additional pregnant women were reached by PMTCT programmes in 2013 compared with 97,000 in previous years. Indeed, in many countries, there has been a decrease in number of pregnant women receiving ART including Botswana, Chad, Ghana, Lesotho, South Africa, Uganda, Zambia and Zimbabwe.30
This has been partly attributed to better monitoring systems in some countries, allowing for more accurate estimates.31 However, research has also highlighted a number of barriers to achieving comprehensive coverage of PMTCT in sub-Saharan Africa within the health system (a shortage of staffing and accessibility) 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.32 33
Voluntary medical male circumcision (VMMC)
Following the discovery that male circumcision could reduce the risk of sexual transmission of HIV from females to males by 60%, in 2007, the World Health Organisation (WHO) and UNAIDS recommended voluntary medical male circumcision (VMMC) as a key component of HIV prevention in countries with a generalised epidemic.
Studies from 2009-2011 indicated that circumcising 80% of men in 14 priority countries in Eastern and Southern Africa in 5 years could avert 3.4 million new infections over the next 15 years and save $16.5 billion in treatment costs.34
As a result, the WHO and UNAIDS launched the Joint Strategic Action Framework for accelerating the scale-up of VMMC for HIV prevention in Southern and East Africa, calling for 80% coverage of adult male circumcision by 2016.35
By 2013, 5.8 million of the estimated 20 million men needed to achieve 80% coverage had been reached by VMMC programmes, requiring a further scale up of existing efforts.36
In response to reported rises in injecting drug use, 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.37
Kenya, Nigeria 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 injecting drug use as part of the agreement, which aims to build an evidence base for harm reduction initiatives.38 39
Antiretroviral treatment (ART) in sub-Saharan Africa
Over the past decade, antiretroviral treatment programmes have been scaled up dramatically in sub-Saharan Africa. In 2012, 68% of people living with HIV in sub-Saharan Africa had access to antiretroviral treatment under the World Health Organisations (WHO) 2010 guidelines (those with a CD4 count of 350 or less).40 However, the WHO’s 2013 guidelines have subsequently made many more people eligible for treatment by expanding treatment initiation to those with a CD4 count of 500 or less, reducing ART coverage to 39% in 2013.41
Under these new guidelines, 79% of people living with HIV in West and Central Africa and 59% of people living with HIV in East and Southern Africa eligible for treatment are not accessing ART. Moreover, 75% of adults with HIV in sub-Saharan Africa who are accessing ART have not achieved viral suppression.42
Access to ART is particularly low for children and they are only half as likely to receive treatment as HIV-positive adults. Under 2013 WHO treatment guidelines, 89% of children living with HIV in West and Central Africa and 63% in East and Southern Africa who are eligible for treatment are not accessing it.43
HIV funding in sub-Saharan Africa
Increased funding is at the centre of efforts to improve HIV and AIDS service provision in sub-Saharan Africa. As the region with the highest HIV burden, it accounts for the largest proportion of global HIV spending - 47% in 2012.44
Developed countries have increased funding support for HIV and AIDS in sub-Saharan Africa in recent years, most significantly through the Global Fund.
In sub-Saharan Africa, 2.3 million people received ART through Global Fund-supported programmes in 2010. The Global Fund finances 100% of antiretroviral treatment programmes in a number of countries in sub-Saharan Africa including Ethiopia, Ghana, Guinea, Malawi, Namibia and Tanzania.45
In 2010, 80% of funding for HIV programmes in sub-Saharan Africa was from donor governments.46
By comparison, South Africa, which has the most people living with HIV anywhere in the world, mostly funds its own HIV response, while Kenya, Togo and Rwanda have all doubled their HIV spending in the past few years.47
The implementation of large-scale HIV treatment and prevention programmes requires a country's health, education and infrastructure to be developed sufficiently. 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.48
Barriers to HIV prevention in sub-Saharan Africa
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).49
While external funds account for two-thirds of HIV spending in sub-Saharan Africa, two-thirds of general healthcare expenditure is sourced from domestic governments. Raising taxes has the potential to increase health expenditure in some countries but not all.50
For example, Zambia's economy is expected to grow by nearly 5% a year between 2011 and 2017, creating an additional $21.8 per capita in healthcare spending. By contrast, Swaziland has a projected growth of minus 0.1% for the same period, and therefore has very limited scope to increase domestic spending on healthcare.51 External borrowing is also an option but many countries in sub-Saharan Africa already have high levels of debt compared to their economic output.52
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. Cultural beliefs about HIV and AIDS around contamination, sexuality and religion have played a crucial role in the development of HIV-related discrimination. In many places, it is thought to have actually increased the number of HIV infections by preventing people from accessing HIV services.53
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.54
- The status of women
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 involved. Gender-based violence has been identified as a key driver of HIV transmission in the region.55
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.56 57
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.58
The past decade has seen new wave of HIV-specific criminal legislation in parts of sub-Saharan Africa. In Western 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.59
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 pregnant women living with HIV could be prosecuted for transmitting the virus to their baby.60
The future of HIV and AIDS in sub-Saharan Africa
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. Moreover, 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.
As the HIV epidemic develops, countries in sub-Saharan Africa will need to assess how to allocate what are currently limited treatment resources. 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.
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