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HIV in Africa

Alexander Roedlach, Ph.D.

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Throughout this course, "Africa" refers to sub-Saharan Africa (Africa south of the Sahara desert), unless otherwise stated.

This brief course presents some of the characteristics of AIDS in Africa and can only begin to address the complexity of the issues and the often-heated controversies surrounding them. Addressing the epidemic in the whole of sub-Saharan Africa poses a further problem. Keep in mind that Africa is a vast region inhabited by myriad ethnic groups that are characterized by highly diverse cultural traditions and social settings with dissimilar historical backgrounds, economic circumstances, and political conditions. Consequently, there is no single "African" epidemic. The nature of the epidemic varies significantly between and within sub-regions and countries.

THE BIOLOGY OF HIV

The human immunodeficiency virus (HIV) belongs to the group of retroviruses that integrate with the genetic material of the host cell to establish a permanent infection within the body. HIV also belongs to the group of lentiviruses, which only slowly develop diseases in the infected individual.

As with all viruses, HIV mutates rapidly. By the turn of the century, two main types of HIV—HIV-1 and HIV-2—and more than ten distinct subtypes of HIV-1 were known. HIV-2 appears to take much longer to cause disease and to be less easily transmitted sexually and from mother to child than HIV-1. Their geographical distribution varies widely around the globe.

Up to now vaccine research has concentrated on the subtypes prevalent in Europe and America. It is not clear how effective a vaccine developed to fight one subtype would be against other subtypes, for example the subtypes found in Africa. Another complicating issue is that, in some parts of Africa, the subtypes are mixing, creating hybrids, possibly with a greater virulence of the virus (Essex, 2002, p. 35).

The virus is related to viruses affecting certain monkey species, the simian immunodeficiency viruses (SIVs), that crossed over to humanity. Exactly how this happened is not fully known. Within the human body, SIV mutated and evolved into HIV. The first isolated incidents of HIV infection were identified in stored human blood samples from the 1950s and 1960s (Jackson 2002, pp. 41–42).

Controversy still rages among many Africans as to whether HIV actually causes AIDS. Though people can develop weak immunity for other reasons than HIV infection—for instance, when they are malnourished or have certain cancers—it is scientifically established that the progression of HIV infection leads to a collapse of the immune system unless medical treatment is begun. Yet some African scientists and activists argue either that HIV does not exist, or posit that HIV is harmless and does not lead to AIDS, or maintain that HIV is harmless on its own. In 1999 President Thabo Mbeki of South Africa gave this view considerable support. He and others are correct only to the degree that poverty and malnutrition hasten the progression to AIDS, and that tackling them is also crucial to addressing the AIDS epidemic. However, his denying that the social context of HIV-infection, and not HIV itself, is the cause of AIDS did much harm to HIV prevention efforts (Jackson, 2002, pp. 6–7).

HIV INFECTION AND AIDS

It appears there is a difference in infectivity among the virus subtypes prevalent in different parts of the world. Some seem more readily transmitted heterosexually than others, notably the type that is most common in southern Africa.

The HIV virus is found in significant amounts in blood, semen, and vaginal fluids. To cause infection, the virus must pass in significant amounts from one person's body fluids into another person's. This has to happen quickly, because HIV has a lipid outer membrane and the virus dies rapidly when it becomes dry (Jackson, 2002, pp. 81–82).

When HIV enters the human body, the immune system fights the virus by producing antibodies in the blood through some of its white blood cells. This process is called seroconversion. Particularly, the CD4 cells, also called T4 cells, activate other cells to produce antibodies and attack the viruses. It is difficult for the body to fight an HIV infection, because HIV is infecting and hiding in CD4 cells. When HIV enters a cell, it produces copies of itself until the cell dies and breaks open. Then HIV finds other CD4 cells and the process begins afresh. Over time the amount of HIV, the so-called viral load, increases and the number of CD4 cells decreases. As a result, the infected individual's immunity becomes weaker and the person develops infections.

After the initial infection with HIV, seroconversion can take six weeks or longer. During this period no antibodies can be detected in the infected individual's body. The time lag between infection and detection of antibodies is called the window phase. People are highly infectious to others during this stage of the infection, because the virus is replicating fast. At this stage, effective treatments and good nutrition can help the immune system to produce more CD4 cells that fight opportunistic infections.

In the developed world, the average incubation period between infection with HIV and falling ill with AIDS is 10 to 12 years, though the length of this period is highly variable. In developing countries, including most of Africa, the average incubation period in adults is much shorter. After 7 to 8 years, about 50% of people with HIV develop full-blown AIDS. In infants, the incubation period is often less than two years because their immune systems are not yet fully developed (Hunter & Williamson, 2000).

A combination of factors is responsible when full-blown AIDS develops relatively early. Most important, poor socioeconomic conditions with very limited health care, so common across Africa, expose individuals to other infections that are often left untreated, keeping the immune system highly active and thus vulnerable when coupled with an HIV infection. Further, infection with some types of HIV-1 that are common in Africa can be particularly stressful on the immune system, which may contribute to a quicker development of AIDS. Additionally, individuals' immune responses differ from each other, with some less able to fight infections (Jackson, 2002, pp. 43–46).

HIV INFECTION THROUGH SEXUAL INTERCOURSE

The AIDS epidemic in Africa shows us a face of the epidemic different from the prevalent image in the West. The predominant mode of HIV transmission in Africa is heterosexual vaginal intercourse affecting the general population; this is in contrast to other regions of the world where special high-risk groups are identified.

The rate of the sexual transmission of HIV in Africa increases when other illnesses are present, especially sexually transmitted diseases (STDs). These and some other reproductive-tract infections increase the risk of HIV transmission because of genital lesions or sores associated with some of these infections through which the virus can readily spread. Further, genital infections, even without the presence of sores, increase the number of CD4 cells in the genital area—the cells that HIV primarily targets. The effective detection and treatment of these infections is essential for preventing new HIV infections. However, due to poor healthcare facilities in many parts of Africa, these are often left untreated (Green, 2003, pp. 33–36).

The rate of sexual transmission decreases when other factors are present, such as male circumcision. This practice is undertaken in various African cultures at puberty as part of rites of passage into manhood. A study in South Africa found that adult male circumcision reduced men's risk of contracting HIV during sexual intercourse by over 60% (Williams et al., 2006, p. 1033). The protective effect is possibly the result of the toughening of the skin of the glans of the penis after circumcision, which lessens the risk of abrasions during sexual intercourse. Virologists further believe that, because the foreskin is more vulnerable to various STD infections, HIV spreads more easily via the special immune receptors known as Langerhans cells, which are highly concentrated in the foreskin but largely absent from the circumcised penis (Oppong & Agyei-Mensah, 2004).

Sex work (prostitution) contributes substantially to HIV transmission in Africa; however, in Africa prostitution is often not easily distinguished from other forms of transactional sex. Much casual sex is transactional, that is, it involves the man paying for sexual services through buying gifts, paying for food and drinks, and so forth; yet the women involved would not identify themselves as sex workers. Women often refer to selling sex out of economic desperation because it is one of the few ways for them to earn a living. In some African countries, after agriculture, beer brewing and transactional sex are the two major sources of livelihood for women.

We should not conclude that people in Africa engage in casual sex with a variety of partners more often than people elsewhere. Recent research has shown that, for example, Scandinavians engage more frequently in both premarital and extramarital sex than people in most parts of Africa. The patterns of sexual partnerships differ.

Scandinavians tend to have a single partner with whom they have regular sex, and only begin another steady relationship when they stop having sex with their first partner (ie, serial monogamy); people in many parts of Africa tend to have more than one continuing partnership at the same time and are likely to have sexual relations with all of their partners.

Because their partners also have concurrent partnerships that include sexual relations, people are connected in a wide sexual network that allows HIV to spread rapidly when the virus is introduced. This tendency, together with other factors mentioned in this course, helps to explain why the AIDS epidemic reached such dramatic proportions in Africa.

The role of homosexuality in the transmission of HIV in Africa, most probably not a major contributing factor, has not been well studied. Male homosexuality is widely stigmatized in much of Africa and is frequently regarded as a Western import. However, men were having sex with men in Africa long before colonialism. For instance, in Zimbabwe, when an adult showed no sexual interest in the opposite sex, he or she would be said to have been taken over by a spirit of the opposite sex. Should a female spirit possess a man, he must have sex with men to fulfil the needs of the female spirit in him. Anthropologists have seen this belief as a coping mechanism that helped someone to deal with the shame associated with having a sexual orientation different from the majority in society.

PERINATAL HIV INFECTION

The corollary of heterosexual sex, mother-to-child infection, is the second most common way of HIV infection in Africa. The virus can pass from the mother's bloodstream and other body fluids, including breast milk, into the baby and cause infection. Without protection, roughly one-third of babies born to mothers with HIV-1 will acquire the virus before or during birth, or through breastfeeding.

The rate of HIV transmission to babies can be drastically reduced by a combination of interventions, most importantly by antiretroviral therapy (ARV). Generally, nevirapine—a relatively affordable drug that is easy to administer—is given in a single dose to the mother in labor and another single dose to the newborn at 2 to 3 days of age. Some African countries with a high prevalence of HIV have developed policies for free national provision of nevirapine to all HIV-positive mothers.

If the mother is HIV-positive, it is advisable to avoid unnecessary invasive procedures during labor, such as early rupture of membranes, routine episiotomy, and the use of forceps, because these increase the extent to which the baby is exposed to maternal secretions and blood. A cesarean section reduces the risk of transmission during birth and is a way of reducing the risk of an infection to the newborn; yet this is not an option in many African countries because of the high cost or simply because the necessary medical facilities are not available.

As HIV can be transmitted to the baby through breastfeeding, bottle feeding or heat treatment of expressed breast milk could be considered; however, in much of Africa this is not an option either because substitutes for breast milk are unavailable or unaffordable. Free provision of formula for babies would be a simple strategy to prevent some infections in African babies. On the other hand, lack of hygienic conditions, particularly in rural areas, could make formula feeding a risky strategy if it increased transmission of other infections to the infant. The expression and sterilizing of breast milk is particularly difficult. A practical alternative is to breastfeed and then wean abruptly after a couple of months. The advantage is that the time span for risk of HIV infection is substantially reduced.

HIV INFECTION WITH INFECTED BLOOD

Because HIV lives and reproduces in blood cells, blood-to-blood contact with someone who has HIV through blood or organ transfusion carries the risk of an HIV infection. The same is true for contact with an open sore or wound of an infected individual, eye splash with infected blood, and sharing of implements that might have traces of infected blood on them.

Because of the risk from infected blood, most African countries screen blood for HIV. Zimbabwe has successfully adopted strategies to make the country's blood supply safe. Blood donors are selected from safer populations such as secondary school students that are carefully screened on reported behavior and health as well as through blood tests. Despite an estimated prevalence rate of 25% in pregnant women nationwide, Zimbabwe has managed to reduce the infection rate in donated blood to below 2% of donors and less than 1% of all donated blood.

Any medical procedures involving blood carries a possible risk of infection to the patient or the health worker. Nonetheless, these risks are small for HIV compared with other infections. Nevertheless, the appropriate response to this risk is to make invasive medical procedures as safe as possible. In the case of occupational risk of HIV infection, postexposure prophylaxis (PEP) is available. PEP means putting the person who may have been exposed to HIV (eg, from a prick with an infected needle) on a one-month course of antiretroviral treatment. This approach is estimated to substantially reduce the risk of a permanent HIV infection but further data are needed to confirm PEP's effectiveness.

In Africa, many governments are exploring PEP for hospital staff. Because many AIDS patients are cared for at home by their relatives, the caregivers also need to take such precaution against HIV infection. Plans to provide PEP for them are, however, nonexistent.

HIV PREVALENCE IN AFRICA

Africa is the overall leader in the number of people living with HIV and dying of AIDS. Although Africa has only a little more than 10 percent of the world's population, an estimated two-thirds of all AIDS cases are found there. The highest prevalence of HIV is in the southern and eastern part of the continent. Southern Africa is the global epicentre of the epidemic. Almost 1 in 3 people infected with HIV globally live in this sub-region (UNAIDS, 2006, p.15).

Some startling numbers can be viewed on the AidsinAfrica.net website. (Viewing Instructions: Clicking this link will open a new browser window or tab. On the AidsinAfrica.net website, the information, titled "People Charts", is presented in a Flash movie. After the program has loaded, click on links 1, 2, and 3.)

Figure 1.    HIV prevalence in adults in sub-Saharan Africa, 2005 (UNAIDS, 2006, p.14).

The collection of data on AIDS in some African countries is problematic. One reason is that the poor healthcare system, particularly in rural areas, lacks the capacity to record deaths and their causes. Another major problem in collecting HIV and AIDS information is the heavy stigma associated with the infection; AIDS is linked with immoral sexual behavior. Subsequently, many people hesitate to be tested for HIV or to reveal positive HIV status, and healthcare providers are reluctant to mention AIDS openly as the underlying cause of opportunistic infections (Jackson, 2002, p. 22).

Surveillance means measuring infection levels in selected population samples that indicate trends in the development of the epidemic in key population groups at risk of infection. In Africa, HIV surveillance data are generally collected on pregnant women attending antenatal clinics. This makes sense because the main route of HIV transmission is heterosexual vaginal intercourse, and pregnant women provide the best indication of HIV infection in the sexually active population aged 15 to 49. Their data cover most of the age range with the highest risk of infection and allow an assessment of how many babies are at risk.

Obviously caution is needed when generalizing from women to men and to the entire population of women from prenatal clinic attendees. The growing number of population-based HIV prevalence surveys in sub-Saharan Africa, new and improved HIV surveillance data globally, and improved analyses in some countries indicate that HIV prevalence in several countries is lower than had previously been estimated (UNAIDS, 2006, p. 10).

Among notable new trends are recent declines in national HIV prevalence, for example in Kenya and Zimbabwe, alongside indications of significant behavioral change—including increased condom use, fewer partners, and delayed sexual debut. In the rest of sub-Saharan Africa, epidemics appear to be leveling off but still remain at high levels in most of southern Africa (UNAIDS, 2006, pp. 8–9).

The high infection levels and prevalence rates in many African countries lead to a lowering of the average life expectancy, which is measured from birth and reflects the risk of dying at various ages throughout life. In a few African countries, the average life expectancy has declined by over half (Figure 2). That means that, on average, people in these countries can expect to live less than half their projected lifespan before AIDS.

Figure 2.    Impact of AIDS on life expectancy in five African countries, 1970–2010 (UNAIDS, 2006, p. 81).

Infection levels in Africa are projected to stay high through at least 2010 and the number of deaths (Figure 3) will likely increase over the next two decades because of the lag between infection and death. As a result, the AIDS epidemic is dramatically changing the demographic makeup of African countries. By 2010, five countries are projected to have negative population growth and eleven to have life expectancies of only thirty years, a statistic not seen since the end of the 1800s (Hunter, 2003, p. 45).

Figure 3.    Estimated number of deaths (all ages) due to AIDS in sub-Saharan Africa, 1985–2005 (UNAIDS, 2006, p. 9).

CULTURE, SOCIETY, AND AIDS

Because heterosexual intercourse is the main way through which HIV infection is acquired, it is important to understand that patterns of sexual behavior are determined by an array of factors beyond individual morality, personal choice, and private decisions about risk. Socioeconomic, cultural, religious, political, legal, and other factors are all important in creating the "risk environment" in which people live (Schoepf, 2004; Lwanda, 2004).

New survey data underscore the disproportionate impact of the AIDS epidemic on women in Africa, where, on average, 3 women are HIV-infected for every 2 men (Figure 4). Among young people, that ratio widens considerably, to 3 young women for 1 young man. Though generally women are more easily infected than men due to the easy rupture of the vaginal mucous membrane during intercourse, there has been an increasing recognition that gender inequality is the reason African women are infected more often and earlier in their lives than men (Akeroyd, 2004; Campbell, 2004; Susser & Stein, 2004).

Figure 4.    HIV prevalence (%) by gender in selected sub-Saharan African countries, 2001–2005 (UNAIDS, 2006, p. 19)

Because of the typical pattern of sexual partnerships, often involving younger women with older men, females also contract HIV at a much younger average age than males and they die younger. Deaths from AIDS typically peak in women in their twenties and in men in their late thirties and early forties.

Women in many parts of Africa are at a higher risk because of cultural understandings of gendered behavior that encourage women to be submissive toward males, while males are expected to be dominant over women, to take risks, and to engage in promiscuous sex. Thus women are less likely to be able to negotiate for safe sex or condom use, or to prevent their husbands or partners from having other sexual relationships. Consequently, in southern Africa marriage has become for women the highest risk factor for acquiring HIV.

Further, cultural understandings that encourage female submission contribute to women becoming vulnerable to sexual abuse. In some African countries, abuse has become so widespread that rape contributes significantly to the AIDS epidemic. South Africa, for instance, has the highest reported incidence of rape in the world. These sexual acts carry a high risk of infection if the man has HIV, because of the trauma to the delicate lining of the vagina.

Males may use force to push women into the first sexual encounter. By doing so the man asserts his masculinity and the woman proves that she is a respectable girl. This is related to a commonly held view that sex is for male pleasure. Respectable women do not seek enjoyment during sex. If they were to enjoy sex, then they might be called "loose."

Associated with this cultural view is that sex in marriage is for procreation, while sex outside marriage is for pleasure, which encourages males to have a variety of partners outside marriage.

Efforts to prevent new HIV infections are further hindered by the common agreement in many African cultures that sex is performed but not talked about, particularly between sexual partners. This is especially problematic within marriage because it is difficult for married partners to speak about sexuality, negotiate sex, or discuss the use of condoms. Not surprisingly, HIV prevention is not easily discussed either.

The media report many incidents of sexual abuse of very young girls, even female infants. In some parts of Africa it is widely believed that an infected man can get rid of HIV by having intercourse with a female virgin. AIDS sufferers turn to this "remedy" in their desperation because they have no access to medical treatment, fear imminent death, and have lost hope of regaining their health. Understanding such reasoning does not, however, make it acceptable. Such behavior is criminal.

Polygamy is practiced in all regions of Africa, though the actual percentage of polygamous marital unions in most countries is relatively low. Polygamy is particularly risky because if just one individual in a polygamous union seeks extramarital sex and becomes infected with HIV, that person will infect all the others.

In some parts of Africa, it is believed that during sexual intercourse not only do males ejaculate into females but also females ejaculate into males; further, the body fluids of one partner are drawn into the body of the other partner. At times this belief leads to the fear that condom can get sucked into the body, causing pain and illness. This leads to reluctance in using condoms and increases the risk of HIV infection if one of the sexual partners is HIV-positive.

The practice of dry sex is common in much of Africa. The vagina is supposed to be dry, and in some cases tight, for the man to really enjoy sex; the dryness ensures that the woman is "clean." Vaginal secretions are seen as dirty and also indicate that the woman is sexually aroused, which may not be socially acceptable. Women use various herbs, liquids, and creams to clean and dry the vagina, what may cause irritation and subsequent high risk of HIV infection.

Sometimes rites of passage and rituals surrounding the death of an individual involve sexual activity. Among some groups, initiation rites for adolescent girls include having sex with a selected male from the community. In some groups the widow is expected to become the wife of her deceased husband's brother, even though her husband may have died of AIDS and she herself has HIV. Sometimes the widow is to have sex with the brother in a cleansing ceremony connected to the death of the husband.

In some parts of Africa, AIDS is interpreted in terms of witchcraft. The symptoms of AIDS have some affinity with traditionally known diseases that are "caused" by these occult practices. The problem with such interpretations is that attention is not given to the sexual transmission of HIV but to counteract the aggressions of a witch or sorcerer (Roedlach, 2006).

Throughout Africa, conspiracy theories abound that attribute blame for the AIDS epidemic to an evil agent, usually an American or at least a European, who plots to kill all Africans (Roedlach, 2006). In other words, people seeing credibility in such beliefs tend to view themselves as in the hands of malicious outside forces that will resist all efforts to combat the AIDS epidemic. Hence, they conclude that focusing on preventing HIV infection is just a waste of time.

This short sample of cultural beliefs shows that cultural understandings can negatively impact prevention efforts. However, culture, tradition, beliefs, and values are dynamic, changing over time, and they can be influenced in positive ways. Sensitive approaches promote discussion and involvement, not authority from outside the culture, and are based on socio-cultural research to determine what the risk factors are, what sustains harmful practices, traditions, attitudes, beliefs, and behaviors, and what is required to transform them. This does not mean to abolish a particular practice, but to change the damaging elements while retaining the overall custom, its symbolism, and its meaning. One example is the earlier mentioned sexual cleansing for widows, which is being replaced among some African ethnic groups with nonsexual rituals so that the overall ceremony continues and retains its value to the culture.

PREVENTING SEXUAL HIV INFECTION

Prevention of HIV infection rests on educating people at risk of becoming infected. More than two decades of campaigning to raise awareness about the AIDS epidemic has resulted in a large percentage of African people most affected by the epidemic being aware of the modes of HIV transmission and how to prevent HIV infection.

It is known that the most effective ways to prevent the sexual transmission of HIV are not having sex or staying faithful to one uninfected lifelong monogamous partner. Traditional African worldviews, as well as world religions present in Africa, provide norms and values that emphasize abstinence and marital fidelity. These norms and values need to be complemented with strategies to promote the consistent use of condoms for preventing HIV infections. Careful social marketing of condoms has enormously increased condom availability and use in many African countries.

The so-called ABC of AIDS prevention (Abstain, Be faithful, or use Condoms if you cannot follow A and B) systematizes these three approaches. Though some think of the ABC approach as a conservative plot rather than a proven public health intervention, it is immediately understood by many in Africa. It signals that there is a need for several complementary interventions that have contributing roles. ABC also implies a balanced approach, a menu of options instead of only one or two (Green, 2003, pp.13–21; Green & Herling, 2006).

Some religious groups vehemently oppose condom use, focusing solely on abstinence and monogamy. They need to balance a concern for saving lives against preventing sex that they consider immoral, even at the price of higher infection rates and death—death not only among the immediate "immoral" risk takers but also among monogamous spouses and their offspring. Exploring areas of common ground with religious groups is of utmost importance because in much of Africa faith-based organizations have the only functional networks; they enjoy considerable trust among residents and thus have a high potential for HIV/AIDS mitigation, prevention, and care (Green, 2003, pp. 286–302).

Other barriers to the sexual transmission of HIV besides condoms are less well developed, but will in time include microbicide foam, sponges, gels, and film, to kill HIV and other microorganisms in the vagina. They will be useful in conditions where HIV prevention is not discussed between sexual partners because women can use them without discussing the issue with their male sexual partners.

Social control does have some relevance. Some African parents are returning to or re-inventing virginity testing as a means of preventing early sexual behavior and avoiding the risk of HIV. Once declared a virgin, girls and boys acquire social respectability. Girls are tested to ascertain whether they have an unbroken hymen, while boys' foreskins are investigated to identify tiny breaks in the skin resulting from sexual activity. Such testing, though often culturally acceptable, is problematic because of its dubious scientific value and because it particularly stigmatizes young women who, for reasons other than sex, have a broken hymen. Yet this testing reinforces the value of delaying sexual activity and might have a short-term benefit.

It is crucial to turn around sexual and gender stereotypes that promote high-risk behavior, but this is complex to achieve. For instance, it can be taught that a "real man" cares enough about his wife to be faithful to her and is responsible and caring enough toward any partner to use a condom. Endorsing men's important role as fathers may further encourage responsible sexual behavior. In various African countries men are establishing action groups. Although small, these initiatives are an important beginning in helping to challenge existing stereotypes and ideas around masculinity and male-female relationships. Part of their importance lies in providing African role models of men who take a different approach to gender.

Effective programs preventing new HIV infections are generally the result of collaboration by the political, economic, religious, and other sectors in society. Further, an integration of various prevention and care approaches has shown to be highly successful (Green, 2003, pp. 273–74). Recent predictions support this view (Figure 5). Programs that concentrate on treatment alone do not go far in preventing new HIV infections. Prevention programs show some success, which further increases when they integrate treatment programs.

Figure 5.    Impact of various scenarios on HIV infection in sub-Saharan Africa, 2003–2020 (UNAIDS, 2006, p. 126).

The problem in several of the African countries is that they lack a functioning political administration, have a weak economy, and have a hopelessly under-funded healthcare system, which compromises the effectiveness of HIV prevention efforts. Yet, in some African countries, data from sentinel surveillance and other surveys show a declining trend in HIV prevalence (Gregson et al., 2006; Mahomva et al., 2006; UNAIDS, 2006, pp. 16–17).

A combination of delayed sexual debut, avoiding sex liaisons, increased condom use, wide AIDS awareness, relatively extensive health infrastructure, and other factors might be responsible for this development. Unfortunately, a significant part of the decline in HIV prevalence can also be attributed to high mortality rates.

Testing and Counseling

Over the last few years, many countries in Africa and elsewhere have established voluntary counseling and testing (VCT) centers to help people learn their HIV status long before they become sick. Though these services are either free or available for a small fee, some are reluctant to use them because of the stigma of AIDS. Yet among those who use the services there is some indication that condom use increases with casual sexual partners after VCT, suggesting responsible behavior changes.

The most widely used tests for HIV detect antibodies in the blood of an individual, not the virus itself. Thus, persons must wait up to three months after the last risk of exposure to HIV before having a test. Increasing in use are rapid tests that generate results in a few minutes. The rapid tests are ideal for Africa, because they are simple to administer, do not require the sample to be sent to a laboratory, are small and light and thus easy to transport to rural areas, and are useful in areas with a high prevalence of HIV to determine who can donate blood in emergencies.

Testing requires confidentiality. In the context of Africa, confidentiality needs to be redefined because individual health and welfare problems are viewed as family problems needing family solutions. An overemphasis on individual confidentiality with respect to HIV/AIDS may cause harm because it undermines the family's capacity to play its traditional role of support. In some African countries, AIDS counselors have replaced the term "confidentiality" with the concept of "shared confidentiality." This transforms the narrow Western concept of individual confidentiality into a concept of confidentiality among the relevant family members and others concerned with the welfare of the community.

After tests that indicate an HIV infection, counseling is necessary. Health staff and counselors need to be sensitive to the complex cultural interpretations people may have of their diagnosis, helping them to seek support and advice that address their needs at different levels. Counselors need to involve traditional, religious, and biomedical practitioners to meet the spiritual, emotional, and medical needs of the patients.

In some African countries medical doctors are reluctant to test for HIV when AIDS is suspected. First, there are so many of suspected cases that they have neither time nor facilities to test all of them. Their realistic assessment is that they would not be able to offer counseling if a test indicated HIV infection. Further, they cannot help the individual through ARV treatment because the drugs are either unaffordable or unavailable. Another medical problem is that spouses rarely come together for testing, and if one partner is infected the other spouse most likely is too (Mutetwa, 2001).

Treatment and Vaccines

The provision of ARV treatment is important because it shows HIV-positive individuals that there is hope for them. It is widely accepted that more people are likely to participate in VCT if there is hope of treatment (Nattrass, 2006, pp. 40–41).

In the past few years the costs for ARV in the developing world have gone down. In Africa, the number of people on antiretroviral therapy more than doubled in 2005 alone, with roughly 1 in 6 people who needed treatment receiving antiretroviral medication by December 2005 (Figure 6) (UNAIDS, 2006, p. 151). Yet, most people in Africa still have no access to the treatment. While some organizations provide ART at no cost, not everyone is able to access their help. Even if drug prices for ARV were reduced substantially, the poor infrastructure in many African regions presents a major problem in distributing the drugs and monitoring their use.

Figure 6.    People in sub-Saharan Africa on antiretroviral treatment as percentage of those in need, 2002–2005 (UNAIDS, 2006, p. 153).

An important goal is for pharmaceutical companies and developing nations to work together to develop affordable medications. Pharmaceutical companies have social responsibilities, particularly in the case of a global epidemic (Resnik, 2006). However, in many instances pharmaceutical companies appear to be concerned only for their profits, arguing against substantial lowering of prices for ARV and for protection of patents guaranteeing that they alone can market the drugs. Patents on medications are currently valid for twenty years under the international Agreement on Trade-Related Aspects of Intellectual Property Rights (TRIPS). The 137 member states of the World Trade Organization are bound by this agreement. Developing countries do have some means of strengthening their negotiating power by declaring—for example, in southern Africa—national or regional AIDS emergencies. Through this procedure, the TRIPS agreement can be legally suspended. This would enable the petitioning countries to import cheaper, generic ARV drugs and their governments to adopt ARV treatment policies (Hunter, 2003, pp. 34–36).

Vaccines against many viruses and other microbes are highly successful—much more so than treatments. Three main types of HIV vaccines are being investigated: preventive vaccines to stop HIV infection from becoming established after exposure; therapeutic vaccines to prevent HIV from progressing to AIDS; and perinatal vaccines to prevent transmission from mother to baby in utero, at birth, or through breastfeeding. However, although they hold out such an exciting long-term promise, they cannot replace existing HIV prevention efforts.

Even when vaccines are eventually available, they may confer only limited protection. Such protection is far lower than that provided by consistent condom use. The value of vaccines is their add-on to other methods. Together with delayed sexual activity, reduced partner change, consistent condom use, STD treatment, and other prevention approaches, HIV transmission rates could plummet (Jackson, 2002, pp. 56–80).

Self-Help and the Community

Before HIV-positive individuals fall ill they are often encouraged to join peer groups, the so-called People Living With HIV and AIDS (PLWHA). These groups give people in the environment of stigma and fear surrounding AIDS the opportunity to openly discuss their HIV status, what it means, and how they are coping. People with HIV and AIDS have also helped influence medical approaches to holistic care, sensitizing doctors to the need to support patients' emotional, mental, and social well-being as well as their physical needs. They have helped break the silence and reduce the stigma attached to the disease. Many people living with HIV/AIDS "go underground" because of the stigma of the epidemic (Hunter 2003:38).

Most support groups in Africa, however, have tended to be markedly different from the activist groups in other regions. People join support groups in Africa out of desperate need, being without financial, organizational, nursing, or counseling skills. However, the support groups and the networks that are supposed to assist them tend to be severely underfunded.

In Zimbabwe in the early 1990s, some HIV-positive individuals developed an approach to help people cope with the infection by the technique of visualization (Jackson, 2002, pp. 229–230). They propose to imagine the virus as a person, animal, or other being, giving it a name and addressing it personally. This strategy aims at helping people to accept the virus' presence, gain confidence in fighting it, and take control over their lives again. The approach improved many people's quality of life.

As their HIV infection progresses to AIDS, people need medical care. However, most cannot afford long hospital stays and, in any case, hospital beds are limited in many African countries. Patients are often sent home to die because the hospital staff can do nothing further for the patient or because they feel scarce supplies are better utilized on someone with greater chances of recovery. Yet in many African countries home care can actually mean home and community neglect. Patients are no longer overseen by medical services, and many poor families lack access to even the most basic medications. The economic burden on the family is substantial. Many patients die miserable, painful deaths, and yet the critical problem is usually not so much the disease itself as poverty.

Families from the lower socioeconomic strata need material support to provide good care for the patient, including provision of basic medical supplies. Further, the quality of care given by the family and community members is likely to improve greatly if given some basic training in looking after the patients. Most caregivers are women who are already contributing substantially by running the household, doing subsistence farming, and working in other ways to make a living. They look after the children, the elderly, and the person who is sick. These caregivers are often in dire need of support to prevent burnout.

Another way to care for patients would be the so-called halfway houses, where families could bring patients for temporary treatment, learn nursing skills, and recharge their energy. Such centers could also help reduce isolation and stigma if integrated into wider support programs in connection with hospitals and nongovernmental organizations (NGOs). Currently in virtually all African countries, multilevel care programs that integrate home care with halfway houses and hospitals cover only a limited geographical area. This means that the majority of patients in need are receiving no services outside the formal health system beyond what their own families and local support groups can provide.

A key way to improve home care is to involve community volunteers who support family caregivers by teaching them basic nursing skills, organizing the transfer of patients into halfway houses and clinics if necessary, and simply providing emotional support. These volunteers are often drawn from religious groups and women's associations. As the epidemic spreads, it is necessary to pay attention so that such volunteers do not also burn out.

As mentioned earlier, faith-based organizations in Africa have the advantage of extensive networks and structures and high credibility in the community. In remote areas, they are often the only functional network. Nonetheless, they may have limitations because of their deeply moral views about issues such as sex. Many problems arise around the non-acceptance of alternatives for HIV prevention that go beyond abstinence and marital fidelity.

In much of Africa, traditional healers are a well trusted and widely utilized source of spiritual support, problem solving, and healthcare. These healers consult the supernatural world to identify the cause of an illness and utilize herbal medicine to cure it. They are often successful in treating symptoms and curing certain diseases. However, some of their interpretations of AIDS-related illnesses are not compatible or even complementary with biomedical understandings. This is the case, for instance, when they diagnose ancestral anger or sorcery as the source of an AIDS-related illness.

Some African countries try to overcome such difficulties through training programs for traditional healers, encouraging them to treat AIDS-related symptoms but also to refer patients to clinics or hospitals if they cannot provide adequate help. Traditional healers can join efforts for HIV prevention by promoting abstinence, marital fidelity, and condom use. In some cases, they made highly innovative suggestions on ways to adapt cultural practices that carry a high risk of HIV infection (Green, 2003, pp. 302–317).

In Africa, more than anywhere else, children are affected by HIV and AIDS through seeing their parents become ill and die, having to take on care roles in the family, being withdrawn from school, living in increasing poverty, and suffering from stigma and discrimination. One of the most tragic measures of the epidemic in Africa is the huge and growing number of orphans in the region (Hunter, 2003, p. 46). In 2005 there were 12 million orphans living in sub-Saharan Africa (UNAIDS, 2006, p. 15).

In many African cultures, the term orphan has little meaning because the parents' brothers and sisters are considered to be mothers and fathers with responsibilities comparable to those of the biological parents. Provided an aunt or uncle remains alive and can care for the child, the child is not regarded as an orphan. Long before the emergence of the HIV/AIDS epidemic, the extended family in Africa had been taking care of vulnerable children. It has been common practice in many African cultures for orphaned children to stay for varying periods, even for the whole childhood, with relatives other than their parents.

However, with the escalation of poverty, and the sheer number of children now being orphaned by AIDS, the extended family is stretched beyond its limits and child-headed households are emerging for the first time on a wide scale. Further, there is a concomitant rise in the number of street children that is associated with the same factors. An appropriate response would be strengthening family capacity to cope with the increase in the number of orphans through direct government and NGO support. In some African countries with highly urbanized populations, such as South Africa, the need for residential childcare facilities is increasing (Ghosh & Kalipeni, 2004).

AIDS AND THE NATION

AIDS primarily affects the productive age range in the population. Where the epidemic is most serious it affects economic production. On a household level, there is loss of income leading to increased poverty and bad nutrition while there is increasing expenditure on healthcare and funerals. As a result less money is used on food, clothing, school, and other ordinary costs. The macro-economic impacts in hard-hit countries and regions include increased spending on health at the expense of investment in other sectors, as well as a heavy impact through the loss of skilled labor that is difficult to replace (Jackson, 2002, pp. 23–25). Figure 7 shows the projected massive loss of labor in the agricultural section in some African countries.

Figure 7.    Projected reduction in African agricultural labor force due to HIV and AIDS by 2020 (UNAIDS, 2006, p. 100).

Even without the AIDS epidemic, annual health expenditure in Africa is usually under $10 per capita, not enough to meet even the basic health needs of people. AIDS made this situation immeasurably worse. The epidemic negatively affects the health sector itself, as ill health and death increase among service providers, and as the workload increases. AIDS patients occupy more than half of the hospital beds in hard-hit countries. HIV infection also makes other infections harder and more costly to treat. HIV is implicated in increased deaths from other causes such as malaria and cholera. Most seriously, AIDS has led to an epidemic of tuberculosis (TB), the leading cause of death in AIDS patients in Africa (UNAIDS, 2006, p. 90). Figure 8 shows how closely related is the AIDS epidemic in Africa with the increase in TB cases.

Figure 8.    TB notification rate in 20 African countries versus HIV prevalence in sub-Saharan Africa, 1990–2004 (UNAIDS, 2006, p. 91).

Some African countries have basic social welfare provisions to ensure a safety net for those who are destitute, homeless, and unable to care for themselves or to be cared for adequately within their families. The International Monetary Fund and the World Bank led economic austerity programs in many African countries that increased unemployment and raised costs for basic commodities, which drove many families into poverty, increasing the need for welfare support. However, the same economic programs often reduced funding for social welfare programs, making it impossible to cope with the increased number of people in need (Lurie et al., 2004; Rugalema, 2004; Zulu et al., 2004). This has repercussions for the AIDS epidemic because poverty is the social context within which AIDS thrives.

HIV/AIDS impacts most heavily on the disadvantaged, the poor, and the less-educated (UNAIDS, 2006, pp. 84–85). Rising number of AIDS sufferers then plunge Africa into an even deeper economic crisis—a vicious circle (Niekerk, 2006; Schoepf, 2004, p. 15). Governments are increasingly recognizing the importance of tackling poverty as a response to AIDS and tackling AIDS as a means of reducing poverty.

In their 2000 meeting in Okinawa, Japan, the group of eight leading industrialized nations (the G8) made a commitment to set up what has become known as the Global Fund to Fight HIV/AIDS, Tuberculosis, and Malaria. The money is pledged by countries, private foundations, and others. In the first round of country applications to the Global Fund in 2002, the great majority of submissions were for HIV/AIDS, and nearly 70% of all submissions were from sub-Saharan Africa.

Of the 39 most heavily indebted countries identified by the World Bank, 32 are in Africa, where most HIV-positive people live. National governments in Africa pay out four times more to service debts than they spend on health and education. By relieving debt in the poorest countries, money now exported to service debt could be reinvested into AIDS prevention and care. The Highly Indebted Poor Country (HIPC) Initiative aims to reduce debt over the coming years, cancelling debt in return for the debtor governments' commitment to mobilize resources for poverty reduction or AIDS. Several African countries already include HIV/AIDS specifically in their poverty-reduction strategies and in HIPC agreements.

CONCLUDING REMARKS

It is challenging to address the complexity of the AIDS epidemic for a large and diverse region such as the African continent. Those interested in more detailed information on the African AIDS epidemic should consult the literature in the References below. I further recommend the following three websites:

• The Joint United Nations Programme on HIV/AIDS, UNAIDS (http://www.unaids.org/en), brings together the efforts and resources of ten UN organizations to the global AIDS response. This website provides the most recent data on the AIDS epidemic.
• The Global AIDS Program, GAP (http://www.cdc.gov/nchstp/od/gap) of the Centers for Disease Control and Prevention helps resource-constrained countries prevent HIV infection; improve treatment, care, and support for people living with HIV; and build capacity and infrastructure to address the global HIV pandemic.
• The President's Emergency Plan for AIDS Relief, PEPFAR (http://www.pepfarwatch.org), was intended as an U.S. initiative on the global AIDS epidemic. The initiative has as its goals to prevent new infections, treat people living with AIDS, and provide care and support for persons affected by AIDS. While acknowledging the positive value of the initiative, critics have cited its refusal to fund certain prevention activities, such as needle exchange programs for intravenous drug users and safer-sex campaigns targeting commercial sex workers.

Posted January 29, 2007

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