HIV as a Global Force in Sub-Saharan Africa
A brief history:
HIV is thought to have first made its way into the human population roughly 70 years ago as a zoonosis in central Africa, although the current pandemic did not start gaining momentum until the late 1970's, and was not isolated until 1983.1-3 HIV is a broad term used to describe two unique viruses (and their many subtypes): HIV-1 and HIV-2, although both lentiviruses (a genus of retroviridae) they are thought to have arisen via separate zoonoses from chimpanzees and sooty mangebeys, respectively; it is interesting, epidemiologically, that these two distinct viruses should both make the species jump at roughly in the same times-span and area, suggesting perhaps an endemic level of HIV acquisition in certain African populations before conditions allowed for widespread HIV dissemination .3,4 However, of these two viruses HIV-1 is the most common virus world-wide and the term "HIV" has oft come to mean "HIV-1."3
A global perspective:
From a global perspective the numbers are alarming. Currently there are 40 million persons world-wide infected with HIV, 3 million people are expected to succumb to the virus in the next year, while an additional 5.5 million are expected to contract the disease during this time. Recently during the XIV AIDS conference in Barcelona it was described as one of the most prominent problems facing the 21st century, having already killed some 20 million people, a number greater than all casualties of all the wars of history combined.
An African perspective:
Worldwide, sub-Saharan Africa has been hit hardest by the pandemic where 70% of the 40 million HIV positive individuals reside, although only comprising 10% of the world's population overall. In 2001 sub-Saharan Africa experienced 68% of new infections and 77% of deaths related to HIV globally. 6 The 28 million HIV cases in Africa is more than double the 13 million in 1995, and at a global prevalence of 40 million, well ahead of the 26 million forecasted in 1996.7 Sub-Saharan Africa is also the home to 90% of AIDS orphans and children infected with the virus.6 Across sub-Saharan Africa the HIV incidence in 2001 was estimated to be 8.4% while they remained well below 1% throughout the rest of the world (excluding the Caribbean region with a 2.2% prevalence). (2) Alas, many individual regions of Africa experience prevalence of HIV as high as 40% in pregnant women tested in various locations in Botswana, Zimbabwe, and Swaziland.2,6 The HIV explosion is aptly named as such, by some accounts South Africa attained a 25% HIV prevalence in 2000, an amazing increase from its 1990 level of 1%.(10) It is due to this disproportionate bourdon of the HIV pandemic on the African continent that this paper will focus primarily upon its impact therein.
Factors contributing to the HIV epidemic.
Duration of epidemic HIV:
While it could be assumed that Africa has experienced a longer incubation period due to it's role as the birthplace of HIV, the timeframe cannot fully account for the high prevalence of the virus. For example, epidemic HIV in both South Africa and Thailand did not begin in earnest until the early 1990's, but a decade later the HIV prevalence rates differed by nearly 18%; 19.9% and 2.2%, respectively.2
There are many cultural potentiators to the sub-Saharan Africa HIV epidemic, chief amongst these is the subordinate position of women in many African societies. In greater African culture it is oft permissible, if even expected for males to have many sexual partners, regardless of his marital status. Additionally wives are not allowed to refuse sex from her husband nor is it permissible for women to admit knowledge regarding sex, leaving them in a position unable to promote safe-sex practices. Bride payments are a contributing factor to the lack of female empowerment by furthering the misplaced ideology of brides being the property of their husbands, while also providing a financial incentive for a prospective bride's family to pressure her into marriage. Cultural expectations limiting the empowerment of women are perhaps ancillary to the fact that the vast majority of African women wholly depend upon their husbands financially which robs them of any leverage they may have had for the promotion of safer-sex practices. In addition sex before marriage is a common phenomenon. Of non-marital sexual relationships young women are also disadvantaged by virtue of the fact that womens' sexual partners are a median of 6-7 years older than themselves, in and of itself an HIV risk factor, while young males typically engage in intercourse with females either their own age or slightly younger. In addition to this promiscuity many women actively choose against condoms as they pursue pregnancy as a strategy for acquiring a husband.2,6
Poverty provides numerous avenues by which to increase HIV incidence within a population. In Africa endemic poverty has increased unemployment, caused massive cuts to social services, increased prostitution, decreased perceived opportunities for future betterment, and causes HIV to be a low priority for individuals due to an uncertain long-term future, and a decreased level of education in the community. All of these have been shown to be independent risk factors for HIV acquisition, although there is poor correlation between actual per capita income and HIV prevalence in many African countries poverty is one of the major contributing factors of HIV transmission. An inequitable distribution of wealth oft skews statistics as the per capita income may be high, but large numbers of individuals may still be extremely poor.2
Prostitution has received copious amounts of media attention as the "cause" for the ramped HIV in Africa, while an increase due to poverty-stricken women becoming forced to trade sex for money, gifts or food does serve as a catalyst for HIV transmission, various other factors have a very substantial impact on the degree of this potentiation. Again a comparison of South Africa and Thailand indicates that an almost 3-fold higher use of condoms in Thailand than South Africa in its sex industry has had a drastic abating effect of their HIV epidemic. Thus in many African nations prostitution is but a single part of the overall inability of society to cope with the impact of HIV in their poor and uneducated denizens.
There is a positive correlation between HIV incidence and the degree of urbanization of a country. Cities have historically been associated with sexual liberation, large numbers of poor individuals, erosion of social networks, and a loss of culture for individuals moving from rural areas, and this is certainly true for modern African cities. Predominantly it is the young who are most likely to move to urban areas, and often this is a population most likely to engage in risky sexual practices, and abuse drugs, both increasing the likelihood of contracting HIV. Additionally married rural men are often separated from their spouses for long periods of time as they may work in urban environments and return to their rural homes periodically, thus increasing the chances of them employing professional sex workers, or otherwise obtaining multiple sex partners. Women in urban centers are oft worse off than if residing in rural areas, and resorting to trading sex for gifts or money is not a difficult opportunity to exploit in many of Africa's urbanized areas, nor is it uncommon.2
In addition to the aforementioned, social and civil unrest are enormous catalysts for the transmission of HIV, soldiers place a low priority on potential HIV infection in light of more prominent and immediate dangers, and often engage in the rape of civilians. War also commonly leaves areas impoverished for long periods of time increasing the likelihood of sex being used as a survival strategy among females in the area, additionally large numbers of people may be displaced by military conflict which leads to an increase in risky sexual behavior as a result of the interruption of established social cohesion. Since 1980 more than 28 of the 53 sub-Saharan Africa nations have been at war at least once.2
The Effects of HIV on sub-Saharan Africa:
HIV/AIDS has had a devastating effect on the peoples of Africa. In rural Botswana, Zimbabwe, and South Africa the life expectancy is expected to fall from 60 in 1990 to 30 by 2010, and many African nations show similar, yet slightly less dire, projections. HIV is also decimating the educational infrastructure of many African nations as increasing poverty due to the premature deaths of family breadwinners as children are often required to earn money instead of attend school, and governments lose the ability to finance education. The enormous effects of HIV on the public health infrastructure go beyond that of simply HIV, the virus has allowed several diseases such as malaria and tuberculosis (TB) to increase their incidence, and today in areas of high HIV prevalence a full 30% of malaria cases may be accounted for by HIV, and TB incidence has increased 9 fold since 1988 and is expected to rise at 10% per year in countries with a heavy HIV load.8 While the macroeconomic impact of HIV is open to much speculation the Economist recently reported that Botswana, by 2010 is projected to have 32% less economic output than it would have had without HIV, government expenditures will be cut by 1/5, the average Botswanan primary breadwinner will need to support an additional 4 dependents, and the country will be forced to care for 214,000 orphans.9 These predictions are not far-fetched, and do little justice to the grief caused by HIV, furthermore they are supported by known data gathered across sub-Saharan Africa. By 2002 40% of the healthcare budget of Zambia is being used by HIV, and 50% of Zimbabwe's healthcare dollars are currently being spent on HIV.12 In 2001 2.4 million children in sub-Saharan Africa were HIV positive, about 4 times the population of North Dakota that year.10,11 Additionally by the end of 2001 12.1 million children have lost either their mother or both parents to HIV and this number is expected to double within the next 10 years, 9% of children under 15 in sub-Saharan Africa will be orphans by 2010.10
The need for action.
With scientific circles debating whether a cure is even theoretically possible, the closest vaccines well over the horizon and of questionable efficacy anyway (alas it appears even seroconverted individuals may contract new HIV strains despite conservation of immunogenic viral structures), and the urgent need to curb the devastation caused by HIV, it becomes clear that action to implement effective prevention programs and provide essential drugs cost-effectively is paramount to addressing the issue. The need for easy access to anti-retroviral pharmaceuticals from rich western nations is often cited as the primary need of sub-Saharan African nations to combat the HIV pandemic, this, however, is only part of a much-needed reform of many facets of the HIV landscape. While treatment of HIV-infected individuals is undoubtedly important, especially for pregnant women the key to a long-term, sustainable recovery from the havoc wrought by this virus, is prevention. It has been reported that the cost of preventing HIV contractions can cost as little as $11 per incidence through traditional programs of education and access to free condoms, and vertical transmission can by averted by single-dose Nevirapine for as little as $20.12 Since every prevented HIV infection leads to further preventions later, this certainly seems to be the best long-term solution to the current problem. Perhaps the most important first step in HIV prevention is a shifting of public opinion away from stigmatization and marginalization which accompanies an HIV diagnosis. First and foremost of this "first step" process is the need for political change to not only promote the empowerment of women (currently sexual violence is tolerated in many African nations), but also to face up to the challenges brought forth by HIV, we all know about Thabo Mbeki's aversion to the issue, while president of one of the countries most devastated by the virus, South Africa; going so far as to say publicly, just a few years ago, that HIV is not the cause of AIDS, to the chagrin global scientific community.
While pharmacological treatment is not the most cost-effective means of controlling HIV costing $15,000 per year in first world countries, and even at $1 per day above the income power of the average African, drug treatment is important, if not necessary. Of greatest need is the use of antiretrovirals in the prevention of vertical transmission of HIV, now a leading cause of death in sub-Saharan African children. But also, as discussed at this years AIDS summit, to provide an incentive for individuals to be tested for the virus. Studies (as well as common sense) have shown that individuals without access to antiretroviral therapy have a disincentive to being tested, as a positive result would yield no benefit, only stigmatization. It is thus important that cheap antiretroviral agents be made available to the African people as an incentive to learn their HIV status. Cheap drugs have traditionally been acquired at discounted prices from the patient-holding companies of rich first world nations, but treatment is still far too expensive for most sub-Saharan Africans and currently only 30,000 people use them.1 If US and European companies refuse to provide these agents at prices needed by African countries, Africa may be forced to manufacture their own generic drugs, as Brazil has done legally by declaring AIDS a national emergency, or simply buy them from Brazil.1
Kofi Annan, secretary-general of the UN has announced that roughly $10b would be required yearly to address the African HIV/AIDS problem(s) adequately. Roughly half of this money for prevention, and half for treatment. Currently the Global Fund (the monetary entity dispersing the money) has raised $2.1 billion, with the United States being the largest contributor.1 Contrary to the belief of many industrialized nations, HIV is not primarily the problem of the African continent. China, Russia and India are showing the first signs of major HIV epidemics within their borders, and Indonesia is showing troubling signs of a potential epidemic shortly thereafter.1 The populations of these countries are 1.28b, 144m, 1.05b, and 232m, respectively. If these countries attain sub-Saharan Africa's 8.4% prevalence of HIV, they will acquire 230m new HIV cases, if they follow the path of South Africa: over 500m will be infected within the next 10 years. The global impact of such a scenario is beyond our current ability to calculate and represents an incentive to pursue immediate and sustained efforts to allay future expansion of the virus. Works Cited.
- Staff. "Hope for the best. Prepare for the worst." The Economist, Jul 11, 2002.
- Buve', Anne. Et al. "The spread and effect of HIV-1 infection in sub-Saharan Africa." The Lancet Vol 359; June 8, 2002.
- Reeves, Jacqueline D. Doms, Robert W. "Human Immunodeficiency virus type 2." Journal of General Virology. Vol 83; June 2002.
- Levin, Bruce R. et al. "Epidemiology, Evolution, and Future of the HIV/AIDS Pandemic."Emerging Infectious Diseases. Vol 7, No. 3; Jan. 2001.
- Staff. "The long war."The Economist, Jul 11, 2002.
- Cock, Kevin M De. Et al. "Shadow on the continent: public health and HIV/AIDS in Africa in the 21st century."The Lancet. Vol 360; July 6, 2002.
- Quinn, Thomas. "Global burden of the HIV pandemic." The Lancet. Vol 348; July 13, 1996.
- Corbett, Elizabeth. Et al. "HIV-1/AIDS and the control of other infectious diseases in Africa." The Lancet Vol 359 June 22, 2002.
- Staff. "How to live with it, not die of it." The Economist, May 9, 2002.
- Francois, Dabis. Et al. "HIV-1/AIDS and maternal and child health in Africa." The Lancet. Vol 359; June 15, 2002.
- US Census Bureau, quickfacts.census.gov/qfd/states/38000.html Aug. 2, 2002.
- Creese, Andrew. Et al. "Cost-effectiveness of HIV/AIDS Interventions in Africa: a systematic review of the evidence." The Lancet. Vol 359; May 11, 2002.
by tid242 | posted on 8/5/2002