AIDS in Africa
AIDS in Africa |
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Current global
burden of disease caused by HIV
HIV has caused a real epidemic of injustice. It affects poor countries more than
rich countries and within each country it predominantly affects the poor,
disadvantaged and marginalized members of society. According to the United
Nations Global Report on AIDS 2004, at the end of 2003 there were 37.8 million
people living with HIV worldwide (1). The greatest burden of disease is found in
sub-Saharan Africa where 25 million people (66% of the global total) are
infected with the virus. Among the 2.1 million children who are infected with
HIV, 1.9 million (90% of the global total) live in sub-Saharan Africa. The
global problem of HIV becomes worse each year. In 2003 alone an estimated 4.8
million people became infected with the virus, the majority of whom (3 million)
lived in sub-Saharan Africa. In 2003, HIV killed 2.9 million people, more than
any other infectious disease. 2.2 million of these deaths (76% of the total)
occurred in sub-Saharan Africa, indicating that anti-retroviral treatment is not
currently getting to those who need it most.
Impact of HIV on society
HIV has had a profound impact on life expectancy in sub-Saharan Africa. In many
countries the progress of the last 20 years has been reversed. For example in
Zambia, life expectancy at birth is now less than 35 years. HIV-related
morbidity and mortality has also led to increased poverty and hunger. In
families affected by HIV, household income is often decreased by as much as 80%.
There has been an overall 20% reduction in the agricultural workforce in the
worst affected African countries and this is likely to lead to food shortages.
HIV is affecting education because many teachers have died from the infection.
In addition many girls are denied education because they need to stay at home to
care for sick relatives. It has been estimated that in the health sector
workforce 19-53% of employee deaths are due to HIV. This is likely to lead to
severe shortages of skilled workers and increasing difficulties in delivering
health services.
Challenges facing the global control of HIV
UNAIDS has identified seven major challenges facing global control of HIV (1).
These are:
1. The increasing proportion of infections occurring in women. In sub-Saharan
Africa 57% of those living with HIV are women. Gender and cultural inequalities
have made women more vulnerable to HIV infection than men. It is usually men who
determine whether or not condoms are used during sexual intercourse and in many
societies women have little control over their partner’s sexual activities
outside marriage. In traditional societies women often have poorer access to
education than men. This makes them difficult to reach by health education
services and ignorance about HIV then makes them more vulnerable to infection.
2. The rise in new infections occurring in young people. Those aged 15-24 years
account for 50% of new HIV infections in sub-Saharan Africa. Young women are at
the highest risk because relationships between young women and older men are
common. In some countries the rates of HIV infection in girls are six times
higher than the rates in boys. Schooling and access to sexual health care have
been shown to be important protective factors against HIV infection. However in
many countries universal education has not been achieved and there are still
considerable barriers to its implementation.
3. Difficulties in scaling up anti-retroviral treatment programs in developing
countries. Fewer than 4% of those who need anti-retroviral therapy in
sub-Saharan Africa are receiving it. There are considerable logistical barriers
to distributing anti-retroviral therapy to those who need it, particularly for
those living in rural areas. Many countries have over-stretched health services
and have difficulty providing even basic primary health care to the most
disadvantaged groups. Attempting to deliver anti-retroviral therapy could place
additional strain on these services and potentially damage other health care
delivery.
4. Problems with delivering public services due to inadequate numbers of trained
staff. The need for trained health personnel will increase because of the need
to screen for HIV and provide treatment with anti-retroviral drugs. However the
number of trained personnel is decreasing because public sector staff are
migrating to the private sector or to other countries in search of better pay
and quality of life. Inadequate salaries have also contributed to the spread of
corruption. This can affect local health care delivery, by diverting resources
or charging patients for services which were intended to be free. AIDS itself
has caused the death of many trained public sector personnel further worsening
the staff shortages. Teachers are also in short supply and this will decrease
the number of qualified personnel coming through from the next generation.
5. Difficulties in scaling up prevention programmes, which are a vital
complement to treatment programs. It is estimated that HIV prevention programmes
are only reaching one in five of those at risk. Throughout sub-Saharan Africa
only one in ten pregnant women is offered antenatal screening which is essential
to prevent mother-to-child transmission. This problem could be compounded if
governments divert resources from prevention to treatment services. The
obstacles to prevention are considerable because those most at risk are usually
the most disadvantaged and hardest to reach groups.
6. The stigma and discrimination experienced by HIV-positive people. The stigma
and discrimination associated with HIV infection can be a major barrier for HIV
prevention and treatment programmes. Discrimination prevents many people coming
forward for testing and reduces the effectiveness of prevention of
mother-to-child-transmission programmes. Discrimination also causes
marginalization of high-risk groups such as commercial sex workers, injecting
drug users and men who have sex with men. This acts as a barrier to them
accessing health services. Orphans of parents who die from HIV may also suffer
from discrimination. Families may deny them support and care because of the fear
that surrounds the virus.
7. The neglect of orphans of parents killed by HIV. AIDS has created 12 million
orphans in sub-Saharan Africa. Many of these children become homeless and fail
to receive education and medical care. Those caring from them may suffer
hardship because of the additional financial burden placed upon them. This
burden is particularly felt by single mothers and female relatives of the
deceased parents.
The 3 by 5 initiative
Sub-Saharan Africa carries the greatest burden from HIV but has the fewest
resources to deal with the problem. WHO and UNAIDS recognized this problem and
launched the “3 by 5” initiative. This is an ambitious attempt to get 3 million
people in transitional and developing countries onto anti-retroviral medication
by the end of 2005 (2). At the end of 2003, when the initiative was launched
only 400,000 people in these countries were taking anti-retroviral medication
(2, 3). A huge scaling-up of treatment programmes would therefore be required
before this objective could be realized.
HIV prevention programmes
HIV prevention programmes are much more cost-effective than treatment
programmes. It is therefore essential that prevention programmes are developed
in parallel with the 3 by 5 treatment initiative. It has been estimated that
comprehensive prevention programmes could prevent 29 million of the 45 million
(64%) new HIV infections which are predicted to occur during the next decade
(3). WHO and UNAIDS have identified the following essential components for
comprehensive HIV prevention programmes:
1. AIDS education and awareness for the general public.
2. Behaviour change programmes for high risk groups.
3. Condom promotion.
4. Voluntary counselling and testing programmes.
5. Treatment services for sexually transmitted infections.
6. Screening services to prevent mother-to child transmission.
7. Harm reduction programmes for injecting drug users.
8. Screening services to make blood transfusions safer.
9. Adequate infection control in health care facilities.
10. Education programmes to counter the stigma associated with HIV.
11. Changes to the law and social values to reduce the vulnerability of
disadvantaged groups including women.
What is needed to make the 3 by 5 initiative successful?
WHO and UNAIDS have identified five structures which must be implemented if the
3 by 5 initiative is to be successful (2). These are:
1. Global leadership. It is essential for WHO to provide leadership to show
governments and non-governmental organisations how effective HIV treatment
programmes can be delivered. It is also essential for the major funding agencies
to give support to WHO’s efforts.
2. Government support. For HIV programmes to be implemented successfully in each
country they will need the full support of the host government. WHO believes
that for national programmes to work they will need one national plan, one
coordinating mechanism and one system for monitoring progress (nicknamed the “3
ones”).
3. Standard tools for delivering HIV therapy. WHO and UNAIDS are developing
standard treatment manuals, guidelines and other educational materials to help
countries to develop and deliver effective HIV treatment programmes. Currently
WHO has approved 4 different drug regimens for first-line HIV therapy in
developing countries. These are:
a. Zidovudine + lamivudine + nevirapine.
b. Stavudine + lamivudine + nevirapine.
c. Zidovudine + lamivudine + efavirenz.
d. Stavudine + lamivudine + efavirenz.
4. Affordable medicines and diagnostics. The price of anti-retroviral medication
has fallen dramatically. In the year 2000, the cost of treating one patient for
one year was over US$10,000. In many countries anti-retrovirals are now
available for less than US$300 per year. WHO is continuing to negotiate to
attempt to achieve further decreases in price. However even with affordable
prices there are still considerable obstacles to achieving effective supplies of
drugs. Individual governments will need to ensure that the supply of
anti-retroviral drugs to individual clinics is reliable and uninterrupted.
5. Identifying and reapplying knowledge gained. There will be considerable
challenges in providing HIV treatment programmes. It is essential that there is
an effective system of disseminating the knowledge and lessons learned during
the implementation of local programmes. WHO aims to develop systems to identify
useful local knowledge and to disseminate it to the global health community.
Funding requirements needed to make the 3 by 5 initiative happen
In 1996 international funding agencies spent US$300 million on HIV programmes in
developing and transitional countries. This funding has increased and in 2003
US$5 billion was committed to HIV programmes. Although this is a considerable
sum it is insufficient to meet the requirements of the 3 by 5 initiative. It is
estimated that US$12 billion will be needed for HIV programmes in 2005. 43% of
this funding is needed by sub-Saharan Africa which has the greatest need for HIV
treatment and prevention programmes.
After 2005, funding requirements will continue to increase. In 2007, US$20
billion will be required to meet the growing demands made by HIV. This funding
would be sufficient to provide anti-retroviral therapy for 6 million people,
voluntary counselling and testing for 200 million adults, HIV education for 900
million school children, peer counselling for 60 million young adults and
support for 22 million orphans (3).
What progress has been made with the 3 by 5 initiative?
At the end of 2004, WHO and UNAIDS published a report on the progress which had
been made up to the end of June 2004 (3). 440,000 people living in developing
and transitional countries were receiving anti-retroviral treatment, an increase
of 40,000 on six months previously. 24% of the HIV testing and counselling sites
which would be needed had been set up. 15% of the staff who would be needed had
been recruited and trained and 5% of the anti-retroviral delivery outlets had
been established. Clearly a lot of work would be needed in the following 18
months to achieve the 3 by 5 objectives.
Conclusions
The World Health Organisation has set an ambitious target of treating 3 million
people with anti-retroviral drugs by the end of the year 2005. Many people have
stated that this target is unrealistic and that the programme is doomed to
failure. However the project cannot be allowed to fail because Africa’s future
depends on it.
References
1. UNAIDS. Report on the global AIDS epidemic: 4th global report. UNAIDS:
Geneva, 2004.
2. WHO. Treating 3 million by 2005. Making it happen: the WHO strategy. WHO,
Geneva, 2004.
3. WHO. 3 by 5 progress report December 2003 through June 2004. WHO: Geneva,
2004.
©2004 Sexual Health Matters. Published Quarterly by Express
Print Works, Middlesbrough, UK
ISSN 1469-7556
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