HIV and AIDS in Africa Questions

AIDS in Africa is basically exactly the same thing as AIDS in the USA, China or anywhere else. The cause of AIDS is always the same – a virus called HIV (Human Immunodeficiency Virus). There are just a couple of small differences worth noting:

1. The most common HIV subtypes in Africa are slightly different to the most common subtypes in other regions, and this might affect responses to treatment and future vaccines (should any be developed). However, the routes of transmission are exactly the same, and all HIV subtypes cause AIDS.
2. Some opportunistic infections are more common in Africa than elsewhere. For example, someone living with HIV in Botswana is more likely to fall ill with TB than someone living with HIV in the USA, who is more likely to develop other illnesses.

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The numbers are staggering. At the end of 2010 there were an estimated 22.9 million people living with HIV in sub-Saharan Africa (the part below the Sahara desert), and 470,000 in North Africa and the Middle East. AIDS is now the leading cause of death in sub-Saharan Africa – killing an estimated 1.2 million people in 2010 alone. In the same year another 1.9 million became infected with HIV.¹

The impact of AIDS is extremely severe and wide-ranging. Life expectancies have fallen below 49 years in some African countries due to AIDS, which is lower than they were in the 1970s.^{2 3} Most AIDS deaths occur among young adults, and these deaths have a devastating effect on families, communities and economies. The epidemic is wiping out development gains, orphaning millions of children, fuelling the spread of other diseases (including tuberculosis), and even threatened to undermine national security in highly-affected societies.⁴

Read more HIV and AIDS statistics.

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Although HIV has now spread throughout Africa, the proportion of people living with the virus varies widely between countries. In Botswana, Lesotho, and Swaziland, more than one in five adults are infected, whereas in some parts of North Africa the rate is below one in a thousand, which is much lower than in the USA.

Today the highest HIV rates are found in Southern Africa. Several East and Central African countries also have very severe and mature epidemics, which are causing a very high number of AIDS deaths. West Africa has been less severely affected but, because it has such a large population, Nigeria has more people living with HIV than any other African country except South Africa. The lowest HIV rates are found in North Africa, where only Sudan has so far been badly affected.⁵

For the latest data, see our sub-Saharan Africa statistics.

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Africa's overall HIV prevalence (the proportion of people living with HIV) appears to have declined slightly since 2000. However, because of general population growth and increased access to treatment the number of people living with HIV continues to rise.⁶

Read the History of AIDS in Africa to see how the epidemic has changed over time.

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No-one really knows the full answer to this question. However, we do know there are many factors that influence the rate at which HIV is transmitted.^{7 8} Such factors include: poverty, economic disparity, social instability, gender inequality, sexual violence, other sexually transmitted infections (which facilitate HIV transmission), lack of male circumcision, high mobility, rapid urbanisation and modernisation, and ineffective leadership during critical periods in the epidemic’s spread. Some scientists believe that differences between HIV subtypes have an effect on transmission rates. There is also some evidence that genetic factors and parasitic worm infections (common in sub-Saharan Africa) may make a contribution.^{9 10 11}

The extent to which concurrent sexual partnerships in sub-Saharan Africa contribute to HIV epidemics in the region is an issue of debate.^{12 13} UNAIDS defines a concurrent sexual partnership as "overlapping sexual partnerships where sexual intercourse with one partner occurs between two acts of intercourse with another partner".¹⁴ In other words, an individual is involved in a sexual relationship with more than one person at the same time.¹⁵

Some researchers state that whilst people in sub-Saharan Africa don’t have more partners in a lifetime than people in other parts of the world, many individuals have concurrent long-term relationships. During the period immediately after becoming infected with HIV an individual is most infectious and therefore most likely to transmit HIV if they engage in unprotected sex. Some believe that by individuals having long-term parallel relationships, they create a sexual network along which HIV from one individual is transmitted to many people rather than just one, which would be the case if people only engaged in monogamous relationships over a life time.¹⁶

Whilst the risk of concurrent partnerships has been widely acknowledged and implemented into HIV programmes, others argue that more empirical evidence is needed to support the concurrency hypothesis.¹⁷ Some question whether HIV prevention policy should concentrate on concurrency at the expense of other prevention messages.¹⁸ For example, some researchers argue that multiple partnerships are proven to contribute to HIV transmission, and that prevention messages should not be overshadowed by the issue of concurrency.¹⁹

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On current evidence, it seems likely that Africa was where the transfer of HIV to humans first occurred. However, how exactly the virus spread from Africa to America and beyond remains a mystery. It is quite possible that separate 'pockets' of the virus could have been developing in a number of different countries years before the first cases were ever officially identified, making it virtually impossible to trace one single source.

Read more about the origin of HIV.

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Most experts agree that the vast majority of HIV infections in Africa are the result of unsafe sex, not unsafe injections. The World Health Organisation (WHO) says that it has "previously estimated that unsafe injection practices account for about 2.5% of HIV infections in sub-Saharan Africa. Although there is a margin of uncertainty around this estimate, the conclusion remains that unsafe sex is by far the predominant mode of transmission in sub-Saharan Africa." There is strong evidence to support this position. Nevertheless, the number of infections due to unsafe injections is not insignificant, and efforts to improve the safety of medical procedures form an essential part of HIV prevention programmes across Africa.^{20 21}

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Some cultural and traditional practices do have an effect on HIV transmission in some parts of Africa. For example, drying the vagina before sex can increase the likelihood of abrasions, which in turn may increase the chances of the virus being transmitted (though the evidence for this is as yet inconclusive).²² Also any practice that involves transferring fresh blood carries a significant risk of infection. But it should be remembered that Africa is a very large and highly diverse continent, home to hundreds of distinct cultures. A practice that is traditionally widespread in one area may be completely unheard of elsewhere.

HIV prevention efforts should aim to make behaviour and practices safer while respecting local cultures. In many cases this may be achieved through relatively small changes in cultural practices, such as sterilising blades or switching to alternative rituals that are culturally acceptable but carry a lower risk of HIV transmission.²³

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AIDS is caused by HIV, the Human Immunodeficiency Virus. AIDS is not caused by poverty.

Poverty is one of a number of factors that can, in some situations, make people more likely to become infected with the virus. For example, some poor people may be more vulnerable because they have not been taught about HIV prevention; because they are compelled to exchange sexual favours for gifts or money; because they cannot afford to buy condoms or to treat other sexually transmitted infections (which facilitate HIV transmission); or because they are struggling just to keep themselves fed, and have little time to worry about less immediate threats like AIDS. In addition, poorer people usually have less access to HIV counselling and testing facilities, and those who are unaware of their infection are more likely to pass it on.

On the other hand, in some cases the most vulnerable people may be those who can afford to travel around a lot, or to pursue a busy social life, or whose jobs keep them away from home for long periods. In the mid-1980s, when the epidemic was in its early stages, a number of studies found HIV to be associated with relatively rich city-dwellers. More recently, similar patterns have been observed in Tanzania and elsewhere.²⁴

In summary, the relationship between AIDS and poverty is both complex and varied.²⁵ A comprehensive review of the issue published in 2007 concluded that:

"AIDS cannot accurately be termed a 'disease of poverty'. Although it is true that poor individuals and households are likely to be hit harder by the downstream impacts of AIDS, "their chances of being exposed to HIV in the first place are not necessarily greater than wealthier individuals or households."²⁶

Nevertheless, it is true that under resourced African countries are less able to provide adequate HIV education, prevention and testing services, and to care for those who are already infected, than richer parts of the world. It is quite possible that if Africa had been much richer in the 1980s then the response to HIV and AIDS would have been more effective, and fewer people would have become infected. It is certain that poverty has worsened and is continuing to worsen the suffering from AIDS, by restricting access to treatment and care.

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AIDS is not a solution to anything. Most people killed by AIDS are young adults – among the most productive members of society. Their deaths not only cause immense human suffering, but also worsen poverty, food shortages and social instability - the very same problems that overpopulation can cause. The solution to excessive population growth is a reduction in birth rates. This has already been achieved elsewhere in the world, largely through poverty reduction, promotion of gender equality and family planning services. Such measures also play an important role in HIV prevention.

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These days the vast majority of Africans are aware that HIV causes AIDS and that the virus can be transmitted through unprotected sex. However, this knowledge by itself does not always lead to lower rates of transmission. Many people find it very difficult to permanently change their sexual behaviour.

In many countries women have a lower status than men and are unable to negotiate condom use or to demand fidelity from their husbands. Moreover condoms are often inaccessible or unaffordable, especially in rural areas, and unprotected sex is necessary for couples who wish to have children. Another problem is that most Africans have never been tested for HIV and so don't know whether or not they are infected. Usually when people know that they are infected with HIV they take more precautions so as not to infect others.

To read about effective responses to such problems, see our overview of HIV prevention.

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In recent years, HIV testing and counselling in sub-Saharan Africa has increased. There are estimated to be 36,000 HIV testing and counselling facilities in the region, or 12 per 100,000 of the population, and 45 million adults aged 15 and over are estimated to have received an HIV test in 2010.²⁷ From 2008-2009 alone, the number of tests carried out increased by 50% or more in 11 sub-Saharan African countries. However, the percentage of people who have been tested at least once in their lifetime and know their result varies widely in the region. For example, in Kenya and South Africa around half of the population have been tested at least once. However, this figure is lower in Tanzania (31.5%), Zambia (28%), Swaziland (26%), Mozambique (25%), and Nigeria (14.3%).²⁸

The progress made in increased access to HIV testing and counselling must be maintained. A 2007 population wide survey in Kenya found that half of the HIV positive people surveyed did not know their status because they had never been tested or had not received their results. Of the remaining half who said they did know their status, almost a third mistakenly believed they were HIV negative.²⁹ The proportion of young people, aged 15-24, that know their HIV status is particularly low in sub-Saharan Africa. A recent survey found that only around 1 in 6 young women and 1 in 10 young men have been tested and know their HIV status.³⁰ Therefore, encouraging an uptake of testing and making testing facilities easily available must continue to be a priority for governments in sub-Saharan Africa.

Read more about HIV testing.

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Some African countries have seen declines in the proportion of adults living with HIV (known as HIV prevalence). The most celebrated example is Uganda, where prevalence fell from around 15% in the early 1990s to 7% in 2001.³¹ This decline is thought to be at least partly due to effective HIV prevention campaigns, though an increase in the AIDS death rate was probably also significant. Other countries that have seen significant declines in HIV prevalence among adults include Côte d'Ivoire, Kenya and Zimbabwe. Senegal has also won praise, for keeping HIV prevalence low.

However, most African countries have only seen small declines in HIV prevalence, and even Uganda still has a very serious epidemic. But examples such as these demonstrate that HIV in Africa does yield to determined, sustained interventions.

AVERT.org has more about HIV and AIDS in Uganda.

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The global response to HIV and AIDS has improved considerably in recent years. Funding comes from many sources, the largest of which are the Global Fund to fight AIDS, TB and Malaria, and the US initiative known as PEPFAR. In Africa the response includes:

• Education and prevention, including efforts to change sexual behaviour, to prevent mother-to-child transmission of HIV and to improve the safety of blood supplies.
• HIV testing and counselling.
• Care for people living with HIV, AIDS orphans and other affected groups.
• Measures to prevent and treat HIV-related opportunistic infections.
• Antiretroviral treatment programmes.

Read more about Introduction to HIV treatment and care.

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Some African treatment programmes have reported relatively high rates of patients lost to follow-up (when a patient has tested positive but either does not return for treatment or stops treatment). One cross-country study in Africa found that 40% of people discontinued treatment within 2 years, either because of death or loss to follow-up.³² Reasons for people dropping out include the cost of treatment, poor drug supply, and problems with transport. These issues can be overcome and are generally not the fault of the patients.

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In 2002, only around 50,000 people in sub-Saharan Africa were receiving antiretroviral treatment. At the end of 2004 this number had risen to an estimated 310,000, and by the end of 2008 it was around 2.9 million. In December 2010, 5 million people in sub-Saharan Africa who needed treatment were receiving it.³³ However, this represents a coverage of only 49% and around 5.5 million people in the region are still in need of antiretroviral therapy.

Antiretroviral treatment relieves suffering and saves lives. Providing access to treatment is therefore a moral obligation. It is also an effective way to lessen the social and economic impact of AIDS, by allowing people to remain at work and look after their families. One of the best ways to help children and address the rise in orphanhood is to prevent deaths among parents. Providing treatment can reduce overall health costs by preventing serious illness. It can also give a substantial boost to HIV prevention efforts, by offering an incentive for people to get tested.

The world’s leaders pledged in 2005 to provide as close as possible to universal access to treatment by 2010. However, despite a rapid scale up of access to treatment, coverage in the region fell far short of the target of 80% by 2010. The most recent international target aims to achieve universal access by 2015.³⁴

Find out more about universal access to HIV treatment.

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African countries face some very substantial challenges in scaling up treatment. Perhaps the greatest of these is a shortage of trained staff to provide the medicines, counselling and regular check-ups. Another major obstacle is reluctance to be tested for HIV, which is fuelled by stigma and fear. The cost of the drugs themselves is less of a problem than some people might imagine. Prices have fallen sharply in recent years, and the total cost of providing treatment is now a few hundred dollars per patient per year, making it a very cost effective way to save lives.

Programmes across Africa are demonstrating that the challenges to providing treatment can be overcome through the dedicated efforts of African governments and external donors, with help from local organisations, churches and the private sector. Training and recruitment programmes can ease staff shortages, while treatment-awareness and education campaigns can counter stigma and increase the demand for testing.

Some pioneering countries have already shown that national treatment programmes can succeed even in the worst affected parts of Africa. Botswana began the first such programme in January 2002. By December 2010, almost all of those who needed treatment in Botswana (around 170,000 people) were receiving it, most of whom were getting it free through the public sector.³⁵

Namibia and Rwanda have also succeeded in providing treatment to more than 80% of those in need.³⁶

Read more about the challenges involved in achieving universal treatment access.

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The AIDS epidemic in Africa causes immense suffering and millions of deaths. It is also inextricably linked to many of the other major problems Africa faces. AIDS distorts social structures by killing young adults and orphaning children; it fuels the spread of other infectious diseases, including tuberculosis; and it seriously threatens economic development and national security in the worst affected countries. The scale of the epidemic's impact is unique.

Efforts designed to combat AIDS can have wide-ranging social and economic benefits. Development organisations see combating the epidemic as central to their campaign to end poverty; World Vision has called AIDS “the biggest single challenge facing development”.³⁷

HIV-specific programmes can strengthen health systems by improving infrastructure, laboratories, supply chains and health worker training.³⁸ Moreover, the provision of antiretroviral treatment reduces the burden of HIV-related illness, freeing hospitals to treat other conditions. Effects can also be seen in the improvement of human rights and equality, and the empowerment of community organisations.

There is wide agreement among economists and public health experts that combating AIDS should be one of the very highest priorities for donor funding; the ratio of benefits to costs is exceptionally high.³⁹

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Despite growing substantially in recent years, spending on HIV and AIDS still falls well short of what is required. HIV/AIDS spending increased during the first decade of the 21st century (in 2008 an estimated $15.6 billion was spent on HIV/AIDS compared to $300 million in 1996). However, the effects of the global financial crisis have had an effect on HIV/AIDS funding; spending requirements for HIV in 2009 were estimated to be $23.6 billion but only $15.9 billion was made available.⁴⁰ Then in 2010, the amount of available HIV-specific funding declined further to $15 billion.⁴¹ Most sub-Saharan African countries are heavily reliant on donor funding (around 80 percent of funding for HIV/AIDS programmes in the region comes from foreign donors) and organisations working on the ground have noted that reduced funding is having a negative impact on their programmes.⁴²

Read more about funding for the HIV and AIDS epidemic.

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AIDS is a name created in 1982 to describe an entirely new epidemic caused by a virus called HIV, which until the early 1980s was very rare in Africa and elsewhere. HIV gradually destroys the human immune system, making people much more vulnerable to other infections and cancers, such as pneumonia, Kaposi’s sarcoma and tuberculosis (TB). AIDS describes the syndrome (a group of symptoms) associated with the most advanced stages of HIV disease.

Although the germs that cause AIDS-defining diseases have been around for a long time, most of them don’t usually cause severe illness or death in people without HIV. For example, someone infected with both TB and HIV is 30-50 times more likely to develop the active form of TB than someone infected with TB alone.⁴³ Tuberculosis disease in Africa was once confined to the poor, the weak and the elderly, but today it kills many thousands of young adults who are HIV-positive, including well-educated members of the middle class. Unless treated, most people develop a severe AIDS-defining illness within ten years of becoming infected with HIV.⁴⁴

Read more about tuberculosis and HIV.

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A tiny minority of scientists dispute the theory that HIV causes AIDS, and some have suggested various non-infectious causes. These theories have gained a certain amount of popularity on the Internet. However, the vast majority of scientists agree that the evidence that HIV causes AIDS is abundant and conclusive. Numerous studies in Africa and elsewhere have shown that HIV infection is the only factor that predicts who will develop AIDS, and that AIDS does not occur without HIV.

AVERT.org has a review of the evidence that HIV is the cause of AIDS.