African governments must make prevention of the further spread of HIV and mitigation of the impact of AIDS an urgent public priority -- with the support of donors and non-governmental organizations -- if the epidemic is to be overcome. A recent World Bank report argues that the costs of inaction are "potentially enormous," and that prevention among those most likely to contract and spread the disease is still the most cost-effective way of reducing infection rates.
According to the report, Confronting AIDS: Public Priorities in a Global Epidemic, this is particularly true for African and other developing countries, where 90 per cent of HIV infections worldwide occur. Health systems in those regions are overburdened and under-resourced, while the new and sophisticated drugs to control HIV infection and to treat and prevent AIDS-related illnesses are reaching only 10 per cent of the world's people who are living with HIV. Until a vaccine or cure affordable to developing countries is found, the best way to arrest the epidemic, according to the Bank, is to assist individuals to reduce the risky behaviour that may lead to HIV infection.
Governments have been reluctant to intervene in the HIV/AIDS epidemic, and too few countries have mounted a truly comprehensive response, says Dr. Peter Piot, Executive Director of the Joint UN Programme on HIV/AIDS (UNAIDS). This failure is all the more critical in light of the most recent UNAIDS data showing that rates of HIV transmission in sub-Saharan Africa have been "grossly underestimated."
Released to mark World AIDS Day in December, the UNAIDS report states that of the 30.6 million people -- or one in every 100 people of reproductive age -- infected with HIV worldwide, two-thirds are in sub-Saharan Africa. The region has the fastest growing epidemic, with an staggering 7.4 per cent of those aged 15 to 49 now believed to be living with HIV. In 1997, there were some 3.4 mn new infections among adults, and some 530,000 infected infants -- around 90 per cent of the world's total -- born to mothers with HIV in the region.
"Predictions of stabilization of the epidemic in Africa need to be revised," Dr. Piot told the Washington Post. "It has to happen some time, but it is not that time yet."
The rate of HIV transmission in Africa was previously underestimated, according to UNAIDS, because calculations were made from data gathered from the few countries with the best surveillance systems, such as Uganda, and then extrapolated to the entire region. Ugandan statistics showed that infection rates were beginning to level off.
But by 1997, data from other countries became available which indicated that the epidemic has not followed the Ugandan pattern. Rather, infection rates in many countries have continued to soar beyond levels thought possible when the previous data was collected.
While East Africa was one of the first areas to witness a regional HIV epidemic, UNAIDS reports that today, Southern Africa is the worst affected part of the continent. The statistics from the region paint a bleak picture:
In most of West Africa, rates of infection have stabilized at significantly lower levels than in East or Southern Africa. Dr. Ibra Ndoye, manager of Senegal's Anti-AIDS Programme, told the 10th International Conference on AIDS and Sexually Transmitted Diseases in Africa, held in Abidjan last December, that his country's stable HIV prevalence was attributable to increased condom use, regulation of the health of commercial sex workers, strict surveillance, an early response to the epidemic and a head of state who has shown leadership in the fight against AIDS.
Uganda was one of the first
African countries to take high-profile action to contain the spread of the
virus. It continues to see a drop in the proportion of adults infected:
figures gathered in 1997 from three surveillance sites indicate infection
levels of between 5 and 9 per cent -- a decrease of about one-fifth compared
with 1996. And the decrease appears to be concentrated in the younger age
groups, confirming findings that the youth have adopted safer sexual practices
than was the case a decade ago. HIV prevalence among pregnant women attending
antenatal clinics in Uganda is also declining.
Studies are needed to ascertain whether these declines are a result of policy interventions, says the World Bank. Nonetheless, the benefits of the Ugandan approach are apparent, where efforts have focused on information campaigns, distribution and promotion of the use of condoms and control of sexually transmitted diseases (STDs). Today, there is widespread knowledge of how HIV is transmitted among young Ugandans, for whom the death of family members from AIDS may also be a deterrent.
But in other countries, such as Nigeria, says UNAIDS, efforts to address the epidemic need "strengthening." According to the National AIDS Programme in Nigeria, there may now be some 2.2 million people living with HIV. Earlier on in the epidemic, even the reporting of reliable statistics was sporadic.
The World Bank notes that many public health problems such as malnutrition and preventable childhood diseases compete for scarce resources in Africa and other developing regions. But the AIDS epidemic calls for special attention because it continues to grow and has already begun to have a direct impact on life expectancy.
In the hardest-hit countries, life expectancy has been pushed back to levels of more than a decade ago, and in others the rate of progress of the past three decades has slowed down (see graph above). AIDS is also taking an increasing share -- about one-third -- of deaths from infectious diseases in Africa.
Another reason for stronger government action is that although HIV/AIDS is expected to have a small net impact on per capita growth of gross domestic product, it will exacerbate poverty in the most severely affected countries. As it afflicts economically active adults in their prime income-earning years, AIDS is likely to deepen poverty and leave increasing numbers of children without parental support.
Poverty and gender inequality have been recognized as among the factors which facilitate the spread of HIV. Poor women in situations of dependency often find it more difficult to negotiate safe sex. In addition, accelerated labour migration, rapid urbanization and cultural modernization, as well as conflict and large-scale movements of people, are facilitators of HIV transmission.
The current situation in Angola is a microcosm of these factors. Ms. Marilia Cabral Afonso, an Angolan delegate at the Abidjan conference, warns that her country is grappling with an explosive AIDS crisis arising out of three decades of civil war. Millions of people, including the youth, have been uprooted, creating conditions ripe for the spread of HIV. There has also been a recent influx of thousands of refugees, traders and illegal miners from other countries where HIV prevalence is high, worsening the epidemic. And areas still controlled by the opposition movement, UNITA, are off-limits to national AIDS control efforts. Appealing for international support to Angola's National AIDS Programme, Ms. Afonso said prevention activities only began two years ago.
An expanded response to the epidemic is critical, Dr. Piot of UNAIDS notes, bringing in resources and expertise from beyond the health sector, including the private sector. An example is a collaborative effort supported by UNAIDS between governments, pharmaceutical and diagnostic companies to increase access to HIV/AIDS drugs in developing countries (see article AIDS drugs plan starts in Uganda and Côte d'Ivoire). Another initiative involves the manufacturer of the female condom, with which UNAIDS has negotiated a reduced price to increase its accessibility in the developing world. South Africa has ordered 1.5 mn of the condoms, which give women an extra option to protect themselves against HIV and other STDs, and other countries are expected to follow.
Early intervention is especially critical in those countries where the epidemic is still nascent, says the Bank. In North Africa and in Cape Verde, Madagascar, Mauritania, Mauritius and Somalia, for example, governments have a "unique opportunity" to intervene aggressively to avert a full-scale epidemic. HIV prevention is obviously less expensive than treatment, a fact particularly relevant in low-income countries where health care is often publicly financed.
Photo: UNICEF / Douglas Clement
As the numbers of cases and treatment costs mount, AIDS will consume increasing amounts of public resources that could be used for other needs, warns the Bank. Those countries where the epidemic has already progressed need active government involvement to slow transmission rates and provide appropriate care to mitigate the impact of the disease.
With sufficient political commitment, governments can work to slow HIV transmission in a variety of ways, among them subsidizing information campaigns, the sale of condoms and clean syringes, regulating commercial sex work, and adopting policies which remove social and economic constraints to safer practices. The latter include promoting the acceptability of condoms and improving the status of women.
Increasing the amount and quality of information on the nature and extent of risky sexual behaviour in the population can contribute to ensuring that prevention programmes target those most likely to contract and spread HIV. In Kinshasa, for example, an STD prevention programme offering 500 HIV-negative sex workers free condoms, STD tests, treatment and counseling resulted in a reduction in the incidence of STDs, including HIV. Before the programme, only 11 per cent of the sex workers used condoms, but three months into it, more than half reported they used condoms consistently.
Although treatment of HIV is difficult and expensive, governments can mitigate the impact on individuals and the overall health sector by:
They can also continue to work with bilateral and multilateral donors which have been instrumental in providing funding for national AIDS prevention programmes, and with local and international NGOs and community-based organizations, which in Africa have been in the forefront of providing care for people living with HIV and AIDS, the Bank report says.
