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AIDS Epidemic in sub-Saharan Africa

Sub-Saharan Africa has more than 10% of the world’s population, but is home to 70% of all people living with HIV—some 25 million (range: 23.1–27.9 million) compared to 23.8 million (range: 22 million—26.6 million) in 2001. In 2003 alone, an estimated 3 million people became newly infected, while 2.2 million people died of AIDS – 75% of deaths globally.

  • Many African countries are experiencing generalized epidemics (national HIV prevalence rates above 1%). This means HIV is spreading throughout the population, rather than being confined to people who are at higher risk of exposure, such as sex workers and their clients, men who have sex with men, and injecting drug users.

  • In sub-Saharan Africa, adult HIV prevalence appears to have stabilized. However, a stable prevalence is only possible if AIDS-associated deaths are replaced by new infections. Thus, in sub-Saharan Africa, a stable prevalence still represents more than 2 million new infections each year.

  • No country has so dramatically reversed its epidemic as Uganda, where national prevalence dropped from 12% in the early 1990s to 4.1% in 2003. Kampala’s prevalence was around 8% in 2002—down from 29% 10 years ago. Still, even Uganda cannot afford to relax: surveys suggest today’s young people may have less AIDS knowledge than their counterparts in the 1990s.

  • Women in Africa are being infected at an earlier age than men, and the gap in HIV prevalence between them continues to grow. Today, there are, on average, 13 HIVpositive women for every 10 HIV-positive men—up from 12 infected women for every 10 infected men in 2002. The difference in HIV-infection levels between women and men is even more pronounced among young people aged 15–24. This ranges from 20 young women for every 10 young men in South Africa, to 45 young women for every 10 young
    men in Kenya and Mali.

  • Recently, unsafe medical injections in health-care settings were suggested to account for the majority of sub-Saharan Africa’s HIV transmission. However, a thorough review
    concluded that, while a serious issue, unsafe injections are responsible for only 2.5% of all infections. Heterosexual sex remains this region’s predominant transmission mode.

  • There is no typical ’African’ HIV epidemic. In six countries, adult HIV prevalence is below 2%, while in six other countries it is more than 20%. These extreme differences in prevalence levels fall roughly into geographically separate areas.

  • Within countries, HIV prevalence varies by region. A review of national community-based studies shows HIV prevalence in urban areas is about twice as high as in rural areas. The difference in men’s and women’s infection levels is also more pronounced in urban areas (14 women for every 10 men) than in rural areas (12 women for every 10 men).

  • Southern Africa remains the world’s worst-affected region, with epidemics that have grown rapidly. Of the seven countries in the region, all have prevalence above 15%. Botswana and Swaziland have the highest prevalence with 37.3% and 38.8% respectively. They are followed by Lesotho (28.9%), Zimbabwe (24.6%), South Africa (21.5%), Namibia (21.3%), and Zambia (16.5%).

  • There is no single explanation for why the epidemic is so rampant in Southern Africa. A combination of factors, often working in concert, seem to be responsible, including:
    poverty and social instability that result in family disruption; high levels of other sexually transmitted infections; the low status of women; sexual violence; high mobility, which is largely linked to migratory labour systems; and ineffective leadership during critical periods in the epidemic’s spread.

  • West Africa’s HIV prevalence is much lower than Southern Africa’s, with most countries having prevalence between 1–5%, and no country having prevalence above 10%. National prevalence has remained relatively low in the Sahel countries, with prevalence around 1%. However, the overall figures can conceal high infection levels among certain population groups. In Senegal, national HIV prevalence is below 1%; yet, among sex workers in two cities, prevalence rose from 5% and 8% respectively in 1992, to 14% and 23% in 2002.

  • Côte d’Ivoire’s prevalence is 7%—the highest in West Africa, although the capital Abidjan recorded its lowest level (6%) in a decade in 2002.

  • Benin and Ghana show HIV prevalence in the 2–4% range, with little change over time. Nigeria, with a population of more than 120 million, has the highest number of people living with HIV in West Africa. In 2003, the national prevalence was 5.4%.

  • In countries in Central and East Africa, adult prevalence falls somewhere between those in Southern and West Africa, ranging from 4–13%. In several places, there are signs of
    real decline in the number of infections. In the Ethiopian capital, Addis Ababa, prevalence has fallen from a peak of 24% in 1995 to 11% in 2003—a significant development, given the country’s epidemic is largely concentrated in its cities. Prevalence has also dropped in several Kenyan sites, while stabilizing in others.

  • However, not all countries in the region show stabilized levels. In Madagascar, there has been an alarming rise in prevalence among pregnant women; it increased almost fourfold since 2001, to reach 1.1% in 2003.

  • National reports tracking progress towards implementation of targets contained in the 2001 UN Declaration of Commitment on HIV/AIDS show that a large number of countries have no national orphan policies in place, voluntary counselling and testing coverage is low at 7%, and prevention of mother-to-child transmission reaches only 5% of pregnant women in sub-Saharan Africa.

  • But the past two-to-three years have also seen an upsurge of political support, stronger policy formulation, boosted funding, and moves towards cushioning societies against the
    epidemic’s impact—a momentum that has to be maintained to reverse the epidemic.

For more information, please contact Dominique De Santis, UNAIDS, Geneva, tel. +41 22 791 4509 or mobile (+41 79) 254 6803, or Abby Spring, UNAIDS, Geneva, tel. +41 22 791 4577 or mobile (+41 79) 308 9861. For more information about UNAIDS, visit www.unaids.org.

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