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1. AIDS in Africa--the rapid spread continues.

During the past decade more than 11 million adults and 1 million children-roughly two-thirds of the estimated global total--have been infected with the human immunodeficiency virus in Africa. Every day 1,800 more Africans are infected. Projections suggest that within five years the cumulative number of infected people in Africa (1) will increase by a third, reaching 15 million (WHO 1995). Rapid increases in infection are occurring among adolescents and young adults, particularly females.

The majority of HIV infections are in East and Central Africa, with the epidemic spreading to contiguous areas in Southern Africa, principally Botswana, South Africa, Swaziland, Zambia, and Zimbabwe (map 1.1, next page). The government of South Africa estimates that more than 500 black South Africans are infected with HIV each day. In Swaziland national AIDS control program managers expected the 1993 HIV infection prevalence rate among pregnant women to be twice the 1992 level of 3.9 percent, but instead the rate quintupled, to 21.9 percent (AIDS Analysis Africa 1994b).

Rates of infection are also rising in limited areas of West Africa--Burkina Faso, Cote d'lvoire, Guinea-Bissau, Niger, and Nigeria. The slow but steady increase in infection rates in Nigeria (from about 1.4 percent among pregnant women attending antenatal facilities in 1991 to 3.8 percent in 1994) is a cause of concern because of that country's large population and considerable internal and external migration (Federal Ministry of Health and Social Services 1995).


Throughout the continent, HIV has spread along the major migration routes. Several studies have shown that a change of residence is strongly associated with an increased risk of HIV infection. Thus, the extensive labor migration in Central and Southern Africa, the longdistance commercial transportation lines operating in both East and West Africa, and the mobilization and entrenchment of military forces are clearly tied to the spread and acceleration of the epidemic.

Political and social instability gives rise to migration and thus to increased HIV transmission among both soldier and civilian populations. Some observers believe that HIV and AIDS were an important cause of the widespread despair and unrest in Rwanda before the recent upheavals. HIV prevalence among Rwandan soldiers was estimated to be as high as 65 percent in 1994 (AIDS Analysis Africa 1994b). Interviews with the military found fear, anxiety, and uncertainty in the ranks because AIDS was seen as "more dangerous than bombs," since it was invisible. The subsequent months of displacement and living in enclosed camps for the millions of Rwandan refugees will undoubtedly fuel the epidemic. Cooperative for Assistance and Relief Everywhere (CARE) estimates that 33 percent of sexually active adults in refugee camps in Tanzania are HIV positive.


Population density and disease go together. Recent studies in urban areas in Cdte d'lvoire, Malawi, Zambia and Zimbabwe show a consistent and swift increase in HIV infection levels (figure 1.2). In Harare, Zimbabwe, for example, more than 38 percent of pregnant women attending antenatal clinics (a group considered most representative of the general adult population) are estirhated to be infected.


On average, HIV prevalence in urban areas is five times that in rural areas. The proportion of women to men in urban areas appears to influence HIV transmission. An analysis of 1987 HIV seroprevalence rates and female-male ratios found that higher HIV prevalence is associated with urban areas in which there are fewer young adult women than men (Over and Piot 1993).

The overwhelming proportion of HIV infections in Africa occur through sexual activity. Hence, HIV is classified as an STD, along with gonorrhea, chlamydia, syphilis, chancroid, trichomonas, and herpes. While it is not clear how extensive the spread of HIV infection may be throughout the population, herpes prevalence rates as high as 50 percent of adult populations in urban areas have been reported in Africa (Nahmias and others 1990). Thus HIV infection rates could potentially reach such levels.

The HIV epidemic is also worsening the region's tuberculosis problem, with large numbers of people infected by dormant tuberculosis likely to develop active tuberculosis once HIV weakens their immune response. The annual number of deaths from tuberculosis in Africa is projected to double from 1995 to 2000.


Rates of HIV and other STDs are highest among individuals who have unprotected sex (intercourse without a condom) with many partners: sex workers, clients of sex workers, truck drivers, migrants, and the military and police. HIV prevalence rates are approaching 100 percent among sex workers in Nairobi and Abidjan (U.S. Bureau of Census 1994). A 1992 study among truck drivers from eight countries who drive the Mombasa-Nairobi highway found an HIV prevalence rate of 27 percent (Bwayo and others 1992). Among truck drivers in Ouagadougou, Burkina Faso, the HIV prevalence rate in 1993 was 13 percent. The rates among military personnel are believed to be higher than 50 percent in some countries.

Two principal factors facilitate the sexual transmission of HIV in Africa: the viral subtype and having other STDs. Two other important biological factors may influence HIV transmission as well. First, the immature genital tracts of adolescent women make them very susceptible to infection. This susceptibility would help explain the high rates of HIV infection among young women. Second, men who are not circumcised appear to have greater risk of HIV (figure 1.3- next page).

The risks of acquiring HIV can be reduced significantly by the use of condoms during sexual intercourse. But condom use remains low in Africa because of inadequate supply, high cost, poor demand, and psycho-social barriers to use.

Data from several studies suggest that age, sex, education, and marital status are influential demographic predictors of sexual behavior--and of the risks of contracting HIV and other STDs. Individuals younger than twenty-four years old account for more than half of new HIV infections, according to a recent WHO review of countries with high seroprevalence levels. Most of these infections are among young women. In Africa men consistently report higher numbers of sexual partners than women (figure 1.4). Most women report having only one sexual partner, which suggests that infected married women have been infected as a consequence of their husband's high-risk behavior.



Like other STDs, HIV infection is gender sensitive in acquisition and consequences. HIV-infected females outnumber infected males six to five and, as mentioned previously, the ratio increases significantly among younger age groups, where young women are much more likely to be infected than young men (WHO 1995). This difference is thought to be not only a result of greater female biological susceptibility, but also of asymptomatic infections with other STDs, lack of female-controlled preventive methods (for example, a female condom), and unequal power relations that limit women's ability to influence the conditions under which sexual intercourse occurs.

Several pathways have been proposed to show how gender inequality in Sub-Saharan countries translates into increased female vulnerability to acquiring HIV. One hypothesis focuses on sexual inequality, positing that the inferior status of women induces young women to form relationships with older men and to accept money and favors in exchange for sex, placing them at risk of HIV infection. In addition, the subordinate sexual status of women makes it difficult for them to question a male partner's sexual activities or non-use of safe sex methods. Economic and political inequality between the sexes is thought to encourage commercial sex. In environments where women's ability to be financially independent is constrained by laws or customs that restrict their ownership of or access to land and other productive assets, or to education and employment, women may be forced to turn to commercial sex. The paucity of health facilities that promote comprehensive reproductive health care for women, the poor health-seeking behavior of women, low self-esteem, and limited freedom of movement in some societies are also thought to inhibit diagnosis and treatment of STDs among women.

Several traditional practices increase the risk of HIV transmission for both genders and can fuel the epidemic in a community. These include:

* Ritual cleansing (2) and inheritance of a widow by the late husband's brother;

* Heirship for chieftaincy, where each household in the community support the sexual union of a female member with the chief, to ensure that each family has the opportunity to produce an heir to the chief; and

* Use of unsterile equipment during male circumcision and female genital mutilation. (3)

Widespread cultural reluctance to discuss sexual issues-particularly information on healthy practices-with children and adolescents also increases the risks of acquiring HIV. Early family planning program studies in Africa found that, as in many parts of the world, sexual behavior and experience, and opinions on sexually related matters are rarely, if ever, discussed. This reluctance exists among peer groups, between spouses, and especially between generations. The breakdown of traditional norms and values resulting from urbanization and modernization (isolation from extended family, commercialization, improved modes of transportation) are also thought to contribute to increased rates of HIV and other STDs. Such changes have lessened the role of community elders in instilling moral and cultural values, especially where extended families are separated.

Socioeconomically, HIV/AIDS is a disease of both poverty and affluence. Studies among population groups in Ethiopia, Kenya, Nigeria, Tanzania, and Zimbabwe find an association between high rates of HIV infection and low income, unemployment, or low levels of education. But other studies in Malawi, Rwanda, Tanzania, Zaire, and Zambia find that high educational attainment and socioeconomic status are associated with higher rates of infection.

In the end, it is sexual behavior--the numbers of partners with whom an individual has unprotected sex and, correspondingly, the number of partners with whom his or her partner(s) has unprotected sex--that determines the risk of individual becoming infected.


The biological and socioeconomic determinants described above help explain why Africa has experienced such high levels of heterosexual transmission of HIV. These determinants include unprotected sex with several partners, a viral subtype that many scientists believe is extremely efficient in sexual transmission, noncircumcision of males, widespread prevalence of STDs, gender inequalities, disproportionately high ratios of men to women in urban areas, and extensive migration (figure 1.5). The HIV epidemic in Africa would have been less severe if not for the pervasiveness of these determinants.
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Title Annotation:AIDS Prevention and Mitigation in Sub-Saharan Africa: An Updated World Bank Strategy
Publication:AIDS Prevention and Mitigation In Sub-Saharan Africa: An Updated World Bank Strategy
Date:Apr 1, 1996
Previous Article:Executive summary: confronting AIDS in Africa.
Next Article:2. AIDS undermines development--and exacerbates poverty.

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