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How many people in Africa are infected with HIV/AIDS ?

Africa continues to dwarf the rest of the world in how the region has been affected by AIDS. Africa is home to 70% of the adults and 80% of the children living with HIV in the world. The estimated number of newly infected adults and children in Africa reached 3.5 million at the end of 2001. It has also been estimated that 28.5 million adults and children were living with HIV/AIDS in Africa by the end of the year. AIDS deaths totalled 3 million globally in 2001, and of the global total 2.2 million AIDS deaths occurred in Africa.

In sub-Saharan Africa HIV is now deadlier than war itself. In 1998, 200,000 Africans died in war, but more than 2 million died of AIDS. AIDS has become a full-blown development crisis. Its social and economic consequences are felt widely not only in health but in education, industry, agriculture, transport, human resources and the economy in general.

The overall incidence of HIV infection in Africa does however now appear to be stabilising. Because the long-standing African epidemics have already reached large numbers of people whose behaviour exposes them to HIV, and because effective prevention measures in some countries have enabled people to reduce their risk of exposure, the annual number of new infections has stabilised or even fallen in many countries. These decreases have now begun to balance out the still-rising infection rates in other parts of Africa, particularly the southern part of the continent. Overall, the total of 3.5 million infected people in 2001 was slightly less than the regional total of 3.8 million in 2000. But this trend will not continue if countries such as Nigeria begin experiencing a rapid increase.

How are different countries affected?

National HIV prevalence rates vary widely between countries. They range from under 2% of the adult population in some West African countries to around 20% or more in the southern part of the continent, with countries in Central and East Africa having ates midway between these. However, prevalence rates do not convey people's lifetime risk of becoming infected and dying of AIDS. In the eight African countries where at least 15% of today's adults are infected, conservative analyses show that AIDS will claim the lives of around a third of today's 15 year olds.

Sixteen African countries south of the Sahara have more than one -tenth of the adult population aged 15-49 infected with HIV. In seven countries, all in the southern cone of the continent, at least one adult in five is living with the virus.

• In Botswana a shocking 38.8 % of adults are now infected with HIV
• In South Africa 20.1% of adults are infected with HIV. With a total of 5 million infected people, South Africa has the largest number of people living with HIV/AIDS in the world.

West Africa is relatively less affected by HIV infection, but the prevalence rates in some large countries are creeping up.

• Côte d'Ivoire is already among the 15 worst affected countries in the world.
• Nigeria, by far the most populous country in sub-Saharan Africa has, 5.8% of its adult population infected with HIV.

Infection rates in East Africa, once the highest on the continent, hover above those in the West of the continent but have been exceeded by the rates now being seen in the Southern cone.

• The prevalence rate among adults in Kenya has reached double - digit figures and continues to rise. In Kenya 15% of the adult population (15-49) are living with HIV/AIDS.

What is the result of this?

Over and above the personal suffering that accompanies HIV infection wherever it strikes, the virus in sub-Saharan Africa threatens to devastate whole communities, rolling back decades of progress towards a healthier and more prosperous future.

Sub-Saharan Africa faces a triple challenge of colossal proportions:

• bringing health care, support and solidarity to a growing population of people with HIV-related illness,

• reducing the annual toll of new infections by enabling individuals to protect themselves and others,

• coping with the cumulative impact of over 17 million AIDS deaths on orphans and other survivors, on communities, and on national development.

Millions of adults are dying young or in early middle age. They leave behind children grieving and struggling to survive without a parents care. Many of those dying have surviving partners who are themselves infected and in need of care. Their families have to find money to pay for their funerals, and employers, schools, factories and hospitals have to train other staff to replace them at the workplace.

Who is most affected? What is the effect on education?

Just as the better-educated segments of the population in the industrialised countries were the first to adopt health-conscious life-styles, a similar pattern now seems to be emerging in sub-Saharan Africa. Studies focusing on 15-19 years olds, have found that teenagers with more education are now far more likely to use condoms than their peers with lower education. They are also less likely, particularly in countries with severe epidemics, to engage in casual sex.

This was not the case early in the African epidemic. At that stage, education tended to go hand in hand with more disposable income and higher mobility, both of which increased casual sex and the risk of contracting HIV. But as information about HIV has become more widely available, education has switched from being a liability to being a shield.

The effect on education is that AIDS now threatens the coverage and quality of education. The epidemic has not spared this sector any more than it has spared health, agriculture or mining.

On the demand side, HIV is reducing the numbers of children in school. HIV positive women have fewer babies, in part because they may die before the end of their childbearing years, and up to a third of their children are themselves infected and may not survive until school age. Also, many children have lost their parents to AIDS, or are living in households which have taken in AIDS orphans, and they may be forced to drop out of school to start earning money, or simply because school fees have become unaffordable.

On the supply side, teacher shortages are looming in many African countries. In Zambia teachers are increasingly dying of AIDS and for many teachers their teaching input is decreasing because they are sick. Swaziland estimates that it will have to train more than twice as many teachers as usual over the next 17 years just to keep the services at their 1997 levels.

What is the economic impact?

It is exceptionally difficult to gauge the economic impact of the epidemic. Many factors apart from AIDS affect economic performance and complicate the task of economic forecasting - drought, internal and external conflict, corruption, economic mismanagement. Moreover, economies tend to react more dramatically to economic restructuring measures, a sudden fuel shortage, or an unexpected change of government, than to long, slow difficulties such as those wrought by AIDS.

But there is growing evidence that as HIV prevalence rates rise, both total and growth in national income - gross domestic product, or GDP -fall significantly. African countries where less than 5% of the adult population is infected will experience a modest impact on GDP growth rate. As the HIV prevalence rate rises to 20% or more, GDP growth may decline up to 2% a year.

In South Africa, the epidemic is projected to reduce the economic growth rate by 0.3-0.4 % annually, resulting by the year 2010 in a GDP 17% lower than it would have been without AIDS and wiping US$22 billion off the country's economy. Even in diamond-rich Botswana, the country with the highest per capita GDP in Africa, in the next 10 years AIDS will slice 20% off the government budget, erode development gains, and bring about a 13% reduction in the income of the poorest households.

What about prevention?

Continuing rises in the number of HIV infected people are not inevitable. Early and sustained prevention efforts can be credited with the lower rates in some countries. For example in Senegal there was effective early prevention. Uganda has brought its estimated prevalence rate down to around 8% from a peak close to 14% in the early 1990s with strong prevention campaigns, and there are encouraging signs that Zambia's epidemic may be following the course charted by Uganda.

But elsewhere, where far less has been done to encourage safer sex, the reasons for the relative stability remain obscure. Research is under way to explain the differences between epidemics in different countries. Factors that may play a role include patterns of sexual networking, levels of condom use with different partners, the availability of condoms and promptness in diagnosing and curing other sexually transmitted diseases (which if left untreated can magnify 20-fold the risk of HIV transmission through sex).

The overall provision of condoms to sub -Saharan Africa is only 4.6 per man per year, so another 1.9 billion condoms need to be provided if all countries are to have the same amount as the highest six countries in Africa. Botswana, South Africa, Zimbabwe, Togo, Congo and Kenya are supplied with about 17 condoms per man aged 15 to 59 years. It would cost an estimated $47.5 million (Ł34m) a year to fill the 1.9 billion condom gap excluding service delivery costs and production. Relative to the enormity of the HIV/AIDS pandemic in Africa, providing condoms is cheap and cost effective.¹

However condoms are not without their drawbacks, especially in the context of a stable partnership where pregnancy is desired, or where it may be difficult for one partner to suddenly suggest using condoms. For many individuals and couples in Africa, where HIV prevalence rates are high, finding out their infection status could expand their range of HIV prevention options.

How much would it cost, and what needs to be done, to make a difference?

As the illness and death from AIDS rose in Africa, some two decades ago, one or two countries reacted quickly. Other countries waited rather longer before intensifying their efforts, but they too are being rewarded for their efforts. There have been a number of success stories which include Senegal, Uganda and Zambia. But most countries in Africa lost valuable time because AIDS was not fully understood and its significance as a new epidemic was not grasped. Some action was taken, but not on the scale that was required to stem the tide of the epidemic.

The scale of action necessary does of course increase exponentially along with the epidemic. Early on in a heterosexual epidemic, most new infections are acquired and passed on by a minority of people with an especially high turnover of partners. If condoms are used in most of these transactions, the epidemic can be contained relatively easily. But once HIV has become firmly established in the general population most new infections occur in the majority of adults who do not have an especially high number of partners. This means that prevention campaigns have to be expanded greatly, making them harder and costlier, though still very worthwhile.

Most countries in Africa are at this stage. Yet few have expanded their HIV prevention programmes to the scale that would be needed to make a significant dent in the number of new infections. Since past prevention failures eventually turn into current care needs, failure to head off the epidemic early on also imposes a greater burden of care on countries where HIV prevalence is high. And as the HIV-infected fall ill and die, alleviating the impact on orphans, other survivors, families and communities becomes the third challenge.

Recently researchers have tried to determine how much money would be needed to make a real difference to the AIDS epidemic in Africa, and it is clear that scaling up the response to Africa's epidemic is not only imperative but it is affordable.

US$1.5 billion a year would make it possible to achieve massively higher levels of implementation of all the major components of successful prevention programmes for the whole of sub-Saharan Africa. These would cover sexual, mother-to-child and transfusion-related HIV transmission, and would involve approaches ranging from awareness campaigns through the media to voluntary HIV counselling and testing, and the promotion and supply of condoms.

In the area of care for orphans and for people living with HIV or AIDS, costs depend very much on what kind of care is being provided. It is estimated that, with at least US$1.5 billion a year, countries in sub-Saharan Africa could buy symptom and pain relief (palliative care) for at least half of AIDS patients in need of it; treatment and prophylaxis for opportunistic infections for a somewhat smaller proportion; and care for AIDS orphans. At the moment, the coverage of care in many African countries is negligible, so reaching coverage at these levels would be an enormous step forward.

Making a start on coverage with combination anti-retroviral therapy would add several billion dollars annually to the bill.

Of course, providing AIDS prevention and care services involves more than just these funds. A country's health, education, communications and other infrastructures have to be well enough developed to be able to deliver these interventions. In some badly affected countries, these systems are already under strain, and they are likely to crumble further under the weight of AIDS. Then, too, money can only be used wisely if there are sufficient people available and the shortage of trained men, women and young is already acute.

These are some of the serious challenges that African countries and their partners in the global community will have to face if they are to make a real difference to the epidemic.

The proportion of adults (15 to 49 years of age) living with HIV/AIDS in 2001 using 2001 population numbers

These figures are estimates at the end of 2001, published by UNAIDS in the 'Report on the Global HIV/AIDS Epidemic, July 2002'. These estimates include all people with HIV infection, whether or not they have developed symptoms of AIDS, alive at the end of 2001. For each of these countries, the 1999 prevalence rate published by UNAIDS was applied to the country's 2001 adult population to produce estimates given in the table. The estimates are given in rounded numbers. However, unrounded numbers were used in the calculation of rates and regional totals, so there may be minor discrepancies between the regional/global totals and the sum of country figures.

Adults in this report are defined as men and women aged 15-49. This age range captures those in their most sexually active years. While the risk of HIV infection continues beyond the age of 50, the fast majority of people with substantial risk behaviour are likely to have become infected by this age. Since population structures differ greatly from one country to another, especially for children and the upper adult ages, the restriction of 'adults' to 15-49 has the advantage of making different populations more comparable.

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