The HIV/AIDS Crisis in Africa

By Welile Shasha, WHO Liaison Officer, South Africa

Introduction

1.The HJV/AIDS epidemic is the biggest threat to health and development in Africa, and women and girls bear the brunt of its impact. The response to the epidemic at all levels (from individual to global level), has been complex, extremely variable, and largely inadequate. Consequently the epidemic has spread to every corner of the globe over the past 20 years. At present the bulk of the epidemic is in Sub-Saharan Africa, where it has unfolded into a menacing crisis in many countries. Efforts to control the epidemic through public health measures have been severely constrained by two major factors, namely, stigma and poverty

2.This presentation will outline some basic facts on HIV/AIDS, on the basis of international experiences. The focus will then move to aspects of stigma, based on research experiences from Uganda and India. The aim will be to prepare the ground for key intervention strategies within the context of prevention and treatment, given the resource realities of the continent. Such key interventions will include (1) the continuum of care, support, and treatment; (2) prevention of mother-to-child transmission; (3) concurrent improvement of health care infrastructure and managerial capacity; and (4) all within the context of poverty reduction and sustainable development.

Some Basic Facts on HIV/AIDS

3.The infective agent in HIV/AIDS is a retrovirus that gets into the CD4 cells of the blood and reduces the body immune mechanisms. This allows opportunistic infections to penetrate the internal and external body surfaces (lungs, gastro-intestinal tract, and skin), usually in the form of TB, pneumonia, diarrhoeal disease, and so on. Important routes of infection by the virus in Africa are sexual intercourse (90%), vertical transmission from mother to child (7%), and infected blood or blood products (3%). These figures may vary slightly according to country.

4.Other sexually transmitted infections make it easy for the virus to penetrate the protective membrane of the genital tract following sexual intercourse with an infected person, and women are twice as likely to be infected than men. Also, anal intercourse increases the risk of infection.

5.At the end of year 2000, 36.1 million people were living with HIV (infected); and 25.3 million of these were in Sub-Saharan Africa. Also, the epidemic had killed 22 million people, and 17 million of these were in Africa. Both deaths and infected individuals are now common knowledge to most people in Africa. The prevalence of infection in Southern Africa is about 20%. Examples are Botswana (36%), Lesotho (24%), Namibia (20%), South Africa (11%), Swaziland (25%), Zambia (20%), and Zimbabwe (25%).. Lastly, there were 1.1 million infected children under the age of 15 years in Africa, and generally the prevalence of HIV infections is not decreasing. In fact it is increasing in many countries, the notable exception being Uganda where it has decreased from 14% to 8% following sustained interventions. Indeed, this epidemic has got the potential to reduce populations in African and Eastern countries, and at a time when control of other communicable diseases is successful. But why?

Why is HIV/AIDS different?

6.Most communicable diseases are now getting under control, the first evidence being successful eradication of small pox, with the help of the World Health Organization. Furthermore, huge gains are being made to control onchocerciasis (river blindness) in West Africa, poliomyelitis, measles, tuberculosis, malaria, and most recently, cholera in the Kwazulu-Natal province of South Africa. Indeed the synergies between the country, bilateral funding agencies, and the World Health Organization have been admirable and inspiring. Furthermore, South Africa remains a shining star in the control of the tobacco epidemic in Africa. Again, a key strategy has been to work closely with the WHO. The question that remains to be addressed then is: Why is HIV/AIDS different? Why are the skills, strategies, and resources that are utilised for the control of other communicable diseases not harnessed in full for HIV/AIDS?

Stigma is part of the answer

7.The difference between the other communicable diseases and HIV/AIDS is the issue if stigma. It poses a formidable challenge to the control of the epidemic especially as it does not allow appreciation of the exact number of cases or number of deaths, as very few individuals dare to emerge and declare their status. It is therefore a major constraint in the prevention and control of HIV and AIDS, hence the World Health Assembly Resolution (WHA 41.24), that was passed in 1988, encouraging member states to foster a spirit of understanding and compassion for HIV-infected persons. Countries were also encouraged to pass legislation to address the problem of discrimination on the basis of HIV and AIDS. However, the problem continues despite the WHA Resolution and national legislation. But why?

Stigma begets denial responses

8.The Joint United Nations Programme on HIV/AIDS (UNAIDS) has also been concerned about the problem of stigma, hence the sponsoring of research on Uganda and India to throw some light on aspects of the phenomenon. We outline below the key findings in terms of denial responses of governments; stigma and discrimination at community level; and individual responses and experiences

9.Denial responses of governments manifest themselves as "apathy in providing systems of prevention, treatment and care". Governments also "cover up and conceal cases or fail to maintain reliable and transparent report systems". The quotations indicate use of actual words from the authors of the report, which is available in the internet at the UNAIDS web site.

10.At community level, stigma and discrimination manifest as harassing and scapegoating of individuals; as well as acts of violence and murder in extreme cases. The latter have been reported in Brazil, Colombia, Ethiopia, India, and South Africa. The killing of Gugu Dlamini in Decenber 1998 is still fresh in memory

11.Individual responses and experiences include the following: (i) isolation of affected individuals, example, exclusion from social and sexual relationships. (ii) Even where protective laws exist, most people are not prepared to go to court, lest their identity becomes known far and wide. (iii) Women are stigmatised more due to a common belief that they spread the infection, when in reality it is the men that spread it more as they have many more casual sex partners. The woman may even be evicted from the house after the death of the husband

12.The common contexts of HIV/AIDS related discrimination and denial are family and community; and also employment and workplace. In both contexts, the infected person may find it very hard to emerge and declare their status. In extreme cases the person may commit suicide or seek euthanasia

Why do some (few) countries make it?

13.Some countries have been able to control the epidemic despite the odds, and it may help to learn from them. Uganda has been able to reduce the prevalence of HIV/AIDS from 14% to 8%. This has been through strategies that include community mobilization. The actual reasons for the success can only be appreciated through visits to the country, as strategies may work in one place and not in another. However, some proposals can be made to reduce the effects of stigma, especially on masking the prevalence of HIV infections and related deaths

Proposals to unmask prevalence

14.Antenatal care clinic (ANC) surveys are a good way to monitor the epidemic of HIV/AIDS, but they open only one window to the prevalence. We propose herewith four additional mechanisms. Firstly, countries can use sentinel surveillance sites that are carefully selected to represent various community groups. Secondly, HIV/AIDS could be made notifiable like all the other communicable diseases, but in a way that will not expose the infected person to discrimination or risk of expulsion from the workplace. Thirdly, widespread voluntary counselling and testing can go a long way to reflect prevalence better. Fourth and last, all persons admitted to health care institutions could be tested anonymously and results coded for purposes of improving prevalence figures for both HIV infections and related deaths. The data would then inform policy and strategies at the highest level.

15.An accurate prevalence of HIV infections and related deaths would be ideal for monitoring effectiveness of interventions. However, the epidemic can still be controlled even under the current realities in countries, and we recommend below strategies for doing that

Recommended strategies

16.Strategies that can be implemented include mitigation of stigma; improvement of health infrastructure; the continuum of care, support, and treatment; and prevention of mother-to-child transmission. These four strategies can immediately be carried out concurrently, with technical support from the WHO and UNAIDS. This would be a starting point (a lot of which is already in place), and could be reviewed in 12 months. At the review, a comprehensive plan of access to antiretroviral drugs can then be unveiled, to the extent of its affordability and sustainability. The Global AIDS Fund could play and important role in this regard.

Mitigation of stigma

17.The national and regional government structures could tackle the issue of stigma more decisively. Our suggestions in this regard go beyond formulation of relevant legislation. They include visible warmth and support toward persons infected by HIV (as afforded soldiers wounded at war); tax or other incentives to enable companies to address stigma and discrimination in the workplace; and voluntary counselling and testing, as tax deductible expense for all persons, especially those in leadership positions. There may be many more, but this would be a good start.

Improvement of health infrastructure

18.The health system should immediately be assessed for capacity to sustain treatment of opportunistic infections, as well as prevention of mother-to-child transmission (MTCT). The MTCT pilot sites in South Africa are an excellent start in this regard, and resources of the appropriate international organizations (like WHO, UNAIDS) could support the process according to the needs of each country

19.Local health service or health research organizations or institutions could be strengthened and utilized to sustain the strengthening of the health system, especially in the area of appropriate research and human resource development, as these relate to the control of the HI/AIDS epidemic

20.The capacity of health institutions to deliver could also be improved through training of managers on issues of work plans, expected results, staff appraisal and monitoring of staff performance, and financial management. The schools of public health in South Africa would likely welcome that role

Care, Support, and VCT

21.Treatment of opportunistic infections should be part of the continuum of support to infected and affected persons. The capacity for widespread voluntary counselling and treatment (VCT) should be developed and assured, and utilize all available resources within the context of the district health system, and/or the framework of integrated and sustainable development, as the case may be.

Prevention of mother-to-child transmission

22.Prevention of mother-to-child transmission could constitute the most important thrust for operations, as it engenders confidence in the health system for the population. It would be an important incentive to encourage people to come out and declare their status, and all pregnant women could be encouraged to take advantage of it. Being affordable, it would also improve the figures on prevalence of HIV infections. One is convinced that related issues of breast-feeding and infant foods are not going to pose insurmountable difficulties

Conclusion

23.In conclusion, we applaud the government of South Africa for appropriate policies and mechanisms for integrated and sustainable development in rural and urban areas. We are confident that these will constitute a solid foundation and suitable context for poverty reduction, mitigation of stigma in HIV/AIDS, and improvement of the capacity of the health system to enable it to sustain more creative strategies for control of HIV/AIDS in the country and sub-region