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Africa: AIDS Report

AfricaFocus Bulletin
Dec 3, 2004 (041203)
(Reposted from sources cited below)

Editor's Note

Despite over 3 million deaths from AIDS worldwide this year, the number estimated to be living with HIV continued to climb to an all-time high of 39.4 million people around the world. Almost two thirds of those infected (25.4 million), and almost 75 percent of the deaths (2.3 million) were in Sub-Saharan Africa.

The AIDS Epidemic Update 2004, from UNAIDS ( notes that the AIDS epidemics in different African regions differ substantially, with declines in prevalence being registered in some East African countries, still relatively low levels in most West African countries, and devastatingly high levels throughout Southern Africa, except Angola. Common to the pandemic in Africa and worldwide, however, is the fact that gender inequality fuels the pandemic. It does this both by making prevention messages irrelevant when women are unable to make their own decisions to protect themselves and by imposing disproportionate burdens of care on women.

Inadequate financial resources, lack of political will, and shortages of health care personnel are also fundamental factors in the failure of the world's response to keep pace with the pandemic. But, as this report stresses, the shortfall in prevention and treatment programs is not only quantitative. No program can be successful in confronting AIDS unless it also confronts the power inequalities between men and women.

This AfricaFocus Bulletin contains excerpts from the introduction and from chapter on Africa of the full UNAIDS report. Another Bulletin sent out today has excerpts from the report of the UN Secretary-General's Task Force on Women, Girls and HIV/AIDS in Southern Africa

For previous AfricaFocus Bulletins on AIDS and other health issues, visit


Many thanks to those of you who have recently sent in a voluntary subscription payment to support AfricaFocus Bulletin. If you have not yet made such a payment and would like to do so, please visit for details.

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AIDS epidemic update: December 2004

Excerpts from Introduction

The total number of people living with the human immunodeficiency virus (HIV) rose in 2004 to reach its highest level ever: an estimated 39.4 million [35.9 million-44.3 million] people are living with the virus. This figure includes the 4.9 million [4.3 million-6.4 million] people who acquired HIV in 2004. The global AIDS epidemic killed 3.1 million [2.8 million-3.5 million] people in the past year. ...

Sub-Saharan Africa remains by far the worst-affected region, with 25.4 million [23.4 million-28.4 million] people living with HIV at the end of 2004, compared to 24.4 million [22.5 million-27.3 million] in 2002. Just under two thirds (64%) of all people living with HIV are in sub-Saharan Africa, as are more than three quarters (76%) of all women living with HIV.

The epidemics in sub-Saharan Africa appear to be stabilizing generally, with HIV prevalence at around 7.4% for the entire region. But such a summary perspective hides important aspects. First, roughly stable HIV prevalence means more or less equal numbers of people are being newly infected with HIV and are dying of AIDS. Beneath the apparent constancy of steady prevalence levels lie devastating realities especially in southern Africa, which accounts for one third of all AIDS deaths globally. Second, the epidemics in Africa are diverse, both in terms of their scale and the pace at which they are evolving. There is no single "African" epidemic. Some urban parts of East Africa display modest declines in HIV prevalence among pregnant women, while in West and Central Africa prevalence levels have stayed roughly steady at lower levels than in the rest of sub-Saharan Africa. ...


Women Are Increasingly Affected

The AIDS epidemic is affecting women and girls in increasing numbers. Globally, just under half of all people living with HIV are female. Women and girls make up almost 57% of all people infected with HIV in sub-Saharan Africa, where a striking 76% of young people (aged 15-24 years) living with HIV are female. In most other regions, women and girls represent an increasing proportion of people living with HIV, compared with five years ago.

These trends point to serious gaps in the AIDS response. ... the vulnerability of women and girls to HIV infection stems ...their pervasive disempowerment. Most women around the world become HIV-infected through their partner's high-risk behaviour, over which they wield little if any control. ...

AIDS Response Needs to Keep Growing

There has been a sea-change in the global AIDS response since 2001. Global funding has increased from roughly US$ 2.1 billion to an estimated US$ 6.1 billion in 2004 , and access to key prevention and care services has improved markedly (UNAIDS, 2004). The number of secondary-school students receiving AIDS education has nearly tripled, the annual number of voluntary counselling and testing clients has doubled, the number of women offered services to prevent mother-to-child transmission has increased by 70%, and the number of people receiving antiretroviral therapy has increased by 56%, according to a recent survey in 73 low- and middle-income countries which represent almost 90% of the global burden of HIV (Policy Project et al., 2004). ...

Despite the improvements, however, coverage remains uneven and, in several respects, highly unsatisfactory. Approximately 440,000 people in low- and middle-income countries were receiving antiretroviral treatment as of June 2004 (WHO, 2004). This means that nine out of every ten people who need antiretroviral treatment - the majority of them in sub-Saharan Africa - are not receiving it. ...

Business as usual spells disaster. A massive effort is needed to achieve a response on a scale that matches that of the global AIDS epidemic. Without invigorated HIV prevention strategies that deal boldly with the epidemic, and that also address the wider imperatives of social justice and equality, the world is unlikely to gain the upper-hand over AIDS in the long run.

AIDS epidemic update: December 2004

Excerpts from chapter on Sub-Saharan Africa

Table: Sub-Saharan Africa
HIV and AIDS statistics and features, end of 2002 and 2004

Adults and children living with HIV

2004: 25.4 million [23.4-28.4 million]
2002: 24.4 million [22.5-27.3 million]

Number of women living with HIV

2004: 13.3 million [12.4-14.9 million]
2002: 12.8 million [11.9-14.3 million]

Adults and children newly infected with HIV

2004 3.1 million [2.7-3.8 million]
2002 2.9 million [2.6-3.6 million]

Adult prevalence (%)

2004: 7.4% [6.9-8.3%]
2002: 7.5% [7.0-8.4%]

Adult and child deaths due to AIDS

2004: 2.3 million [2.1-2.6 million]
2002: 2.1 million [1.9-2.3 million]

The AIDS epidemics coursing through this region are highly varied. There is no single, "African" epidemic. Sub-Saharan Africa has just over 10% of the world's population, but is home to more than 60% of all people living with HIV some 25.4 million [23.4 million-28.4 million]. ...

Adult HIV prevalence has been roughly stable in recent years. But stabilization does not necessarily mean the epidemic is slowing. On the contrary, it can disguise the worst phases of an epidemic when roughly equally large numbers of people are being newly infected with HIV and are dying of AIDS.

Not one epidemic, but many

While a bird's-eye view might discern overall stabilizing trends in HIV prevalence, the AIDS epidemics coursing through this region are highly varied both between and within sub-regions. It is therefore inaccurate to speak of a single, "African" epidemic and misleading to apply insights about the epidemic gleaned from specific parts or subregions, to the entire sub-Saharan Africa region. ...

East Africa now boasts several examples of gradual, modest declines in median HIV prevalence among pregnant women in urban areas. These are still early days, though. Even Uganda, which has shown consistent declines in HIV prevalence levels since the mid-1990s, remains burdened with a serious epidemic. In West and Central Africa there is little evidence of changes in prevalence levels, which have stayed steady at 5% or lower (with the significant exceptions of Cameroon and Cote d'Ivoire, where median HIV-prevalence levels have reached and then remained at roughly the 10% mark among pregnant women at some sites in recent years) (Asamoah-Odei, Garcia-Calleja and Boerma, 2004). National prevalence statistics, though, can hide much higher levels of infection in particular provinces, states or districts.

Unfortunately, southern Africa offers only faint hints of impending declines in HIV prevalence. With the exception of Angola (where the epidemic's progression may have been retarded during the country's long civil war with the result that national HIV prevalence has not exceeded 5%), each country in this subregion is experiencing national HIV prevalence of at least 10%. This means that an estimated 11.4 million (10.5 million-12.6 million) people are living with HIV in these nine countries almost 30% of the global number of people living with HIV in an area where only 2% of the world's total population resides.

While HIV prevalence measured at antenatal clinics has edged lower in parts of some countries and in specific age groups (for example, Lilongwe, Malawi), there is no sign yet of an overall, national decline in any southern African country. ...

But underlying this diversity are some striking consistencies. Across the region, women are disproportionately affected by HIV. On average, there are 13 women living with HIV for every 10 infected men and the gap continues to grow. In most countries, women are being infected with HIV at earlier ages than men. The differences in infection levels between women and men are most pronounced among young people (aged 15-24 years). Recent population-based studies suggest that there are on average 36 young women living with HIV for every 10 young men in sub-Saharan Africa. In Ghana the ratio widens to more than nine to one.

In a study among women in Harare (Zimbabwe), Durban and Soweto (South Africa), 66% reported having one lifetime partner, 79% had abstained from sex until at least their 17th birthday (roughly the average age of first sex in most countries in the world), and 79% said they used a condom. Yet, 40% of the young women were HIV-positive (Meehan et al., 2004). Many are being infected despite staying loyal to one partner.

Sexual abuse and violence much, but not all of it directed against females are serious problems that transcend economic, social, ethnic and geographical lines. Adolescents, children and young women and girls in particular experience increased abuse in the form of domestic violence, rape and sexual assault, and sexual exploitation or undergo female genital mutilation. In some Ugandan surveys, 46% of women said they have endured regular physical abuse, while in Kenyan and Zambian studies more than 40% of women have reported abuse. For some young women, their first sexual encounter occurs under coercion or force, which can be associated with an increase in HIV transmission.

Southern Africa

Southern Africa remains the worst affected subregion in the world, with data from selected antenatal clinics in urban areas showing HIV prevalence surpassing 25%, having risen sharply from around 5% in 1990.

South Africa continues to have the highest number of people living with HIV in the world. An estimated 5.3 million [4.5 million 6.2 million] people were living with HIV end-2003 in South Africa 2.9 million [2.5 million 3.3 million] of them women. Unfortunately, there is no sign yet of a decline in the epidemic. Overall HIV prevalence among pregnant women was 27.9% in 2003, compared with 26.5% in 2002 and 25% the year before that. ... One recent population-based survey has indicated possible shifts towards safer sex among young South Africans (Reproductive Health Research Unit, Medical Research Council, 2004). However, prevalence levels among pregnant women aged 15 24 years have continued to rise from 23.1% in 2001 to 24.3% in 2003. ...

Very high HIV prevalence often exceeding 30% among pregnant women is still being recorded in four other countries in the region, all with small populations: Botswana, Lesotho, Namibia and Swaziland. There, comparisons of prevalence levels at selected antenatal clinics have shown no evidence of a decline. ... Elsewhere in the subregion, HIV infections in pregnant women appear to be stabilizing at lower levels around 18% in Malawi (2003), 16% in Zambia (2003), and 25% in Zimbabwe (2003) but there is little evidence of an impending decline. In Zimbabwe's case, it is estimated that new HIV infections have stayed roughly steady since 1996-1997. As in the other countries in the region, women are disproportionately bearing the brunt. ... Overall, almost 57% of people with HIV in 2003 were women and an equal proportion of AIDS deaths were among women (Ministry for Health and Child Welfare Zimbabwe, 2004). ...

Angola is an exception in the region. During nearly two generations of war, civilians' movements were restricted, transport links severed, and parts of the country were intermittently cut off from the outside world. Available data suggest that those conditions probably slowed the spread of HIV. ...After two years of relative peace and with normal life resuming for millions of Angolans, there is every reason to fear much more widespread and rapid HIV transmission in this country.

Newly published study findings show southern Africa to be firmly in the grip of the AIDS epidemic, as more people succumb to HIV-related illnesses and die. Life expectancy at birth has dropped below 40 years in nine African countries Botswana, Central African Republic, Lesotho, Malawi, Mozambique, Rwanda, Swaziland, Zambia and Zimbabwe. ...

Detailed demographic surveillance is providing further evidence of steep rises in mortality. One such survey, conducted in a rural area of KwaZulu-Natal province, which has high HIV prevalence among pregnant women, has confirmed a sudden and massive rise in adult mortality starting in the late 1990s, with AIDS (with or without TB) constituting the leading cause of adult death (48%) by 2000. The risk of dying from AIDS for women peaks among women aged 25-39 years and among men aged 30-44 years. These AIDS mortality rates will almost certainly worsen in the coming years, since HIV-prevalence levels in this particular district rose steeply in the late 1990s. AIDS mortality reflects HIV incidence roughly a decade or so earlier (Hosegood, Vanneste and Timaeus, 2004).

Youth, sex and HIV in South Africa

Effective prevention among young people is essential. Throughout southern Africa, HIV prevalence sharply increases once people reach their twenties. The trend is vividly captured in a new, comprehensive study on HIV and sexual behaviour among young South Africans (conducted by the Reproductive Health Research Unit and Medical Research Council).

The study shows HIV prevalence to be comparatively low among 15-19 year-olds, at 4.8%. This is not that surprising, given that the mean age of first sex reported by respondents was 16.4 years for young men and 17 years for young women. It's in the next age group among 20-24 year-olds that HIV prevalence soars, reaching 16.5%. In this age group, HIV infections are massively concentrated among women. About one-in-four (24.5%) women surveyed was HIV-positive, compared to one-in-thirteen (7.6%) men. Indeed, more than three quarters (77%) of young South Africans living with HIV are female, a discrepancy that only begins to fade among South Africans 30 years and older. Similar to young people around the world, many young South Africans (62%) who learn they are HIV-positive believed they had faced little or no risk of contracting the virus.

Young women were found to be disproportionately at risk of HIV infection. Sexual aggression is common, with more than one quarter (28%) of the women saying their first sexual experience was unwanted, and one in ten (10%) saying they had been forced to have sex. Almost half (49%) the young women who'd had sex said they had been pregnant at some point suggesting that condom use was not the norm. Indeed, fully one third of those youth who had had sex in the previous 12 months never used a condom, and two thirds had not used one with their most recent sexual partner (Reproductive Health Research Unit, Medical Research Council, 2004).

East Africa

Some countries in East Africa do display signs of real declines in HIV infection levels. Uganda, where national prevalence fell from 13% in the early 1990s to 4.1% (2.8 6.6%) by end-2003, is the most notable, but by no means the only example. Comparisons of HIV prevalence among antenatal clinic attendees across the subregion show an overall significant decline from a median of 12.9% (7.0- 16.9%) in 1997-1998 to 8.5% (5.3-14.0%) in 2002 (Asamoah-Odei, Garcia-Calleja and Boerma, 2004). ...

The downward trend is most firmly established in Uganda, which saw HIV prevalence decline steeply during the mid- and late-1990s, remaining subsequently at 5% to 6%. Recent data suggest Kenya could be on a similar path. There, data from antenatal clinics show median HIV prevalence falling from 13.6% (12.2-27.1%) in 1997-1998 to 9.4% (6.6-14.3%) in 2002 and then staying largely unchanged in 2003. Figures for Burundi also suggest a decline in HIV prevalence, but this is based on limited data from only six clinics (Asamoah-Odei, Garcia-Calleja and Boerma, 2004).

Ethiopia's epidemic is most severe in urban areas, including in the capital Addis Ababa. However, there are encouraging signs that the declining HIV trend among pregnant women in the capital (first detected in 1997) is continuing. By 2003, HIV prevalence in the city had fallen to 11%, less than half the level (24%) it had reached in the mid-1990s. Overall, in 10 antenatal clinics in Ethiopia, median prevalence dropped from 13.7% in 1997-1998 to 11.8% in 1999-2000, and has remained at about 12% since then (Asamoah-Odei, Garcia-Calleja and Boerma, 2004).

These are heartening developments but still-high HIV-prevalence levels underscore the need to redouble and extend prevention efforts throughout these countries. It is much too early to claim that these recent declines herald a definitive reversal in these countries' epidemics and, furthermore, the need for treatment, care and support will continue to increase for years to come.

Meanwhile, a clearer picture is emerging of the epidemic in Eritrea, where the most detailed round of HIV sentinel surveillance to date has fixed prevalence at 2.4% in 2003. Overall HIV prevalence in the country appears to be stabilizing. However, infection levels vary considerably highlighting a need to intensify and to refine the focus of prevention efforts. Prevalence reached 7.2% along the country's southern coastal strip, and was more than three times as high in urban than in rural areas. ... (Ministry of Health Eritrea, 2004).

Overall, there is no evidence of nationwide HIV prevalence decline in Tanzania. However, in Mbeya region, which has been the focus of intense prevention efforts over the past 13 years, HIV prevalence among 15-24 year-old women fell from 20.5% in 1994-1995 to 14.6% in 2000, while condom use rose and treatment for other sexually transmitted infections increased, and a significant delay in age at first sex was noted over the same period. ...

AfricaFocus Bulletin is an independent electronic publication providing reposted commentary and analysis on African issues, with a particular focus on U.S. and international policies. AfricaFocus Bulletin is edited by William Minter.

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