Despite the fact that sub-Saharan Africa contains only about 11 percent of the Earth’s population, the region is the world’s epicenter of HIV/AIDS. The numbers are daunting. Adult HIV prevalence is 1.2 percent worldwide (0.6 percent in North America), but it is 9.0 percent in sub-Saharan Africa. UNAIDS estimates that at the end of 2001, there were 40 million people living with HIV/AIDS, 28.5 million of them from sub-Saharan African. Five million adults and children became newly infected with HIV in 2001, 3.5 million of them from sub-Saharan Africa. Three million people died from AIDS-related causes in 2001, and 2.2 million of these deaths were among sub-Saharan Africans.2
AIDS is now the leading cause of death in sub-Saharan Africa. (Worldwide, AIDS is the fourth leading cause of death.) Life expectancy at birth has plummeted in many African countries, wiping out the gains made since independence. The combination of high birth rates and high AIDS mortality among adults, including many parents, has meant that more than 90 percent of children who have been orphaned as a consequence of the HIV/AIDS epidemic are in this region.2
These statistics disguise an important part of the story, however. Most of the worst affected countries form an “AIDS belt” in eastern and southern Africa. This belt consists of about 16 countries3 and stretches from Djibouti and Ethiopia down the east side of the continent through South Africa. These countries constitute only a little more than 4 percent of the world’s population but account for more than 50 percent of HIV infections worldwide.
According to UNAIDS, all the worst affected countries (with prevalence rates over 20 percent) are contiguous to one another in the lower part of the continent. These include South Africa, Lesotho, Swaziland, Botswana, Namibia, Zambia, and Zimbabwe. Botswana, Lesotho, Swaziland, and Zimbabwe have prevalence rates above 30 percent.4
Further north in the AIDS belt, Mozambique, Malawi, Burundi, Rwanda, Kenya, Tanzania, and Ethiopia all have adult prevalence rates in the 6-15 percent range. Adult prevalence in Uganda is estimated to be around 5 percent. Uganda is the one country in the region that has probably achieved a longstanding decline in HIV prevalence. Prevalence in Uganda may have peaked in the 12-13 percent range in the early 1990s before the onset of this decline.
Elsewhere, Somalia, Eritrea, Djibouti, and Sudan have little or no data, and Madagascar remains an interesting case. Despite tourism, an active commercial sex trade, and high rates of other sexually transmitted infections (STIs), and despite being separated from the African mainland by only 60 kms of water, adult HIV prevalence remains below 1 percent.5
Though having overall adult prevalence rates lower than in the eastern and southern parts of the continent, the middle part of Africa6 is undergoing a serious and generalized7 HIV/AIDS epidemic. Among the countries in the region, the Democratic Republic of Congo, Chad, and Equatorial Guinea show adult HIV prevalence rates under 5 percent. Angola has been war-torn and chaotic for so long that it is difficult to know exactly what is transpiring with the epidemic there. However, UNAIDS places the adult prevalence rate at 5.5 percent. Elsewhere in the region, UNAIDS reports prevalence rates of 7.2 percent in the Congo, 11.8 percent in Cameroon, and 12.9 percent in the Central African Republic.8 Many of the worst affected countries in middle Africa have the highest rates of other STIs on the continent.
Among the 15 countries of West Africa,9 only a few countries have prevalence rates over 5 percent. These include Burkina Faso (6.5 percent), Côte d’Ivoire (9.7 percent), Nigeria (5.8 percent), and Togo (6.0 percent). With an estimated population of 127 million, Nigeria is the demographic giant of sub-Saharan Africa. After South Africa, Nigeria has more people living with HIV/AIDS (3.5 million in 2001) than any other place on the continent. Côte d’Ivoire receives a large number of male migrants from neighboring countries who are temporary workers. Along with a vibrant commercial sex industry, especially in the capital city of Abidjan, this helps explain why Côte d’Ivoire has emerged as the epicenter of the epidemic in West Africa.
Table 1
Estimated Number of People in the African “AIDS Belt” Living with HIV/AIDS, end of 2001
Total Adults and Children
Total Women (15-49)
Adults (15-49) rate (%)
Global Total
40 million
18.5 million
1.2
Sub-Saharan Africa
28.5 million
15 million
9.0
Djibouti
–
–
–
Ethiopia
2.1 million
1.1 million
6.4
Uganda
600,000
280,000
5.0
Kenya
2.5 million
1.4 million
15.0
Tanzania
1.5 million
750,000
7.8
Rwanda
500,000
250,000
8.9
Burundi
390,000
190,000
8.3
Mozambique
1.1 million
630,000
13.0
Malawi
850,000
440,000
15.0
Zambia
1.2 million
590,000
21.5
Zimbabwe
2.3 million
1.2 million
33.7
Namibia
230,000
110,000
22.5
Botswana
330,000
170,000
38.8
Swaziland
170,000
89,000
33.4
Lesotho
360,000
180,000
31.0
South Africa
5.0 million
2.7 million
20.1
Source: UNAIDS, Report on the Global HIV/AIDS Epidemic: July 2002.
Why have rates in West Africa not soared to the levels found in the AIDS belt countries of eastern and southern Africa? If the African epidemic has its roots in the Great Lakes region, the epicenter could well have moved westward into middle and western Africa. Instead, it moved primarily southward. The question is an intriguing one and no consensus has emerged in response. Cultural and social norms may have played a role.10 For example, in countries with conservative Islamic traditions and a large proportion of Muslims in the population, sexual networking may be more circumscribed than in other countries.
Demographers John and Pat Caldwell suggest at least two additional factors. They point out that the presence of other STIs is probably the single most important factor contributing to the rapid spread of HIV. However, it is not all STIs, but especially those that cause genital ulcers that serve as an effective conduit of HIV. In West Africa, gonorrhea is the most common STI, but this is a non-ulcerative STI and an ineffective transmitter of HIV. By contrast, syphilis and chancroid are the dominant STIs in eastern and southern Africa. Both are ulcerative STIs that greatly increase the probability of HIV transmission.
Also, in most societies in West Africa, male circumcision is almost always practiced, while it is uncommon in a very large swathe of the AIDS-belt countries.11 Several studies conducted over the last decade and a half point to an association between male circumcision in some areas of sub-Saharan Africa and a reduced risk of HIV infection. However, it is still not clear whether circumcision’s apparent protective effect is due to culturally or religiously dictated behaviors — such as limiting the number of sex partners — or what the foreskin’s biological role is in male infection with HIV and other STIs.
Is the epidemic still worsening or is the situation improving? Uganda is still the only country in the region that has achieved a sustained decline in HIV prevalence. In some places — parts of Zambia, for example — prevalence appears to be dropping among the younger age groups, a possible prelude to an overall prevalence decline.
UNAIDS indicates that in 2000 the number of annual new infections went down for the first time relative to the previous year.12 While this is an encouraging trend, a drop in the annual number of new infections over a short period does not mean very much by itself. Some eventual downturn in incidence (annual new infections) would eventually occur even in the absence of any successful prevention efforts. The high levels of incidence that drove expansion of the epidemic during the 1990s could not be sustained indefinitely. This happens, in part, because prevalence levels become so high in certain high-risk groups that there is little room for expansion. A drop in incidence over a number of years is needed before it signifies a change in the overall course of the epidemic. Also, a rise in a few key but large countries — Congo and Nigeria, for example — could see incidence climbing again.
The best assessment is that, while there are some hopeful signs, overall the epidemic continues to rage throughout the Africa region. Even if prevention efforts become radically more successful in the near future than they have been, the impacts of the HIV/AIDS epidemic are going to echo for generations. If prevention, treatment, and care programs evolve at a more modest pace, it is certain that HIV/AIDS will have a profound impact on African development well into the 21st century.
References
The Joint United Nations Programme on HIV/AIDS (UNAIDS), Report on the Global HIV/AIDS Epidemic: July 2002 (Geneva: UNAIDS, 2002).
USAID, Leading the Way: USAID Responds to HIV/AIDS (Washington, DC: The Synergy Project, 2001).
The definition of the AIDS belt can vary. In this case, it includes 16 contiguous countries in eastern and southern Africa with serious HIV/AIDS epidemics. The countries are Djibouti, Ethiopia, Uganda, Kenya, Tanzania, Rwanda, Burundi, Mozambique, Malawi, Zambia, Zimbabwe, Namibia, Botswana, Swaziland, Lesotho, and South Africa.
UNAIDS, Report on the Global HIV/AIDS Epidemic: July 2002.
UNAIDS, Report on the Global HIV/AIDS Epidemic: July 2002.
Middle Africa countries include Angola, Cameroon, the Central African Republic, Chad, Democratic Republic of Congo, Congo, Equatorial Guinea, and Gabon.
One definition of a generalized HIV/AIDS epidemic is that HIV has spread beyond initial subpopulations engaged in high-risk sexual behavior to the general population, as evidenced by prevalence rates of 5 percent or more in urban areas. See, for example, Confronting AIDS: Public Priorities in a Global Epidemic, A World Bank Policy Research Report (New York: Oxford University Press, 1997): 87.
UNAIDS, Report on the Global HIV/AIDS Epidemic: July 2002.
West African countries include Benin, Burkina Faso, Cote d’Ivoire, Gambia, Ghana, Guinea, Guinea-Bissau, Liberia, Mali, Mauritania, Niger, Nigeria, Senegal, Sierra Leone, and Togo.
Leading the Way: USAID Responds to HIV/AIDS.
John C. Caldwell and Pat Caldwell, “Toward an Epidemiological Model of AIDS in Sub-Saharan Africa,” Social Science History 4 (Winter 1996): 567, 576, 578-585, 592.
UNAIDS, AIDS Epidemic Update: December 2000 (Geneva: UNAIDS, 2000).
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