The region is experiencing diverse epidemics in terms of scale and maturity. HIV prevalence rates have risen to alarming levels in parts of southern Africa, where the most recent antenatal clinic data reveal levels of more than 30% in several areas. In Swaziland, HIV prevalence among pregnant women attending antenatal clinics in 2000 ranged from 32.2% in urban areas to 34.5% in rural areas; in Botswana, the corresponding figures were 43.9% and 35.5%. In South Africa's KwaZulu-Natal Province, the figure stood at 36.2% in 2000.
At least 10% of those aged 15-49 are infected in 16 African countries, including several in southern Africa, where at least 20% are infected. Countries across the region are expanding and upgrading their responses. But the high prevalence rates mean that even exceptional success on the prevention front will now only gradually reduce the human toll. It is estimated that 2.3 million Africans died of AIDS in 2001.
This notwithstanding, in some of the most heavily affected countries there is growing evidence that prevention efforts are bearing fruit. One new study in Zambia shows urban men and women reporting less sexual activity, fewer multiple partners and more consistent use of condoms. This is in line with earlier indications that HIV prevalence is declining among urban residents in Zambia, especially among young women aged 15-24.
According to the South African Ministry of Health, HIV prevalence among pregnant women attending antenatal clinics reached 24.5% in 2000. About one-in-nine South Africans (or 4.7 million people) are living with HIV/AIDS. Yet, there are possibly heartening signs that positive trends might be increasingly taking hold among adolescents, for whom prevalence rates have dropped slightly since 1998. Large-scale information campaigns and condom distribution programmes appear to be bearing fruit. In South Africa, for instance, free male condom distribution rose from 6 million in 1994 to 198 million five years later. In recent surveys, approximately 55% of sexually active teenage girls reported that they always use a condom during sex. But these developments are accompanied by a troubling rise in prevalence among South Africans aged 20-34, highlighting the need for greater prevention efforts targeted at older age groups, and tailored to their realities and concerns.
Progress is also being made on the treatment and care front. In the southern African region, relatively prosperous Botswana has become the first country to begin providing antiretroviral drugs through its public health system, thanks to a bigger health budget and drug price reductions negotiated with pharmaceutical companies.
Within the context of a public/private partnership between five research-and-development pharmaceutical companies and five United Nations agencies, there is increasing access to antiretroviral therapy in Africa. As of the end of 2001, more than 10 African countries were providing antiretroviral therapy to people living with HIV/AIDS.
In five West African countries -- Burkina Faso, Cameroon, Côte d'Ivoire, Nigeria and Togo -- national adult prevalence rates already passed the 5% mark in 2000. Countries such as Nigeria are boosting their spending on HIV/AIDS and extending their responses nationwide. This year, Nigeria launched a US$240-million HIV/AIDS Emergency Action Plan. Determined prevention efforts in Senegal continue to bear fruit, thanks to the prompt political support for its programmes.
On the eastern side of the continent, the downward arc in prevalence rates continues in Uganda -- the first African country to have subdued a major HIV/AIDS epidemic. HIV prevalence in pregnant women in urban areas has fallen for eight years in a row, from a high of 29.5% in 1992 to 11.25% in 2000. Focusing heavily on information, education and communication, and decentralized programmes that reach down to village level, Uganda's efforts have also boosted condom use across the country. In the Masindi and Pallisa districts, for instance, condom use with casual partners in 1997-2000 rose from 42% and 31%, respectively, to 51% and 53%. In the capital, Kampala, almost 98% of sex workers surveyed in 2000 said they had used a condom the last time they had sex.
But despite such success, huge challenges remain. New infections continue to occur at a high rate. Most people with HIV do not have access to antiretroviral therapy. Already, by the end of 1999, 1.7 million children had lost a mother or both parents to the disease. Providing them with food, housing and education will test the resources and resolve of the country for many years to come.
Uganda's experience underlines the fact that even a rampant HIV/AIDS epidemic can be brought under control. The axis of any effective response is a prevention strategy that draws on the explicit and strong commitment of leaders at all levels, that is built on community mobilization, and that extends into every area of the country.
Although they are exceptionally vulnerable to the epidemic, millions of young African women are dangerously ignorant about HIV/AIDS. According to UNICEF, more than 70% of adolescent girls (aged 15-19) in Somalia and more than 40% in Guinea Bissau and Sierra Leone, for instance, have never heard of AIDS. In countries such as Kenya and the United Republic of Tanzania, more than 40% of adolescent girls harbour serious misconceptions about how the virus is transmitted. One of the targets fixed at the UN General Assembly Special Session on HIV/AIDS in June 2001 was to ensure that at least 90% of young men and women should, by 2005, have the information, education and services they need to defend themselves against HIV infection. As in other regions of the world, most countries in sub-Saharan Africa are a considerable way from fulfilling that pledge.
The vast majority of Africans living with HIV do not know they have acquired the virus. One study has found that 50% of adult Tanzanian women know where they could be tested for HIV, yet only 6% have been tested. In Zimbabwe, only 11% of adult women have been tested for the virus. Moreover, many people who agree to be tested prefer not to return and discover the outcome of those tests. However, other obstacles remain. A study in Abidjan, Côte d'Ivoire, shows that 80% of pregnant women who agree to undergo a HIV test return to collect their results. But of those who discover they are living with the virus, fewer than 50% return to receive drug treatment for the prevention of mother-to-child transmission of the virus.
More than half of the women who know they have acquired HIV, and who were surveyed by Kenya's Population Council this year, said they had not disclosed their HIV status to their partners because they feared it would expose them to violence or abandonment. Not only are voluntary counselling and testing services in short supply across the region, but stigma and discrimination continue to discourage people from discovering their HIV status.
Accumulating over the past year have been many encouraging developments. Thirty-one countries in the region have now completed a national HIV/AIDS strategic plan and another 12 are developing such a plan. Several regional initiatives to roll back the epidemic are under way. Some, such as those grouping countries in the Great Lakes region, the Lake Chad Basin and West Africa, are concentrating their efforts on reducing the vulnerability of refugee and other mobile populations. The political commitment to turn the tide of AIDS appears stronger than ever. Gatherings such as the 2000 African Development Forum meeting last December, and the Organization of African Unity Summit on HIV/AIDS, Tuberculosis and Other Related Infectious Diseases in April 2001, appear to be cementing that resolve. At the latter meeting, Heads of State agreed to devote at least 15% of their countries' annual budgets to improving health sectors. Fewer than five countries had reached that level in 2000.
AIDS has become the biggest threat to the continent's development and its quest to bring about an African Renaissance. Most governments in sub-Saharan Africa depend on a small number of highly skilled personnel in important areas of public management and core social services. Badly affected countries are losing many of these valuable civil servants to AIDS. Essential services are being depleted at the same time as state institutions and resources come under greater strain and traditional safety nets disintegrate. In some countries, health-care systems are losing up to a quarter of their personnel to the epidemic. People at all income levels are vulnerable to these repercussions, but those living in poverty are hit hardest. Meanwhile, the ability of the state to ensure law and order is being compromised, as the epidemic disrupts institutions such as the courts and the police. The risks of social unrest and even socio-political instability should not be underestimated.