YEAR IN REVIEW 2000: SPOTLIGHT

Africa's Struggle Against AIDS by Elizabeth Pisani Sub-Saharan Africa will move into the 21st century carrying the crippling burden of AIDS, a disease that is slashing life expectancy, shattering families, pushing industries to the brink of bankruptcy, and creating a generation of orphans. This disease was by far the leading cause of death among adults in much of the continent at the end of 1999, and yet it was virtually unknown just two decades ago. A full 70% of the 33.6 million people in the world currently estimated to be living with the virus-HIV-that causes AIDS live in African countries south of the Sahara, a region that accounts for just 10% of the world's population. A year's course of existing life-prolonging therapies for a single person costs 20 times the average per capita income for the region. Without such therapies most of those currently infected will die within the next 10 years. They will join the 14 million Africans who have already died of HIV-related illnesses, according to estimates made at the end of 1999 by the Joint United Nations Programme on HIV/AIDS and the World Health Organization. They will doubtless be joined in turn by millions more-some 9,400 people in Africa were estimated to have become newly infected with the fatal virus every day of 1999. These estimates are derived largely from the anonymous testing of blood taken from pregnant women during regular antenatal visits and from epidemiological models based on what is known about the transmission and progression of the virus. Early attempts to measure the size of the epidemic by calculating backwards from registered AIDS cases and deaths foundered because of confusion over what constitutes an AIDS case, a lack of diagnostic facilities, reluctance to report AIDS as a cause of death because of the stigma associated with the disease, and poor health reporting systems. Explanations for the rapid spread of HIV in sub-Saharan Africa remain politically controversial, even though the expansion of the epidemic itself has been well documented. It is known that it is easier both to contract and to pass on the virus if a person is also suffering from another sexually transmitted disease (STD). Prevalence of other STDs is high in much of the continent, and poor access to health facilities means they are less likely to be promptly treated and cured than in richer parts of the world. Condom use in most countries is low, especially within marriage. High fertility and near-universal breast-feeding contribute to the transmission of HIV from mothers to children in Africa-nearly half a million children are born with HIV in Africa each year, compared with 70,000 in the rest of the world. Large studies of sexual behaviour also suggest that sexual activity begins very young, with high proportions of both men and women having premarital partners, and that extramarital sex is common, especially among men. The pattern of HIV infection is not consistent across the continent. East Africa was the first area to suffer a major onslaught of HIV and then AIDS. Some countries in this region, notably Uganda, have been rewarded for extremely active prevention efforts by a fall in new infections in the youngest age groups. In others, such as Kenya, HIV prevalence rates continue a gradual but steady rise. The most explosive growth has been in the countries of southern Africa. It is estimated that close to one adult in five aged between 15 and 49 is currently infected with HIV in Botswana, Lesotho, Namibia, South Africa, Swaziland, Zambia, and Zimbabwe. West Africa, on the other hand, is less affected by HIV. Information for populous Nigeria is at best sketchy and Cte d'Ivoire is known to be badly affected, but HIV prevalence among adults in most West African countries is probably 5% or less. Recent studies have suggested that these differences may be related in part to near-universal male circumcision in many areas of West Africa. Although high proportions of men are infected with HIV in some countries where circumcision is common, new data suggest that circumcision is partially protective against HIV, independently of other factors such as sexual behaviour and other STDs. Economic structure may also contribute to patterns of infection. Large concentrations of men who are separated from their families to work in mining, commercial agriculture, and other industries tend to provide a ready market for sex workers, who contribute disproportionately to the rapid spread of HIV because of high partner turnover. When these men go to visit their families, they may well carry the infection back into rural areas. The increase in labour mobility following the end of apartheid in South Africa has doubtless contributed to the rapid spread of HIV. Many efforts have been made to estimate the impact of HIV and AIDS on the economies of Africa, with little result. Many of the continent's economies are in flux, and all are subject to a vast array of influences that are both independent of the AIDS epidemic and interdependent with it. Clearly, however, a tripling or worse of death rates among economically productive adults will affect economic well-being at many levels. The easiest effect to measure is probably at the company level. In Kenya several firms report that medical payments have increased 10-fold in the past decade, while illness and death have leapt from last to first place among reasons for employees' leaving the workforce. At the family level one of the most visible impacts is the growth in the number of surviving children who must grow up and make a living without the financial or emotional support of their parents. UNAIDS estimates that by the end of the century 10.7 million children in Africa will have lost their mother or both their parents to AIDS before they reach their 15th birthday. Can nothing be done to stop the relentless spread of HIV, of incapacitating illness, and of funerals across Africa? Some countries, notably Uganda and Senegal, have managed to arrest and even reverse the march of AIDS. Their epidemic situations differ, but the responses share common characteristics, among them very strong leadership at the highest political level, public acknowledgement of the epidemic and the behaviours that spread it, efforts to reduce the stigma associated with HIV, active involvement of community and religious leaders in prevention activities, widespread provision of services, including condoms, STD treatment combined with counseling and voluntary HIV testing, and massive efforts to respond to the information and sexual health needs of young people. In other countries these responses have been diluted by the refusal of leaders to recognize the realities of sexual behaviour and provide the wherewithal for people to make safer choices. Unless efforts are made to emulate the continent's prevention successes, the future for much of sub-Saharan Africa is stark. As South African Pres. Thabo Mbeki put it, "For too long we have closed our eyes as a nation . By allowing HIV to spread, our dreams as a nation will be shattered." Elizabeth Pisani is a consultant to the Epidemiology, Monitoring, and Evaluation Team of the Joint United Nations Programme on HIV/AIDS. She is based in Nairobi, Kenya.