Issue Brief

February 2001

Aids in Africa

Why should we care?

When the medical history of our time is written, I believe there will be two phenomena standing out above all others. The positive one will be the incredible increase in scientific knowledge that has allowed us to cure many diseases and help people live longer, healthier lives. From the development of antibiotics to the human genome project, from the first pacemaker to live organ transplants, the growth in our knowledge about the human organism has been breathtaking. 

On the negative side of that history will be the global HIV/AIDS epidemic that will soon have killed more people than any infectious disease in recorded history. Unlike the Black Death in 14^th Century Europe we know the means of controlling AIDS, yet it remains unchecked in much of the world. Nowhere is the effect of that epidemic more severe than at its epicenter in sub-Saharan Africa. 

What is the real story of HIV/AIDS in Africa? Why does it matter to us?    

Basic feature of HIV/AIDS in Africa 
In the summer of 1991 inside the Central Intelligence Agency, Interagency Intelligence Memorandum 91-10005 foretold one of the deadliest calamities in human experience. That simple memo titled, "the Global AIDS Disaster," projected 45 million infections by the year 2000, the vast majority of them in Africa.  Since the disease is always fatal, this memo was predicting more deaths from AIDS than all the combatants killed in World War I, World War II, Korea, and Vietnam combined.  

Today, less than ten years later, we know those estimates were conservative. Yet, due to a complex set of factors including authentic doubts and willful ignorance much valuable time has been lost and the magnitude of the disaster in Africa can no longer be ignored.

Since the AIDS epidemic began, 19 million people have lost their lives to the disease, more than 70 percent of them in sub-Saharan Africa. This toll can be expected to double over the next decade because estimates show that more than 34 million people are now living with HIV or AIDS and about five million new infections occur each year.

According to the Global Overview published by the UNAIDS organization, the proportion of adults between 15 and 49 years of age living with HIV/AIDS at the end of the year 2000 was 8.8 percent in sub-Saharan Africa. That is 15 times the rate of infection in the next two hardest-hit regions: North America and South/Southeast Asia.

The number of Africans living with HIV or AIDS is now estimated to be over 25 million, more than two-thirds of the world’s infected population. Considering that this region holds only ten percent of the world's population that number is truly devastating. 

In eight African countries, at least 15% of all people between the ages of 15 and 49 are infected. In these countries, even after the situation improves, AIDS will claim the lives of a third of today's 15-year-olds.

Unlike every other region of the globe, HIV/AIDS in Africa is transmitted mainly through heterosexual intercourse.  

Sub-Saharan Africa is the only place where infection rates are higher in young women than in young men.  Current estimates show that there are about 12 women living with HIV for every 10 men who have the virus in the region. But in some countries teenage girls show infection rates five times higher than teenage boys and among young people in their twenties, the rates for women are three times higher than young men. 

Deaths from this disease are premature deaths and as such, wipe out people in the prime of life. In Africa today the majority of infected people acquire HIV by the time they are in their 20s or 30s and, on average, die within ten years. These premature deaths are radically altering the societal structure in these countries, creating millions of orphans and rolling back decades of economic and social progress. The statistics go on and on but they can't begin to convey the true human misery of this epidemic.

Why does it matter to us? 
Most of us feel we have enough to worry about without thinking about HIV/AIDS in Africa. Aside from some moral need to "worry about our fellow man," it really doesn't have anything to do with us.  Unfortunately, that is not the case.

Whether we like it or not, the world has become a much smaller place and we cannot safely ignore our neighbors in Africa any more than we can ignore our neighbors in Texas. Aside from basic humanitarian concerns, there are two selfish reasons why we need to stop this epidemic. The first reason involves basic public health and the second involves world security.

Public Health 
Annual deaths in our country from infectious diseases have almost doubled in the last 20 years. Many of these diseases originated outside of the US and were brought here by travelers, businessmen, immigrants and our own military personnel. Infectious diseases such as AIDS, malaria, tuberculosis, measles, and pneumonia are the diseases of the poor in both industrialized and developing countries. They interfere with economic growth and international security. 

The organisms that cause disease need no passports and respect no boundaries. It is important that we work to control infectious diseases all over the world not just in our own country.

HIV/AIDS interacts with a number of other infectious diseases and in the case of tuberculosis has fostered more virulent strains than ever existed before. These infections do not stay at home. In fact, in just one year's time drug-resistant tuberculosis was imported to Germany and Denmark and these countries have seen an increase of 50 percent in this disease. Obviously, it is in our own self-interest to fight this problem.

International  Security 
The second reason we need to help Africa solve its HIV/AIDS problem is international security. In sub-Saharan Africa, HIV/AIDS is dramatically changing the structure of society. Extended families are disintegrating as their young adult members die, and children are forced to leave school to provide for their families. Studies have found that orphaned children often can't cope with the agricultural tasks left to them. Unfortunately the resources that might help these children learn how to survive are themselves eroded by HIV. In many of these countries the agricultural extension workers who would normally help these children learn how to care for livestock and crops spend at least ten percent of their time attending funerals. 

Given these conditions it is not surprising that poverty is skyrocketing and a spiral of decline has started in many of these countries exacerbating already volatile situations.  

Because of the dire nature of the epidemic in Africa, the Clinton administration declared AIDS a threat to US national security. Further the United Nations Security Council devoted two meetings last year to the subject of AIDS -- its first time ever to focus on a health issue. The Security Council's unprecedented decision to address AIDS shows how seriously the epidemic has destabilized sub-Saharan Africa. In his statement to the 15-member council, UN Secretary-General Kofi Annan said, "...By overwhelming the continent's health and social services, by creating millions of orphans, and by decimating health workers and teachers, AIDS is causing social and economic crises which in turn threaten political stability. In already unstable societies, this cocktail of disasters is a sure recipe for more conflict. And conflict, in turn, provides fertile ground for further infections."

What is being done? 
In the US, AIDS is addressed as a medical problem to be solved with health care and public health policy.  In African countries looking at AIDS that way is a luxury they cannot afford. In these places the epidemic needs to be treated as an education and welfare issue before it can ever be approached as a medical problem. Obviously, this approach requires the support of an informed government

It is no surprise that the African countries that are making the most headway against AIDS are also the countries that have the most stable democracies in the region.

While the scourge of AIDS in Africa is a truly distressing story, it is not without some hope. Now that it is finally out in the open there are several things that can be done to make things better:

Prevention and education 
First and foremost is prevention. Two African countries, Uganda and Senegal, have created successful prevention programs and have significantly reduced the infection rate among their citizens. 

Prevention efforts are most effective when they are locally based and reflect the prevailing mores and culture of the community. In Uganda, the whole nation has mobilized to end stigma, urge prevention, and change behavior. In Senegal, the religious and political leadership of the country joined together at the beginning of the epidemic to get prevention messages out and they now have one of the lowest HIV infection rates on the continent.

It is estimated that more than 90 percent of the people infected with HIV do not know they have the virus. Therefore, testing and counseling are essential tools in prevention efforts. Uganda's AIDS Information Center (AIC) is a nongovernmental organization that has served 350,000 clients with confidential counseling and testing since 1990. 

Many educational efforts are being supported in the international community to help African nations deal with the problem. An International Partnership Against AIDS in Africa, composed of African governments, donor countries, UN bodies, civil society and the private sector is being established.  Information on the epidemic is being disseminated on the world wide web through the Country Response Monitoring Project supported by UNAIDS and international agencies of the governments of the United States, the United Kingdom and Sweden.  The UN Security Council last fall in adopting Resolution 1318, affirmed "...its determination to continue to sensitize peacekeeping personnel in the prevention and control of HIV/AIDS in all operations." And last fall the United States Peace Corps sent a letter to all its former volunteers who served in Africa over the last 35 years asking them to return to Africa for three to six months to help in AIDS education and treatment programs.

Treatment 
Even in a wealthy country like ours, the treatments for HIV/AIDS are very expensive. Nevertheless, we have discovered ways to help people with the disease live longer, healthier, and more productive lives.

One of our greatest successes has been in reducing the transmission of HIV from mother to child. In Africa, where the incidence of the disease among young women is so high, this is a critically important need. A partnership between Uganda and NIH scientists has identified an effective, safe and inexpensive drug regimen for preventing perinatal HIV transmission. They have found a way to treat mothers and babies for $4.00 instead of the $800 regimen we use here and cut the rate of HIV transmission in half.  Obviously, this can only work where a health care infrastructure exists to support it.

Vaccine 
The importance of developing an effective vaccine for the virus grows every day, as that is the greatest hope for ending the epidemic. Vaccines have been our most useful tool in eradicating feared diseases in the past such as smallpox, diphtheria, polio, tetanus, and many others. Again, Uganda is leading the way, working with NIH to initiate the first vaccine trial in Africa. But again, even if an effective vaccine can be developed, its utility will depend greatly on the availability of a health care system to deliver it.  

Conclusion 
Obviously, the problem of HIV/AIDS in Africa is severe. In the last ten years much valuable time has been lost as many African nations and much of the rest of the world did not deal with it. Now, however, the epidemic is finally being brought out into the open. Much more needs to be done and many resources will be required, but a start has been made. And in countries like Uganda and Senegal where strong political leadership and cross-cutting responses have come together clear success has been demonstrated.  I was pleased to see that Secretary of State Colin Powell made a visit to the Africa desk in the state department, his first stop on starting his new job. I hope the new Administration and Congress will be willing to devote badly-needed resources to helping our African friends stop this terrible epidemic before it gets any worse.