Sub-Saharan Africa has just over 10% of the worlds population, but is home to more than 60% of all people living with HIV. The overall prevalence of HIV in Africa is 7.4%.

In the early 1990s, no-one really saw quite how massive a problem HIV could become in sub-Saharan Africa. While some countries, notably Uganda and Senegal, have been credited with impressive achievements in limiting and reversing the spread of HIV, other countries have seen rises to levels that were previously thought extremely unlikely.

Current estimates from UNAIDS are that 25.4 million people are living with HIV or AIDS in sub-Saharan Africa, of whom 13.3 million (57%) are women, nine million are young people (aged 15-24) and almost three million are children under 15. Three point one million people were newly infected with HIV during 2004 in this region, and 2.3 million adults and children died during the same period.

There are ten countries in which more than one-tenth of the adult population aged 15-49 is HIV-positive. In six, more than one adult in five now has HIV.

However one cannot really talk about one HIV epidemic in Africa. There are (at least) three regional ones see the charts below.

In East Africa, the countries that first bore the brunt of African HIV infection in the 1980s have either successfully made progress in controlling their epidemic during the 1990s or appear to be doing so now.

Even in Ethiopia, a populous and poor country tipped to be one of the next to see a large generalised epidemic, HIV prevalence among pregnant women usually seen as the best indicator in the absence of population surveys dropped from 14% in 1997-98 to 11.8% in 1999-2000 and has remained there since, while in Addis Ababa specifically prevalence fell much more sharply form 24% in 1997 to 11% in 2003.

Somalia is slowly recovering from a decade or more of civil wars but at present is split into unilaterally-independent areas. A 2004 survey determined prevalence to be 0.9 percent but noted "zonal variations." In the self-declared autonomous regions of Somaliland and Puntland, prevalence was 1.4 percent and 1.0 percent, respectively. Antenatal prevalence in Somaliland rose from 0.9% in 1999 to 1.4% in 2004, while prevalence was 3.5% among STD patients and 5.6% among TB patients (Reference: Agence-France Presse).

Eritrea next door is also recovering from decades of war; its first comprehensive surveillance programme in 2003 found HIV prevalence of 2.4%.

Uganda has long been lauded as a success story of HIV prevention. Although much of the decline in prevalence is due to the fact that, as the first country in the world with a generalised epidemic, much of the first high-prevalence generation has now died. But without the prevention campaigns of the late 1980s, its current prevalence of 5-6% would look a lot more like the 24% prevalence back in 1990.

Kenya could be on a similar path. There data from antenatal clinics show HIV prevalence in pregnant women falling from 13.6% in 1997-8 to 9.4% in 2002-03. Figures from Burundi also show some signs of a decline.

Tanzania is the one exception to this east African success story. Its overall prevalence has not fallen. In parts of the country where there have been intensive prevention programmes, prevalence has fallen from 20.5% to 14.6% in pregnant women between 1994 and 2000, whereas in areas that have not seen programmes, it rose from 22.5% to the very high figure of 30.2%.

For Sudan, see North Africa and the Middle East.

Southern Africa is now by a long way the most affected part of the world. In six of the nine countries in the region more than one adult in five has HIV and in two countries (Botswana and Swaziland) a scarcely believable one in three rates not thought possible till they happened.

South Africa itself continues to have the most people with HIV of any country in the world, and the epidemic here does not appear to have reached saturation point, with prevalence among pregnant women continuing to rise in all states except Free State and Gauteng. Overall it was 27.9% in 2003 compared with 26.5% in 2002, and was at the pandemic level of 37.5% in KwaZulu Natal.

Nine countries in Africa all in the south with the exception of the Central African Republic now have life expectancies at birth of under 40 years. In Namibia, adult female mortality was 3.5 times the level in 2000 than it was in 1993. In Zimbabwe, life expectancy at birth was 34 in 2003, compared with 52 in 1990. And in the South African province of KwaZulu Natal, half of all adults were dying of AIDS or HIV-associated TB by 2000. In southern Africa, the Great Dying has begun, with incalculable effects on the fabric of society.

There are some signs of hope. There is early evidence that the epidemic in Zambia may be following a similar course to Kenya and Uganda; HIV rates among pregnant 15-19 year olds in the capital Lusaka almost halved from around 28% to near 14% between 1996 and 2002.

And in the middle of all this devastation is Botswana, a small-population country with a third of its population HIV-positive, relative prosperity by African standards, 50% of its people in need already on antiretrovirals, and a programme to get every adult to test for HIV. Botswana is in many ways a fascinating experiment into what might be possible and the limits of HIV treatment. No one has ever tried putting a large proportion of the population of a country on HIV treatment before. It will be interesting to see what happens to its life expectancy and if the huge cost of its programme can be maintained.

In West Africa, HIV prevalence exceeds 5% in eight countries in west and central Africa, including Cameroon (6.9%), Central African Republic (13.5%), Cô´¥¦#160;dIvoire (7.0%) and Liberia (5.9%), with war-torn Sierra Leone and Guinea-Bissau with unknown prevalence.

In west-central Africa, the sharp rise in HIV prevalence among pregnant women in Cameroon (more than doubling to over 11% among those aged 2024 between 1998 and 2000), shows how suddenly the epidemic can surge, but in this country and the neighbouring Central African Republic prevalence in pregnant women now seems to have stabilised, albeit at the high level of 10%. Prevalence in the Democratic Republic of the Congo has slightly declined, from 5% to 4.2%, with the copperbelt region bordering Zambia worst affected.

Cô´¥¦#160;dIvoire remains the worst-affected country in West Africa, but even here prevalence has fallen from 13% in 1999 to 6.4% in 2003. West Africa also contains success stories like Senegal, which has kept its prevalence below 1% throughout the epidemic, with imaginative and bold HIV prevention campaigns taking place in Islamic schools and elsewhere, though prevalence among female sex workers in the capital Dakar was recently reported to be around 15% and higher in other towns.

But the big epidemic in West Africa is in Nigeria. Because of its large population (137 million), its 5.4% prevalence means that is has 3.5 million people living with HIV - the third-largest number after South Africa and India. In this diverse and large country, prevalence ranges from a low of 2.3% in the south west, to 7% in the conservative Muslim north and12% in the Cross River district bordering Cameroon.

In 2002 the Nigerian government started an ambitious treatment programme to get 15,000 people on to ARVs within 1 year. In 2004 the programme suffered a major setback when it was hit by a shortage of drugs- some people received no treatment for up to three months, a stark warning about the importance of capacity. The programme eventually resumed but has not yet achieved the 2002 goal because of poor infrastructure and management.

Nigeria is also a country that has seen many people afraid to come forward for testing and treatment due to stigma against people living with HIV/AIDS. HIV-positive people often lose their jobs or are denied healthcare services because of the ignorance and fear about HIV and AIDS. One recent survey found that 60% of healthcare workers thought HIV-positive patients should be isolated from other patients.

Nineteen African countries have set up national HIV/AIDS councils or commissions at senior levels of government even Somaliland, an autonomous region of Somalia, set up one in 2005 - and local responses are growing in number. Across the region, 40 countries have completed national strategic AIDS plansevidence of their determination to reach the targets outlined in the UN Declaration of Commitment on HIV/AIDS. Also encouraging is the active involvement of regional bodies, such as the Economic Commission for Africa, the Africa Union, and the Southern African Development Community, in tackling HIV/AIDS as a development issue.

An insurmountable problem?

It is hard to imagine a way forward for many of these resource-poor countries, especially ones in southern Africa with a near-majority of young adults infected. However, the most inspirational example of a country that, through its own determination, has managed to turn the HIV epidemic round is also to be found in this region.

In the early 1990s the estimated adult prevalence rate in Uganda was almost 14%, after nearly a decade of prevention work, the rate has now declined to around 5%. The government, under the leadership of President Yoweri Museveni was quick to act upon the realisation that HIV represented a grave threat to national development and adopted a strong response to the epidemic. They enrolled support from religious and other community organisations in order to reach as large a proportion of the population as possible and to communicate in the most effective and meaningful ways.

AIDS orphans

When one considers that half of all people who become HIV-positive do so before they reach their 25th birthday and progress to AIDS and death by the time that they reach 35, it is hardly surprising that a generation of children are left parentless, to be brought up by their grandparents or often among child-headed households.

Current estimates suggest that the cumulative number of children who have lost their mother or both parents to AIDS before the age of 15 since the epidemic began stands at 12,100 000 for sub-Saharan Africa alone. By 1997, in many African countries, the proportion of children who had lost one or both parents to AIDS had reached between 7 and 11%. Pre-AIDS estimates of orphans in developing nations pitched the rate at 2%.

Across Africa, many governments have rallied support in order to set up mechanisms to care for the children left behind. As early as 1986, Janet Museveni, wife of the Ugandan President Yoweri Museveni set up UWESO, the Uganda Women's Effort to Save Orphans. It was intended to assist orphans in the resettlement camps used after the civil war and eventually return the children to their extended families. The organisation now has 35 branches nationwide and funds education and training for the children as well as helping the guardians of the children -usually female relatives of the children- to set up small businesses.

The impact on education

It has been suggested that children finish school when their parents die, regardless of their age. Large household surveys are beginning to validate these claims. Certainly, it would appear that when both parents die the likelihood of a child continuing in education diminishes even further.

It is not uncommon for dying parents to marry their daughters off, partly to ensure that she is cared for after their death. In one study of orphans in Kenya, 41% of girls left school to get married and 28% because they became pregnant.

HIV has been shown to take up precious resources, and even when a child has two parents who are alive, the cost of care for them should they become sick, can have a direct effect upon the amount of money that is available for education.

In the Central African Republic, a recent study has shown that as many as 107 schools have closed due to staff shortage, and only 66 remain open. Over 85% of deaths among teachers between 1996 and 1998 were due to AIDS. As many teachers died between 1996 and 1998 as retired.

In Zambia, around 2000 new teachers are trained each year. During the first ten months of 1998, the country lost 1300 teachers to AIDS. It has been suggested that HIV has further exacerbated the gap between educational achievement in rural areas and the cities. Many teachers are disinclined to work in rural areas, largely because of a desire to be close to some kind of health care.

The impact on the economy

HIV has the potential to restrict economic growth through:

• reducing the number of workers available and increasing production costs which, in turn, could reduce international competitiveness.
• decreasing personal, corporate and public sector savings as a result of HIV-related expenses.
• reducing the amount any government can invest in infrastructure, as spending on HIV increases.

Food insecurity

HIV devastates the agricultural sector. It causes farm labour losses and depletes family income that would normally purchase food, with a resultant impact on the health of the entire population. A recent famine in Zimbabwe – a country formerly known as ‘the breadbasket of Africa’ – was in part caused by HIV reducing adults’ capacity to work on the land.

AIDS is intensifying chronic food shortages. In Zambia, research shows the poorest economically active households rely heavily on cash income for food. When the price of food increases, poor families are hit hardest.

In high-prevalence countries, a vicious cycle exists between food shortages, malnutrition and AIDS. In Zimbabwe, by 2000, AIDS had robbed the country of between 5 and 10% of its agricultural workforce. By 2020, farm labour losses will approach 25%. In Malawi, households that lost females under age 60 were twice as likely to experience a food deficit as households in which men in the same age bracket had died. In Uganda, 1990s research demonstrated food insecurity and malnutrition were the most serious problems for many female-headed AIDS-affected households.

Food insecurity is especially damaging for people living with HIV because they need more calories than uninfected individuals. Furthermore, malnourished HIV-infected people progress more quickly to AIDS. HIV prevention, nutritional care, and AIDS mitigation measures need to be incorporated into general food security and nutrition programmes.

A security issue

Development in countries badly affected by HIV has clearly been undermined. HIV in sub-Saharan Africa is now deadlier than war itself. To put this in context, during 1998 200,000 people died as a result of war in sub-Saharan Africa. The number lost to AIDS in the same year was already ten times higher, at 2 million.

AIDS is rapidly becoming the major issue for human security in sub-Saharan Africa. On the 10 January 2000 the United Nations Security Council held a meeting on AIDS in Africa. This was the very first time that the Security Council had discussed any health issue.

The prevalence of HIV among military personnel is often higher than in the population as a whole, following the long-established pattern of other sexually transmitted infections. This has serious implications for the role of the military within societies as well as internationally, in peacekeeping operations.

An even deeper concern raised by HIV and AIDS is that large numbers of orphans, lacking in education and adult guidance, may be recruited into militias and armies that then destabilise the continent. The breakdown of government and society in Sierra Leone and Liberia is seen as an awful warning of what could happen elsewhere.

This concern can be overdone: some have suggested that the current regimes in Uganda and Rwanda, which are credited with having restored order and improved government to deeply traumatised countries, were both installed by "armies of orphans".

Reference (Somalia):