Harvard School of Public Health AIDS Initiative: Harvard AIDS Review

HIV in Southern Africa

A person living in southern Africa is ten times more likely to become infected with HIV than someone living in North America. In fact, five of the six countries with the highest rates of HIV infection in the world are now in southern Africa.

Throughout the 1980s, southern Africa lagged far behind Central and East Africa in the number of people with HIV. Yet that has changed dramatically in this decade. From 1990 to 1996, for example, Lesotho experienced a 1,500 percent increase in the number of newly reported AIDS cases. Twenty-five percent of the adult populations of Botswana and Zimbabwe are already infected with HIV.

In the world's largest and busiest hospital, located in Soweto, South Africa, half of all medical admissions are now HIV related. In Namibia, AIDS-related deaths are now twice as frequent as deaths caused by malaria, the next most prevalent cause of death. In Zimbabwe, an estimated 1.5 million people are infected with HIV, and a reported 700 people die each week from AIDS.

Horrifying as these figures are, they indicate only a fraction of those infected, says John Mulwa, Botswana's Permanent Secretary of Health. "One of the biggest problems in Botswana is underreporting," he explains. "You can easily multiply the figures of HIV and AIDS cases by two or three."

Studies indicate that those most severely affected are between 15 and 40 years old, the population segment whose work supports the economy. In 1996, Botswana's economy grew by 4.1 percent. The future, however, looks less promising. With half of the population under 15 years of age and HIV rapidly killing the young, it is unclear how countries like Botswana will sustain themselves. Projected life expec-tancies for the region are already dropping due to AIDS. The current life expectancy in Botswana is a projected 61 years in the absence of AIDS; by 2010, the U.S. Bureau of the Census estimates, it will be 33.

Heterosexual Transmission
Southern Africa's rate of HIV infection is "the highest noted in Africa in recent years," says Daniel Tarantola, director of the International AIDS Program of the François-Xavier Bagnoud Center for Health and Human Rights at the Harvard School of Public Health. "Social, cultural, and familial uprooting, lower access to local health and social services, and gender imbalance among domestic and international migrant populations have all increased the frequency of risk-taking sexual behavior and, as a result, the vulnerability of these populations to HIV infection.

"It has been estimated that 93 to 95 percent of all HIV infections in the age group 15 to 49 in sub-Saharan Africa were due to heterosexual transmission, and that, by 1996, more than half of these infections were in women," adds Tarantola.

These women are vulnerable to HIV because of a power imbalance in their relationships with men. Many women fearing backlash or abuse are unable to ask their partners to practice safer sex, despite education efforts stressing the importance of such proactive behavior. In Botswana, where over 90 percent of pregnant women visit prenatal clinics to obtain medical care, the HIV prevalence rate increased from 6 percent in 1991 to more than 30 percent two years later. The rates of HIV infection are similar in clinics throughout the region.

The region's workforce patterns have contributed to the epidemic's spread. Southern Africa's prosperity largely depends on economic migration, whereby men travel from their homelands to job opportunities in urban areas and mining communities, often in neighboring countries. Long separations from their families promote the practice of having more than one sexual partner, which has resulted in an increase in the number of unsafe sexual encounters, including those with sex workers.

The rapid spread of HIV among heterosexuals in southern Africa also is attributable in large part to the specific viral subtype that has become prevalent there, according to Harvard AIDS Institute Chairman Max Essex. Researchers in Essex's laboratory have found that subtype C, which has spread rapidly through southern Africa in the past several years, is more easily transmissible through vaginal intercourse than any other HIV subtype.

Perinatal Transmission
Perinatal transmission is the second most common mode of HIV transmission in southern Africa. In Francistown, Botswana, over 43 percent of the pregnant women visiting prenatal clinics are HIV positive, resulting in the birth of an estimated 45,000 infected babies a year. At King Edward VIII Hospital in Durban, South Africa, mother-to-infant transmission accounts for 34 percent of HIV infections.

Most women with HIV in southern Africa do not have access to current treatments such as AZT, which, when administered before and during pregnancy, has been proven to reduce transmission of the virus to infants by two-thirds.

Another battle HIV educators face is teaching women about the potential risks of breastfeeding. Long thought to be the only way for mothers to provide the necessary nutrients to their newborns when access to food and clean water was scarce, breastfeeding also can transmit HIV from mothers to infants. Restricting breastfeeding, however, alters a practice deeply ingrained in many southern African cultures, and many southern African women cannot afford alternatives, such as formula feeding.

Political Unrest
Social and political instability, such as South Africa's struggle against apartheid, also has contributed to the spread of HIV. Unequipped to fight the epidemic, which has predominantly hit the country's black population, South Africans have seen infection rates skyrocket. Consequently, more than 6 percent of South Africa's population-2.8 million people-are now infected, a dramatic rise of one-third since 1995. The South African Health Ministry reports 50,000 new HIV infections each month.

"South Africa is undergoing a transition," explains Hoosen Coovadia, a professor of medicine at the University of Natal in Durban. "The effects of apartheid have created a Dickensian nightmare with a huge disparity between rich and poor."

The effects of this unequal social structure can best be seen in access to medical treatment. Current medicine, such as antiretroviral drugs that have improved the quality of life for many people with HIV, are not available in southern Africa. Drug therapy can cost more than $10,000 per person each year-a steep price even for those in industrialized countries, and out of reach for sub-Saharan Africa, where the amount spent per capita each year for health care is often less than $10. Some countries in southern Africa-such as Botswana, Lesotho, Swaziland, and Zimbabwe-may be able to spend more on health care per person, but their resources still cannot meet the needs of people with HIV.

"Combating AIDS is not so simple," says Coovadia. "You cannot just hand out medication. You must build laboratories, hire counselors, create the necessary infrastructure."

The infrastructure Coovadia and many others call for is expensive and time-consuming to establish. In the meantime, public health officials, physicians, and community leaders face ethical dilemmas in allocating meager resources. "When funding is limited and so many people are in need, how do we determine who should receive new drug treatments?" asks Permanent Secretary Mulwa. "What is the fairest thing to do?"

Prevention Efforts
Strong prevention efforts in other sub-Saharan countries have resulted in a control of the number of new HIV infections: Uganda's HIV prevalence rate decreased from 13 percent in 1994 to 9.5 percent in 1997; Senegal's safer sex campaign has kept the infection rate at 2 percent. Southern African leaders must now take similar measures to battle the epidemic's continued spread.

AIDS prevention efforts-from posters and billboards to rallies and youth dance troupes-are under way throughout the region. Techniques vary. For example, in Botswana and South Africa, education programs target truck drivers and sex workers-two groups at high risk for infection-by distributing educational materials along trucking routes.

In Zambia, the Ministry of Sport, Youth, and Child Development recently agreed to support HIV programs aimed at teaching young people how to change risky behavior. Also in Zambia, HIV testing and counseling for couples have been combined into one visit, a necessity when so many people do not return for follow-up visits because of the cost of travel or the fear of test results. In addition, throughout southern Africa, the distribution and sale of male and female condoms are on the rise.

Rose Mandevu, head of the Botswana Ministry of Health's AIDS/STD Unit, knows well the challenges facing AIDS educators. Changing behavior is a slow process. In Botswana, where the national AIDS policy was approved by Parliament in 1993 and efforts to combat the disease are still in their infancy, 4 million condoms have been distributed to encourage safer sex. The results have been mixed. "We have found that people use condoms when the relationship is new," Mandevu says. "Once the relationship is established, they stop using them."

From the veldts of KwaZulu Natal to the shores of the Zambezi to the prenatal clinics of Francistown, this exploding epidemic presents challenges to public health officials. With so many people from diverse religions, languages, cultures, and political backgrounds, officials say the response to the epidemic must be swift, adaptable, and creative to meet the needs of the region.

The devastating consequences of inaction and misinformation are already being felt. "Despite increased levels of awareness, we think we're achieving only minimal behavior change," says Mulwa. "It's one thing to know what to do and another to take these measures. And now, people are dying. People are now developing full-blown AIDS, and they're dying."