Photo: Daudi Were

HIV/AIDS: How Sub-Saharan Africa Can Win the Battle

In recent years, Southern Africa has made notable strides to combat the disease, but there is still immeasurable progress that needs to be achieved. In an effort to advance the fight, Kenya launched its third National AIDS Strategic Plan in January 2010. The UN Joint Program on HIV/AIDS (UNAIDS) reports that Kenya has made leaps in its HIV response: AIDS related deaths have fallen by one-third since 2002 and “HIV prevalence in the country has consistently declined over the past few years.”

But despite Kenya’s remarkable progress, there are still 1.5 million people living with HIV in the country. Moreover, UNAIDS estimates that in 2009, 76,300 new HIV infections developed in Kenya. The Strategic Plan, which builds upon the country’s previous AIDS strategies, will run until 2013. UNAIDS Executive Director Michel Sidibé believes that it provides hope – not only for Kenya but also for sub-Saharan Africa as whole – that the region can begin to win its battle against HIV/AIDS. “By pursuing a prevention revolution, we can reduce sexual transmission of HIV,” Sidibé said at the plan’s launch in Nairobi. “Let 2010 be the year when change begins and universal access to HIV prevention, treatment, care, and support moves from rhetoric to reality.”

Strategic plans in Kenya and beyond

The UNAIDS/WHO 2009 AIDS Epidemic Update states, “In 2008, sub-Saharan Africa accounted for 67% of HIV infections worldwide, 68% of new HIV infections among adults and 91% of new HIVinfections among children.The region also accounted for 72% of the world’s AIDS-related deaths in 2008.” The report says that most of the new infections among children under the age of 15 in 2008 are “believed to stem from transmission in utero, during delivery or post-partum as a result of breastfeeding.”

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But Kenya’s Third National AIDS Strategic Plan offers a new approach to HIV/AIDS prevention and will reach those traditionally not considered at high risk, such as men and women in committed relationships, who account for 44 percent of the nation’s new infection, according to UNAIDS. This statistic was not incorporated into the country’s previous preventative policies.
Still, at least one non-profit organization has voiced criticisms about the plan. Human Rights Watch (HRW), an independent non-profit human rights advocacy group, claims that Kenya’s plan neglects to incorporate human rights abuses that can stem from some of its proposed strategies. In particular, the group believes the plan needs to strengthen its policy on children’s rights.

In February 2009, HRW released “Human Rights Watch Submission regarding the Kenya National HIV/AIDS Strategic Plan, 2009-2014,” a six-page document that calls for building childrens’ rights into Kenya’s plan. In their statement, HRW says that Kenya’s plan “should define levels of vulnerability to abuse among children and design appropriate strategies for protecting different vulnerable groups, such as orphans, children living with HIV, street children, child sex workers, child drug users, child-headed households, migrant children, disabled children, children living in slums, and children in pastoralist communities, among others.”

Kenya’s strategies have had significant success. But what is being done in the rest of sub-Saharan Africa? In addition to having the world’s highest HIV rates, the region accounts for 72 percent of AIDS-related deaths. With more than 5 million people infected, South Africa is home to the world’s largest population of people living with HIV. Swaziland has the world’s highest infection rate, with an adult HIV prevalence of more than 26 percent.

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While these countries, along with several others in Africa’s sub-Saharan region, do have national HIV/AIDS strategic plans, the prevalence of the infection is the region remains a formidable force. Ms. Thembi Ngubane, a 20-year-old South African woman, was HIV positive for years without knowing it. Eventually, her HIVinfection developed into AIDS. In 2006, she told PBS’s Frontline of her struggle: “Now I’m considered stage 4. When you are stage 4, you are no longer HIV positive anymore. They say you’ve got AIDS. The doctor told me I was very much at risk of getting sick. He said it’s like swimming in a lake where you have crocodiles. You can swim for some time without getting bit, but if you stay for a long time, at some point you’re going to get bitten. … I didn’t want to hear my sick voice. I didn’t want people to see me like this and hear me like this. I couldn’t even look in the mirror – the way I looked, my face was sort of becoming like bones and dark, and my eyes were kind of big, and I was shaking. I couldn’t walk.” On June 5, 2009, after years of living with the disease, Ms. Ngubane died of complications from AIDS-related tuberculosis.

Preventative measures

The WHO and UNAIDS promote the condom—both male and female—as the most basic, preventative measure against HIV/AIDS. In fact, UNAIDS declares the male latex condom to be “the single, most efficient, available technology to reduce the sexual transmission of HIV and other sexually transmitted infections.” UNAIDS reports that most sub-Saharan African countries have seen an increase in condom use in recent years. However, condom distribution in the region still falls short of the necessary amount needed. The UNFPA reports that sub-Saharan Africa, despite having the world’s greatest HIV prevalence as well as the largest share of the 2.1 billion donated condoms in 2004, received about 10 condoms per man of reproductive age (15-59) annually—which was not nearly enough to meet the demand.

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A major barrier that condom distribution and usage faces is religious tradition. For example, the Vatican’s negative stance on the condom has affected condom distribution and usage in sub-Saharan Africa, as Catholicism is a dominant religion in the region. When Pope Benedict XVI visited the region in March 2009, he promoted abstinence and marital fidelity as HIV solutions, and spoke out against condom distribution. According to BBC News, he said: “HIV/AIDS is a tragedy that cannot be overcome through the distribution of condoms, which can even increase the problem.” The Vatican believes that condoms promote sexual promiscuity, which contributes to spreading the disease. The Vatican’s perspective could seem valid when examining Uganda’s HIV strategies and its leaders’ rhetoric. According to the Population Research Institute, Uganda’s abstinence campaign has been a major contributing factor to the country’s declining HIV rates. UNAIDS statistics show that the country’s HIV rates peaked in 1990, with a 15 percent HIV prevalence in adults. Since then, they have been in continuous decline; UNAIDS reports that Uganda’s adult HIV prevalence rates were at 6.5 percent in 2009. Ugandan President Yoweri Museveni attributes this success to the country’s national HIV/AIDS strategies, a large part of which include abstinence-only campaigns and programs. However, the country incorporates condom use in its strategies as well. Uganda’s campaign is called the ABC approach: A is for abstinence until marriage, B is for being faithful to one’s partner, and C – the last resort – is for condom use when absolutely necessary.

The WHO and UNAIDS promote abstinence, calling it the most cost-effective preventative measure. However, both organizations also hail the effectiveness of the condom, as promoting only abstinence does not incorporate the possibility of sexual intercourse, both inside and outside of marriage. The UNFPA reports that studies show that with consistent condom use among one infected and one uninfected parnter, the HIV infection rate for the uninfected partner is less than one percent per year. According to “Closing the Condom Gap,” a report published by the Johns Hopkins School of Public Health, people are more likely to use condoms when they think others do. Thus, creating a positive image for condoms could improve rates of distribution and usage. To underline this, the report uses examples of religious leaders who have spoken out in favor of condoms: “In Bermuda, for example, the Anglican Archdeacon has placed baskets of condoms at the rear of his church and urged distribution in schools. In Mauritania, a Muslim imam has been named president of Stop SIDA, an organization that promotes HIV/AIDS awareness. He explains that condoms do not encourage prostitution but rather they prevent AIDS.” While these are examples that exist outside of sub-Saharan Africa, countries in the region that promote condoms on a national scale have seen success. Senegal, for example, encourages condom use as part of its national AIDS programs, and UNAIDS reports that the county has adult HIV prevalence rates of about 1.8 percent.

Traditional gender roles also affect condom distribution and usage in sub-Saharan Africa. According to UNAIDS and the UNFPA, men are physiologically more likely to transmit HIV to women than vice-versa. Female condoms can counter this imbalance, and allow women to protect themselves against HIV transmission. Moreover, both UNAIDS and the UNFPA regard the female condom to be a form of women’s empowerment. Unfortunately, this measure has socio-cultural limitations. The UNFPA argues that with female condom usage “accepted notions of masculinity and femininity also come into play. For instance, in many cultural settings, young women are supposed to be sexually innocent and may therefore be reluctant to carry or suggest using condoms. Since condoms are also associated with illicit or extra-marital sex, married women are often powerless to request their partner to wear a condom despite suspecting that he may be infected with HIV, for fear of reprisal at the implied accusation of being unfaithful.”

Male circumcision: a new approach to HIV prevention

Another measure that can reduce the risk of acquiring HIV through sex, according to the WHO, UNAIDS, and other organizations, is male circumcision. WHO studies show that circumcision reduces the risk of heterosexually acquired HIV infections in men, and different studies have proved different levels of effectiveness. In WHO/UNAIDS-conducted studies, which involved three randomized controlled trials in South Africa, Kenya, and Uganda, it was concluded that male circumcision – when provided by well-trained health professions in properly equipped settings – is safe. The trials concluded that male circumcision reduced HIV transmission by 60 percent, 53 percent, and 51 percent, respectively. However, the WHO and UNAIDS also warn that circumcision can actually increase the risk of transmission if the wounds do not properly heal following surgery. HIV-positive men who are circumcised are not cured, and can still infect their sexual partners. Thus, the organizations believe that while male circumcision is not a replacement for the basic methods of HIV prevention, it should be considered part of a comprehensive prevention strategy.

While the WHO and UNAIDS both recommend the surgery, the governments of many sub-Saharan African countries do not provide it in helping to fight HIV/AIDS; many also have yet to educate their public about its benefits. There are some countries, like Kenya and Botswana, who are championing the cause. The New York Times reported that in Kenya, nearly 20,000 men have been circumcised in hospitals, dispensaries, village schools, social halls, and tents. In Botswana – where British colonialists and Christian missionaries had largely discontinued it in the late 19th and early 20th centuries – circumcision was started again nationally after former president Mr. Festus Mogae endorsed it. According to the New York Times, between 2008-2009 Botswana’s government trained medical teams to do circumcisions in all of the country’s public hospitals. The country also aims to have circumcised at least 470,000 males from infancy to age 49 – 80 percent of males in that age range in the country – by 2016.

But these countries are exceptional cases. In South Africa, for example, the government does not promote circumcision as an HIV-preventative measure; Dr. Salim Abdool Karim, epidemiology professor at University of KwaZulu-Natal in South Africa and Columbia University, told the New York Times: “Countries around us with fewer resources, both human and financial, are able to achieve more. I wish I understood why South Africa, which has an enviable amount of resources, is not able to respond to the epidemic …” According to the New York Times, South Africa’s largest ethnic group, the Zulus, do not generally practice circumcision. South African President Jacob Zuma is Zulu and has yet to address the subject. Mr. Thabo Masebe, the president’s spokesperson, told the New York Times that the Health Ministry must first set a policy on circumcision before Mr. Zuma, can take a position: “The president gets involved when decisions are made. If the president spoke now, and when the time comes to make a policy, a different decision is taken, it wouldn’t sound good.”

HIV/AIDS and poverty: how families and education can help

While the WHO’s basic preventative measures and male circumcision both are aimed at curbing HIV transmission from sex, there are certain social conditions that can also aid the fight against the infection. The Joint Learning Initiative on Children and HIV/AIDS, an international two-year research project, showed that families could act as a protective force against HIV. According to the project, families take on approximately 90 percent of the financial cost of caring for infected and affected children. In sub-Saharan Africa, many of these families are already living in extreme poverty and few receive support from sources outside their communities. Thus, many families may be hard-pressed to provide financial support. But as an alternative, they can provide those affected by HIV/AIDS social protection, which in itself – through education, care, and assistance – can be a major positive force. Mr. Sidibé, speaking on behalf of UNAIDS, supports the findings of the project. According to the UN News Centre, he said: “Yes, families can be, and are, torn apart by AIDS. But let’s look at this another way: Families can also be highly protective, inoculating members against the worst outcomes of AIDS. They offer a dependable means of prevention education and the clout to keep children in school, on track and out of risk.”

Through care and support, families can provide social protection for people infected with HIV/AIDS, and through education, families can provide preventative measures. But even outside of the family setting, education is proving to be a powerful tool in the fight. According to the New York Times, a recent study by the Partnership for Child Development – a London-based nonprofit group – found that education and information to be “simple, inexpensive methods that helped reduce the spread of the disease among Kenyan teenagers.” The $1 million study, which was conducted over three years among 70,000 students in the sixth to eighth grades in 328 schools in Kenya. Researchers from the study found that classroom debates and essay-writing contests on whether students should be taught about condoms to prevent the spread of HIV increased the use of condoms without increasing sexual activity. Moreover, girls who were informed about the greater risk of sex with older men were 65 percent less likely to acquire HIV from an adult partner. Previously, most of the girls in the study had no idea that adult men were much more likely than boys their own age to infect them with HIV. Dr. Esther Duflo, an economics professor at the Massachusetts Institute of Technology (MIT) and a member of the research team, told the New York Times: “That intervention is very cheap and could be scaled up easily.”

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