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The Decline of HIV/AIDS: A New Paradigm in Sub-Saharan Africa?

Document Cited in Related
Vincent
Published date01 August 2016
Pages362-388
Date01 August 2016
DOI10.3366/ajicl.2016.0159
Author
INTRODUCTION

That Sub-Saharan Africa is more heavily affected by HIV/AIDS than any other region of the world is no longer headline news. It is home to an estimated 24.7 million people living with HIV, representing around two-thirds of the global total. In 2013, around 1.2 million people died from AIDS and 1.5 million people became infected with HIV in Sub-Saharan Africa. Almost 15 million children have lost one or both parents to HIV/AIDS since the beginning of the epidemic. The devastating impact of the disease is clear at all levels from government to households: HIV/AIDS reverses life expectancy gains, erodes productivity, consumes savings, weakens growth efforts and threatens the realization of the Millennium Development Goals (MDG) in Africa.1

In spite of the vast and corrosive impact of the epidemic, an encouraging trend has been emerging from the reported statistics. The 2012 UNAIDS Report2 on the global AIDS epidemic highlighted that in only 24 months, there had been a 60 percent jump in people accessing life-saving treatment with a corresponding drop in mortality. In 2014, 41 percent of all adults living with HIV had access to antiretroviral treatment, which is up by 23 percent in 2010. Between 2005 and 2013, the number of people dying from AIDS-related causes in Sub-Saharan Africa declined by 39 percent, from 1.8 million to 1.2 million. Additionally, there has been a 25 percent decline in new infections in the decade between 2001 and 2011.3 The new infection rate has fallen by 50 percent or more in 25 countries worldwide (13 in Sub-Saharan Africa), with some of the most dramatic improvements seen in African countries with very high prevalence rates: 73 percent drop in Malawi, 71 percent in Botswana, 68 percent in Namibia, 58 percent in Zambia, 50 percent in Zimbabwe, 41 percent in South Africa, and 37 percent in Swaziland (the country with the highest HIV-prevalence rate in the world).4 Even more encouragingly, the population experiencing half of all the reductions in HIV infection rates in the last two years has been children. Six African countries – Burundi, Kenya, Namibia, South Africa, Togo, and Zambia – saw at least a 40 percent reduction in the number of children newly infected by the virus between 2009 and 2011.5 In 2011, coverage of services to prevent mother-to-child transmission (PMTCT) of HIV in Sub-Saharan Africa reached 59 percent. All of this has contributed to Sub-Saharan Africa reducing AIDS-related deaths by 59 percent in the last two years alone.6

However, there are critics who challenge the above findings, and argue that UNAIDS statistics paint a rosy picture, essentially covering the fact that the remarkable gains of recent years have yet to be consolidated and spread. For example, at the same time that the highest-impacted countries were reducing transmission rates, 11 countries in Sub-Saharan Africa saw more modest declines, between 1 and 19 percent. In four countries – Angola, Congo, Equatorial Guinea, Guinea-Bissau – the number of new HIV infections among children actually increased. Furthermore, many prevention ‘success stories,’ when analyzed under a closer lens, turn out to be much less effective than presented. For example, during the 1990s, an ambitious HIV prevention campaign carried out in a South African gold-mining community was held up as a model for the rest of Africa. Health workers raised awareness about HIV using community meetings, drama, and music; condoms were liberally distributed in public places; and treatment services for other sexually transmitted diseases, which make it easier for HIV to spread, were greatly improved. However, in the long run the campaign had no measurable effect on HIV transmission rates.7

In order to sustain the recent gains in combating HIV/AIDS, it is important to research and evaluate the dynamics behind the positive data trends in order to understand which specific changes and policies were key, and how these changes can be consolidated and emulated in other regions. This would establish a pathway to curbing or even eradicating HIV/AIDS in the foreseeable future.

My past research has explored women and HIV/AIDS in Africa, addressing the issues behind women's increased vulnerability in contracting HIV/AIDS on the continent, and on how to address such a disproportionately high rate of infection.8 Having conducted a major research project on this subject in 2004 to 2006, almost ten years later I now believe that the time is ripe to turn a retrospective and analytical eye on the progresses made in fighting the disease.9 Assessing where the continent stands today is particularly vital in a context of the fast-approaching United Nations goal in curbing the AIDS pandemic by 2015.

This article examines the African countries that have made significant progress in reducing new HIV infections, rates of prevalence, AIDS-related deaths, transmissions from mother to child, and any other gains in limiting the impact of this disease. The goal is to pinpoint the factors that propel these trends, and to then determine whether and how they can be implemented in other regions or countries through an in-depth analysis of effective and pragmatic approaches in Africa. Given that adequate resources are a crucial component in dealing with HIV/AIDS, I also pay attention to the role of donor funding, with a focus on the Global Fund to Fight Aids, Tuberculosis, and Malaria, in addition to the President's Emergency Plan for Aids Relief (PEPFAR).10 I further seek to describe how the cultural values that traditionally stood in the way of efforts combating HIV/AIDS have been transformed in the last decade. I highlight the challenges likely to be encountered in emulating what works for one country in another, the lessons learned, as well as the role of the African governments in addressing these issues. Finally, I will analyze the extent to which Sub-Saharan African states have been able to leverage the flexibility of the Agreement on Trade Related Aspects of Intellectual Property Rights (TRIPS) to improve access to HIV/AIDS medicine for their citizens, and thus analyze whether this instrument can be considered part of the success story.

Past and Current Trends of the Epidemic Global and Sub-Saharan Trends 2002/3

In 2002 HIV was the most prevalent infectious disease, and the most common cause of death in Africa.11 According to the World Health Organization/UNAIDS December 2002 report, HIV/AIDS was responsible for over 2.4 million deaths in Sub-Saharan Africa in the year 200212 and 2.3 million in 2003.13 This number was more than ten times the number of people who perished in wars and armed conflict during the same period (in Sub-Saharan Africa). At the end of 2002, more than 29.4 million adults and children, (close to one in ten adults between the ages of 15 and 49 years) were living with HIV/AIDS. This represented about 70 percent of the global total of 42 million persons living with HIV/AIDS.14

 Current Global and Sub-Saharan Trends 2012/14

Globally, 36.9 million (34.3 million – 41.4 million) people were living with HIV at the end of 2014. An estimated 0.8 percent of adults aged 15–49 years worldwide are living with HIV. Sub-Saharan Africa remains most severely affected, with nearly 1 in every 20 adults (4.9 percent) living with HIV and accounting for 69 percent of the people living with HIV worldwide. Worldwide, the number of people newly infected continues to fall: the number of people, adults and children, acquiring HIV infection in 2011 was 20 percent lower than in 2001.15 The sharpest declines in the number of people acquiring HIV infection since 2001 has occurred in the Caribbean (42 percent) and Sub-Saharan Africa (25 percent). Figure 1 shows the downward trend in the number of people newly infected in Sub-Saharan Africa from 2001 to 2012.

UNAIDS Report on the Global Aids Epidemic 2012.

 Examining Categories for Progress

Transformation of cultural values has been a major driver in decreasing the transmission of HIV/AIDS. For example, the circumcision of males is said to reduce sexual transmission of HIV.

Male Circumcision

There is compelling evidence that medical male circumcision reduces the propensity to transmit HIV sexually from women to men by 60 percent.16 Observational studies noted a significantly lower rate of HIV infection in countries where the practice of male circumcision is widespread.17 Information from the trials led the WHO and UNAIDS to issue guidelines on male circumcision as an HIV prevention intervention.18 Since voluntary male circumcision programs for HIV prevention started in 2007, an estimated two million men have undergone circumcision for prevention in Eastern and Southern Africa.19 UNAIDS believes that voluntary medical male circumcision has the potential to prevent an estimated one in five new HIV infections in the region by 2025.20 Consequently, WHO and UNAIDS advise that ‘countries considering introduction or expansion of male circumcision services should ensure that appropriate laws, regulations and policies are developed so that male circumcision services are accessible, provided safely and without discrimination.’21 Ancillary problems raised by the guideline is the question of who carries out the circumcision – i.e. should it be traditional or religious health practitioners or medical doctors? – and at what age should the conduct be carried out – at birth, at adolescence, or at passage to manhood? To this effect, South Africa, for example, passed the Application of Health Standards in Traditional Circumcision Act in Eastern Cape Province, with the goal of setting safety standards for traditional practitioners.22 In the same vein, South Africa's parliament added a section on male circumcision in its Children’ Act, banning circumcision of males under the age of 16 years, except under certain circumstances.23 For children over 16, informed consent and proper counseling in the prescribed...

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