HIV/AIDS IN AFRICA

From the perspective of Africa, HIV/AIDS is one of the most significant ethical and political issues involved with science and technology. The spread of HIV/AIDS in Africa has the potential to undermine almost any other positive benefits of, for example, scientific education and research or sustainable technological development. Of particular importance is the fact that increasing numbers of children are being orphaned and made vulnerable by HIV/AIDS, and the traditional extended family is being strained to the breaking point. To appreciate the extent of the challenge, it is necessary to have some appreciation of the origins, spread, and impact of HIV/AIDS in Africa, and of the debates regarding response and treatment.

African Origins and Impact

HIV is sexually transmitted, and can be passed on through direct blood contact (for example, blood transfusion). In addition to blood, semen, and vaginal fluids, there are sufficient amounts of HIV in breast milk to cause transmission from mother to child. The genesis of HIV is not clear; however, some postulate a link between the virus and oral polio vaccines distributed in the Democratic Republic of Congo in the late-1950s that may have been contaminated by the simian immunodeficiency virus (SIV). Though the theory is largely discredited, the possibility of a connection between the two viruses is still debated (Worobey et al. 2004).

While more than 70 percent of HIV infection worldwide is through heterosexual sex, in sub-Saharan Africa the percentage is higher (Jackson 2002). The second most important route of transmission in the region is from an HIV-infected mother to her child. In Africa transmission via sex among men is far less common, and infection by drug users through sharing contaminated needles is relatively infrequent. Other means of transmission are through use of non-sterile needles and cutting implements in medical procedures, unscreened blood, and inadequate hygiene precautions in the care of AIDS patients. The map below shows the concentration levels over the continent.

Seventy-nine percent of AIDS deaths worldwide have occurred in sub-Saharan Africa. An estimated 71 percent of all adults and 87 percent of all children living with the disease in the early-twenty-first century reside in this region. Eighty-eight percent of all children who have been orphaned by AIDS live in sub-Saharan Africa (AIDS Epidemic Update 2002).

Researchers debate the reasons for the patterns of HIV/AIDS infection in different parts of Africa. Some believe that these patterns are influenced by whether the population is affected by HIV-1, HIV-2, or other strains of the virus, some of which are more virulent than others. Other observers focus on the social and cultural differences among countries. Researchers Jack Caldwell and Pat Caldwell, for example, see a coincidence between low infection rates and male circumcision, which improves personal hygiene and corresponds to low rates of sexually transmitted disease (STDs). Muslim countries in North Africa have relatively low rates of infection, as do Muslim populations within countries that are highly infected.

Factors Contributing to the Spread of HIV/AIDS

Since the sixteenth century, violence and disorder have upset the political and social culture of Africa. To understand the devastating spread of HIV/AIDS on the continent, one must consider events including war and desperate poverty that continue to be familiar and persistent conditions in many African nations.

MIGRATIONS. Massive migrations of displaced persons due to war, social unrest, and economic disadvantage are key contributors to the spread of the virus. In some cases, refugees flee their homelands to countries where the infection rate is already high. Upon resettlement, the refugees bring the disease home with them.

Due to economic depression, workers are forced to look for jobs far from home. For example, many from eastern and southern Africa went to work in the mines of South Africa, living in conditions of poverty and social unease. Poor hygiene, multiple sexual partners, and other social and economic factors that affect such workers promote infection at an accelerated rate.

WAR. Wars and other conflicts raged across Africa in the late-twentieth century and continued into the early-twenty-first century. Refugees help spread the epidemic. But the various armies involved in these conflicts are even more efficient sources of infection. Military personnel, both combatants and peacekeepers with regular pay, are more likely to contract HIV than civilians; in addition, they have higher rates of STDs, a factor known to correlate with easier transmission of the virus. Resolving these conflicts is key to a sustained, effective response to HIV/AIDS (Mills and Sidiropoulous 2004).

POVERTY. At the beginning of the twenty-first century, sub-Saharan Africa accounted for 32 of the 40 least developed UN member states. The region's total income is about the same as that of Belgium. (World Bank 2000).

Poverty leads to health conditions that promote spread of the disease, including chronic, severe malnutrition. In addition, people living in poverty have less access to basic education and health services. Extreme poverty is linked to an increase in commercial sex among women, who have the fastest growing infection rate.

SILENCE, STIGMA, AND DISCRIMINATION. Some African governments have denied the extent of the problem or that it exists at all. In addition, stigma attached to the infection has caused many people to refuse to become involved in finding solutions (Campbell 2003). For example, for several years in the 1980s former Kenyan president Daniel Arap Moi denied that HIV/AIDS infection existed in his country for fear of destroying the tourist industry, a key source of national income. As a result, there was little if any effort to promote precautions against transmission of the virus and the disease spread unabated (Singhal and Rogers 2003).

Social Impacts

HIV/AIDS will have enormous implications for the future of Africa. This entry will address just a few of the most pressing issues at the beginning of the twenty-first century.

ORPHANED CHILDREN. The main impact of the disease is felt through the loss of economically active people in their child rearing years, between the ages of fifteen and forty-five. UNICEF's Africa's Orphaned Generations (2003) puts the number of African children orphaned by AIDS at 11 million, with an estimate that the disease will ultimately rob 20 million children of their parents. Figure 2 shows the increasing numbers of children who will become orphans as a result of the epidemic.

IMPACT ON GOVERNMENT AND SERVICES. Many countries in eastern and southern Africa are already burdened by weak government infrastructures and inadequate human resources, compounded by the migration of skilled professionals due to economic reasons. The epidemic has exacerbated the situation with the attendant loss of workers in their most productive years. Staff attrition in key sectors such as education and agriculture outpaces replacement, causing a loss of institutional memory and low morale. Nongovernmental organizations (NGOs), which have been central to the struggle to control the disease, are focusing more energy on caring for the sick and less on education, prevention, and self-help initiatives in the community. Disintegration of national institutions such as the army and police threaten the security and political stability of many nations. Effects of the disruption of governance, such as displacement, food insecurity, and conflict, spur transmission of the disease, and contribute to the continent's downward cycle.

IMPACT ON NATIONAL ECONOMIES. The World Bank (2001) estimates that per capita growth in half of Africa's countries is falling by 0.5 to 1.2 percent annually as a direct result of HIV/AIDS; by 2010, GDP in some of the countries most affected will drop as much as 8 percent. According to the Food and Agricultural Organization of the United Nations (FAO) (2004), two-person years of labor are lost for each AIDS death. In addition to the stark loss of life, HIV/AIDS deaths contribute to the loss of local knowledge of farming practices and forces communities to opt for less labor-intensive, less productive cropping patterns (FAO 2001).

WOMEN. According to the United Nations Programme on HIV/AIDS (UNAIDS) AIDS Epidemic Update for 2004, 76 percent of all young people (ages fifteen to twenty-four) in sub-Saharan Africa who are infected with HIV are female. Females are three times more likely to be infected than males in this age range. Gender inequality is the most important reason that HIV/AIDS infection has transformed into an epidemic that affects women and girls in disproportionate numbers. Women in Africa hold a lower socioeconomic position than do men. They are likely to be poorer and have less education and less access to social services than men do. Women faced with limited options to earn money sometimes turn to commercial sex; in some cases, for example in areas affected by sustained drought, women and girls resort to exchanging sex for food or other basic survival needs. Other factors related to the imbalance in power between men and women including sexual violence, early marriage, and poor access to information about transmission of the disease (even as relates to motherchild transmission) contribute to the infection rate. Adding to the problem is the fact that women are physiologically more vulnerable to being infected with the virus.

Response and Treatment Debates

Antiretroviral drugs (ARVs) are a great advance in the treatment of HIV/AIDS patients. Such drugs do not prevent infection or cure the virus. They do, however, disrupt the life cycle of the virus, preventing its reproduction. ARVs can reduce the patient's viral load tenfold within eight weeks, and lower it to undetectable levels within six months. For those infected with HIV, the onset of AIDS can be delayed indefinitely. Patients live longer, gain weight, and feel better.

ARVs were unaffordable in Africa until 2001 when an Indian drug company, Cipla, offered to provide a year's supply for $350, one-fortieth the cost in countries such as the United States. Although the price of ARVs has fallen dramatically, few Africans have access to the drugs. In addition, ARVs work most effectively when people are well nourished and have acceptable hygiene standards. In Africa the provision of ARVs is linked not only to challenges to improve the living conditions of sufferers, but to improving distribution of the drugs by strengthening public health systems.

The World Health Organization (WHO) plans to distribute ARVs to 3 million people in Africa by the end of 2005 through its "3 by 5" initiative. In addition to prolonging lives, this effort will slow the rate of orphanhood of the children of HIV/AIDS victims. Major drug companies, due to pressure from the global community, have recognized the need to reduce the cost of life-saving treatments. In an attempt to undo a public relations nightmare caused by the public perception of avarice, some companies provide the drugs free of charge; others have built medical clinics.

However there are those who argue that ARVs will not address HIV/AIDS in Africa due to the scope of the problem and the price of the therapy, and that an effective vaccine is necessary. Where to test such a vaccine, who to test it on, and what treatment should be provided to vaccine subjects who are already infected (where the vaccine is not a preventative but works to slow replication of the virus) are all questions with both medical and ethical importance.

Other efforts continue. Of particular note is the work of the Bill and Melinda Gates Foundation. The foundation's top global health priority is to stop transmission of the HIV virus and it has given more than 1.4 billion dollars toward that goal since 1994 (Gates Foundation).

Conclusion

In the early-twenty-first century, many African governments finally declared the HIV/AIDS epidemic national emergencies—a necessary first step to beginning HIV-prevention programs. Progress to control the epidemic has been made, but spread of the virus continues to outpace such efforts. Denial of the scope of the problem and stigmatization of victims continue. The most daunting task is to acquire the funds and means necessary to develop proven interventions, and provide them to sufferers. Promoting education, developing treatments, and providing relief to victims of the disease in Africa poses ethical challenges to scientists and technicians, not just in the field of medicine, but in host of other fields as well.

PELUCY NTAMBIRWEKI

SEE ALSO Development Ethics;Equality;HIV/AIDS.

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