HIV and AIDS is part of the daily life of vast numbers of people around the global. Today there are 34 million people living with HIV and AIDS (UNAIDS 2012) compared to 26.2 million more than a decade ago in 1999. The increase comes as a result of the significant scale up of antiretroviral treatment (ART) while has allowed many HIV-positive people not only to survive but also to lead normal and productive lives.The global incidence of HIV infection has stabilized and begun to decline in many countries with generalized epidemics. The number of people accessing treatment increased by 63 per cent from 2009 to 2011; however 7 million people eligible for treatment are not getting it. Of even more concern is the fact that 72 per cent of children worldwide who are eligible for treatment are not accessing it (UNAIDS 2012). Moreover, most people receiving ART in high-prevalence countries in sub-Saharan Africa start treatment late, which limits the overall impact of such programmes. Health systems and medical staff are struggling to provide the quality and consistency of services as programmes are scaled up. HIV in Eastern and Southern Africa Eastern and Southern Africa (ESA) continues to be the epicentre of the HIV epidemic. The Southern Africa sub-region, in particular, experiences the most severe HIV epidemics in the world, with one third (34 per cent) of all people living with HIV globally residing in the 10 countries of Southern Africa. Nine of the Southern African countries (Botswana, Lesotho, Malawi, Mozambique, Namibia, South Africa, Swaziland, Zambia and Zimbabwe) have HIV prevalence rates among adults (15 to 49 years) of over 10 per cent. At an estimated 25.9 per cent, Swaziland has the highest rate in the world, followed by Botswana (24.8 per cent) and Lesotho (23.6 per cent). With 5.6 million people infected, South Africa is home to the world’s largest population of people living with HIV and AIDS. In 22 countries in sub-Saharan Africa, however, new infections have dropped by more than 25 per cent between 2001 and 2009, including in some of the countries with the largest epidemics such as Ethiopia, Zambia and Zimbabwe. Zimbabwe was the first country in Southern Africa to record a significant, sustained declined in HIV infections (from 29 per cent in 1997 to 16 per cent in 2007). The annual HIV incidence in South Africa, though still high at 1.5 per cent in 2009, dropped from 2.4 per cent in 2001. The epidemics in Botswana, Namibia and Zambia also appear to be declining while those in Lesotho, Mozambique and Swaziland seem to be leveling off. Angola’s relatively younger epidemic, on other hand, still appears to be growing. Much of the reduction comes as a result of changes towards safer behaviour patterns among young people, including delay of first sex, reduction in the number of partners, and increased condom use. According to UNAIDS data, prevalence among 15 to 24 year olds has decreased by more than a third between 2001 and 2010. Nonetheless, in Swaziland, Botswana and Lesotho, between 8.5 and 11 per cent of young people are living with HIV. Girls and young women are disproportionately affected by HIV. Of the 2.7 million 15–24 year-olds living with HIV in the region, 70 per cent are female. In ESA, prevalence rates among young women aged 15 to 24 years are almost two and a half times higher than among men of the same age, with considerable variations between and within countries. Girls’ vulnerability to an HIV infection not only stems from their greater physiological susceptibility to heterosexual transmission, but also from the severe social, legal and economic disadvantages they often confront. Preventing new infections among young people therefore requires efforts that both tackle cultural and gender norms and also promote knowledge and life skills to help young people protect themselves and their partners from HIV. Surveys show that much more needs to be done to equip young people with such competencies and achieve further reductions in prevalence in this age group. In 2010, 40 per cent of young men and 34 per cent of young women in the region had comprehensive knowledge of HIV and AIDS with only three countries exceeding 50 per cent: Namibia, Rwanda and Swaziland. Children living with HIV in Eastern and Southern Africa
Nearly half (47 per cent) of the world’s 3.4 million children under the age of 15 living with HIV were found in ESA at the end of 2010.
The vast majority of these children became infected during pregnancy, delivery or through breastfeeding. In 2010, an estimated 390,000 children globally were newly infected, a third of them (130,000) in ESA.
Despite progress made in reaching more children with treatment for HIV, AIDS remains a leading cause of death in young children in countries with high HIV prevalence. Just over 400 children under the age of 15 die every day from AIDS-related causes in the region. In the nine Southern African countries (Botswana, Lesotho, Malawi, Mozambique, Namibia, South Africa, Swaziland, Zambia and Zimbabwe), between 10 and 28 per cent of children under five died of HIV-related illnesses in 2010.
Countries throughout the region have made great efforts to establish PMTCT services. In 2010, 64 per cent of HIV-positive pregnant women in ESA received the most effective antiretroviral regimes to prevent the transmission of the virus to their baby, up from only 16 per cent in 2006. However, this regional average masks huge disparities between and within countries. Some countries such as Botswana, Namibia, South Africa and Swaziland have achieved coverage rates of more than 95 per cent, while in others such as Eritrea only have 3 per cent of HIV-positive pregnant women were enrolled in PMTCT programmes.
The percentage of infants born to women with HIV, who received ARV for PMTCT remained significantly lower in 2010, ranging between a low 17 per cent in Angola to more than 95 per cent in Botswana, Namibia and Swaziland.
Many pregnant women in rural areas, however, do not have the means to access to the health centres where these services are offered. Among those who attended antenatal care in ESA in 2010, on average only 47 per cent received an HIV test. Regional disparities are large, with only 1 per cent of pregnant women in Somalia testing for HIV to more than 90 per cent in Botswana, South Africa, Zambia and Zimbabwe.
When tested positive, many drop out of PMTCT programmes, because they fear discrimination and rejection by their male partners and families. Moreover, in most countries in the region, there is continued use of sub-optimal drugs such as single-dose nevirapine as the main HIV prophylaxis, despite recommendations by WHO to replace such medicines with more effective antiretroviral regimens.
Regionally, the percentage of children in need of treatment who received ARV was even lower at 29 per cent in 2010. Only in Botswana and Namibia, more than 80 per cent of those in need were treated with ARV. Looking at the absolute figures, however, reveals the important progress that has been made in just two years, with 315,683 children being reached with ART, up from 195,000 at the end of 2008.
Orphaned and vulnerable children
In 2010, the 21 countries of the ESA region had 22.65 million orphaned children. Of these, more than 40 per cent (or 9.5 million) had lost one or both parents to AIDS, and millions more have become poorer, dropped out of school or ostracized by their communities as a result of HIV-related stigma. For a generation of children and adolescents, HIV and AIDS have redefined the very meaning of childhood.
The risks faced by children whose lives are affected by HIV and AIDS are well documented. The epidemic burdens impoverished families and reducing their ability to look after their children when adults become chronically sick. The impact of HIV weakens social ties and values, and makes children susceptible to abuse, exploitation, discrimination and crime.
With millions of children made vulnerable by the epidemic, care and support to help them survive and stay safe is nowhere near adequate. Where data is available, the percentage of children receiving government support remains low: Only in Swaziland (41 per cent) and Botswana (31 per cent) are significant numbers of vulnerable and orphaned children being reached. In most other countries in the region, only around 20 per cent or less (7 per cent in Tanzania) of these children receive some sort of external support.
More on HIV/AIDS