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HIV/AIDS

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This analytical profile on HIV/AIDS is structured as follows:

Contents

Analytical summary

Two thirds of all people living with HIV and AIDS live in sub-Saharan Africa. Encouragingly, new infection rates are now dropping, due to scaling-up of antiretroviral therapy treatment and more effective preventive interventions.

Forty-four out of the 46 countries of the WHO African Region have policies in place, while 38 have policies on HIV testing and counselling. However, the human resources needed to deliver on these policies fall short of requirements. This shortfall is in the region of 1.5 million throughout Africa, leading to increasing use of task shifting. This strategy is now used by 33 countries and is seen as successful in scaling-up the rate of antiretroviral therapy delivery (see figure).

Percentage of people receiving antiretroviral therapy in the WHO African Region, 2007 and 2009

The present antiretroviral coverage rate is 53% regionally, with an increase of 1 million people treated compared with the previous year. There has also been a significant increase in treatment facilities. This is of utmost importance as WHO has lowered the recommended cell count level at which antiretroviral therapy should be commenced. The benefits of this strategy are expected to outweigh increased logistical and cost challenges in terms of people reached and treated.

However, although the treatment of pregnant women to interrupt mother-to-child transmission has increased by 23% since 2008, nearly half of all HIV-positive pregnant women still do not have access to antiretroviral therapy. Also, only a small fraction of tuberculosis cases coinfected with HIV/AIDS are currently being reached, for reasons thought to be connected with effective programme delivery capacities.

Health workers in African health facilities are greatly at risk. Although policies on post-exposure prophylaxis are in place in almost all African countries, implementation remains low. However, information outreach to populations has been successful, although it is thought that efforts still need to be increased. Men still report higher rates of condom use than women.

Surveillance systems require strengthening. Only just over half of African countries have fully functional sero-surveillance systems, although these are mainly in countries with high disease burdens. The remaining countries have poor surveillance capacity, lacking the ability to appropriately track the epidemic. Deficiency in this fundamental area impacts on the potential benefits of all other health system efforts to address the HIV/AIDS pandemic.



Disease burden

HIV/AIDS mortality rate (per 100 000 population) in the WHO African Region, 2009

The most recent WHO/UNAIDS estimates released in December 2008 give the number of people infected with HIV as 33.5 million.[1] More than two thirds of these live in sub-Saharan Africa. However, across the WHO African Region, the number of new infections and HIV/AIDS-related deaths is decreasing, partially due to the unprecedented scaling-up of care and treatment of people living with HIV and AIDS, and partially because of better information and communication (see figure).

Percentage of people 15–49 years of age living with HIV in the WHO African Region, 2007 and 2009

By December 2009, there were more than 7 million people with advanced HIV infection requiring antiretroviral therapy in countries of the Region. The burden of HIV/AIDS is not uniform across African countries; there is substantial variation by subregion and country (see figure). Southern Africa remains the region with the largest number of people living with HIV/AIDS worldwide. Available data suggest that HIV prevalence in east Africa is stabilizing or declining, although some studies indicate a possible rise in high-risk sexual behaviour.[2] There is a growing possibility that the most at-risk population groups such as commercial sex workers, men-having-sex-with-men and intravenous drug users are fuelling the epidemic. The HIV burden in east Africa ranks second after southern Africa, since it hosts an estimated 1.8 million people with advanced HIV infection who are in need of antiretroviral therapy.

In west and central Africa, the overall HIV prevalence rate is much lower, with the highest levels recorded in Cote d’Ivoire.

National commitment and action

Renewed commitment to combating HIV/AIDS was pledged in the 2001 Abuja Declaration. At the Fifty-fifth Session of the WHO Regional Committee for Africa in 2001, Resolution AFR/RC55/R6, “Acceleration of HIV Prevention Efforts in the African Region”, was adopted. In March 2006, the African Union made a commitment to scaling-up toward universal access to HIV prevention, treatment, care and support in Africa by 2010. The year 2006 also became the Year of HIV Prevention, in which strategies for the acceleration of HIV prevention in the WHO African Region were adopted. As part of their commitment to the comanagement of tuberculosis and HIV, Member States endorsed a strategy for the control of a dual epidemic in 2007. Lastly, during the 2009 Session of the WHO Regional Committee for Africa, a resolution calling for action on HIV prevention and TB/HIV coinfection control was adopted.

At country level, policy decisions were taken, and guidelines developed, to assist the health sector response to the call for universal access to HIV prevention, care and treatment. The most recent data from 44 out of 46 countries in the WHO African Region indicate that by the end of 2008, all had a national policy on antiretroviral therapy. Thirty-seven countries had a policy on prevention of mother-to-child transmission and 38 had a policy on HIV testing and counselling.[3]

Programme Areas

Health systems

Human resource needs

The management and development of human resources for health is a critical challenge in scaling-up access to HIV prevention, care and treatment. According to the Global Health Workforce Alliance, African health systems require about 1.5 million newly trained health workers in order to address the current human resource shortfall. One strategy to counter the shortage of qualified health workers in remote and disadvantaged areas is known as task shifting. This involves the delegation of tasks performed by physicians to staff with lower-level qualifications, and is considered a means of expanding roll-out in resource-poor or human resources for health limited settings.

The number of countries reporting the use of the task-shifting strategy has increased over recent years, from 16 in 2007 and 24 in 2008, to 33 in 2009. Evidence shows that task shifting effectively increases the rate of scale-up of antiretroviral therapy.

Antiretroviral therapy

Soon after the launching of the 3 x 5 initiative (a pledge to reach 3 million people living with HIV/AIDS in low-income and middle-income countries with antiretroviral therapy (ART) by the end of 2005), African countries began to develop national ART scale-up plans based on the primary health care approach. Among other strategies, WHO developed and disseminated simplified ART guidelines for resource-limited countries, and emergency plans to increase front-line health worker capacity. By the end of 2007, two thirds of countries had ART scale-up plans, had expanded ART sites and had increased the number of people on treatment.

By the end of 2009, a total of about 3.9 million people were estimated to be on ART in the WHO African Region, marking 1 million additional patients on treatment in just 1 year. This figure represents an ART coverage rate of 53% (44%─65%). Nineteen countries (Benin, Botswana, Burkina Faso, Chad, Eritrea, Ethiopia, Gabon, Guinea, Kenya, Lesotho, Malawi, Mali, Namibia, Rwanda, Senegal, South Africa, Swaziland, Uganda, Zambia) reached a 50% ART coverage rate, while Botswana, Namibia, Rwanda, Swaziland and Zambia reached the universal access target of 80% coverage.

There has also been significant increase in the expansion of treatment facilities. In 2009, a total of 8278 facilities providing ART services were reported in 42 countries ─ a 37% increase in 1 year. The vast majority of facilities providing ART services were in eastern and southern Africa.

In 2010, WHO updated the HIV treatment guidelines by recommending initiation of ART for all adults and adolescents with a CD4 count of 350 cells/mm3 or less, raising the cut-off point from less than 200 cells/mm3. The new treatment recommendation is expected to increase the number of people in need of treatment by over 50%. However, the benefits of this new policy, which include reduced morbidity and better treatment outcome for patients, outweigh the additional cost implications.

Prevention of mother-to-child transmission

Nine out of 10 children with HIV infection worldwide live in sub-Saharan Africa. Over 90% of children living with HIV are infected through mother-to-child transmission during pregnancy, around the time of birth or through breastfeeding.[4] For this reason, the Joint United Nations Programme on HIV/AIDS, United Nations Children's Fund and WHO, in collaboration with other partners, called for the virtual elimination of mother-to-child HIV transmission by 2015.

To ensure an HIV-free generation, the implementation of a four-pronged strategy needs to be fully integrated into all maternal and child health services. This strategy involves:

  • primary prevention of HIV infection among women of childbearing age
  • preventing unintended pregnancies among HIV-infected women
  • preventing mother-to-child transmission
  • provision of appropriate care and treatment for HIV-infected mother, children and family.

In recent years, national commitment to mainstream prevention of mother-to-child HIV transmission has intensified, and most countries have national scale-up plans in place. With the expansion of antiretroviral therapy and HIV testing and counselling services at subdistrict levels, access to preventing mother-to-child transmission services is increasing every year.

HIV testing for pregnant women and children is critical for prevention of mother-to-child transmission scale-up efforts. In countries with a generalized epidemic, all pregnant women should be tested and counselled during antenatal visits, and those in the first and second trimester who test negative should be retested during their final trimester. Progress made by countries is encouraging, as over 50% of pregnant women in east and southern Africa, which has the highest HIV prevalence worldwide, received HIV tests in antenatal services in 2009. Across the WHO African Region, the percentage of pregnant women tested for HIV infection increased steadily.

In 2009, an estimated 1.2 million pregnant women were in need of antiretroviral treatment for prevention of mother-to-child transmission purposes. Countries reported that about 675 800 pregnant women received antiretroviral medicines for this purposes, representing an increase of 23% increase from 2008. The proportion of HIV-infected pregnant women receiving antiretroviral medicines for prevention of mother-to-child transmission purposes in sub-Saharan Africa increased from 45% in 2008 to 54% in 2009. Although this is a significant achievement, it must not be overlooked that almost half of HIV-positive pregnant women still do not have access to the treatment they need.

Co-management of tuberculosis and HIV treatment

HIV-related tuberculosis (TB) is a major public health concern and a threat to progress towards universal access to HIV prevention, care and treatment. Of an estimated 9.4 million TB cases in 2008, 1.4 million, or 15%, were among people living with HIV. Approximately 520 000 deaths from TB occurred that year among people living with HIV. The risk for TB is 20–37 times greater in people living with HIV than in the general population, depending on the prevalence of HIV.[5].

The vast majority of people living with HIV and TB live in sub-Saharan Africa. As of 2008, about two thirds of all estimated HIV-positive TB cases were in this region, with around one quarter living in South Africa alone. In some sub-Saharan countries, up to 80% of TB patients are also infected with HIV/AIDS.[6]

In 2008, WHO convened an expert consultation to advise on strategies to reduce the burden of TB among people living with HIV. The findings recommended a public health approach consisting of intensified case finding, isoniazid preventive treatment, and infection control. This approach is known as the three 'I's. Effective ways of implementing these strategies still have to be identified in many countries.

WHO guidelines recommend that all suspected and confirmed TB patients should undergo HIV counselling and testing, and that all patients under care and treatment for HIV should be screened for TB on a routine basis. In recent years, close collaboration between the two programmes has greatly benefited national HIV programmes. The rate of HIV testing among TB patients increased to 45% in 2008, or 10 times the rate in 2004.

Antiretroviral therapy is a priority life-saving intervention for people living with HIV. WHO recommends the immediate initiation of antiretroviral therapy for HIV-infected people with TB, regardless of the immunologic stage. In 2009, of 173 000 people with HIV and TB receiving antiretroviral therapy worldwide, 80% were from African countries. However, this figure is still too low, representing only one out of every seven people concerned. Reasons for this may include:

  • underreporting
  • poor performance of national TB and HIV/AIDS programmes
  • inadequate management capacity for patients with dual infections in some settings.

HIV testing and counselling

For HIV-infected individuals, testing is the first step towards early care and treatment. For those not infected, testing provides an opportunity to access appropriate tools and information to reduce the risk of HIV transmission. HIV testing and counselling is therefore critical to the achievement of universal access to HIV prevention, care and treatment.

The most common method of estimating HIV testing and counselling coverage among populations is through household surveys such as the Demographic and Health Survey or the AIDS Indicator Survey. During 2007 and 2008, nine African countries conducted these population-based surveys, targeting men and women aged 15─49 years. The median percentage of people who had received an HIV test within the past 12 months, and knew the result, was 21% for men and 37% for women.[7]

Countries are implementing various models of HIV testing and counselling, from the traditional voluntary counselling and testing to the new concept of provider-initiated HIV testing and counselling. The aim of provider-initiated HIV testing and counselling is to increase uptake of HIV testing and counselling, thereby facilitating early treatment where necessary.[8] Among 38 countries reporting in 2009, the median percentage of health facilities providing HIV testing and counselling was 40%. The total reported number of people who received HIV testing and counselling services at public health facilities in 2009 was over 30 million.

Prevention of HIV in health care setting

The most important cause of HIV transmission in health care settings is the transfusion of unscreened blood or blood products. WHO recommends that all donated blood should be screened for transfusion transmissible infections, mainly HIV, hepatitis B virus, hepatitis C virus and syphilis.[9] In 2006, over 3 million units of donated blood were used in African countries, of which 98% were reported to have been screened for HIV infection, although the quality of testing could not be ascertained everywhere. Quality assurance schemes should be requirements of the standing procedures for all blood transfusion services. The expansion of HIV testing and counselling services to subdistrict facilities across the WHO African Region is encouraging and may reduce the risk of transfusing unscreened blood donations in areas where access to safe blood is limited.

The vast majority of all health personnel worldwide occupationally exposed to HIV work in African health facilities.[10] Risks are mainly due to poor adherence to basic universal principles and standards of health care delivery systems. Equally, patients are at risk of infection through contaminated injections and surgical equipment.

Access to postexposure prophylaxis is critical to protect health workers and patients from occupational exposure to HIV. By the end of 2009, almost all African countries reported having a postexposure prophylaxis policy in place to address occupational exposure purposes – a significant improvement from 2007 when only half had this measure in place. However, the effective implementation of the policy remains a challenge in many countries.

Services for orphans and vulnerable children, and education

The UN General Assembly Special Session on HIV/AIDS in 2001, and on Children in 2002, made concrete commitments to mitigate the impact of the pandemic on children. The Millennium Development Goals, and other global initiatives such as the United Nations Children's Fund's “Unite for Children, Unite against AIDS” campaign, lay the foundations for strategies to improve the welfare of orphans and vulnerable children.

The AIDS pandemic can affect African children in many ways, both directly and indirectly. They are affected:

  • when their health is compromised
  • when they drop out of school to support ailing parents or family members
  • if they are subjected to serious discrimination and stigma following close contact with infected family members.

Over two thirds of AIDS-related deaths worldwide occur in sub-Saharan Africa, leaving more than 14 million orphans vulnerable to neglect, disease and depression. Two thirds of these orphans live in east and southern Africa, where in countries such as Botswana, Lesotho and Zimbabwe, as many as a quarter of all children may be orphaned by the pandemic.

Investigations have recently been made concerning the difference in capacity to meet health and other basic needs in orphans and vulnerable children and non-orphans and vulnerable children, respectively, using data collected in recent Demographic and Health Surveys and AIDS Indicator Surveys from eight African countries (Cameroon, Cote d’Ivoire, Kenya, Lesotho, Malawi, United Republic of Tanzania, Uganda and Zimbabwe).[11] On the basis of this data, no significant differences were found in health and nutritional status, or access to health care, between orphans and vulnerable children and non-orphans and vulnerable children.

Knowledge and behaviour

Information and education for the general public and vulnerable groups is key to HIV prevention. Behaviour change will not occur if communities remain ignorant about essential HIV-prevention messages or have limited access to appropriate services.

Comparative data analysis on recent Demographic and Health Surveys conducted between 1992 and 2006 in 23 African countries shows that knowledge about HIV prevention, and exposure to mass media among men and women age 14─49 years, have improved during the past years.[12] However, it appears that there are still large numbers of sexually active men and women who do not have basic HIV/AIDS knowledge, particularly in west African countries.

Among men and women who reported having higher-risk sex in the last 12 months, the proportion reporting condom use varied considerably, both by sex and by country. Overall, men were much more likely than women to use a condom during higher-risk sex. In the most recent round of surveys, the percentage of women reporting condom use in the last episode of higher-risk sex ranged from 5% in Madagascar to 53% in Burkina Faso. Among men, use was reported from 13% in Madagascar to 70% in Zimbabwe. Condom use during high-risk sexual encounters appears to have increased in some countries and remained unchanged or decreased in others.

In all countries with two AIDS Indicator Survey data points, the percentage of both men and women aged 15–49 years who knew where to get HIV testing increased in recent years, indicating a successful expansion of HIV testing and counselling outside major cities and towns.

Surveys also found that the proportion of young people aged 15–19 years who have sex before the age of 15 years declined in most countries. However, young females reporting having sex before the age of 15 years increased in some countries such as Benin, Mali, Namibia, Nigeria, Rwanda and Zimbabwe. For young males, increases were noted in Chad, Cote d'Ivoire, Mozambique and Rwanda

State of surveillance

The HIV surveillance system for African countries is based on the guidelines for second generation HIV surveillance, developed by the UNAIDS/WHO global working group on HIV/sexually transmitted infection surveillance.[13] The cornerstones of the system are:

  • sentinel surveillance for pregnant women attending antenatal services and other population groups
  • population-based surveys (particularly the Demographic and Health Surveys and AIDS Indicator Surveys)
  • since 2001, HIV/AIDS case-reporting
  • special studies to cover information gaps.

The antenatal-based HIV sentinel surveillance has been operational since the early 1990s. Most African countries collect, through the anonymous-unlinked method, leftover samples for routine antenatal blood work, and screen for presence of HIV antibodies once every 1─2 years. The result of the sentinel serosurveillance system is then calibrated with the prevalence rate from population-based surveys to represent the whole country.

An alternative and more robust method of estimating HIV prevalence among the general population relies on representative household surveys that include a component on collection of blood samples for HIV and other biomarkers such as sexually transmitted infections. These surveys provide more representative population-based estimates of HIV prevalence than the sentinel surveillance of women attending antenatal clinics. In addition, the blood test results are cross-tabulated with household and individual characteristics or behaviours, such as household wealth, education level, condom use or sexual behaviour.

Forty-two African countries have conducted at least one round of antenatal care serosurveillance surveys between 2006 and 2009 in over 2600 sites. Over half of these sentinel sites were located in South Africa. HIV prevalence ranged from 0% in Comoros and Madagascar to 39% in Swaziland, with a regional median of 3.2%.

In 2008, results of a study on the quality of serosurveillance systems of 44 African countries showed that only slightly more than half had fully functional surveillance systems based on criteria including frequency, timeliness, appropriateness, consistency, coverage and quality of testing.[14] Most of the countries categorized as having fully functional surveillance system were those with a high disease burden. Fourteen countries were found to have a partially functioning system. The HIV surveillance systems of the remaining countries were found to be poor, and therefore they lack the tools to successfully track the epidemic.

Endnotes: sources, methods, abbreviations, etc.

The English content will be available soon.

Liste des tableaux recommandées / Chiffres

Atlas Figure 58: Taux de mortalité du VIH / sida dans la Région africaine, 2007 Atlas de la Figure 59: Taux de mortalité du VIH / SIDA dans les Régions OMS, 2007 Atlas de la Figure 60: Prévalence du VIH chez les personnes de 15 ou plus dans les Régions OMS, 2007 Atlas Figure 62: Pourcentage de personnes de 15-49 ans vivant avec le VIH dans la Région africaine, par pays, 2007 et 2001.

Références

1. Global AIDS Update 2009: ONUSIDA et OMS, Genève.

2. Opio A et al. (2008). Tendances liées au VIH comportements et des connaissances en Ouganda, 1989-2005: la preuve d'un changement vers plus de comportements à risque. Journal des Acquis des syndromes d'immunodéficience, 49:320-326.

3. Les rapports des pays d'UC, rapports 2007, 2008 et 2009

4. Épidémie mondiale de SIDA 2008, ONUSIDA

5. Getahun H. et al. Infection par le VIH - tuberculose associée: L'épidémiologie et la réponse. Clinical Infectious Disease, 2010: 50 (Suppl 3).

6. Rapport 2010 l'accès universel (en impression)

7. Rapport d'étape 2009: Vers un accès universel, l'OMS / ONUSIDA / UNICEF

8. Recommandations sur le dépistage à l'initiative et de conseil dans les établissements de santé. OMS, ONUSIDA. Genève, 2007

9. JB Tapko, Paul Mainuka, et AJ Diarra-Nama: Statut de la sécurité transfusionnelle dans la Région OMS-Rapport africain de l'Enquête 2006; OMS AFRO

10. Prüss-Üstün A, E Rapiti, Y. Hutin blessures par objets tranchants: charge mondiale de morbidité due aux blessures par objets tranchants dans le wrokers soins de santé. Genève, Organisation mondiale de la Santé, 2003. Fardeau de l'environnement de la série Maladie, n ° 3;

11. Mishra, Vinod, et Simona Bignami-Van Assche. 2008. Orphelins et enfants vulnérables dans les pays HIVPrevalence haute en Afrique sub-saharienne. EDS études analytiques n ° 15. Calverton, Maryland, Etats-Unis: Macro International Inc

12. Modifications liées au VIH des connaissances et des comportements en Afrique sub-saharienne: EDS rapports comparatifs 24, 2009. Macro International

13. La qualité de la séro-surveillance dans les pays à faible et à revenu intermédiaire: état et tendances jusqu'en 2007. R Lyerla, Gouws E, et JM Garcia-Calleja

References

  1. AIDS update 2009 (pdf 2.9Mb). Geneva, Joint United Nations Programme on HIV/AIDS and World Health Organization, 2009 http://data.unaids.org/pub/report/2009/jc1700_epi_update_2009_en.pdf
  2. Opio A et al. Trends in HIV-related behaviors and knowledge in Uganda, 1989–2005: evidence of a shift toward more risk-taking behaviors. Journal of Acquired Immune Deficiency Syndromes, 2008, 49:320–326
  3. Country reports for universal access reporting 2007, 2008 and 2009
  4. Report on the global AIDS epidemic 2008: executive summary (pdf 2.14Mb). Geneva, Joint United Nations Programme on HIV/AIDS, 2008 http://data.unaids.org/pub/GlobalReport/2008/jc1511_gr08_executivesummary_en.pdf
  5. Getahun H. et al. HIV infection-associated tuberculosis: the epidemiology and the response. Clinical Infectious Diseases, 2010, 50(Suppl. 3): S201–S207
  6. Towards universal access. Scaling up priority HIV/AIDS interventions in the health sector. Progress report 2010. Geneva, Joint United Nations Programme on HIV/AIDS, United Nations Children’s Fund, World Health Organization, 2010 http://www.unicef.org/eapro/Towards_Universal_Access_on_HIVAIDS.pdf
  7. Towards universal access. Scaling up priority HIV/AIDS interventions in the health sector. Progress report 2010. Geneva, Joint United Nations Programme on HIV/AIDS, United Nations Children’s Fund, World Health Organization, 2010 http://www.unicef.org/eapro/Towards_Universal_Access_on_HIVAIDS.pdf
  8. Guidance on provider-initiated HIV testing and counselling in health facilities (pdf 2.65Mb). Geneva, Joint United Nations Programme on HIV/AIDS and World Health Organization, 2007 http://www.who.int/hiv/pub/guidelines/9789241595568_en.pdf
  9. Tapko JB, Mainuka P, Diarra-Nama AJ. Status of blood safety in the WHO African Region. Report of the 2006 Survey (pdf 2.31Mb). Brazzaville, World Health Organization Regional Office for Africa, 2009 http://www.afro.who.int/index.php?option=com_docman&task=doc_download&gid=3835
  10. Prüss-Üstün A, Rapiti E, Hutin Y. Sharps injuries: global burden of disease due to sharps injuries in health care workers (491.32kb). Geneva, World Health Organization, 2003. Environment Burden of Disease Series, No. 3 http://whqlibdoc.who.int/publications/2003/9241562463.pdf
  11. Mishra V, Bignami-Van Assche S. Orphans and vulnerable children in high HIV prevalence countries in sub-Saharan Africa (pdf 1.76Mb). DHS Analytical Studies 15. Calverton, Maryland, Macro International Inc., 2008 http://www.measuredhs.com/pubs/pdf/AS15/AS15.pdf
  12. Mishra V et al. Changes in HIV-related knowledge and behaviours in sub-Saharan Africa (pdf 6.26Mb). DHS Comparative Reports 24. Calverton, Maryland, Macro International, 200 http://pdf.usaid.gov/pdf_docs/PNADQ637.pdf
  13. Guidelines for second generation HIV surveillance (pdf 274.07). Geneva, World Health Organization and Joint United Nations Programme on HIV/AIDS, 2000 http://www.searo.who.int/LinkFiles/Facts_and_Figures_01_2ndgen_Eng.PDF
  14. Lyerla R, Gouws E, Garcia-Calleja JM. The quality of sero-surveillance in low- and middle-income countries: status and trends through 2007. Sexually Transmitted Infections, 2008 August; 84(Suppl. 1):i85–i91