Lancet Examines Prevalence, Spread of HIV-1 in Sub-Saharan Africa; Article is First in Five-Part Series
In the first article of a five-part Lancet series on AIDS in Africa, Anne Buve of the Institute of Tropical Medicine in Antwerp, Belgium, and colleagues examine what factors determine the spread and prevalence of HIV-1 infection in sub-Saharan Africa. According to the authors, the first African AIDS cases appeared in Uganda, Tanzania and the Democratic Republic of Congo between 1978 and 1979, and by 1986 "it was clear" that the disease was "posing a major public health problem" on the continent. Since recognition of the disease in the early 1980s, some African nations have taken steps to raise awareness and change behavior to reduce HIV transmission. Such efforts have been successful in Uganda and Zambia, but the epidemic "continues to spread unabated" in other parts of Southern Africa, with Botswana the worst-affected nation, the authors note. In other areas, such as Western Africa, HIV-1 prevalence has remained low. This "considerable variation" in HIV prevalence is not explainable merely by examining the differences in when the virus was introduced to each region, nor can it be explained by differences in sexual behavior patterns alone, the authors state.
A Multitude of Factors
High HIV-1/AIDS prevalence in sub-Saharan Africa is the result of a "complex interplay of behavioral factors and factors that affect the transmission of HIV-1 during sexual intercourse," the authors state. Sexual behavior patterns are determined by cultural and socioeconomic influences. In many areas, the low status of women and women's economic dependence on men have contributed to a rise in HIV-1/AIDS because women are often unable to negotiate safe sex or rely on sex as a commodity. Poverty, urbanization and modernization have also contributed to the spread of HIV/AIDS, the authors say, noting that the disease is more prevalent in countries with larger urban populations. Urban centers serve as a draw for men and women seeking employment, often leading to the separation of families and feeding the commercial sex industry. The authors add that wars and conflicts have also contributed to the spread of HIV-1 because conflict creates an environment in which the risk of HIV-1 for soldiers is "balanced by stressful situations and dangers related to war." They also note that the presence or absence of other sexually transmitted diseases and male circumcision can affect transmission probability. These factors have combined to facilitate the spread of HIV in sub-Saharan Africa, "profound[ly] chang[ing]" the population structure in many nations with high prevalence rates. As mortality rates rise, life expectancy is compromised and economic growth is stunted, leading to a "vicious circle" of disease and poverty, the authors state. They conclude that HIV prevention strategies and interventions should "not only target individuals, but also aim to change the aspects of these contexts that increase vulnerability to HIV-1 of people and communities" and add that the "recent renewed international attention for the HIV-1/AIDS epidemics in sub-Saharan Africa should translate to a commitment to reconstruct social services, especially education and health services, and to tackle economic underdevelopment" (Buve et al., Lancet, 6/8).
Lancet Series Overview
The Lancet will feature four more articles on different aspects of the HIV/AIDS epidemic in Africa in the weeks leading up to the XIV International AIDS Conference in Barcelona, Spain, which begins on July 7 and runs through July 12. The series, which was designed in the hope that "readers will be stimulated to think about the best way to enhance the prevention of HIV/AIDS and care for patients in Africa," will continue with articles about maternal and child health, HIV/AIDS in relation to other infectious diseases, HIV/AIDS treatment and the development of HIV and AIDS vaccines. The series will end with a piece that examines how HIV/AIDS is dealt with in comparison to other sexually transmitted diseases and how that treatment may be affecting HIV prevention and care efforts (Clark, Lancet, 6/8).