HIV/AIDS in
sub-Saharan Africa
July 2002
01 July 2002 slide number SSA-1
•
•
•
•
•
•
Trends in the HIV/AIDS Epidemic
Different Sectors of the Population
HIV/AIDS and Youth
Impact of HIV/AIDS
Knowledge and Behavior
Success Stories
01 July 2002 slide number SSA-2
Trends in the
HIV/AIDS Epidemic
01 July 2002 slide number SSA-3
HIV prevalence in adults
in sub-Saharan Africa, end 2001
2001
20 – 39%
10 – 20%
5 – 10%
1 – 5%
0 – 1%
trend data unavailable
outside region
01 July 2002 slide number SSA-4
HIV prevalence in adults
in sub-Saharan Africa, 1986-2001
1986
1991
20 – 39%
10 – 20%
5 – 10%
1 – 5%
0 – 1%
trend data unavailable
outside region
01 July 2002 slide number SSA-5
1996
2001
Millions
Number of people living with HIV/AIDS
in sub-Saharan Africa, 1980-2001
30
25
20
15
10
5
0
1980
1983
Source: UNAIDS, 2002
01 July 2002 slide number SSA-6
1986
1989
1992
1995
1998
2001
Thousands
Number of people who died from HIV/AIDS
in sub-Saharan Africa, 1980-2001
2,500
2,000
1,500
1,000
500
0
1980
1983
Source: UNAIDS, 2002
01 July 2002 slide number SSA-7
1986
1989
1992
1995
1998
2001
HIV prevalence among pregnant women
in South Africa, 1990 to 2001
HIV prevalence (%)
30
25
20
15
10
5
0
1990 ‘91 ‘92 ‘93 ‘94 ‘95 ‘96 ‘97 ‘98 ‘99 2000 ‘01
Source: Department of Health, Republic of South Africa
01 July 2002 slide number SSA-8
Estimated adult HIV prevalence
in Kenya, 1990-1999
16
HIV prevalence (%)
14
12
10
8
6
4
2
0
1990
91
92
93
94
95
Source: National AIDS and STD Control Programme, 1999 and UNAIDS
01 July 2002 slide number SSA-9
96
97
98 1999
Kenya: HIV prevalence for adults and pregnant women
HIV prevalence (%)
Major urban and outside major urban areas
50.0
Urban
40.0
Outside
Urban
30.0
Median
(Urban)
20.0
Median
(Outside
Urban)
10.0
UNAIDS
Adult
Prevalence
0.0
1985
1990
1995
2000
Year
Source: 1 UNAIDS/WHO Epi Country Fact Sheets 2001. 2 U.S. Census Bureau Database
01 July 2002 slide number SSA-10
Senegal: HIV prevalence for pregnant women
Major urban and outside major urban areas
3.2
Urban
HIV Prevalence, (%)
2.8
Outside Urban
2.4
Median (Urban)
2.0
Median (Outside Urban)
1.6
UNAIDS adult prevalence
1.2
0.8
0.4
0.0
1985
1990
1995
Year
Source: 1 UNAIDS/WHO Epi Country Fact Sheets 2001. 2 U.S. Census Bureau Database. 3
Conseil National de Lutte Contre le SIDA, Republique du Senegal
01 July 2002 slide number SSA-11
2000
HIV prevalence rates among pregnant women attending
antenatal clinics in urban sites in Cameroon: 1989-2000
20.0
18.0
% HIV-positive
16.0
Bamenda
14.0
12.0
Limbe
10.0
Yaounde
8.0
6.0
Garoua
4.0
2.0
0.0
1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000
Source: National AIDS Programme, Cameroon (1989-2000). Data compiled by the US Census Bureau
01 July 2002 slide number SSA-12
Prices (US$/year) of a first-line antiretroviral
regimen in Uganda: 1998-2001
14,000
12,000
Price US$
10,000
8,000
6,000
4,000
2,000
0
Jun Jul Aug
1998 1998 1998
Source: WHO/UNAIDS, 2002
01 July 2002 slide number SSA-13
Apr
2000
Jul Aug
Oct Nov Dec Jan Feb Mar Apr May Jun
2000 2000 2000 2001 2001 2001 2001 2001 2001 2001 2001
Different Sectors
of the Population
01 July 2002 slide number SSA-14
HIV prevalence among people
consuming alcohol and among non-drinkers,
Carletonville, South Africa, 1998
70
HIV prevalence (%)
60
drinkers
non-drinkers
50
40
30
20
10
0
men
Source: Campbell et al. (unpublished data)
01 July 2002 slide number SSA-15
women
women in
commercial
sex areas
HIV prevalence rate and frequency
of sexually transmitted infection (STI) episodes,
Carletonville miners, South Africa, 1991-1998
HIV prevalence (%)
90
70
50
30
10
1
2-4
5-9
Number of STI episodes
Source: Ballard R, 2000 (unpublished data).
01 July 2002 slide number SSA-16
10+
Percentage of workforce lost to AIDS
by 2005 and 2020 in selected African countries
50
2005
2020
40
30
%
20
10
Sources: ILO (2000) POPILO population and labour force projection; UN Department of Economic and Social
Affairs, Population Division (1998) World Population Prospects: the 1998 Revision
01 July 2002 slide number SSA-17
Zimbabwe
United Rep. of Tanzania
Togo
South Africa
Nigeria
Mozambique
Guinea-Bissau
Ethiopia
Cote d’Ivoire
Central African Republic
Cameroon
Botswana
0
HIV prevalence in military personnel in Africa

Nigeria: 11% among peacekeepers returning from
Sierra Leone and Liberia vs 5% in adult population

South Africa: 60-70% in military vs 20% in adult
population
Source: Nigeria AIDS bulletin No 15, May 20, 2000; The Mail & Guardian, Pretoria, March 31, 2000; UNAIDS/WHO 1999 estimate
01 July 2002 slide number SSA-18
HIV prevalence by self-reported
urban/rural residence among ANC attendees
aged 15-24, Zimbabwe 2000
50
Percent
40
30
20
10
0
Rural
(n=1753)
p = 0.8
Place of Usual Residence
Source: Ministry of Health and Child Welfare, Zimbabwe
01 July 2002 slide number SSA-19
Urban
(n=1544)
120
25
new AIDS cases
medical spending
100
20
80
15
60
10
40
5
20
0
1989
90
91
92
93
94
95
96
1997
Source: Rugalema et al. HIV/AIDS and the commercial agricultural sector of Ken UNDP/FAO, 1999
01 July 2002 slide number SSA-20
0
Medical expenditure
(KSh millions)
Number of newly diagnosed
AIDS cases
Newly diagnosed AIDS cases
and medical expenditure on an agricultural estate
in Kenya, 1989 to 1997
Condom use among men with non-regular partners over time
in selected sub-Saharan African countries: 1994-2000
60
Malawi
Tanzania
50
Uganda
Zambia
%
40
30
20
1994
1995
1996
1997
1998
1999
Source: Macro International (1994-2000) Demographic Health Surveys; Measure Evaluation
01 July 2002 slide number SSA-21
2000
HIV prevalence by educational level
among ANC attendees aged 15-44,
Zimbabwe, 2000
50
Percent
40
30
20
10
0
None
Primary
Secondary
Tertiary
(n=154)
(n=1769)
(n=3718)
(n=9)
p<0.01
Education Level
Source: Ministry of Health and Child Welfare, Zimbabwe
01 July 2002 slide number SSA-22
HIV/AIDS and Youth
01 July 2002 slide number SSA-23
Prevalence among pregnant women
in major urban areas, Uganda
35
Prevalence
30
25
20
15
10
5
0
1985 86
87
88
89
90
Source: Uganda National AIDS Programme
01 July 2002 slide number SSA-24
91
92
93
94
95
96
97
98
99 2000
HIV prevalence by age
among ANC attendees, Zimbabwe 2000
50
Percent
40
30
20
10
0
15-19
20-24
25-29
30-34
n=1286
n=2045
n=1334
n=648
Age Group
Source: Ministry of Health and Child Welfare, Zimbabwe
01 July 2002 slide number SSA-25
35-39
n=284
40-44
n=96
HIV prevalence (%)
HIV prevalence rate among teenagers
by age in Kisumu, Kenya
35
30
25
20
15
10
5
0
boys
girls
15
16
17
18
Age in years
Source: National AIDS Programme, Kenya, and Population Council, 1999
01 July 2002 slide number SSA-26
19
Percentage of women who are mothers
or pregnant by the end of their teens, 1990-1998
Percentage
of women
80
60
40
20
0
Source: Demographic and Health Surveys, various countries
01 July 2002 slide number SSA-27
The Impact of HIV/AIDS
01 July 2002 slide number SSA-28
Age in years
Projected population structure with
and without the AIDS epidemic, Botswana, 2020
80
75
70
65
60
55
50
45
40
35
30
25
20
15
10
5
0
Males
Females
Projected population
structure in 2020
Deficits due to AIDS
140 120 100 80
60
40
20
0
20
40
60
Population (thousands)
Source: US Census Bureau, World Population Profile 2000
01 July 2002 slide number SSA-29
80 100 120 140
Increase in mortality among men between
15 and 60, selected African countries, 1986-1997
80
Probability of dying
from all causes
70
60
estimated for 6 years before survey
estimated for year of survey
50
40
30
20
10
0
Tanzania
1996
Malawi
1992
Source: Timaeus I, AIDS 1998, 12 (suppl): S15-S27
01 July 2002 slide number SSA-30
Zimbabwe
1994
Uganda
1995
Zambia
1996-97
Adult mortality attributable to HIV,
community-based studies in Africa, 1990-1996
Mortality among HIV-negatives
Mwanza, Tanzania
Excess mortality due to HIV
(4% HIV)
Kisesa, Tanzania
(7% HIV)
Masaka, Uganda
(8% HIV)
Rakai, Uganda
(21% HIV)
0
5
10
15
20
25
30
Mortality per 1,000 person - years
Source: Boerma JT et al, AIDS 1998, 12 (suppl 1): S3-S14
01 July 2002 slide number SSA-31
35
40
Trends in mortality among children
under five years old and end-1999 adult HIV prevalence rate,
selected African countries, 1981-1996
Relative under-5 mortality
(1981 = 100%)
110 %
105 %
Zambia
HIV prevalence 19.9%
100 %
95 %
Kenya
HIV prevalence 14.1%
90 %
Cameroon
HIV prevalence 7.7%
85 %
80 %
1980
82
84
86
88
90
Source: Demographic and Health Surveys, Macro International, USA
01 July 2002 slide number SSA-32
92
94
96
1998
Probability of a Zimbabwean boy aged 15
dying before age 50, trends over time,
various national surveys
60
Probability of dying
before age 50 (%)
50
40
reports from surviving siblings
death registration
household reports of death
30
20
10
1980
1985
Source: Feeney G, 1999 (unpublished data).
01 July 2002 slide number SSA-33
1990
1995
2000
Estimated impact of AIDS on under-5 child
mortality rates, selected African countries, 2010
250
Deaths per 1,000 live births
200
Without AIDS
With AIDS
150
100
50
0
Botswana Kenya Malawi Tanzania Zambia Zimbabwe
Source: US Census Bureau
01 July 2002 slide number SSA-34
Changes in life expectancy in selected African countries
with high and low HIV prevalence: 1950 - 2005
65
Life expectancy (years)
60
with high HIV prevalence:
Zimbabwe
South Africa
Botswana
55
50
45
with low HIV prevalence:
Madagascar
Senegal
Mali
40
35
30
1950– 1955- 1960- 1965- 1970- 1975- 1980- 1985- 1990- 1995- 20001955 1960 1965 1970 1975 1980 1985 1990 1995 2000 2005
Source: UN Department of Economic and Social Affairs (2001) World Population Prospects, the 2000 Revision.
01 July 2002 slide number SSA-35
Predicted loss in life expectancy
due to HIV/AIDS in children born in 2000
Predicted life expectancy
Loss in life expectancy due to HIV/AIDS
Botswana
Zimbabwe
South Africa
Kenya
Zambia
Côte d'Ivoire
Rwanda
Mozambique
Haiti
Cambodia
0
10
20
30
40
50
Life expectancy at birth (years)
Source: U.S. Census Bureau, 2000
01 July 2002 slide number SSA-36
60
70
Lifetime risk of AIDS death for 15-year-old boys,
assuming unchanged or halved risk
of becoming infected with HIV, selected countries
risk halved over next 15 years
current level of risk maintained
100%
Risk of dying of AIDS
Botswana
80%
Zimbabwe
South Africa
Botswana
Zambia
60%
Zimbabwe
Kenya
40%
20%
0%
South Africa
Zambia
Côte d’Ivoire
Cambodia
Kenya
Côte d’Ivoire
Burkina
Faso
Cambodia
Burkina Faso
0%
5%
10%
15%
20%
25%
30%
Current adult HIV prevalence rate
Source: Zaba B, 2000 (unpublished data)
01 July 2002 slide number SSA-37
35%
40%
Leading causes of death
in Africa, 2000
25.0
22.6
20.0
% of
Total
15.0
10.1
10.0
9.1
6.7
5.5
4.3
5.0
3.6
3.1
2.9
2.3
0.0
HIV/AIDS
Malaria
Lower
respiratory
infections
Diarrhoeal
disease
Source: The World Health Report 2001, WHO
01 July 2002 slide number SSA-38
Perinatal
conditions
Tuber
culosis
Measles
Ischaemic
Heart
disease
Cerebro
vascular
disease
Maternal
conditions
Leading causes of disease burden
in Africa, 2000
25.0
20.6
20.0
% of
Total
15.0
10.1
10.0
8.6
6.3
6.1
4.5
5.0
3.6
2.8
1.8
1.9
0.0
HIV/AIDS
Lower
respiratory
infections
Malaria
Diarrhoeal
diseases
Perinatal
conditions
Maternal
conditions
Measles
Other
unintentional
injuries*
Tuberculosis
* Unintentional injuries aside from traffic accidents, poisoning, falls, fires and drowning
Source: The World Health Report 2001, WHO
01 July 2002 slide number SSA-39
Pertussis
Impact of HIV/AIDS
on urban households, Côte d’Ivoire
General population
Families living with AIDS
30 000 Francs CFA
25 000
Monthly income
per capita
20 000
15 000
Monthly
consumption
per capita
10 000
5 000
0
Savings/Disavings
– 5 000
Source: Simulation-based on data from Bechu, Delcroix and Guillaume, 1997
01 July 2002 slide number SSA-40
Reduction in production in a household
with an AIDS death, Zimbabwe
Crops
•
•
•
•
•
Reduction in output
Maize
61%
Cotton
47%
Vegetables
49%
Groundnuts
37%
Cattle owned
29%
Source: Stover & Bollinger, 1999
01 July 2002 slide number SSA-41
Estimated and projected deaths at ages 15-34,
with and without AIDS in South Africa: 1980-2025
Deaths (Thousands)
2,000
1,600
Without AIDS
With AIDS
1,200
800
400
0
1980-1985 1985-1990 1990-1995 1995-2000 2000-2005 2005-2010 2010-2015 2015-2020 2020-2025
Source: UN Department of Economic and Social Affairs (2001) World Population Prospects, the 2000 Revision.
01 July 2002 slide number SSA-42
Reduction in size of primary- school-age
population by 2010, in selected African countries
30.0
% reduction
25.0
20.0
15.0
10.0
5.0
0.0
Zimbabwe
Source: World Bank, 2000
01 July 2002 slide number SSA-43
Zambia
Kenya
Uganda
Reduction in life expectancy compared to the
‘no AIDS’ scenario in selected countries: 2000-2005
Botswana
Zimbabwe
Swaziland
South Africa
Kenya
Mozambique
Côte d'Ivoire
Cameroon
Burkina Faso
Haiti
Guyana
Bahamas
Cambodia
Dominican Rep.
Angola
Myanmar
Thailand
0
5
10
15
20
25
30
35
Number of years
Source: UN Department of Economic and Social Affairs (2001) World Population Prospects, the 2000 Revision.
01 July 2002 slide number SSA-44
40
Knowledge and Behavior
01 July 2002 slide number SSA-45
Percentage who do not know
Percentage of 15-19 girls
who do not know that a HIV-infected person
may look healthy, 1994-1999
100
90
80
70
60
50
40
30
20
10
0
Sources: UNICEF, DHS surveys and other nationwide surveys, 1994-99.
01 July 2002 slide number SSA-46
Knowledge of condoms
among adolescent boys
100%
Percentage of 15-19
year old boys
Do not know condoms
75%
50%
25%
0%
Sources: UNICEF, DHS surveys, 1994-1999
01 July 2002 slide number SSA-47
Know condoms but
not where to get them
Know condoms and
where to get them
Percentage of 15-49 year old women
who are aware that HIV can be transmitted
from a mother to her child, 1994-1999
Dominican Rep.
Zimbabwe
Zambia
Uganda
Kenya
South Africa
Peru
Haiti
Tanzania
CAR
Cote d'Ivoire
Cameroon
Benin
Madagascar
Mali
Chad
Niger
Sources: UNICEF, DHS and other nationwide surveys, 1994-1999
01 July 2002 slide number SSA-48
Risk perception
percentage of sexually active women (15-19)
that perceive not to be at risk at all of getting AIDS
Nicaragua
Nepal
Colombia
Bolivia
Guatemala
Brazil
Dominican Rep.
Niger
Benin
Chad
Mali
Cameroon
Togo
Haiti
CAR
Kenya
Uganda
Zambia
Zimbabwe
HIV
Prevalence
(at time of
survey *)
Percentage of
15-19 year old
girls who think
they are not at
risk of AIDS
*HIV prevalence in women attending antenatal care clinics in major urban areas
Sources: UNICEF, DHS surveys, 1994-1999
01 July 2002 slide number SSA-49
Number of reported rapes and convictions
in Botswana, 1984 to 1997
1400
reported rapes
1200
convictions
Number
1000
800
600
400
200
0
1984
85
86
87
88
89
90
91
Source: Emang Basadi Women’s Association, Botswana, 1998
01 July 2002 slide number SSA-50
92
93
94
95
96
1997
Percentage of sexually experienced girls
in South Africa who say …
“I have been forced to have sex.”
“I am afraid of saying no to sex.”
Agree
33%
Yes
39%
No
61%
7%
Agree
55%
Disagree
39%
6%
“There are times I don't want to have sex
but I do because my boyfriend
Insists on having sex.”
Source: Kaiser Family Foundation/KLA (2000) South African National Youth Survey
01 July 2002 slide number SSA-51
Disagree
60%
Condoms per man per year
Condom gap in sub-Saharan
African countries in 1999
Six countries
with highest
condom
procurement
rate
30
25
20
Average condom procurement of top 6 countries = 16.9
15
10
Additional condoms needed to get all
countries to the level of 16.9 = 1.9 billion per year
5
0
1
3
5
7
9
11
13
15
17
19
21
23
25
27
29
31
33
35
37
39
41
43
45
47
Countries in sub-Saharan Africa, ordered by condom procurement rate
Source: Shelton JD, Johnston B (2001) Condom gap in Africa: evidence from donor agencies and key infromants,
British Medical Journal
01 July 2002 slide number SSA-52
Orphans holding the belief (%)
Knowledge and beliefs
concerning AIDS among AIDS orphans,
Rusinga Island, Kenya
100
80
60
40
20
0
0
Believe many
people in their
community have
died of AIDS
Believe people in
extended family
died of AIDS
Source: Johnston T et al. Population Communication Africa, Kenya, 1999
01 July 2002 slide number SSA-53
Believe parents
died of AIDS
Casual sex and condom use
by educational status, Mozambique
Respondents reporting
the behaviour (%)
60
casual sex in the past year
condom use at last casual sex
50
40
30
20
10
0
0-2
3-6
7-9
10+
Number of years respondent spent in school
Source: Agha S, et al. The promotion of safer sex among high-risk individuals in
Mozambique, Population Services International, USA, 1999
01 July 2002 slide number SSA-54
Success Stories
01 July 2002 slide number SSA-55
HIV prevalence rate among 13 to 19-year-olds
Masaka, Uganda, 1989 to 1997
HIV prevalence (%)
5
Girls
4
Boys
3
2
1
0
1989/90 1990/91 1991/92 1992/93 1993/94 1994/95 1995/96 1996/97
Source: Kamali et al. AIDS 2000, 14: 427-434
01 July 2002 slide number SSA-56
HIV prevalence rate among pregnant
15 to 19-year-olds, Lusaka, Zambia, 1993 to 1998
1993
1994
1998
HIV prevalence (%)
35
30
25
20
15
10
5
0
Chelstone
Chilenje
Kalingalinga
Clinic
Source: Ministry of Health, Zambia, 1999
01 July 2002 slide number SSA-57
Matero
Prevalence among pregnant women,
outside major urban areas, Uganda
14
HIV Prevalence (%)
12
10
8
6
4
2
0
1989
90
91
92
Source: Uganda National AIDS Programme
01 July 2002 slide number SSA-58
93
94
95
96
97
98
99
2000
Prevalence in 15-24 years old first time testers
Kampala, Uganda
HIV Prevalence (%)
30
Males
25
Females
20
15
10
5
0
1992
1993
1994
Source: Uganda National AIDS Programme
01 July 2002 slide number SSA-59
1995
1996
1997
1998
1999
2000
Behavioural Indicators
Uganda, 1996-2000
Percentage
60
1996-1997
50
1999-2000
40
30
20
10
0
Reported
non-regular
sexual
partners
Reported
condom
use
with nonregular
partners
Source: Uganda National AIDS Programme
01 July 2002 slide number SSA-60
Reported
incidence
of Urethritis
(men)
Condom use
at last sex
with regular
partner
Age at first sex
Knowledge about HIV/AIDS
Uganda, 1996-2000
Percentage
90
80
1996 - 1997
1999 - 2000
70
60
50
40
30
20
10
0
Knowledge
of preventive
practices
Source: Uganda National AIDS Programme
01 July 2002 slide number SSA-61
Knowledge
of condom source
Knows a friend,
colleague with AIDS
HIV prevalence and reported consistent condom use
among female sex workers, Abidjan, Côte d'Ivoire, 1992-1998
% HIV seropositive
HIV prevalence
Reported consistent condom use
80
80
60
60
40
40
20
20
0
0
1992
1993
1994
Source: Ghys PD et al. (2002) AIDS
01 July 2002 slide number SSA-62
1995
1996
1997
1998
% consistent condom use
100
100
Prevalence of sexually transmitted
diseases among sex workers
Dakar, Senegal, 1991 and 1996
50 STD prevalence (%)
1991
1996
40
30
20
10
0
Trichomonas
vaginalis
Chlamydia
trachomatis
Source: National AIDS Programme, Senegal
01 July 2002 slide number SSA-63
Neisseria
gonorrhoeae
Syphilis
Increase in reported condom use with non-regular
partners in selected districts in Uganda: 1996-2000
% condom use
80
60
40
20
0
1997
1999
Mbara
1996
1999
Mpigi
1997 2000
Masindi
Source: STD/AIDS Control Programme, Uganda (2001) HIV/AIDS Surveillance Report
01 July 2002 slide number SSA-64
1997
2000
Pallisa
Trends in HIV prevalence among pregnant women
in Kampala, Uganda: 1991-2000
40
30
% 20
10
0
1991
1992
1993
1994
1995
1996
1997
1998
Source: STD/AIDS Control Programme, Uganda (2001) HIV/AIDS Surveillance Report
01 July 2002 slide number SSA-65
1999 2000
Guinea-Bissau*
Libyan Arab Jamahiriya
Sao Tome and Principe*
Central African Republic*
Burundi
Morocco
Cape Verde
Congo
Togo
Egypt
Sudan
Eritrea
Somalia
Nigeria
Botswana
Niger*
Cameroon*
Djibouti
Cote d'Ivoire
Benin*
Angola
Gabon
Tunisia
Mauritius
Sierra Leone*
Liberia
Madagascar*
Kenya*
Seychelles
Swaziland
Equatorial Guinea
Mali*
Ghana*
Uganda*
Comoros
Ethiopia*
Rwanda*
Mauritania*
Burkina Faso
Lesotho
Mozambique*
South Africa
Gambia
Namibia
Algeria
Chad*
Zambia*
Guinea*
Senegal*
DR Congo*
Malawi*
UR Tanzania
Zimbabwe
% Expenditure on health
Public expenditure on health as percentage of general
government expenditure in African countries: 1998
18.0
15.0
Abuja Target = 15.0%
12.0
9.0
6.0
3.0
0.0
* Heavily indebted, poor countries
Source: WHO, World Health Report 2001
01 July 2002 slide number SSA-66