The Joint United Nations Programme on AIDS (UNAIDS) report is released every two years and provides an update on the status of the global AIDS epidemic. The end of July saw the release of the 2008 update (2), and comes at the halfway point between the Declaration of Commitment of 2001 and the Millennium Development Goals (MDGs) to effectively address the epidemic by 2015. The MDGs are eight key goals put forward at the Millennium Summit of 2000, and include the reversing of HIV & AIDS progression. The report importantly confirms that, “the world is, at last, making some real progress in its response to AIDS”. The UNAIDS update also comes at a critical time, with just two years to go for the 189 UN Member States to meet their commitments by 2010, following their Declaration of Commitment during the UN General Assembly Special Session on HIV/AIDS in 2000.

In addition to various data collected by UNAIDS, and recommendations put forward to assist in a more effective future response to the epidemic, the report also focuses on progress made thus far, providing a comprehensive overview of successes and failures to date, in global attempts to address HIV & AIDS issues. Data collected has also been used to pinpoint certain HIV & AIDS epidemic epicentres to allow for a more focused mode of action in the coming years, specifically in wake of commitments for 2010, and thereafter the MDGs of 2015.

One of the greatest challenges faced by UNAIDS in compiling a report of this nature is the estimation of global HIV & AIDS prevalence. For such figures to be completely accurate, it would be necessary to know the HIV status of every person, worldwide. For obvious reasons, this is not even a consideration, not least due to ethical implications. UNAIDS and the World Health Organisation (WHO) must therefore use statistical estimates derived from the available data in order to provide prevalence numbers that can be seen as relatively accurate.

The data used is also highly dependent on the specific context from which it is collected. In countries where HIV & AIDS prevalence is high and the rate of infection is sustained regardless of sexual networks and sub-populations that are at higher risk (men who have sex with men, injecting drug users), the HIV prevalence among pregnant woman attending antenatal clinics is generally utilised. In countries which have historically low rates of infection, or where infection risk is based to a large degree on higher risk behaviours practiced by a certain sub-populations, the data utilised originates from studies focused on those key higher risk sub-populations. Both these methods have innate strengths, but also weaknesses that may cause data to be unrepresentative of certain members of a population. In antenatal studies, there is a lack of statistical data to adequately represent HIV & AIDS prevalence in woman older than 49 or younger than 15. This method of prevalence estimation has however been found to be accurate for both men and woman between the ages of 15- 49 in areas of high HIV & AIDS prevalence. Case studies, which use data collected from a high-risk sub-population to estimate broad-spectrum prevalence rates, are highly accurate in determining trends associated with that sub-group, though broad-spectrum prevalence is often overestimated, as the generalisation of such results is not possible.

The most compelling of the findings from this year’s UNAIDS report is that although an estimated 33 million people were living with HIV & AIDS at the end of 2007, the rate of new infections seems to have stabilised globally. This is due, in part, to an encouraging decrease in infections in many regions, though in contrast the rate of infections has increased in several others. An estimated 370,000 children younger than 15, for example, were infected with HIV & AIDS in 2007, which represents an increase in juvenile infections from 1.6 million in 2001 to a current number of 2 million globally. Of all juvenile infections, currently 90% occur in Sub-Saharan Africa.

According to the report, HIV & AIDS infections occur disproportionately in higher risk sub-populations throughout the world, except in Sub-Saharan Africa. Sub-Saharan Africa is estimated to have as many as 22 million people currently living with HIV, constituting an estimated 67% of total HIV infections worldwide. Last year, as many as 2 million people living in Sub-Saharan Africa were newly infected, with an estimated total of 1.5 million HIV & AIDS related deaths in the region. Adult prevalence is estimated to be in the region of 5%, though prevalence varies significantly from nation to nation. Heterosexual intercourse is the major determinant and leading cause of HIV infection, with the high degree of HIV-positive sex workers (in Mali for instance, this is estimated to be as high as 35% amongst female sex workers), as well as intergenerational sex additionally playing a major role in the spread of the epidemic.

The eight nations that constitute the majority of Southern Africa, including Botswana; Lesotho, Mozambique; Namibia; South Africa; Swaziland; Zambia; and Zimbabwe, account for an estimated 35% of total HIV & AIDS infections globally. Unlike the rest of the world, where new infections are distributed evenly between the sexes, here 90% of new infections occur in woman and young girls between the ages of 15 and 24, with 67% of the total HIV-positive population being female. In several of these nations such as South Africa, Malawi and Zambia, the infection rate has stabilised, though South Africa still represents the largest national epidemic, with as many as 6 million HIV-infected people in the country. Reassuringly though, the HIV prevalence amongst pregnant women in Zimbabwe has dropped from 26% in 2002 to 18% at the end of 2006. In addition, in Botswana the rate of HIV-positive mothers has dropped from 25% in 2001 to 18% at the end of 2006.

Global HIV & AIDS financing has seen a six fold increase since 2001 geared specifically towards low and middle-income nations. Currently, this is starting to have many positive effects in the developing world where the epidemic has hit the hardest. This spending has allowed an estimated 3 million people in these countries to now receive antiretroviral (ARV) medications, which represents a 50% increase in access in these nations since the end of 2006. In Namibia, where at the end of 2003 only 6% of those in need were receiving treatment, now 57% coverage has been achieved. Though progress has been achieved, there still exists a large gap in treatment in sub-Saharan Africa, which at the moment has the highest ARV distribution worldwide. Here the higher incidence of HIV-tuberculosis (TB) co-infection also needs to be addressed. It is estimated currently that in Sub-Saharan Africa, between 20% and 70% of people in the region who are infected with TB are also infected with HIV.

UNAIDS has pinpointed several effective methods of HIV & AIDS prevention, which specifically target prevention-of-mother-to-child-transmission (PMTCT) of HIV & AIDS, woman and girls, and the role of people living with HIV & AIDS in the mobilisation of the communities in which they live. Following the 2001 Declaration of Commitment on HIV & AIDS, which aims to achieve 80% access to antenatal preventative HIV & AIDS treatment for HIV-positive mothers, there continues to be massive infection of newborns during birth. It is estimated at this time that one in six new infections are of this nature, or alternatively due to breast-feeding. As was shown in Botswana, where a massive PMTCT campaign was undertaken which reduced mother-to-child transmission to a current rate of 4%, large-scale PMTCT programmes can prove highly effective in low- to middle-income nations. Secondly, there exists a great need in these nations for social programmes that promote female, economic, and individual independence. Recent evidence has found that woman who lacked food were both 70% less likely to take control during sexual encounters, as well as use condoms, and 50% more likely to engage in intergenerational sexual relations. In addition, these women are 80% more likely to have sexual relations for survival purposes, and therefore a focus on the empowerment of women is critical. Finally, the need for grassroots organisations that can reach urban and rural areas alike has been emphasised. UNAIDS has suggested that HIV-positive members of communities lead not only the fight against HIV & AIDS, but also the battle against ignorance and the stigma often associated with the disease in low and middle income settings.

NOTES:

(1) Dylan Stevens is a Research Analyst in the HIV & AIDS Unit at Consultancy Africa Intelligence (dylan.stevens@consultancyafrica.com).