HIV This Week

Hargrove, John. Migration, mines and mores: the HIV epidemic in southern Africa. South Afr J Sci. 2008: Volume 104, Issue 1 & 2:53-61.

The seriousness of the HIV epidemic in southern and eastern Africa has its roots in the 19th century - in the employment practices instituted on mines, farms and in cities, where millions of men have, ever since, lived apart from their families for the greater part of each year. This destruction of the family unit was a sociological disaster waiting for the arrival of HIV and is the source of many other social ills - not least the increasingly violent nature of South African society. In the short term we can promote HIV prevention measures such as male circumcision and condom use. In the medium term, we can hope that the many billions already spent on microbicide and vaccine research begin to pay dividends. In the long term, we need to change fundamentally the way that people live.

Editors’ note: Hargrove cogently argues that it is “Rhodes not roads”, i.e. that it was the colonial migratory labour practices that fragmented families and severely compromised family coherence that were the critical determinants at the heart of the southern Africa epidemic. His unavoidable conclusion is that, in addition to intensifying HIV prevention and treatment, we must urgently rebuild family structures in southern and eastern Africa if the HIV epidemic and many other problems having similar sociological determinants are to be dealt with effectively.

Hladik and colleagues amied to estimate the burden of HIV disease in Uganda and the effect of HIV control programmes to mitigate it. The authors performed mathematical modelling and projecting using surveillance and census data. Using antenatal clinic surveillance (1986-2002) and a recent population-based survey (2004-2005) data, they modelled the adult national HIV prevalence over time (1981-2004), and kept prevalence constant at 6.4% for the years 2004-2010. Using Spectrum software and census data, they estimated the national burden of HIV disease and the effect of selected HIV-related prevention and treatment programmes. In 2005, they estimated that there were 135,300 new HIV infections (adult HIV incidence 0.96%), 691,900 asymptomatic prevalent infections, 88 100 AIDS cases, and 76 400 AIDS deaths. An estimated 647,000 (80%) HIV-infected adults were unaware of their infection; one third of all adult deaths were HIV related. As a result of population growth, by 2008 a similar number of people will be HIV infected (1.1 million) as during the peak of the epidemic in 1994. Although antiretroviral therapy coverage is expected to rise from 67,000 (2005) to 160,000 (2010), the number of persons needing but not receiving antiretroviral therapy will decrease only slightly from 127,600 (2005) to 111,100 (2010). The use of single-dose in 2005 nevirapine probably averted only 4% of the estimated 20 400 vertical infections. In conclusion, HIV continues to be a leading cause of adult disease and death in Uganda. Universal antiretroviral therapy access is probably unachievable. With the absolute burden of HIV disease approaching the historic peak in the early 1990s, more effective prevention programmes are of paramount importance.

Editors’ note: Although HIV prevalence has declined significantly since the mid-1990s in Uganda, a country with one of the oldest epidemics in the world, the burden of HIV remains high. An important majority of people living with HIV are unaware of their HIV status and therefore are not being evaluated for treatment initiation. New HIV infections that continue to outpace AIDS deaths mean that the total number of people living with HIV this year will reach the 1994 historic peak of 1.1 million people living with HIV, all of whom will eventually need treatment. This is no time for Uganda, and other countries reporting declines in HIV transmission in specific populations, to rest on its laurels. Continued treatment scale-up accompanied by intensified, evidence-informed prevention are urgently needed.