Epidemiology
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 W, Musinguzi J, Kirungi W, Opio A, Stover J, Kaharuza F, Bunnell R, Kafuko J, Mermin J. The estimated burden of HIV/AIDS in Uganda, 2005-2010. AIDS. 2008; 19; 22(4):503-10.
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.
1 Comment
December 1st, 2008 at 6:27 pm
It’s unfortunate to note that the initial success story for Uganda is fading away going by the statistics in this article.
Going by epidemiological principles in a fully HIV susceptible population with basically no knowledge of the causative microbe and transmission dynamics and given the social instability/the population boom,improved population mobilities,high rural urban migrations etc.that charcterised the early 80s,conditions were rife for rapid spread of the epidemic. With increasing awareness of the modes of transmission and the resultant change of sexual behaviours among previously irresponsibly highly active youths,the declining pool of irrespsonsibly persistently highly heterogenously active persons, the rigorous government and donor aided IEC campaigns the resultant epidemiological factors dictated the resultant fall in person to person transmission even prior to the advent of HAART.
The other conributing factor to the decline may have been a sort of ‘cohort effect’in which a very high proportion of the younger section of the population who had not yet reached sexually active age group having experienced the terribly sad scenario of HIV/AIDS on their parents and older siblings and hence needing less IEC reminders of the importance of ABC (i.e Abstinence,Being faithful and condom use) reached into sexual active yeears (the 90s) fully equipped with the knowledge and fear of irresponsible sexual activity.(NOTE:i.e hardly any family in many affected regions escaped having a family mmeber sick and treated in the house).This may directly have impacted on reduction of HIV transmission as the pool of high tramsitters’ may have been less in this ‘cohort’
The advent of ART in the mid ninties may have led to a change in a wide spectrum of the factors motivating the decline in HIV rates.i.e
Much as the preventive campaigns may have continued but on a lesser vogorous scale due to the declining rates,the next ‘pre-sexual’ cohort is likely not to have the terrible and instant habit changing experience’ of the earlier cohort.This is a cohort that is coming into the HIV AIDS adulthood limelight when:
1.The general gloomy picture of AIDS is no longer the threat that it was.
2.There is treatment for AIDS opportunsitic infections.
3. Most important of all there is treatment for HIV AIDS for those who get infected.
This new scenario may have a big impact on the way the 90s pre-sexual cohort and more still the 2000s pre-sexual cohort behave in their sexual years and hence on the current and future HIV incidence/prevalence trends.
The advanced epidemics occuring in the rest of the African countries may not be directly compared to the advnaced epidemic of the Ugandan situation as the advnaced epidemics of many other African countries comes in the context of ‘peak incidences’during the HAART era.
The notion of Abstinence,condom use has not been able to control or reduce the pool of highly heterogenously active pool of persons especially men who drive the spread of the epidemic, the current socio-economic circumstances in most of the developing world,the low levels of cgirl child education,the high levels of poverty among rural and periurban communities all of which continue to diminish the sex bargaining power and independence from the community pool of the ‘macho’ men,the scenario of HIV AIDS in developing nations may take on even worse diameters.
With the hope of a vaccine in the next 10 years very ’slim’the threat of the HIV pandemic in african settings may only be starting to get more gloomy.
Though not yet proven on public health level to reduce transmision,HAART theoretically reducing the viral pool in among the most vigilant herterogenously sexually active may i additon to widescale behavioural change campaings,timely access to STD treatment,and improved eductation for the girl child in addition to socio-economic empowerment gradually remove the HIV pandemic.
The hope of universal HIV testing (if the socio-cultural factors preventing people from HIV testin are adressed,)in addition to providing ART universally to all HIV positive at whatever cd4 count seems to an epidemiologically plausible mode of reducing HIV transmission and thence lowering HIV incidence/prevalence
If the above is effective as is already being suggested by some international health organisations,countries like Uganda which according to the article in reported here,are experiencing possible resurgence of HIV rates and for which it may be impracticle to go back to the ABC, may need to the huge resources necessary to implement the universal testing and treatment strategy. This may be the only hope for the elimination of the disease.For however costly the prospected intervention,if effective and solves the problem in a shor time,it will be worth the long term expenses on current slow acting and yet unpredictable current interventions and will also save many lives.
Leave a Comment