"During the past 10 years, the AIDS response has been extraordinary, nowhere more so than in eastern and southern Africa. The countries in this region are using the latest tools available to save people's lives, halt HIV transmission and achieve the dream of ending the AIDS epidemic. ... The rate of new HIV infections has been reduced by more than 30% overall, and by more than 50% in seven countries in the region.
Since 2005, the number of people receiving lifesaving antiretroviral therapy (ART) has increased tenfold-from 625,000 to more than 6 million at the end of 2012. Botswana, Namibia, Rwanda, Swaziland and Zambia reached universal access to HIV treatment (80% coverage of people eligible for treatment) by the end of 2011. Kenya, Malawi, South Africa and Zimbabwe are on track to reach this goal." - UNAIDS
AIDS-related mortality has declined worldwide from an estimated 2.3 million a year in 2005 to 1.7 million in 2011, 1.2 million of those dying in 2011 in sub-Saharan Africa (http://tinyurl.com/ad9o4la). Saving 600,000 lives a year is real progress. But over a million deaths a year means the fight against AIDS is still far from over. So the title of this new report from UNAIDS ("Getting to Zero") is a hopeful projection and a call to action rather than an accomplished fact. As the report itself stresses, the gains must be consolidated and progress accelerated.
This AfricaFocus Bulletin contains brief excerpts from the report, which is available in full, including tables, charts, and footnotes, at http://tinyurl.com/kqmyk5a
For previous AfricaFocus Bulletins on health issues, visit http://www.africafocus.org/healthexp.php - Editor's Note
Getting to Zero: HIV in Eastern & Southern Africa
http://www.unaids.org / direct URL: http://tinyurl.com/kqmyk5a
During the past 10 years, the AIDS response has been extraordinary, nowhere more so than in eastern and southern Africa. The countries in this region are using the latest tools available to save people's lives, halt HIV transmission and achieve the dream of ending the AIDS epidemic.
Ten years ago, the magnitude of the epidemic supported the dire predictions being made for this region, the epicenter of the AIDS crisis. But in only a few years, some of the most heavily-affected countries in the region have made extraordinary progress. The rate of new HIV infections has been reduced by more than 30% overall, and by more than 50% in seven countries in the region. Since 2005, the number of people receiving lifesaving antiretroviral therapy (ART) has increased tenfold-from 625,000 to more than 6 million at the end of 2012. Botswana, Namibia, Rwanda, Swaziland and Zambia reached universal access to HIV treatment (80% coverage of people eligible for treatment) by the end of 2011. Kenya, Malawi, South Africa and Zimbabwe are on track to reach this goal. Through reduced infectivity and rapid treatment expansion, some countries have achieved a "tipping point", where the number of people starting HIV treatment exceeded the number acquiring infections, laying the foundation for moving forward country-specific and economically sustainable responses.
The countries of eastern and southern African are making important progress towards achieving an AIDS-free generation. Between 2009 and 2012, the number of infants newly infected with HIV has fallen by more than half in Botswana, Ethiopia, Malawi, Namibia, South Africa and Zambia, and by more than one-third in Kenya, Mozambique, Swaziland, the United Republic of Tanzania and Zimbabwe. Malawi has been a pioneering country in offering lifelong ART to all pregnant women infected with HIV (Option B+). If we continue to increase this momentum, we can reach our 2015 goal of eliminating new HIV infections among children and keeping their mothers alive.
This dramatic turn-around in the course of the AIDS epidemic has been the result of extraordinary political leadership and engagement from civil society. From the support of African heads of state for AIDS Watch Africa, to the advocacy of the Champions for an HIV-Free Generation, high-level political advocacy and accountability have been critical to the region's progress. The majority of countries in this region have embraced the African Union's Roadmap on shared responsibility and global solidarity for the AIDS, TB and Malaria response.
South Africa has been an outstanding model of this transformation - implementing a series of breakthrough policy decisions since 2009. In 2010, South Africa embarked on an unprecedented national campaign to provide free treatment to all eligible people living with HIV, coupled with a massive programme of testing and counseling for HIV and screening for TB. During the last financial year (2012-2013), more than 9 million people were tested for HIV. The country currently has the largest ART programme in the world, with more than 2.1 million people receiving ART. South Africa's domestic AIDS investments have increased to US$ 1.9 billion per year, the second-largest national AIDS investment in the world.
Many other countries in the region have also adopted bold policies and programmes to increase investments in their national AIDS response. In Botswana, the government provides more than seventy percent of all HIV spending. Zimbabwe's three percent AIDS levy on all taxable income provides invaluable support for its national AIDS programme. Kenya and Tanzania are considering similar innovative funding mechanisms.
Although this region is leading the global AIDS response in the right direction, there is still a lot to be done. In some countries, HIV incidence has been stagnating or even increasing (Lesotho, Uganda, United Republic of Tanzania), raising an alarm for the need to urgently step up prevention efforts. Less than onequarter of children living with HIV in the region are currently receiving treatment. Inefficiencies and inequalities still limit service delivery. Lack of human rights-based responses continues to fuel HIV-related stigma and discrimination. Many people remain at risk and are vulnerable to HIV. In some countries, domestic investments are still inadequate and the challenge for several countries in this region is to further reduce dependency on external resources to treat their own citizens.
The eyes of the world are on this region. The pace at which eastern and southern Africa embraces and acts on new science, evidence and innovations will determine how quickly we will reach the vision of zero new infections, zero AIDS-related deaths and zero discrimination. It is time, through collective innovation, to consolidate the gains and pursue a bold regional approach to accelerate progress toward 2015 and beyond. In the words of Nelson Mandela, "when the water starts boiling it is foolish to turn off the heat".
Michel Sidibé UNAIDS Executive Director
The State of the HIV Epidemic in Eastern and Southern Africa
The past decade has seen remarkable progress in efforts to respond to the HIV epidemics in eastern and southern Africa. In every country, HIV programmes have grown in scale, quality, effectiveness and impact. Positive results are being observed throughout the region:
- In 2011, the number of adults who became newly infected with HIV in eastern and southern Africa was at its lowest level since 1991.
- New HIV infections in children have been halved since 2001.
- AIDS claimed fewer lives in 2011 than in any year since 1998, and the number of TB deaths in people infected with HIV was at its lowest since 1998.
- A total of 6.3 million people in the region were receiving antiretroviral therapy (ART) at the end of 2012.
- In the countries hardest hit by the epidemic, average life expectancy is rising again (1).
These are the results of determined efforts over the last years to scale up prevention and treatment programmes in the region. The rapid scale-up of life-saving HIV treatment, in particular, ranks among the great public health and human rights achievements of our time.
New HIV infections among adults and children are declining
The total number of new HIV infections in eastern and southern Africa has declined substantially in recent years. There were an estimated 1.2 million [1.1 million-1.3 million] new infections in 2011- the lowest annual number since 1991, when the epidemic was still expanding rapidly, and about 30% lower than the estimated 1.7 million [1.6 million-1.9 million] new infections that occurred in 2001 (Figure 1). HIV incidence among adults living in the region decreased from 0.99% [0.93- 1.05%] in 2001 to 0.56% [0.52-0.62%] in 2011.6
Rates of new HIV infections among adults declined significantly in several countries in the region between 2001 and 2011-by more than 50% in Botswana, Ethiopia, Malawi, Namibia, Rwanda, Zambia and Zimbabwe, and by between 25% and 49% in Kenya, Mozambique, South Africa and Swaziland.
The declining trends can be attributed to a combination of factors, including the natural course of the HIV epidemic, demonstrable changes in sexual behaviour (especially among young people in most countries in the region), much wider access to ART, and progress in preventing new HIV infections among children. Levels of reported condom use have been increasing in several eastern and southern African countries, while declines in the number of multiple sexual partners have also been reported in some countries.
There has also been a steep decline in the number of new HIV infections among children younger than 15 years, which fell to an estimated 180,000 [160,000-220,000] in 2011, less than half the 370,000 [330,000-410,000] new infections estimated in 2001. Several countries have made important progress in preventing new infections among children in the past three years:
Between 2009 and 2012, the number of children newly infected with HIV fell by more than 50% in Botswana, Ethiopia, Malawi, Namibia, South Africa and Zambia; and by 30-49% in Kenya, Mozambique, Swaziland, United Republic of Tanzania and Zimbabwe.
This progress is largely due to improved efforts to eliminate new HIV infections among children through the provision of antiretroviral (ARV) treatment or prophylaxis to infected mothers and their infants. In 2011, around 690,000 pregnant women living with HIV received the recommended drugs8 to prevent transmission to their babies- 100,000 more than a year earlier. Coverage of services to eliminate mother-to-child transmission (eMTCT) in this region increased from 61% [55- 67%] in 2010 to 72% [64-80%] in 2011. It is essential that this momentum be sustained in order to reach mothers who still do not have access to such services in the region (estimated at 270,000 in 2011).
AIDS-related deaths are declining
AIDS-related mortality has been declining rapidly since the dramatic increase in provision of ART in the mid-2000s. The 800,000 [730,000-890,000] lives claimed by AIDS in 2011 were 38% fewer than the 1.3 million [1.2 million-1.4 million] lives lost in 2005, when ART became more freely available in eastern and southern Africa (Figure 2).
AIDS-related mortality declined by more than 50% between 2005 and 2011 in several countries, including Botswana, Ethiopia, Kenya, Namibia, Rwanda, Zambia and Zimbabwe.
As a result, fewer children are being orphaned because of AIDS. Despite the decline, a disconcertingly large number of children living in 2011-estimated at 10.5 million [9.8 million-11.2 million] -had lost one or both parents to AIDS, and needed care and support. The strain this causes for extended families, communities, and the children themselves is enormous.
More effective integration of HIV and TB diagnosis and treatment is contributing to the decline in AIDS-related mortality. The TB/HIV death toll in eastern and southern Africa has fallen by about 30% since 2004-6, when it peaked at an estimated 330,000 deaths per year. If this declining trend continues, the region is likely to reach the global target of reducing the number of TB-related deaths among people living with HIV by 50% by 2015.
Rapid increase in the number of people receiving ART
The number of people receiving life-saving ART in eastern and southern Africa has risen tenfold since 2005. A total of 6.3 million people were receiving ART in 2012, compared to 5.2 million people in 2011, and 625,000 in 2005. The region currently accounts for 65% of the 9.7 million people receiving ART globally. According to the 2010 WHO treatment eligibility criteria9, an estimated 64% [61-68%] of people who were eligible were receiving ART in the region in 2011, up from 16% [15-18%] in 2005 and 45% [43-48%] in 2009.
Botswana, Namibia, Rwanda, Swaziland and Zambia had achieved more than 80% coverage10 by the end of 2011, while Kenya, Malawi, South Africa and Zimbabwe had reached more than 60% of people eligible for treatment (2). Countries with coverage below 60% in 2011 include Angola, Comoros, Eritrea, Ethiopia, Lesotho, Madagascar, Mauritius, Mozambique, Uganda and the United Republic of Tanzania.
Of 17.1 million people living with HIV in 2011, 8.1 million met the 2010 WHO ART eligibility criteria. However, the revised 2013 WHO ART guidelines- to initiate ART at CD4 count ? 500 cells/?L and to offer ART to all serodiscordant couples, pregnant women living with HIV, people with TB and HIV, people with HIV and hepatitis B, and all children living with HIV who are younger than five years- will lead to a substantial increase in the number of people eligible for treatment (3).
As more people start and stay on ART, survival times of those infected with HIV are increasing, and the total number of people living with HIV is rising slowly as a result. The total number of people living with HIV in eastern and southern Africa rose from 15.4 million [14.6 million-16.3 million] in 2001 to 17.1 million [16.3 million-17.9 million] a decade later, even though the annual number of new HIV infections declined during this period (Figure 3).
The HIV epidemic among young people
HIV prevalence has been falling among both young women and men (aged 15-24 years), and was about 40% lower in 2011 than a decade earlier. However, the estimated number of new infections among young people was still high at 450,000 [370,000-550,000] in 2011. The vulnerability of young women aged 15-24 years remains of particular concern: the estimated HIV prevalence of 4.5% [3.8-5.6%] among women in that age group in 2011 was more than double the prevalence among their male peers.
In some countries in southern Africa (including Lesotho, Swaziland and South Africa), HIV prevalence among young women aged 15-24 years was still greater than 10%, highlighting the need for increased efforts that adequately address the epidemic in this population group.
The progress in the response to the epidemic in the region confirms that concerted and sustained action can change the course of the HIV epidemic. This progress is also fundamentally important to the overall goal of halting the global HIV epidemic in this region.