Elsevier

The Lancet

Volume 360, Issue 9326, 6 July 2002, Pages 67-72
The Lancet

AIDS in Africa
Shadow on the continent: public health and HIV/AIDS in Africa in the 21st century

https://doi.org/10.1016/S0140-6736(02)09337-6Get rights and content

Summary

Approaches to the prevention and control of the HIV/AIDS epidemic in Africa have been heavily based on early experiences and policies from industrialised countries, where the disease affects specific risk groups. HIV/AIDS has been dealt with differently from other sexually transmitted or lethal infectious diseases, despite being Africa's leading cause of death. In this review, we discuss the evolution of the global response to the epidemic, and the importance of redefining HIV/AIDS in Africa as a public health and infectious disease emergency. We discuss reconsideration of policies and practice around HIV testing and partner notification, and emphasise the need for an increased focus on treatment. Human-rights based approaches to HIV/AIDS prevention might have reduced the role of public health and social justice, which offer a more applied and practical framework for HIV/AIDS prevention and care in Africa's devastating epidemic.

Section snippets

Epidemiology

The epidemiology of HIV/AIDS in Africa is fundamentally different from that in the rest of the world. Sub-Saharan Africa contains about 10% of the world's population, yet, in 2001, accounted for over two-thirds of the 40 million people living with HIV; had 68% of incident HIV infections and 77% of AIDS deaths; and accounted for more than 90% of AIDS orphans and children infected with HIV.8, 9 With the exception of the Caribbean, only in Africa is the epidemic generalised rather than

Evolution of the global response

Since the earliest days of the epidemic, HIV/AIDS has been treated differently from other sexually transmitted or lethal infectious diseases, a trend which Bayer defined as “HIV exceptionalism”.12 Specific areas of public health in which approaches have differed include HIV testing, surveillance, and contact investigation.

HIV testing, available since 1985, has been restricted for medical as well as prevention purposes because of a strong emphasis on informed consent and counselling. Unlike

Definitions

How an issue is defined strongly affects how it is addressed. Portrayal of HIV/AIDS against a background of either human rights, poverty, gender, or public health elicits different responses, but the measure of each response must be its ability to curtail the epidemic, and at what social cost. Our philosophical and technical approaches to HIV/AIDS prevention must interrupt HIV transmission, mitigate the epidemic's clinical and social effect, reduce stigma and vulnerability, and promote the

Public health in Africa in the era of HIV/AIDS

We think that Africa would now benefit most from an approach to HIV/AIDS based on a public health model that includes voluntary counselling, testing, and partner notification; routine HIV testing in prevention services such as prevention of mother-to-child transmission, and treatment for sexually transmitted infections; routine diagnostic HIV testing for patients seeking medical treatment (eg, for tuberculosis); and enhanced access to HIV/AIDS care.

Conclusions

Inadequate resources, infrastructure, and commitment, and reluctance to address HIV/AIDS as a public health and infectious disease issue, are barriers to prevention and care in Africa's high prevalence epidemic. These forces have increased individual and societal vulnerability, and enhanced stigma. Paradoxically, for many Africans, HIV/AIDS has become the main threat to the very notions that an approach based on individual rights aimed to protect. The normalisation of HIV/AIDS in a

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