X HIV/AIDS Prevention and Care in Resource-Constrained Settings

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F igure 2Comparison of Average Number of Clients PerCommercial Sex Worker (CSW) Versus Percentageof Young Men Who Utilized Sex WorkersAverage # of CSW clients/day43.532.521.510.50■ Indonesia■ Philippines■ Cambodia■ Thailand0 10 20 30 40 50 60% of males using sex workersmodes of transmission. These have yet to be adequatelydelineated and entered into the complex equation ofepidemic dynamics.T HE EPIDEMICS OFSUB-SAHARAN AFRICAThe global pandemic consists of a mosaic of individualepidemics in countries around the world. Theoldest set of epidemics can be found in sub-SaharanAfrica. Of the 36 million people living withHIV/AIDS globally, more than 25 million (70 percent)are in sub-Saharan Africa. This region includesonly 11 percent of the world’s population. Nearly onein 10 adults between the ages of 15 and 49 is alreadyliving with the virus throughout the sub-continent.In Africa women are harder hit than men, theopposite of what is found on all other continents. Thedifference between men and women is most pronouncedin those under age 25. A population-basedsurvey in Kisumu, Kenya, showed HIV rates in 15-and 16-year-old girls of 8 percent and 18 percent,while no infections were documented in boys of thesame age. In 19-year-old girls the rates were up to 33percent, and only 9 percent inboys. We do not fully understandthe reasons for these extremelyhigh rates in girls. Young girls’biological vulnerability and the factthat girls frequently have sex partnersof much higher age—withhigh levels of infection—likely playa role.There are at least three patternsof transmission in sub-SaharanAfrica:In the countries of EastAfrica, the oldest HIV epidemicsin the world have had slow, steadyprogress over the past 30 years.These are seen in the Great Lakesregions of East Africa—in thecountries of Uganda, Tanzania,Malawi, Kenya, Zambia and the Democratic Republicof the Congo (formerly Zaire).In the countries of West Africa, where theepidemic seems to have started about 10 years later,progression of the epidemic has been more indolentand is further complicated by the presence of bothHIV-1 and HIV-2. The national prevalence ratesare generally lower, between one percent and eightpercent, except for Côte d’Ivoire.In Southern Africa, where the epidemic startedin the mid-to late 1980s, there has been a series ofexplosive epidemics over the past eight years, reachingthe highest prevalence levels on earth, 20 percent to40 percent. These countries include South Africa,Namibia, Zimbabwe, Botswana, Swaziland andLesotho.Among the features of the epidemics in this region:■■Half of new infections in Africa are among 16- to23-year-olds, three-quarters of them young girlsand women. More than 80 percent of HIV transmissionis heterosexual, with more than 55 percentof infections in sub-Saharan Africa occurring inwomen due to increased physiological and socioeconomicvulnerability.Several studies in sub-Saharan Africa have notedthat HIV prevalence is high in young womenwithin the first few years of sexual activity, but risesHIV/AIDS Prevention and Care in Resource-Constrained Settings IX
F igure 3HIV Seroprevalence for Pregnant Womenin Selected Urban Areas of Africa: 1985–199950HIV Seroprevalence (%)45Francistown4035BlantyreKwazulu/Natal3025201510LusakaKampalaHarareNairobiAbidjanLagos50DakarYaounde1985 1987 1989 1991 1993 1995 1997 1999Note: Includes infection from HIV-1 and/or HIV-2.Source: U.S. Census Bureau, HIV/AIDS Surveillance Data Base, 2000.■more slowly in young men. Recent data from foururban populations and one rural population confirmdramatic male-female differences (see Figure4). In this vicious cycle young girls are infected byolder men; the girls as they age then infect theirsame-age partners and husbands; and these men asthey age in turn infect young girls.The increasing number of HIV-infected womenhas led to the infection of nearly 600,000 infantseach year. Although new, more realistic interventionsto reduce mother-to-child transmission(MTCT) of the virus are being developed, fewerthan five percent of women in sub-Saharan Africahave access to these treatment regimens.T HE EPIDEMICS OF ASIAWith a population of nearly 3.5 billion—representingnearly 60 percent of the world’s population—theAsia-Pacific region has the potential to greatly influencethe course and overall impact of the global HIV-AIDSpandemic. 1 HIV began to spread in this region in theearly to mid-1980s, reflecting risk behavior in two discreteareas: commercial sex work (CSW) and injectiondrug use (IDU). During the 1980s and early 1990s,there was extensive spread among men who have sexwith men (MSM) in several Asian Pacific countries,including Australia, New Zealand, Japan, Malaysia,X HIV/AIDS Prevention and Care in Resource-Constrained Settings
Page 1 and 2: Edited byPeter R. Lamptey, MD, DrPH
Page 3 and 4: © 2001 Family Health International
Page 5 and 6: SECTION II:Chapter 6PAGE 137Chapter
Page 7 and 8: Chapter 21PAGE 501Chapter 22PAGE 51
Page 9 and 10: I N T R O D U C T I O NPAUL R. DE L
Page 11: F igure 1Factors That InfluenceThe
Page 15 and 16: F igure 5HIV Seroprevalence for Com
Page 17 and 18: F igure 7HIV Seroprevalence for Pre
Page 19 and 20: F igure 9Life Expectancy With and W
Page 21 and 22: F igure 11Population of Zimbabwe,Wi
Page 23 and 24: invest; and feedback further amplif
Page 25 and 26: R EDUCING MOTHER-TO-CHILDTRANSMISSI
Page 27 and 28: F igure 13HIV Seroprevalence in Adu
Page 29 and 30: ACKNOWLEDGEMENTSWe wish to express
Page 32 and 33: SOFIA GRUSKIN, JD, MIAAssistant Pro
Page 34 and 35: THOMAS M. PAINTER, PHDBehavioral Sc
Page 36 and 37: glossary of A C R O N Y M SACTG AID

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