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* Address correspondence to this author at the Copperbelt University Health Services, P O BOX 21692, Kitwe, Zambia; E-mail: oscar.simooya @cbu.ac.zm
Editorial: HIV Infection and AIDS in Africa - Issues, Lessons Learnt and Next Steps
Towards the end of the 1980s, and in the midst of a great public health challenge that appeared to threaten the whole existence of mankind, predictions of an apocalyptic end to the human race were being debated as the global family faced unprecedented and widespread deaths from the HIV and AIDS epidemic. The African continent which has borne the largest burden of people living with HIV infection was in particular severely affected by the epidemic and has since lost generations of its people from an epidemic that took advantage of its resource limited health systems which were unable to cope with the effects of HIV and AIDS.
However, today some thirty years or so later, the gloom and fear that characterized the early days of the epidemic has been replaced by a renewed hope that the worst part of the epidemic is over and there is even guarded optimism that the epidemic could be over by the year 2030. Although it can be said that the discovery of highly active anti retroviral treatments (HAART) in the mid 1990s and their subsequent roll out has brought about dramatic changes in the well being of people with HIV infection, it is equally true that a wide variety of prevention and coping strategies developed in response to the epidemic have equally played an important part in mitigating the impact of HIV infection.
This special issue of The Open AIDS Journal looks at the response to HIV and AIDS in Africa and focuses on issues and lessons learnt as the continent aspires to maintain the momentum against the epidemic.
Kasonde Bowa and colleagues from the Copperbelt University in Kitwe, Zambia look at the impact of HIV on the practice of surgery in Africa. They report that HIV has affected surgical pathologies, patient care, and more recently prevention strategies. The surgical patient is more likely to be HIV positive in Africa, than elsewhere in the world. The patients are also more likely to have co infection with Hepatitis B or C and are unlikely to be aware of their HIV status thus increasing the occupational risk for the surgeon. Extra care is therefore required when preparing a patient for theatre. More recently and in an ironic change of roles, surgery has impacted HIV prevention through the role of male circumcision as a significant tool in HIV prevention, which has traditionally focused on behavioral interventions.
Of the estimated 6000 new infections that still occur globally each day, two out of the three are in sub-Saharan Africa with young women continuing to bear a disproportionate burden. Adolescent girls and young women aged 15-24 years have up to eight fold higher rates of HIV infection compared to their male peers. Kharsany and Quarraisha Abdool Karim from the Nelson Mandela School of Medicine in South Africa reflect on the large gap in women initiated HIV prevention technologies especially for women who are unable to negotiate the current HIV prevention options of abstinence, behavior change, condoms and medical male circumcision or early treatment initiation in their relationships.
They authors argue that the possibility of an AIDS-free generation cannot be realized unless we are able to prevent HIV infection in young women. They review the epidemiology of HIV infection in sub-Saharan Africa, key drivers of the continued high incidence, mortality rates and priorities for altering current epidemic trajectories in the region. Strategies for optimizing the use of existing and increasingly limited resources are discussed. Tertiary institutions in Africa have not been spared from the devastation of HIV and AIDS and many Universities on the continent have lost and continued to lose highly trained lecturers and students. As Universities represent the foundation for socio-economic and political development, the negative impact of the AIDS epidemic could lead to a reversal of developmental gains made by African countries since their independence from colonial rule some 50 years or so ago. Nawa Sanjobo and colleagues from the Copperbelt University in Zambia look at the HIV and AIDS response at the University. The main objective of this response is to build the capacity of students and employees in HIV and AIDS. Peer educators and counselors conduct sensitization campaigns through one on one discussion, workshops, and drama performances, distribution of Information, Education and Communication (IEC) materials. The next step is to spearhead the integration of HIV in the university curriculum. Oversight for the program is provided by the University Council, the policy making organ of the institution.
Although the epidemic in Africa is mainly due to heterosexual transmission, the importance of targeting key populations and marginalized groups, including men who have sex with men (MSM) and transgender people has recently been added to the growing agenda for HIV interventions on the continent. Meredith Evans and colleagues from the University of Cape Town and the Human Sciences Research Council (HSRC) in Cape Town South Africa explore the current state of research on HIV risk and MSM, women who have sex with women (WSW) and lesbian, gay, bisexual and transgender (LGBT) populations in South Africa in order to identify gaps in the literature. The authors lament that despite South Africa being the country with the largest number of people living with HIV in the world, there is a limited amount of research on these key populations. They conclude that research with MSM, WSW, and LGBT populations should be prioritized in South Africa in order to appropriately inform HIV prevention strategies that meet the specific needs of these marginalized groups.
Nana Poku of the Health Economics and AIDS Research Division (HEARD) of the University of Kwazulu Natal in South Africa argues that there is no viable substitute for re-energizing, funding and supporting culturally attuned, locally staffed HIV advocacy and prevention programmes, especially in resource-poor settings. The evidence that such interventions are effective remains compelling; and although the cost implications are not negligible, the medium- to long-term outcomes must be regarded not as complementary, but as integral, to bio-medical interventions. Poku reminds us that while the rate of new HIV infections is stabilizing in some of the hardest-hit countries, it remains far too high and the future cost of maintaining an ever-expanding pool of people reliant on daily drugs for survival is unsustainable. He cautions against focusing on treatment as a ‘quick fix’ to end AIDS as a public health concern. A variety of measures are needed simultaneously to appeal to different people, groups and circumstances.
HIV self-testing (HIVST) is an empowering process in which an individual performs an HIV rapid diagnostic test and interprets the result in private. Policy makers have turned to it to facilitate greater uptake, earlier diagnosis, access to prevention, care and treatment services. Engetani Nkuna and Norman Nyazema of the University of Limpopo in South Africa report a study among 300 health sciences students, to assess the potential of HIVST to increase access to and uptake of HIV testing on campus. The results suggest that there is a potential for HIVST to increase uptake for HIV testing. As there are still a large number of HIV infected people who do not know their status on the continent and who as a result are not accessing HAART, this simple and confidential procedure appears to offer greater opportunity for reaching out to this “missing” population.