Sub-Saharan Africa remains the region most heavily affected by HIV worldwide, accounting for over two thirds (67%) of all people living with HIV and for nearly three quarters (72%) of AIDS-related deaths in 2009.
An estimated 1.9 million [1.6 million–2.2 million] people were newly infected with HIV in sub-Saharan Africa in 2008, bringing to 22.4 million [20.8 million–24.1 million] the number of people living with HIV.
In 2008, more than 14 million children in sub-Saharan Africa had lost one or both parents to AIDS.
Sub-Saharan Africa’s epidemics vary significantly from country to country—with most appearing to have stabilized, although often at very high levels, particularly in southern Africa.
The nine countries in southern Africa continue to bear a disproportionate share of the global AIDS burden—each of them has an adult HIV prevalence greater than 10%.
With an adult HIV prevalence of 26% in 2007, Swaziland has the most severe level of infection in the world. Lesotho’s epidemic seems to have stabilized, with a prevalence of 23.2% in 2008.
South Africa continues to be home to the world’s largest population of people living with HIV—5.7 million in 2007.
While the rate of new HIV infections in the region has slowly declined, the number of people living with HIV slightly increased in 2008, partly due to increased longevity stemming from improved access to treatment. Adult (15–49) HIV prevalence declined from 5.8% in 2001 to 5.2% in 2008.
By the end 2008, 44% of adults and children in the region in need of antiretroviral therapy had access to treatment. Five years earlier, the regional treatment coverage was only 2%.
As a result of treatment scale-up, people are living longer in many countries. In Kenya, AIDS-related deaths have fallen by 29% since 2002.
Women and girls continue to be disproportionally affected by HIV in sub-Saharan Africa. Throughout the region, women account for 60% of all HIV infections.
Young women between the ages of 15 and 19 are particularly vulnerable to HIV. In Kenya, young women are three times more likely to become infected than their male counterparts.
Drops in HIV incidence were reported among women in Zambia between 2002 and 2007. In the United Republic of Tanzania, national HIV incidence fell between 2004 and 2008. Zimbabwe has experienced a steady fall in HIV prevalence since the late 1990s, due to changes in sexual behaviour.
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In East Africa, HIV prevalence seems to have stabilized and in some settings may be declining. In Burundi, HIV prevalence fell among young people aged 15 to 24 in urban areas between 2002 and 2008 (4% to 3.8%) and in semi-urban areas (6.6% to 4%) during the same period, while HIV prevalence increased in rural areas from 2.2% to 2.9%.
Although HIV prevalence in West and Central Africa is much lower than in southern Africa, the subregion nevertheless is home to several serious national epidemics in countries such as Côte d’Ivoire (3.9% HIV prevalence) and Ghana (1.9% prevalence).
Key regional dynamics
Heterosexual intercourse remains the epidemic’s driving force in sub-Saharan Africa, with extensive ongoing transmission to newborns and breastfed babies. However, recent epidemiological evidence has revealed the region’s epidemic to be more diverse than previously thought:
Sex work continues to play a notable role in many national epidemics. In Kenya, sex workers and their clients accounted for an estimated 14.1% of new HIV infections. In Uganda, sex workers, their clients and their clients’ partners accounted for 10% of new infections in 2008.
Seven African countries (Benin, Burundi, Cameroon, Ghana, Guinea-Bissau, Mali and Nigeria) report that more than 30% of all sex workers are living with HIV.
Several recent studies suggest that unprotected sex between men is probably a more important factor in sub-Saharan Africa’s HIV epidemics than is commonly thought. In a recent survey of men who have sex with men in Malawi, Namibia and Botswana, the HIV prevalences among the participants were 21.4%, 12.4% and 19.7%, respectively.
Although common in sub-Saharan Africa, homosexual behaviour is highly stigmatized in the region. More than 42% of men who have sex with men surveyed in Botswana, Malawi and Namibia experienced at least one human rights abuse.
Injecting drug users in sub-Saharan Africa appear to be at high risk of HIV infection. In the region, an estimated 221 000 drug users are HIV-positive, representing 12.4% of all injecting drug users in the region. In Nairobi, Kenya, 36% of injecting drug users surveyed tested HIV-positive.
HIV prevention
Evidence suggests that HIV prevention programmes may be having an impact on sexual behaviours in some African countries. In southern Africa, a trend towards safer sexual behaviour was observed among young men and women between 2000 and 2007.
In South Africa, the proportion of adults reporting condom use during their first sexual encounter rose from 31.3% in 2002 to 64.8% in 2008.
As in the case of increased access to antiretroviral therapy, sub-Saharan Africa has made remarkable strides in expanding access to services to prevent mother to child HIV transmission. In 2008, 45% of HIV-positive pregnant women received antiretroviral drugs, compared with 9% in 2004.
