AIDS in Africa PDF
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AIDS in Africa Second Edition AIDS in Africa Second Edition Edited by Max Essex, DVM, PhD Chairman, Harvard AIDS Institute Mary Woodard Lasker Professor of Health Sciences Harvard University, Boston, Massachusetts, USA Souleymane Mboup, PharmD, PhD Professor of Microbiology, Laboratory of Bacteriology and Virology CHU Le Dantec, Université Cheikh Anta Diop, Dakar, Senegal Phyllis J. Kanki, DVM, DSc Professor of Immunology and Infectious Diseases, Department of Immunology and Infectious Diseases and the Harvard AIDS Institute, Harvard School of Public Health, Boston, Massachusetts, USA Richard G. Marlink, MD Senior Research and Executive Director Harvard AIDS Institute, Boston, Massachusetts, USA and Sheila D. Tlou, PhD Associate Professor, Department of Nursing Education University of Botswana, Gaborone, Botswana Managing Editor Molly Holme Department of Immunology and Infectious Diseases and the Harvard AIDS Institute Harvard School of Public Health, Boston, Massachusetts, USA KLUWER ACADEMIC PUBLISHERS NEW YORK, BOSTON, DORDRECHT, LONDON, MOSCOW eBookISBN: 0-306-47817-X Print ISBN: 0-306-46699-6 ©2002 Kluwer Academic Publishers NewYork, Boston, Dordrecht, London, Moscow Print ©2002 Kluwer Academic/Plenum Publishers New York All rights reserved No part of this eBook maybe reproducedor transmitted inanyform or byanymeans,electronic, mechanical, recording, or otherwise, without written consent from the Publisher Created in the United States of America Visit Kluwer Online at: http://kluweronline.com and Kluwer's eBookstore at: http://ebooks.kluweronline.com To Elizabeth, Marie, Pascal, Kim, Tom, and Carel Contributors Quarraisha Abdool Karim, PhD, Univer- Health, Population Council, Johannesburg, sity of Natal Medical School, Durban, South Africa South Africa Elisabeth Bouvet, MD, Infectious Disease Iain W. Aitken, MB BChir, DCMT, MPH, Physician and Professor, Bichat Hospital, Lecturer on Maternal and Child Health, University and GERES, Paris, France Harvard School of Public Health, Boston, Bluma G. Brenner, PhD, McGill Massachusetts, USA University AIDS Centre, Montréal,Québec, Anthony Amoroso, MD, Assistant Canada Professor of Medicine, Institute of Human Virology, Baltimore, Maryland, USA Carl H. Campbell, Jr., MPA, Senior Public Health Advisor, Global AIDS Program, Gabriel M. Anabwani, MBChB, MMed, Centers for Disease Control and Prevention, MSc, Professor of Pediatrics, Senior Atlanta, Georgia, USA Consultant Pediatrician, Princess Marina Hospital, Gaborone, Botswana Robert Colebunders, MD, PhD, Professor of Infectious Diseases, Institute of Tropical Ahidjo Ayouba, PhD, Centre Pasteur, Medicine and University of Antwerp, Yaoundé, Cameroon Antwerp, Belgium Francis R. Barin, PhD, Professor, Université François Rabelais, Tours, France Sylvie Corbet, PhD, Serum Statens Institute, Copenhagen, Denmark Augustine Barnaba, Queen Elizabeth Central Hospital, Blantyre, Malawi Brian Coulter, MD, Senior Lecturer in Tropical Child Health, Liverpool School of Françoise Barré-Sinoussi, PhD, Professor, Tropical Medicine, Liverpool, United and Head, Retroviral Biology Unit, Institut Kingdom Pasteur, Paris, France Charles E. Davis, MD, Assistant Professor Michael Bartos, MEd, Senior Policy of Medicine, Institute of Human Virology, Advisor, Joint United Nations Programme Baltimore, Maryland, USA on HIV/AIDS, Geneva, Switzerland Seth Berkley, MD, President and CEO, Martin Dedicoat, Liverpool School of International AIDS Vaccine Initiative, New Tropical Medicine and the Africa Centre, York, New York, USA Hlabisa Hospital, Hlabisa, KwaZulu Natal, South Africa Gunnel Biberfeld, MD, PhD, Professor, Department of Immunology, Karolinska Beth A. Dillon, MSW, MPH, Centers for Institute, Stockholm, Sweden Disease Control, Atlanta, Georgia, USA Kelly Blanchard, MSc, Robert H. Ebert Ousmane M. Diop, PhD, Institut Pasteur, Program on Critical Issues in Reproductive Dakar, Sénégal viii CONTRIBUTORS José Esparza, MD, PhD, WHO-UNAIDS Phyllis J. Kanki, DVM, DSc, Professor of HIV Vaccine Initiative, World Health Immunology and Infectious Diseases, Organization, Geneva, Switzerland Harvard School of Public Health, Boston, Massachusetts, USA Max Essex, DVM, PhD, Chairman, Harvard AIDS Institute, and Mary Woodard Lasker Saidi H. Kapiga, MD, MPH, ScD, Assistant Professor of Health Sciences, Harvard Professor of Reproductive Health, Harvard University, Boston, Massachusetts, USA School of Public Health, Boston, Massachusetts, USA Eka Esu-Williams, PhD, Population Elly T. Katabira, MD, World Health Council, Horizons Program, Johannesburg, Organization, Harare, Zimbabwe South Africa David A. Katzenstein, MD, Associate Wafaie W. Fawzi, MD, DrPH, Associate Professor of Medicine, Stanford University Professor of International Nutrition and School of Medicine, Stanford, California, Epidemiology, Harvard School of Public USA Health, Boston, Massachusetts, USA Patrick K. Kayembe, MD, DrPH, Associate Geoff Foster, MBBS, DCH, MRCP, Professor of Medicine and Public Health, Consultant Pediatrician, Mutare Provincial University of Kinshasa, Kinshasa, Hospital, Mutare, Zimbabwe, Democratic Republic of Congo Stefan Germann, Masiye Camp, Bulawayo, Poloko Kebaabetswe, RN, RM, MPH, Zimbabwe CHES, Botswana-Harvard AIDS Institute Partnership, Gaborone, Botswana Peter B. Gilbert, MS, PhD, Assistant Research Professor, Department of Annamaria K. Kiure, MD,SM, Harvard Biostatistics, University of Washington, School of Public Health, Boston, Seattle, Washington, USA Massachusetts, USA Sofia Gruskin, JD, MIA, Assistant Mark W. Kline, MD, Professor of Pediatrics, Professor of Health and Human Rights, Baylor College of Medicine, Houston, Texas, Harvard School of Public Health, Boston, USA Massachusetts, USA Sibylle Kristensen, MPH, MSPH, Co- Aïssatou Guèye, Institut Pasteur, Paris, director, AIDS International Training and France Research Program, University of Alabama at Birmingham,Birmingham, Alabama, USA Aissatou Guèye-Ndiaye, PharmD, Marc Lallemant, MD, Perinatal HIV Assistant Professor of Microbiology, Centre Prevention Trial, Thailand, Institut de Hospitalier Universitaire, Dakar, Senegal Recherche pour le Développement, Chiang Amar A. Hamoudi, Center for International Mai, Thailand Development, Harvard University, Anne Laporte, MD, Institut de Veille Cambridge, Massachusetts, USA Sanitaire, Saint-Maurice, France Keith E. Hansen, MPA, JD, Deputy Sophie Le Coeur, MD, PhD, Institut Manager, AIDS Campaign Team for Africa, National d’Études Démographiques, Paris, The World Bank, Washington, DC, USA France Samuel Kalibala, MD, Horizons Project, Tun-Hou Lee,SD, Professor of Virology, East and Southern Africa, Population Harvard School of Public Health, Boston, Council, Nairobi, Kenya Massachusetts, USA CONTRIBUTORS ix Shahin Lockman, MD, Harvard School of Gernard I. Msamanga, MD, ScD, Associate Public Health, Boston, Massachusetts, USA Professor, Department of Community Health, Muhimbili University College of Chewe Luo, MBChB, MMED, PhD, Health Sciences, Dar es Salaam, Tanzania HIV/AIDS Officer, UNICEF, Gaborone, Botswana Katawa Msowoya, MSc, Malawi AIDS Counseling and Resource Organization, Eligius Lyamuya, MD, PhD, Senior Blantyre, Malawi Lecturer and Head, Department of Microbiology and Immunology, Muhimbili Michaela C. Müller-Trutwin, PhD, Institut University College of Health Sciences, Dar Pasteur, Paris, France es Salaam, Tanzania Ruth Nduati, MBChB, MMed, MPH, Senior Lecturer, Department of Pediatrics, Miriam Maluwa, LLB, LLM, The Joint University of Nairobi College of Health United Nations Programme on HIV/AIDS, Sciences, Nairobi, Kenya Geneva, Switzerland Ann Marie Nelson, MD, Chief, AIDS Indu Mani, DVM, Harvard School of Public Pathology Branch, Armed Forces Institute of Health, Boston, Massachusetts, USA Pathology, Washington, DC, USA Richard G. Marlink, MD, Senior Research Eric Nerrienet, PhD, Head, Virology and Executive Director, Harvard AIDS Laboratory, Centre Pasteur, Yaounde, Institute, Boston, Massachusetts, USA Cameroon Elizabeth Marum, PhD, Centers for Disease Robert Newton, MBBS, DPhil, MFPHM, Control and Prevention, Nairobi, Kenya Radcliffe Infirmary, Oxford, United Philippe Mauclère, MD, PhD, Director, Kingdom, Institut Pasteur de Madagascar, Kathleen F. Norr, PhD, Associate Professor, Antananarivo, Madagascar University of Illinois at Chicago, College of Harriet Mayanja-Kizza, MBChB, MMed, Nursing, Chicago, Illinois, USA MSc, Senior Lecturer and Head, Department Vlad Novitsky, MD, PhD, Harvard School of of Medicine, Makerere University Medical Public Health, Boston, Massachusetts, USA School, Kampala, Uganda Stephen J. O’Brien, PhD, Chief, Laboratory Dorothy Mbori-Ngacha, MBChB, MMed, of Viral Carcinogenesis, National Cancer MPH, Senior Lecturer, Department of Institute-Frederick, Frederick, Maryland, Pediatrics, University of Nairobi College of USA Health Sciences, Nairobi, Kenya Churchill L. Onen, MBChB, MMed, Souleymane Mboup, PharmD, PhD, Senior Consultant Physician and Head of Professor of Microbiology, CHU Le Department of Medicine, Princess Marina Dantec/Université Cheikh Anta Diop, Dakar, Hospital, Gaborone, Botswana Senegal Martine Peeters, PhD, Institut de Recherche Kenneth McIntosh, MD, Professor of pour le Développement, Montpelier, France Pediatrics, Children’s Hospital/Harvard Peter Piot, MD, PhD, Executive Director, Medical School, Boston, Massachusetts, Joint United Nations Programme on USA HIV/AIDS, Geneva, Switzerland Monty Montano, PhD, Assistant Professor Jean-Christophe Plantier, PhD, Assistant of Medicine, Boston University School of Professor, Laboratoire de Virologie, Hôpital Medicine, Boston, Massachusetts, USA Bretonneau, Tours, France x CONTRIBUTORS Kirthana Ramanathan, MD, MPH, Daniel Tarantola, MD, Senior Policy Harvard AIDS Institute, Boston, Advisor, Director General’s Office, World Massachusetts, USA Health Organization, Geneva, Switzerland Robert R. Redfield, MD, Professor of Sheila D. Tlou, PhD, Associate Professor, Medicine and Director of Clinical Care and Department of Nursing Education, Research, Institute of Human Virology, University of Botswana, Gaborone, Baltimore, Maryland, USA Botswana Boris Renjifo, MD, MS, PhD, Harvard Coumba Toure-Kane, PharmD, MD, School of Public Health, Boston, Assistant Professor, Laboratoire de Massachusetts, USA Virologie, Hôpital Le Dantec, Dakar, Senegal Renée Ridzon, MD, Centers for Disease Control and Prevention, Atlanta, Georgia, Sten H. Vermund, MD, PhD, Professor and USA Director, Division of Geographic Medicine, University of Alabama at Birmingham, Jeffrey Sachs, PhD, Galen L. Stone Birmingham, Alabama, USA Professor of International Trade, and Director, Center for International Mark A.Wainberg, PhD, Professor, McGill Development, Harvard University, University AIDS Centre, Montréal, Québec, Cambridge, Massachusetts, USA Canada Jean-Louis Sankalé, PharmD, DSc, Neff Walker, AB, MA, PhD, Senior Advisor Harvard School of Public Health, Boston, for Statistics and Modeling, United Nations Massachusetts, USA Joint Programme on HIV/AIDS, Geneva, Switzerland Roger L. Shapiro, MD, Harvard School of Public Health, Boston, Massachusetts, USA Carolyn Williamson, Associate Professor, François Simon, MD, PhD, Head, Faculty of Health Sciences, University of Retrovirology Laboratory, Centre Capetown, Capetown, South Africa International de Recherche Médicales de Anne Willoughby, MD, MPH, Director, Franceville, Franceville, Gabon Center for Research for Mothers and Moses Sinkala, MD, MPH, Director, Children, National Institute of Child Health Lusaka Urban District Health Management and Human Development, Rockville, Board, Lusaka, Zambia Maryland, USA Freddy Sitas, PhD, Head, Cancer Cheryl A. Winkler, PhD, National Cancer Epidemiology Research Group, National Institute-Frederick, Frederick, Maryland, Cancer Registry, South African Institute for USA Medical Research, Johannesburg, South Debrework Zewdie, PhD, Manager, AIDS Africa Campaign Team for Africa, The World Bank, Karen A. Stanecki, MPH, Chief, Health Washington, DC, USA Studies Branch, International Programs John L. Ziegler, MD, MSc, Professor of Center, U.S. Census Bureau, Washington, Medicine, Emeritus, and Director, Cancer DC, USA Risk Program, University of California at Zena A. Stein, MA, MB BCh, Professor of San Francisco Comprehensive Cancer Public Health and Psychiatry Emeritus, Center, San Francisco,California, USA Mailman School of Public Health, Columbia Lynn S. Zijenah, PhD, Senior Lecturer, University, New York, New York, USA Department of Immunology, University of Arnaud Tarantola, MD, GERES, Faculté Zimbabwe Medical School, Harare, Xavier Bichat, Paris, France Zimbabwe Foreword The way we deal with AIDS in Africa will All of them take account of the local cultural determine Africa’s future. The devastation context. But they all have something else in wrought by HIV/AIDS on the continent is so common; they stem from a political will to acute that it has become one of the main fight AIDS, and a recognition that facing up obstacles to development itself. AIDS to the problem is the first step towards con- threatens to unravel whole societies, com- quering it. I am convinced that, given that munities, and economies. In this way, AIDS will, every society can do the same. is not only taking away Africa’s present—it We have seen a growing understanding is taking away Africa’s future. of the inextricable link between prevention This crisis requires an unprecedented and treatment, and a conviction that treat- response. It requires communities, nations, ment can work even in the poorest societies. and regions, the public and the private sector, We have seen AIDS drugs become more international organizations and nongovern- available and affordable in poor countries, mental groups to come together in concerted, and scientific progress promises simplified coordinated action. Only when all these treatment regimes. Above all, we have seen a forces join in a common effort will we be able growing understanding that the key is politi- to expand our fight against the epidemic to cal commitment to providing treatment, decrease risk, vulnerability, and impact. All backed up by community involvement. of us must be open about HIV, and raise our Our challenge now is to build on the voices against stigma and discrimination. All momentum that has been achieved. Practical of us must rise above turf battles and doctri- medical education is a vital pillar in that nal disputes. The only acceptable result is that process, and this book promises to be an we replace suffering with hope. invaluable tool. I am especially heartened that This is indeed a time of hope, for after so many of its chapters are written by years of slow and inadequate responses, we Africans—for the solutions to this crisis must have seen a turning point in the fight against come primarily from Africa itself, with sup- HIV/AIDS. For much of the international port from the wider internationalcommunity. community, the magnitude of the crisis is Whether you are a practitioner, a policymaker, finally beginning to sink in. At no time in a public health expert, a person living with dealing with this catastrophe has there been AIDS, or a concerned member of the public, I such a sense of common resolve and collec- hope you will use this authoritative work to tive possibility. At no time have we seen advance our fight against AIDS in Africa. such strength of purpose shown by African leaders themselves. We have seen examples of effective pre- Kofi A. Annan vention efforts across the continent. All of Secretary-General of the United Nations them were developed by actors inside the and Winner of the 2001 Nobel Peace country; they were not imposed from outside. Prize Preface Eight years ago the first edition of AIDS Over the last eight years, there has been in Africa was published. Since then, many a massive expansion of the AIDS epidemic millions of Africans have died of AIDS in Africa. During the same period there have and huge numbers of children have become also been major milestones of progress. orphans. In some countries, life expectancy Perhaps the most dramatic of these has been has been reduced by more than a third, and the recognition that the lives of most AIDS more than a third of young women are patients can be saved with the use of combi- HIV-infected. nations of antiretroviral drugs. However, The worldwide AIDS epidemic has with very few exceptions, Africans have not now surpassed the former benchmark of yet benefited from the fruits of research on infectious disease epidemics—the bubonic AIDS treatment. plague—in total deaths. That epidemic of For more than 15 years, there have been the 14th century eliminated entire civiliza- statements of intent to develop a vaccine. tions and changed the course of history. Yet, such statementshave never been backed Numbers of annual deaths from AIDS also by resource allocation for vaccine research recently surged past those representing the that has matched the allocations for drug burden of death from malaria. While the research. Preventive medicine has never numbers for AIDS morbidity and mortality been as popular as therapy to save the lives worldwide may seem astounding, they of those who are already ill, even when it is should be even more astounding when we much more cost-effective. Those who can- consider that more than 70% of the world’s not pay the cost of treatment are often left burden is concentrated in sub–Saharan to die. Africa, home to just 10% of the world’s There is some good news. Some of the population. drugs designed for treatment have been During the 1980s most of the attention shown to be remarkably effective and also given to AIDS issues focused on the United cost-effective for preventing the transmis- States and Europe. Africa was largely sion of HIV from mother to child. Some ignored by the rest of the world and many countries within Africa, such as Senegal and African governments were in denial. Few Uganda, have made impressive progress in political leaders remain in denial, but the controlling HIV epidemics. A few interna- devastation of AIDS in Africa is still largely tional agencies, especially the Bill and ignored by governments of the affluent Melinda Gates Foundation, have made nations of the North. Even some countries important commitments to the problem of that were previously considered models of AIDS in Africa. The United Nations has success in Africa—those with expanding established the Global Fund. economies, lack of violence, and good gov- The new edition ofAIDS in Africa has ernments—have been devastated by HIV been completely reorganized and revised to and AIDS. reflect the current and future epidemics of
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