The SADC region is without doubt the epicentre of the AIDS pandemic in the world: Prevalence rates vary from 15% to 28% of the population. In 2007, sub-Saharan Africa – primarily SADC countries – was home to 67% (22.1 million) of all people living with HIV in the world. Of these, 60% are women. Almost half (45%) of those infected are between the ages of 15 and 24. Ninety percent of children living with HIV in the world today are in sub-Saharan Africa.

The impact of HIV/AIDS

What has AIDS done to our societies? The scope of the impact of HIV and AIDS in SADC countries is profound: Reduction of the average adult lifespan by more than 20 years; Creation of millions of child-headed households; Deepening of poverty; Reduction in economic output; Increasing resource disparities between rural and urban populations; Reversal of educational progress; Alteration of agricultural output types and production levels; Deaths of young adults. This list is by no means complete.

On the other hand, HIV and AIDS have resulted in equally unprecedented efforts to deal with the multitude of social and infrastructural problems and inequities in our societies. Extraordinary efforts have been made to ensure universal access to ART (antiretroviral treatment), resulting in a slowing down of the deaths from AIDS over the last few years; Gender equity programmes to address vulnerability of women; PMTCT (Prevention of Mother to Child Transmission) programmes have produced remarkable results in reducing infections in newborns.

It is now possible to state – tentatively, and with conditions – that HIV is no longer a death sentence. In those areas and populations with access to the ART and PMTCT and related infrastructure, the life expectancy of a person living with HIV now exceeds the life expectancy of a person with diabetes. Considering the context of the time-span in which this has occurred - 25 years – this is indeed cause for quiet celebration. However, this is a single battle victory in a much larger war against the scourge of our times, and other battles are by no means won. Indeed, it may be argued that we may be winning the war in treatment, and losing the larger war of prevention.

Measuring our efforts

Theoretically, we may measure our combined efforts – prevention and treatment access – by examining national and regional HIV prevalence rates.  Essentially, the prevalence for a specific period is the previous year’s total prevalence, plus new infections, and minus AIDS deaths. When HIV prevalence rates stabilise – i.e., do not increase or decrease significantly – this simply means that new infections and AIDS deaths are equal.

If the total prevalence rate increases, this means one of two things: Either new infections have increased faster than AIDS deaths, or more people requiring ART are receiving such live-saving treatment, compared to new infections. Conversely, a drop in total prevalence means one of two things: Either more people are dying from AIDS than those newly infected, or there are fewer new infections compared to AIDS deaths.

In many SADC countries, the total prevalence is stabilising. The question is whether this is due to successful prevention programmes, or AIDS deaths increasing to match new infections.

There is no doubt that there have been significant successes in making ART available to more people, thus reducing AIDS deaths. However, the evidence suggests that the need for ART is currently outpacing its’ availability. I.e., AIDS deaths are still a major factor in determining total prevalence rates. Ironically, if everyone who needed ART was receiving such treatment, the total prevalence rates should increase, not decrease, as the total pool of infected people was not decimated through death, and only newly infected people were added to the total.

We need to keep in mind that HIV/AIDS is a ‘slow wave’ pandemic: It takes between 6 and 8 years from infection until AIDS symptoms develop, and a further 1 to 2 years for death from AIDS to occur, in the absence of ART.  Furthermore, infection rates were doubling every 18 to 24 months in the previous decade. The end-result is that, despite massive efforts to provide ART to as many people as possible, these efforts would need to double such access every 18 to 24 months. If this does not occur, AIDS deaths will outpace ART access. This appears to be the case, currently.

What about prevention? The key variable in assessing prevention efforts is new infections per annum. Other key indicators are birth rates and STI (Sexually Transmitted Infections) figures. If standard ABC (Abstinence, Be faithful, Condomise) prevention programmes are working, then all three statistics should logically decline.

The evidence suggests otherwise: For every two people who start ART, there are five new infections (UNAIDS, 2008); Furthermore: “There is also no evidence ... that HIV prevalence is decreasing in the sub-region. In 2005 there were 1,5 (1,3 -1,7) million new HIV infections in the SADC region representing more than 36.5 percent of all new infections globally” (SADC Report: Expert think tank meeting on HIV prevention on high-prevalence on Southern Africa, 2006). It appears, despite the most strenuous efforts, that the ABC prevention model has not been the success we hoped for.

It also needs to be noted that public messaging has not yet fully resolved the conflict between the ‘prevent infection because AIDS can kill you’ message and the ‘get tested and treated – you can live a long life’ message.

Prevention: The long war

There have been significant changes in the epidemiological nature of HIV in the SADC region:  For example, commercial sex workers are no longer primary vectors of infection. In many locations, the prevalence rates of commercial sex workers is not significantly different from married and unmarried women in the same area. Commercial sex workers are also more likely to use condoms than other women of the same age. It is also the case that the primary focus of infection has shifted to ‘ordinary’ committed relationships.  In other words, the days of focusing upon ‘high risk sex with strangers’ has passed; Instead, the focus is now married couples, and couples who have long-term relationships. For example, it has been found that the probability of a man wearing a condom is 60% if he is having sex with a stranger, 30% if it is a regular girl friend, and only 10% if it is his wife. I.e., people are generally aware of the risk of casual sex, and know how to reduce the risks.

For many years we – HIV/AIDS educators – blamed the failure of prevention efforts on the lack of knowledge regarding prevention (typically ABC), or lack of access to condoms. However, various studies have indicated that most adults – in excess of 90% - are well aware of how HIV is transmitted, and how to prevent it.  What was not taken into consideration in our prevention efforts is the basic cultural imperative to reproduce children. In our experience, the need to reproduce children over-rides knowledge of the individual risks regarding HIV. Until this conflict is resolved – having children versus protecting yourself – prevention efforts will produce poor results.

In this regard, there is a glimmer of hope: Recent studies have indicated that sero-discordant couples (one HIV-positive, the other HIV-negative) may safely conceive sexually if the person living with HIV has an undetectable viral load, no untreated STI’s, and is under medical supervision. The implications of these findings have yet to be explored in terms of public messaging.

There have also been significant research findings that may change the course of regional and local prevention efforts: The fact that (medical) circumcision can reduce the chances of a man becoming HIV-infected by up to 60%; Sociological studies that have determined that the presence of concurrent relationships (more than one sexual relationship – often long-term – occurring simultaneously) is a key factor in variations in HIV prevalence. Furthermore, there is emerging evidence that poverty and resource-related issues (clean water, access to medical care, nutrition) cause differences in vulnerability to HIV infection, and also speed of progression to AIDS.

Given the lacklustre outcomes from conventional ABC prevention programmes, these new developments provide new avenues to bolster prevention strategies. Under consideration in some countries is incentivised male circumcision, and circumcision at birth, as is the case in the USA. Concurrent relationships also provide a focus for relationship-based programmes emphasising monogamy. The latter was successfully employed in Uganda in the late 1980’s (Zero Grazing).

The road forward

A review of major global pandemics – the Black Death and Bubonic Plagues as examples – shows that pandemics change the core values of societies. In the 25 years that HIV has been recorded, the pandemic has outpaced our willingness and ability to change: The price of inflexibility has been enormous, and even if a cure was found today, we would continue to pay the price for generations.

However, both sociological and medical understanding of HIV and AIDS is maturing: We are finally coming to grips with the real social forces that are driving the pandemic, and the next five years will see a major reorientation of prevention methodology towards circumcision and the reduction of concurrent relationships. It is particularly the latter that will force societies to discuss the widespread phenomena of what is essentially open-ended polygamy based upon economic factors. We fully expect prevention efforts to shift from the conventional ABC to focus upon monogamy, with condom promotion becoming a secondary strategy.

In terms of treatment access, there is no doubt that this will be systematically expanded, and treatment outcomes improved. However, one of the key issues confronting our medical infrastructure is non-adherence – a behavioural issue – which has led to the current situation where almost 1 in 5 new infections being drug-resistant, potentially creating a scenario similar to drug-resistant TB. If this issue is not addressed with urgency, the respite in deaths from AIDS may fade within a few short years.

Effective prevention is – and should be - the ultimate goal in any HIV/AIDS strategy. SADC countries cannot indefinitely bear the costs of having large segments of the population on life-long chronic medication. Yes, it is cheaper to treat than not to treat. However, it is even cheaper – economically - to prevent, if we are willing to pay the psychological and cultural price for the necessary changes.

Authors Background (David R. Patient (MHT) & Neil M. Orr (MA)):

The opinions in this article reflect those of the authors based on their combined experiences.

David Patient – a person living with HIV for 26 years - and Neil Orr - a research Psychologist in the area of health - have worked in HIV/AIDS, since 1983 and 1985, respectively, with the last 15 years working in 17 countries in Africa, India and South East Asia.

They are best-selling authors of Positive Health (17 million copies in circulation in 19 languages) and Choices: All about HIV and AIDS (Jacana, 2008), trainers, facilitators and program designers. Their work has covered many aspects of health and HIV/AIDS, from regional N.G.O.’s to whole country interventions.

For more information on the authors and the scope of their work, please visit http://empow.co.za  or email David Patient on This e-mail address is being protected from spam bots, you need JavaScript enabled to view it